Well being, work environment and work accidents

We examine factors that influence accident proneness among employees. We agree that the determinants of accident proneness include organizational, emotional and personal factors. Using logistic regression we estimated three models, and their predictability for accident proneness among sample of 200 injured workers interviewed upon entering hospital emergency wards in Israel. Work injuries were not contingent on age, religion, nor education. The effects of gender were strong but non-significant. Subcontracted and higher-paid workers are more likely to get repeat injuries. Prior injury experience sensitized employees to stronger perceptions of risk associated with unsafe practices. Large family households, ameliorates stress feelings and lessens the likelihood of accident proneness while poor housing conditions have the opposite effect. The full model demonstrates considerable prediction of injuries when focusing on type of employment, personal income level, being involved in dangerous jobs, emotional distress and a poor housing environment. The model contains most of the significant results of interest and provides a high level of predictability for work injuries.

Physician assessments of patient compliance with medical treatment

In a study of how physicians evaluate patient compliance, practitioner judgments were compared to the self-reports of 138 adult patients receiving treatment for pulmonary diseases at an outpatient clinic. The research found no significant relationship between physician evaluations of compliance and accounts given by the same patients. The conclusions of physicians regarding patient compliance proved to be influenced by their views on the seriousness of the condition and the effectiveness of treatments, but patient reports were different. Physicians clearly have difficulties in appraising the compliance behavior of their patients.

Use of losartan in the treatment of hypertensive patients with a history of cough induced by angiotensin-converting enzyme inhibitors

The objective of this study was to determine the incidence of dry cough in hypertensive patients with a history of angiotensin-converting enzyme (ACE) inhibitor-induced cough after treatment with losartan (an angiotensin II-receptor antagonist), lisinopril (an ACE inhibitor), or placebo. One hundred patients from 16 outpatient treatment centers in the United States were included in this double-masked, randomized, parallel-group, active- and placebo-controlled study, with stratification according to sex. After a challenge phase with lisinopril and a placebo washout phase, patients were randomly allocated to receive losartan 50 mg once daily, lisinopril 20 mg once daily, or placebo for a maximum of 8 weeks. The primary efficacy end point of the study was the presence or absence of dry cough during the double-masked period, as rated by the patient at each visit using a validated symptom assessment questionnaire. A secondary end point was the frequency of dry cough, as measured at each visit using a visual analogue scale (VAS). The incidence of dry cough was significantly higher in the lisinopril group than in the losartan and placebo groups (87.5% vs 36.7% and 31.4%, respectively) at the end of the double-masked treatment period; there was no statistically significant difference between the losartan and placebo groups. Mean VAS scores showed that patients treated with lisinopril rated themselves as having a significantly higher frequency of cough than did patients treated with losartan or placebo (4.0 vs 1.2 and 1.5, respectively). Again, the difference between the losartan and placebo groups was not statistically significant. All treatments were otherwise well tolerated, and no serious clinical or laboratory adverse events were reported during the double-masked phase of the study. These results demonstrate that the incidence, severity, and frequency of dry cough in patients with a history of ACE inhibitor-induced dry cough are significantly lower in those treated with losartan than in those treated with lisinopril and are similar to the incidence, severity, and frequency of dry cough in those receiving placebo.

Comparative antihypertensive effects of losartan 50 mg and losartan 50 mg titrated to 100 mg in patients with essential hypertension

The antihypertensive activity of losartan potassium (losartan, Cozaar), an angiotensin II receptor antagonist, was evaluated in a parallel 12-week, double-blind, placebo-controlled trial in hypertensive patients with mild-to-moderate hypertension. After a 4-week, single-blind, placebo lead-in period, which included monitoring of baseline variables, 366 patients with a group mean sitting diastolic blood pressure of 101 +/- 5 (s.d.) mmHg were assigned randomly to one of three treatment groups: placebo, losartan 50 mg, or losartan 50 mg with the option to titrate to 100 mg after the first 6 weeks if the target sitting diastolic blood pressure (< 90 mmHg) was not reached. To assess the potential blood pressure response associated with the act of titration, patients in the placebo and losartan 50 mg treatment groups with a sitting diastolic blood pressure of > or = 90 mmHg at week 6 were mock titrated (changed to a new tablet containing the same study medication and dose). Sitting diastolic blood pressure was also evaluated at the end of the trial during a 1-week off-drug period to assess for rebound hypertension. At week 6, patients in the active-drug-treatment arms experienced significantly greater peak (6 h post-dose) and trough (24 h post-dose) reduction in systolic and diastolic sitting blood pressures compared with placebo (p < or = 0.01). Based on trough blood pressures at week 12, active drug (both arms) was more effective than placebo in lowering sitting diastolic blood pressure, with a very small additional benefit associated with increasing the dose of losartan to 100 mg in patients who did not reach the target blood pressure after the first 6 weeks on losartan 50 mg. There was no evidence of rebound hypertension during 1 week after withdrawal of losartan. The correlation between baseline plasma renin activity and reduction in peak and trough blood pressure at week 12, although statistically significant, was generally poor in the active treatment groups. In this trial, losartan was efficacious and well tolerated, and was similar to placebo with regard to adverse-experience profile. Adverse experiences that could reasonably be related to excessive lowering of blood pressure were not common and there was no evidence of rebound hypertension.

