Issues for patient and family

This article explores managed care in the 1990s from the perspective of patient and family. This perspective is a complicated one because there is no one managed care program and there is even more diversity among patients and families. Four major issues are singled out for discussion: choice, access, cost, and quality of care. Also discussed are the skills needed by patients and families, as well as health care professionals, that are taking on growing importance in the managed care environment: communication, negotiation, and advocacy.

Office diagnosis and management of group A streptococcal pharyngitis employing the rapid antigen detecting test. A 1-year prospective study of reliability and cost in primary care centres

The impact of introducing the rapid antigen detecting test for the diagnosis of group A streptococcal pharyngitis in primary care centres and the direct and comprehensive cost-effectiveness of four alternative strategies for the management of group A streptococcal pharyngitis and the prevention of rheumatic fever were assessed in a 1-year prospective randomized study, carried out in children between the ages of 5 and 14 years. Data from the study showed that the test was easy to perform and reliable when introduced as a service in primary care. The strategy of using the rapid antigen detecting test and a 10-day oral penicillin course for diagnosis and treatment proved to be the safest and most cost-effective. If compliance with a 10-day course of oral penicillin is unlikely to be achieved, the strategy of introducing the test and treatment by intramuscular benzathin penicillin G proved to be the second best cost-effective alternative. In developing countries, where acute rheumatic fever is still common and the cost of the test and a 10-day course of penicillin may prove to be formidable, a strategy of treating all children with pharyngitis with intramuscular benzathin penicillin G seems to be the most cost-effective. The strategy of diagnosing group A streptococcal pharyngitis on clinical grounds proved to be the worst.

Potential public expenditures under managed competition

This DataWatch estimates the public cost of providing universal coverage under a managed competition model. First, a uniform benefit package is specified; next, the lowest-cost premium for this coverage is estimated, based on average costs in a well-managed health maintenance organization (HMO). Based on these estimates, the cost of premium subsidies and tax revenue effects are determined. It is estimated that if coverage is extended to currently uninsured persons using these estimates and assumptions, spending for these persons will increase 73.9 percent over current levels. The authors estimate a net increase of $47.9 billion in 1993 health spending under a managed competition program with low patient cost sharing. This includes savings of $4.5 billion from wider use of managed care and $11.2 billion in administrative cost savings.

From bench to bedside: research and testing of Internet resources and connections in community hospital libraries

Access to information becomes more valuable with the continuing proliferation of medical knowledge and the increasing economic pressure being experienced by health care organizations. This is particularly so for community hospitals in rural or isolated areas, where the economic pressures are at least as great as in urban areas and where access to information is often inadequate. These conditions have implications for the quality of patient care and for economic viability. In response to this, the National Library of Medicine, the University of Washington, and seven community hospitals in five Pacific Northwest states have joined forces in a broad-scale technology diffusion project to facilitate the application of research work to clinical care. There are three components to the project: 1) a pilot connections component to extend Internet access to the community hospitals, 2) a research component to test the performance of a client/server model for network access to anatomical text and images, and 3) a clinical component to develop a registry of DNA diagnostic laboratories facilitating the provision of genetic information to clinicians. The pilot connections component is described and preliminary findings are reported.

[Thyroid function tests and their use by the general practitioner]

OBJECTIVE

We aimed to discover how thyroid function tests (TFTs) were used in general practice (GP) consultations. We would evaluate how many TFTs were requested, their efficiency, cost and their impact on referrals to endocrinology.

DESIGN

This was a longitudinal, retrospective and observational study. SITE. At the Primary Care level, in the La Chana Health Centre, Granada.

PATIENTS

69 patients with possible Thyroid Disease, and who had a TFT performed by their GP, were surveyed. The test comprised parallel TSH, free T4 and free T3.

MAIN MEASUREMENTS AND RESULTS

2.46 TFTs per GP per year were requested. 14 showed positive (20.28%) and a definite diagnosis of Thyroid Function Disease (TFD) was made in 11 cases (15.94%). The cost per test was 1,718 pesetas; and per diagnosis, 8,467 pesetas. 78.26% of the cases were resolved by the GP without need of referral.

CONCLUSIONS

The GPs carried out few FTFs; but those they did were very efficient. Cost was low and patients benefited from the fact that their GPs were able to use this technique. Endocrinology referrals were reasonable. All general practitioners should have use of TFTs.

Assessing the quality of pharmaceutical care. I. One perspective of quality

OBJECTIVE

To evaluate the concept of pharmaceutical care (PC) as a standard of quality care for ambulatory pharmacy practice.

DATA SOURCES

Donabedian's article on the seven pillars or characteristics of quality provides a framework for a discussion of the merits of PC as a definition of quality. A MEDLINE search augmented by a manual review of International Pharmacy Abstracts was also used to identify pertinent English-language pharmacy literature; indexing terms included quality, community pharmacy services, ambulatory, pharmacy services, and pharmacist(s).

STUDY SELECTION

Representative articles and studies promoting PC were considered.

DATA EXTRACTION

The literature was independently reviewed by the primary author.

DATA SYNTHESIS

An interpretation of the principles of Donabedian's article was applied to PC. PC appears to be consistent with the quality characteristics of efficacy and acceptability. The effectiveness, cost-effectiveness, and efficiency of PC should be firmly established by its practitioners as barriers are eliminated and/or overcome. The pillars of optimality, equity, and legitimacy seem to be overlooked under the current definition of PC. This article contends that PC assumes an individualist definition of quality, by definition, because of its covenantal relationship with the patient.