Losartan and low-dose hydrochlorothiazide in patients with essential hypertension. A double-blind, placebo-controlled trial of concomitant administration compared with individual components

BACKGROUND

Angiotensin II acts at the cellular level through specific angiotensin II subtype I, AT-1 receptors. Losartan is the first of a new class of antihypertensive agents that specifically block angiotensin II at AT-1 receptors. By acting on complementary and different pharmacologic mechanisms, the concomitant use of low doses of hydrochlorothiazide with losartan may offer an additive antihypertensive activity with fewer adverse experiences.

METHODS

This double-blind study evaluated losartan concomitantly administered with hydrochlorothiazide as initial therapy in 703 patients with essential hypertension.

RESULTS

The greatest reduction in blood pressure was observed in the 50 mg of losartan potassium and 12.5 mg of hydrochlorothiazide group (17.2 mm Hg in sitting systolic blood pressure and 13.2 mm Hg in sitting diastolic blood pressure [P < or = .001]), and the effects of the two components appeared to be additive. Seventy-eight percent of the patients treated with 50 mg of losartan potassium and 12.5 mg of hydrochlorothiazide had an excellent or good antihypertensive response (sitting diastolic blood pressure < 90 mm Hg or > or = 90 mm Hg with a reduction of 10 mm Hg or more). Peak (6 hours after dosing) and trough placebo-adjusted ratios for the losartan-hydrochlorothiazide groups ranged from 62% to 85%, indicating that there was a smooth reduction in sitting diastolic blood pressure that was sustained over 24 hours. The most common clinical adverse experiences (> or = 4%) that occurred with an incidence slightly greater than that reported by the placebo-treated patients were headache, asthenia or fatigue, dizziness, sinusitis, and upper respiratory infection.

CONCLUSION

The concomitant administration of losartan potassium, 50 mg, with 12.5 mg of hydrochlorothiazide once daily produced an additive reduction in trough sitting systolic and diastolic blood pressure and was well tolerated.

Comparative effects of combination drug therapy regimens commencing with either losartan potassium, an angiotensin II receptor antagonist, or enalapril maleate for the treatment of severe hypertension

OBJECTIVE

To compare the efficacy and safety of a regimen of losartan potassium (losartan) and a regimen of enalapril maleate (enalapril) in a randomized trial of patients with severe hypertension in which the initial treatments were blinded.

DESIGN AND METHODS

Seventy-five patients, 23-74 years of age, with sitting diastolic blood pressure of 115-130mmHg, were enrolled in a 12-site multicenter study. The primary efficacy parameters were the change in trough systolic and diastolic blood pressure, as well as response to treatment in terms of categories of hypertensive response.

RESULTS

A gradual reduction in mean sitting diastolic blood pressure was observed in all patients treated from week 1 to 12 (10-29mmHg for the losartan regimen and 14-32 mmHg for the enalapril regimen). At week 4, a substantial number of patients remained on monotherapy at either the initial dose or double the dose of losartan (52%) or enalapril (72%). The blood pressure curves for each treatment were parallel over time. The enalapril-based regimen elicited a statistically significantly greater reduction in blood pressure than the losartan-based regimen, although the mean differences in the blood pressure response between the two treatment groups was small. Based on sitting diastolic blood pressure < 90 mmHg or a reduction in blood pressure of at least 10 mmHg, 98% of the patients assigned to the losartan regimen and 100% of the patients assigned to the enalapril regimen had a satisfactory response with a regimen of one to three antihypertensive drugs. Headache was the most common adverse experience in both treatment groups (occurring in 22% of patients assigned to the losartan regimen and 20% of patients assigned to the enalapril regimen).

CONCLUSIONS

In this study, the losartan-based regimen effectively lowered blood pressure, was generally well tolerated, and was generally similar to the enalapril-based regimen in the treatment of patients with severe hypertension.

Controlled trial of losartan given concomitantly with different doses of hydrochlorothiazide in hypertensive patients

The purpose of this trial was to evaluate the antihypertensive efficacy of the concomitant administration of selected doses of hydrochlorothiazide (HCTZ) on a background of losartan potassium (losartan) 50 mg, a selective angiotensin II receptor antagonist. Patients with essential hypertension ( > or = 95 mmHg inclusion criteria) with a mean sitting diastolic blood pressure (SiDBP) of 105 +/- 0.4 (S.E.) mmHg entered a 4-week, single-blind monotherapy period of losartan 50 mg once daily. At the end of the monotherapy period, patients whose blood pressure was adequately controlled were discontinued. Patients whose blood pressure was partially controlled based on a SiDBP > 92 mmHg entered a 12 week double-blind period and were randomly assigned to either receive placebo (n = 80), HCTZ 6.25 mg (n = 80), HCTZ 12.5 mg (n = 72) or HCTZ 25 mg (n = 80) in addition to losartan 50 mg. During the losartan monotherapy period, there was a 4 mmHg fall in SiDBP with a further fall of 5 mmHg after 12 weeks of double-blind therapy in the losartan/placebo control group. Based on the between group differences in BP change from the end of the losartan monotherapy period (baseline) to end of 12 weeks of double-blind, the concomitant administration of a very low dose of HCTZ (6.25 mg) with losartan did not significantly decrease SiDBP compared with the fall in blood pressure in the losartan/placebo control group (diff. between groups = -2 (95% C.I.[-4.1, +0.9] mmHg)). However, the concomitant administration of HCTZ 12.5 or 25 mg with losartan 50 mg resulted in significantly different (p < or = 0.05) reductions in diastolic blood pressure compared to the losartan/placebo group (diff. between groups = -4 (95% C.I. [-6.3, -1.1] mmHg) for 12.5mg combination group; -6 (95% C.I. [-8.3, -3.3]) mmHg for the HCTZ 25 mg combination group). The proportions of patients treated with losartan plus HCTZ 12.5 mg or 25 mg that achieved a trough SiDBP < 88 mmHg or a trough SiDBP > or = 88 mmHg but with a decrease of at least 5 mmHg were 71% and 83%, respectively. The percentage of clinical adverse experiences that were considered drug-related as assessed by the investigator were generally similar across all treatment groups. There were no reports of orthostatic hypotension in any of the treatment groups. Changes in serum glucose, potassium and uric acid were not appreciably different amongst the treatment groups. In summary, in patients with predominantly moderate to severe essential hypertension, the addition of HCTZ 12.5 mg or 25 mg to losartan 50 mg produced effective control of blood pressure in a substantial majority of patients who only partially responded to losartan monotherapy. There were no differences amongst the treatment groups with respect to drug-related adverse experiences in this trial.

Losartan potassium as initial therapy in patients with severe hypertension

This 12-week, open-label study was conducted to gain experience with losartan potassium, an angiotensin II receptor antagonist, in patients with severe hypertension. Patients were either untreated or withdrawn from current therapy for at least 48 h before initiation of losartan 50 mg once daily. Patients were titrated to 100 mg as needed to achieve a goal of sitting diastolic blood pressure (SiDBP) 90 or 95 mm Hg. Hydrochlorothiazide (12.5 mg once daily titrated to 25 mg) was added and followed by either a dihydropyridine calcium channel blocker (CCB) and/or atenolol, if BP was not controlled. A total of 179 patients with a pretreatment mean baseline BP of 172 +/- 17/112 +/- 18 mm Hg enrolled in the trial and BP was recorded 24 h after dosing at baseline and weeks 2, 4, 8 and the final week (10-12 weeks). The mean reductions in SiDBP from baseline were 7.3, 9.3, 15.9 and 18.9 mm Hg, respectively, and these changes from baseline were statistically significant, P < 0.001. At the end of the trial, 22% of patients remained on losartan monotherapy, 30% required the addition of hydrochlorothiazide (HCTZ) and 31% required both HCTZ and a CCB; 11% required HCTZ and atenolol while 4% required HCTZ, a CCB and atenolol; 2% of patients were on regimens not specified by the protocol. SiDBP < 90 mm Hg was achieved in 68 patients by the final visit; 24% of these patients were treated with losartan monotherapy (50 or 100 mg), 41% achieved control with the addition of HCTZ (12.5 or 25 mg) and 24% required triple therapy which included losartan, HCTZ and a CCB. As assessed by the investigator, 25% of the patients in the study had drug-related clinical adverse experiences. Headache was the most frequently reported clinical adverse event (26% of patients). No clinically significant changes in laboratory parameters were observed. It is concluded that losartan potassium can be used as initial therapy for patients with severe hypertension and can be administered concurrently with hydrochlorothiazide, calcium channel blockers and atenolol.