CONCLUSIONS

Quality is defined in terms of the values of individuals and society. For now, PC appears to be the appropriate standard for defining quality in pharmacy because of the importance of individual maximal benefits within our society.

Cervical cancer and health care resources in Newark, New Jersey, 1970 to 1988

OBJECTIVES

In the past, the predominantly Black population of Newark, NJ, had little access to programs promoting or providing Pap tests. The ratio of in situ to invasive cases of cervical carcinoma was markedly reduced in all age categories, indicating inadequate screening for this cancer in this population. Funding became available to provide and publicize Pap smears but ceased after 5.5 years. We examined the effect of these changes in funding.

METHODS

Data came from all Newark hospitals and practitioners and from the state cancer registry. There are now data on incidence of in situ and invasive cervical cancer in Newark from 1970 through 1988, including years before, during, and after program funding.

RESULTS

The ratio of in situ to invasive cervical cancer increased and decreased in a striking parallel with the provision and subsequent cessation of funding.

CONCLUSIONS

Cessation of funding of education and screening programs can result in resumption of an unfavorable in situ/invasive cervical carcinoma ratio in a poor population.

[Cost analysis of a bone bank]

The costs of a bone-bank working in accordance with the guidelines of the german federal chamber of physicians are described. Establishing a bone-bank storing deep-frozen bone is not very expensive. The main costs are due to laboratory costs for excluding HIV, hepatitis, syphilis and bacterial contamination of bone grafts. In our experience with 206 bone grafts about 20% of them are to be discharged because of positive laboratory tests. The costs of each bone graft are DM 327. A second HIV-Test of the donor 3 months after explantation of a bone graft will cause rising of costs up to 47%. About 20-30% of bone graft donors will probably not carry out this test. In this case discharging of the bone graft is necessary.

Economic/reimbursement issues in MR imaging with gadolinium contrast agents

Implementation of an accurate, reliable index of cost effectiveness would help to advance technology assessment and reimbursement of MR imaging procedures, including gadolinium enhancement. To this end, an objective, consensual measure that satisfies the need for "gold-standard" confirmation of diagnostic impressions in routine clinical practice and limits interpreter bias has been developed. Eponymously termed Diagnostic Merit, this barometer is expressed as the percentage of independent judges confirming diagnostic impressions entered by case-blinded radiologists assigned unenhanced and enhanced image sets for interpretation. The judges, who are informed of clinical indications, clinical follow-up, and unblinded diagnostic interpretation of the MR scans, confirm only those case-blind interpretations deemed "close enough for diagnostic utility" to actual clinical profiles. According to this method, gadopentetate dimeglumine has been shown to be cost effective by promoting optimal diagnostic performance. This improvement in utility offsets the cost of the gadolinium contrast agent. Efficacies of gadodiamide and gadoteridol, two other contrast agents in development, have been demonstrated by other measures but are probably also evaluable through the Diagnostic Merit method. CPT-4 codes for contrast-enhanced MR imaging are reviewed.

[Possibilities for the use of basic cephalosporins]

The always growing number of cephalosporins constitutes a significant part of the betalactam antibiotics. Depending on antibacterial spectrum and in vitro activity, different groups, e.g. the "cefuroxime-group" and the "cefotaxime-group" have been defined. Based on epidemiologic and comparative in vitro data, the present review offers some guidance where the less expensive cephalosporins of the "cefuroxime-group" may still be clinically useful.

Health spending by state: new estimates for policy making

A new data set from the Health Care Financing Administration gives estimates of state spending for hospital care, physician services, and retail purchases of prescription drugs, which together account for 70 percent of health expenditures nationwide. Analysis of these data, which are the first uniform state data to be produced for nearly ten years, shows considerable variation among states and among regions in health care spending. The New England and Mideast regions show the consistently highest spending levels for all three categories; the Southwest and Rocky Mountain regions spent the smallest amount (as much as 17 percent below the U.S. average).

Rising to the challenge of home health care

The managed care concept has had a major impact on most health care delivery systems (from the hospital to home) and the professional practice of the people within those systems. It is important that all types of providers who are involved in an individual's care have a basic understanding of the challenges they each face. Sharing information may contribute to a more efficient transfer of the client's care from one provider to another and improve continuity of care and cost containment. This article presents some of the challenges that the Visiting Nurse Association of Chicago (VNAC), a home care provider, has faced as a participant in managed care.

[The development of an automated system for computing the "standard" values of the economic loss brought by one case of infectious disease]

An original and technically realizable system for the determination of the values of economic damage produced by a single case of an infectious disease has been developed, based on a concrete socio-economic analysis. The system has been realized with the use of an IBM PC/AT by means of the Econ program module developed in the SuperCalc-4 tabulated processor program environment. The use of the average socio-epidemiological, national economic and demographic statistical data has made it possible to calculate the "standard" values of the economic damage produced by a single case of 15 infectious diseases (total average, as well as for different groups of patients and measures). Analysis of the values thus obtained shows their, on the average, 1.25-fold growth, as well as their considerable variability reflecting the clinico-epidemiological nature of infectious diseases.

Quality of life issues in lung cancer. New symptom management strategies

Diagnosis and treatment of lung cancer can significantly affect a patient's quality of life. Survival rates are dismal, but improvements have been made in dealing with common symptoms and side effects. This article reviews the nature of the problem, pertinent risk factors, and symptoms associated with nausea and vomiting, cachexia, hypercalcemia, and pain. Physicians, nurses, and other health care professionals can play a vital role in the identification and management of these complications, and thereby help to improve quality of life.