Randomised, double-blind, parallel study of the anti-hypertensive efficacy and safety of losartan potassium compared with felodipine ER in elderly patients with mild to moderate hypertension

This study investigated the anti-hypertensive efficacy and tolerability of once-daily losartan potassium (50 mg titrated to 100 mg), an angiotensin II receptor antagonist, compared with once daily felodipine extended release (ER) (5 mg titrated to 10 mg), a calcium channel blocker, after 12 weeks of therapy in elderly hypertensive patients. Following a 4-week, single-blind, placebo baseline period, qualifying patients were randomly allocated to 12 weeks of double-blind treatment with losartan potassium or felodipine ER. After 6 weeks, patients with a 24 h post-dose sitting diastolic blood pressure > or = 90 mm Hg had their dose doubled for the remaining 6 weeks. At 6 weeks, there was a greater BP response for felodipine ER than losartan potassium in elderly patients with mild to moderate hypertension. However, after 12 weeks of therapy, losartan potassium reduced BP as effectively as felodipine ER with no differences in mean BP reduction or anti-hypertensive response category between treatment groups. In this study, both treatments were well tolerated; felodipine ER was associated with a numerically higher incidence of headache and oedema while the incidence of asthenia was numerically higher in losartan-treated patients.

Effects of losartan on a background of hydrochlorothiazide in patients with hypertension

The purpose of this multicenter trial was to compare the antihypertensive efficacy and safety of losartan potassium (losartan), a selective angiotensin II receptor antagonist, when added to hydrochlorothiazide in hypertensive patients whose blood pressure was not adequately controlled by 25 mg hydrochlorothiazide monotherapy. After a 4-week monotherapy period of 25 mg hydrochlorothiazide, 304 patients with trough (22 to 26 hours postdose) sitting diastolic pressure between 93 and 120 mm Hg were maintained on 25 mg hydrochlorothiazide and randomized double-blind into treatment arms consisting of either 25, 50, or 100 mg losartan or placebo once daily for 12 weeks. The reductions in sitting diastolic pressure for patients treated with 25, 50, or 100 mg losartan concomitantly administered with 25 mg hydrochlorothiazide were significantly greater (P < or = .05) than the reductions observed in the 25 mg hydrochlorothiazide plus placebo group beginning 1 week after randomization. The antihypertensive response in all groups was greater at week 3 than week 1, with some additional decrease in blood pressure in some groups at later times. Sitting systolic pressures were also significantly reduced in each group over time. Standing blood pressures at week 12 were similar to sitting blood pressures. A dose-response relationship to losartan was observed in this patient population. The percentages of the total drug-related clinical adverse experiences as assessed by the investigator were generally similar in the 25, 50, and 100 mg losartan plus 25 mg hydrochlorothiazide groups (10.3%, 24.4%, and 20.0%, respectively) compared with the placebo plus 25 mg hydrochlorothiazide group (24.7%).(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy and tolerability of losartan potassium and atenolol in patients with mild to moderate essential hypertension

The objective of this study was to compare the antihypertensive efficacy and tolerability of losartan potassium (losartan) and atenolol in patients with mild-to-moderate essential hypertension. This was a multinational, prospective, randomized, 12-week double-blind parallel study with a follow-up of 4 to 10 days posttreatment to assess any adverse effects of abrupt therapy withdrawal. Two hundred two patients were randomized (2:1) to treatment with losartan or atenolol, 50 mg once daily. Patients were titrated after 6 weeks to 100 mg once daily if their blood pressure was uncontrolled (sitting diastolic blood pressure > or = 90 mm Hg). Trough sitting diastolic blood pressure reductions at weeks 6 and 12 were similar in both the losartan (-9.2 mm Hg and -8.3 mm Hg) and atenolol (-10.8 mm Hg and -10.1 mm Hg) groups and a similar percentage of patients responded to each drug. Both agents were generally well tolerated, although eight patients (two patients taking losartan, and six taking atenolol) were withdrawn because of clinical adverse events (P < or = .05). Reduction in pulse rate from baseline averaged 10 beats/min in the atenolol group with no pulse rate reduction observed in the losartan group (P < .01). No evidence of rebound hypertension was observed in either group. In conclusion, losartan was as efficacious as atenolol in blood pressure reduction, and was at least as well tolerated.

A randomized, placebo-controlled, double-blind, parallel study of various doses of losartan potassium compared with enalapril maleate in patients with essential hypertension

The efficacy and safety of various doses of losartan potassium, a specific and selective angiotensin II receptor antagonist, were compared with those of placebo and enalapril maleate 20 mg in patients with mild to moderate essential hypertension in a randomized, double-blind, parallel study. We randomly allocated 576 patients at the end of a 4-week placebo baseline period to 8 weeks of once-daily double-blind treatment with losartan potassium 10, 25, 50, 100, or 150 mg, enalapril maleate 20 mg, or placebo. After 8 weeks of treatment, mean reductions from baseline in supine systolic/diastolic pressure 24 hours after dosing (trough) for losartan potassium 10, 25, 50, 100, and 150 mg, enalapril maleate 20 mg, and placebo were 7.6/7.9, 7.8/6.8, 13.0/10.1, 8.9/9.9, 10.5/9.7, 14.7/11.2, and 3.8/5.6 mm Hg, respectively. Compared with mean changes in supine diastolic pressure in the placebo group, losartan potassium 50 to 150 mg and enalapril maleate 20 mg produced clinically important and statistically significant reductions (P < or = .01) in blood pressure. At 24 hours after dosing, the blood pressure changes obtained with losartan potassium 50 mg were essentially identical to those obtained with enalapril maleate 20 mg. While there was a dose-related effect with losartan potassium from 10 to 50 mg at peak (6 hours after dosing), doses of 10 and 25 mg were not consistently different from placebo 24 hours after dosing. To assess the once-daily effect of losartan potassium, trough-to-peak ratios of the mean changes in supine diastolic pressure after 8 weeks of treatment were calculated.(ABSTRACT TRUNCATED AT 250 WORDS)

Safety and tolerability of losartan potassium, an angiotensin II receptor antagonist, compared with hydrochlorothiazide, atenolol, felodipine ER, and angiotensin-converting enzyme inhibitors for the treatment of systemic hypertension

This report presents data on the safety and tolerability of losartan potassium (losartan), a selective antagonist of the angiotensin II AT-1 receptor, in approximately 2,900 hypertensive patients treated in double-blind clinical trials. In these studies, headache (14.1%), upper respiratory infection (6.5%), dizziness (14.1%), asthenia/fatigue (3.8%), and cough (3.1%) were the clinical adverse experiences most often reported in patients treated with losartan. These adverse experiences were also frequently reported in patients receiving placebo: 17.2%, 5.6%, 2.4%, 3.9%, and 2.6%, respectively. Dry cough as an adverse event was reported in 8.8% of patients treated with angiotensin-converting enzyme inhibitors, and in 3.1% and 2.6% of patients treated with losartan or placebo, respectively. Only dizziness was considered "drug-related" more often in losartan-treated (2.4%) than placebo-treated (1.3%) patients. In controlled clinical trials, losartan was better tolerated than other antihypertensive agents as determined by the incidence of patients reporting any drug-related adverse experiences. Rates of discontinuation due to clinical adverse experiences in patients who received losartan monotherapy or losartan+hydrochlorothiazide were 2.3% and 2.8%, respectively, compared with placebo (3.7%). No laboratory adverse experiences were unexpected or of clinical importance. First-dose hypotension rarely occurred with losartan or with losartan plus hydrochlorothiazide, and withdrawal effects such as rebound hypertension were not observed in clinical trials. There were no clinically important differences in the clinical or laboratory safety profiles in the demographic subgroups for age, gender, or race. In controlled clinical trials, losartan demonstrated an excellent tolerability profile.

Blood pressure effects of the angiotensin II receptor blocker, losartan

BACKGROUND

Losartan potassium, the first nonpeptide selective blocker of angiotensin II at the AT1 receptor, has been shown to exhibit clinical antihypertensive effects. The aim of the present study was to characterize the efficacy and duration of action of losartan by ambulatory blood pressure monitoring.

METHODS

The study was performed in nonblack hypertensive patients whose baseline untreated clinical diastolic blood pressures were 95 mm Hg or higher and whose average 24-hour ambulatory diastolic blood pressures were 85 mm Hg or higher. Patients were randomized, double-blind, into four treatment groups: placebo (n = 32) or losartan, 50 mg once daily (n = 29), 100 mg once daily (n = 30), or 50 mg twice daily (n = 31). Clinical and 24-hour ambulatory blood pressures were measured at baseline (off treatment for at least 4 weeks) and after 4 weeks of treatment.

RESULTS

By clinical sphygmomanometer measurements at the end of the 24-hour or 12-hour dosing intervals (trough), all three losartan dosages were significantly more effective than placebo at decreasing systolic and diastolic blood pressures. By average 24-hour ambulatory systolic/diastolic blood pressure measurements, the decreases produced were 0.0/0.2 mm Hg for placebo and 9.2/6.9, 9.9/6.4, and 13.2/8.5 mm Hg, respectively, for losartan, 50 mg once daily, 100 mg once daily, and 50 mg twice daily. All drug effects were different from placebo (P < .01). The effects of losartan, 50 mg twice daily, were not significantly different from those of losartan, 100 mg once daily, but, as expected, the effects were greater than those of losartan, 50 mg once daily (P < .05). Addition of hydrochlorothiazide, 12.5 mg/d, during an additional 2-week treatment period in patients whose clinical diastolic blood pressure remained at 85 mm Hg or higher while receiving monotherapy produced additional and clinically meaningful blood pressure decrements that were similar in all four treatment groups. There was no clinically important difference in the incidence of adverse events among the losartan-treated and placebo groups [corrected].

CONCLUSION

Ambulatory blood pressure monitoring, which virtually eliminated antihypertensive placebo responses, demonstrated clear 24-hour efficacy for losartan, 50 mg once daily, as well as for higher doses of 100 mg once daily and 50 mg twice daily. This AT1 receptor blocker had antihypertensive effects that appeared additive when combined with low-dose diuretic therapy. Losartan was generally well tolerated.

Home care: the next frontier of pediatric practice

An overview of pediatric home care issues reveals the breadth and scope of services available to permit pediatricians to provide care at home. This care option has undergone explosive growth and represents one of the fastest-growing health expenditures. Paradoxically, direct physician involvement in the home has been limited during this expansion because of the way home care has been designed and organized with inadequate reimbursement for physician participation, and lack of awareness by, and education of, physicians concerning their roles and responsibilities. The rationale for physician involvement in home care includes the need for determination and reevaluation of the medical necessity of home care services. Future changes in health care delivery and payment will encourage even more consideration of alternative care sites. Physician participation in program and protocol design will facilitate and encourage the appropriate use of the home as a care setting. For the pediatrician to know about home care requires the development of a curriculum to be implemented in academic centers for physicians-in-training and in professional associations for continuing medical education. This curriculum should enable physicians to become primary participants in home care and should lead to research opportunities to evaluate the benefits of home care.

Technology assessment and support of life-sustaining devices in home care. The home care physician perspective

Practicing physicians are increasingly using life-sustaining devices in the home setting for patients with long-term needs due to chronic conditions. At the same time, public policy focus on technology assessment has broadened from narrow medical concerns about safety and efficacy to considerations of effectiveness, quality of life, patient preferences, and cost/benefit. Around the world high-technology home care (HTHC) features a number of ways to evaluate outcomes. One category of HTHC that requires initial and on-going technology assessment is home mechanical ventilation (HMV). Home MV has developed in nations with a variety of healthcare finance systems: England (national health system), France (national health insurance), and the United States (regulated/market-economy). Approaches to technology assessment differ among nations according to organizational design and evolution. Physician behavior is a major determinant in the application of medical technologies. There are new physician roles that an influence what, when, and how technology is appropriately used in the home--initially and over time. For this reason, it is crucial to consider the role of the practicing physician in home care technology assessment.

Extended-release felodipine in patients with mild to moderate hypertension. Felodipine ER Dose-Response Study Group

Two hundred eighty-six patients with mild to moderate hypertension who had untreated diastolic blood pressure while seated of 95 to 115 mm Hg were randomized to receive placebo or once-daily doses of 2.5, 5, or 10 mg of the dihydropyridine calcium channel blocker felodipine extended release (ER). Blood pressure was measured 24 hours after dosing (at trough). Mean reductions in diastolic blood pressure after 8 weeks of double-blind treatment were significantly greater in each of the ER felodipine treatment groups (2.5, 5, and 10 mg ER felodipine: -7.8, -9.5, and -11.3 mm Hg, respectively) than in the placebo group (-5.3 mm Hg). The effect was dose dependent for both diastolic and systolic blood pressure. Moreover, much of the peak antihypertensive effect was still present at trough, confirming the 24-hour efficacy of the drug. Felodipine was well tolerated.

A new home care role for physicians. Mechanical ventilation outside the hospital

The increasing opportunities for oxygen-dependent and ventilator-assisted infants and children to receive long-term care in the home creates a new, vital role for physicians. Understanding and fulfilling this role requires determining which patients are suitable for home care; exploring the clinical, organizational, and management issues that home care introduces; and carefully strategizing discharge planning and followup medical care.

Combined nasal intermittent positive-pressure ventilation and rocking bed in chronic respiratory insufficiency. Nocturnal ventilatory support of a disabled person at home

The use of intermittent positive-pressure ventilation via nasal mask with a rocking bed provided the necessary ventilatory support for a person with quadriplegia living at home. This option was required to maintain an independent life-style of choice. The combination of techniques and the linkage of devices demonstrated an effective use of simple available technology for respiratory care at home and the adaptation of the respiratory prescription to the total needs of each person: medical, social, and financial. The further use of nasal mask ventilation in selected cases is encouraged by clinical research protocol.

The Ventilator-assisted Individuals Study

A paucity of reliable data exists concerning ventilator-assisted individuals (VAIs) for program planning. The Chicago Lung Association, with funding from Blue Cross/Blue Shield of Illinois, conducted a community action project to determine the magnitude of the issues in Illinois. The purposes of the VAI Study were to ascertain needs and resources, generate recommendations, and recruit community involvement. The survey identified 453 VAIs: 145 in hospitals, 105 in extended-care facilities, and 203 at home. A majority (62 percent) of hospitals provided services to VAIs; many more would with proper reimbursement incentives. Only 60 percent of hospitals serving VAIs had active discharge teams; discharge was accomplished by a variety of mechanisms and personnel. Monthly hospital charges averaged $22,190 with a range from $10,020 to $66,750 depending on the location of the patient. Most reimbursement was public; private funding was fragmented. Major discharge barriers were inadequate payment for community-based services, limited community resources, constrained consumer's finances, and lack of access to information. Recommendations for future community action included establishing a technology transfer system, home care case management, an integrated management system, a documentation center, and trials and demonstrations prior to program and policy development.

Home health care for children assisted by mechanical ventilation: the physician's perspective

To obtain the physician's perspective concerning their care of children at home who required prolonged life-supportive medical technology, we conducted a mailed survey of 126 physicians caring for 25 children assisted by ventilators who had been discharged from 11 Illinois hospitals to their homes. The 51 (41%) physicians who responded included those practicing in many specialties from a variety of hospital settings throughout Illinois. The majority of respondents had less than 4 years' experience with ventilator-assisted children and were in their earlier years of practice. Most physicians surveyed had participated in discharge planning and maintained an active role with their patients at home after discharge. The majority believed that changes in ventilatory settings could be accomplished in the home and found hospitalization unnecessary for adjustments of the home care prescription. The physicians thought that the roles and responsibilities should be defined for both the tertiary and community-based physician before hospital discharge, and that development and support of resources at the community level were essential for the success of home care.

Home care for life-supported persons: the French system of quality control, technology assessment, and cost containment

Home care for persons who require the prolonged use of life-supportive medical technology is a reality in several nations. France has had more than a quarter of a century of experience with providing home care for patients with chronic respiratory insufficiency and with a system to evaluate the patients' outcomes. The French approach features decentralized regional organizations which offer grassroots involvement by the beneficiaries who participate directly in the system. Since June 1981, a national organization has provided patients, professionals, and others concerned with direct access to national funding authorities and governmental officials and has created a data base for evaluation of the experience. This system permits direct input by current users of the services and creates informed opinion among members of the general public, governmental officials, and others involved (health care professionals and service providers). This is essential for the development of responsive public policy and for the determination of the relevancy of programs. In the United States, increasing demands are being made upon expensive hospital services by patients with diseases such as AIDS and other catastrophic, long-term care conditions. Cost-saving, community-oriented home care models serving complex medical-societal needs abroad are worthy of study to discern possible applications to health and social problems in our nation.

Life-sustaining technology and the elderly. Prolonged mechanical ventilation factors influencing the treatment decision

In 1985, the Office of Technology Assessment (OTA) was requested by the House and Senate Aging Committees (US Congress) to study implications of life-sustaining technology and the elderly. One concern was mechanical ventilation of patients with critical illness or terminal conditions. Information was requested concerning the factors that influence treatment decisions. This report brings together opinions from medical experts in focus groups about a variety of issues raised by the OTA. The answers to those questions represent the therapeutic dilemma facing the decision-maker dealing with the elderly patient and a condition of prognostic uncertainty. Although a variety of responses is presented, some uniform trends among experts are evident. Considering the current public policy debate concerning catastrophic and long-term care of the elderly, the need is apparent to establish a clearing-house of information providing documentation, education, and networking. A documentation center would serve as a resource for public policy and program planning to serve the population that requires prolonged mechanical ventilation.

Quality of care for life-supported children who require prolonged mechanical ventilation at home

Home care is now possible for ventilator-dependent children. It is crucial, however, to ensure that the children's conditions are medically stable and that their home care is carefully planned before they are discharged. The Ventilator-Dependent Discharge Program at Children's Memorial Hospital in Chicago uses a comprehensive, multidisciplinary approach to discharge planning. The program includes training for parent caregivers, organization of community resources, and arrangement for funding.

Home care for life-supported persons. Is a national approach the answer?

In France, home care services for ventilator-assisted persons are provided by 28 not-for-profit regional associations. National issues are resolved by an organization (ANTADIR) which is a federation of these associations. Each component of the system has defined, specific roles and responsibilities. This cost-saving approach has made life possible in the community for over 1,200 ventilator-assisted people. Realities in other nations may demand that a system be put in place to meet the needs of this patient population and those involved in serving them. Although differences exist between countries, there is value in scrutinizing what is already in place in France to help determine what can be developed in other nations.

Home care for life-supported persons in England. The Responaut Program

Home care for persons who depend upon life-supportive technology represents a complex situation for analysis and planning. As a case-example, the ventilator-dependent patient illustrates a formidable health care challenge for all sectors of society. England provides an established model for study. The "Responaut Program" (London) is a hospital-based home ventilator care system of services established in 1965 at St. Thomas' Hospital by Dr. G. Spencer. The elements of success of the English program presented herein are applicable to some of the current political, social, and economic realities of the United States. Operational home care concepts abroad are available for scrutiny as we in the United States plan pioneering efforts in this field.

Home care for life-supported persons: an approach to program development

Eighteen ventilator-dependent children were returned to their homes from Illinois. Each candidate was selected according to physician-designated guidelines for medical stability as well as predetermined social-environmental and reimbursement criteria. Each individualized occurrence was organized according to a comprehensive home care plan. Unanticipated improvement in medical condition and psychosocial development has resulted at home. The children and families have returned to a safe environment that best promotes the health of all involved. In addition, initial cost savings were at least 70%. These demonstrations have evolved into an organized regional approach to the ventilator-dependent child which utilizes available resources. The required continuum of health care and personal services includes intermediate intensive care, respiratory rehabilitation, transitional care, home care, and community-oriented alternatives to home. Problems of the ventilator-dependent child are those encountered by all children with handicaps and their families. The appropriate solutions will provide models for other complex health care and societal issues.

Sequelae of prolonged ventilatory support for pediatric surgical patients

The evolution of intensive prolonged respiratory support has been a major development in improving survival in the critically-ill child. That intensive respiratory support can be maintained for prolonged periods of time even in the home with survival of good babies is the subject of this report. In a 3-yr period, 2112 surgical patients were admitted to intensive care facilities with an over-all survival of 95%. Ventilatory support was required in 368 (17.4%) of these children, and survival in this group was 75.3%. Prolonged mechanical ventilation was necessary in 13 of the 368 children (3.5%) for a mean support time of 359 days (range 101 to 1095). Of these 13 children, 4 died while hospitalized (30.8%), and 3 died subsequently after being discharged (23.1%) for a total mortality of 53.8%. However, 6 children (46.2%) survive, 3 free of ventilatory support and 3 being weaned from their machine at home. The greatest cost in this expensive program was delivered to the survivors and psycho-social and developmental data confirm that these children are good babies with favorable long-term prognoses.