HMO market structure and performance: 1985-1995

This paper estimates the effect of market structure on hospital days and ambulatory visits in independent practice associations (IPAs) and group-model health maintenance organizations (HMOs) where market structure is measured by HMO penetration and the number of HMOs operating in a market. There was a steady decline in inpatient use in HMOs during the study period and a steady increase in use of ambulatory care. In multivariate analyses, inpatient use is significantly higher in IPAs, but there is no difference in ambulatory use. As HMO penetration increases and the number of HMOs increases, group-model HMOs have lower hospital use and greater ambulatory use. In contrast, use of both inpatient and ambulatory care decreases in IPAs but only at high levels of penetration and numbers of competitors.     

Gram-negative enteric bacteremia in children in the Negev (1989-1994)

During 1989-1994, there were 322 episodes of Gram-negative enteric bacteremia in 308 children. The incidence increased from 31/100,000 in children younger than 15 years of age during 1989-1991, to 50/100,000 during 1992-1994. The most common pathogens were Klebsiella, E. Coli, Salmonella and Enterobacter. 39% of episodes were nosocomial and a significant increase was recorded for each species during the last 3 years of the study. Klebsiella represented the most common pathogen causing nosocomial bacteremia, while E. coli and Salmonella were the main pathogens causing community-acquired bacteremia. In this study in southern Israel, the incidence of Gram-negative enteric bacteremia was significantly higher in Bedouin children, with the exception of bacteremia due to Salmonella, which occurred mainly in Jewish children.     

Traumatic spinal cord injuries in Thailand: an epidemiologic study in Siriraj Hospital, 1989-1994

AIM: The term zygomycosis comprise mycotic infections produced by mucorales and entomophtorales. Mucorales become pathogenic in some conditions, principally diabetes mellitus, immunosuppression, trauma or burn. METHODS: We describe two cases of leukaemic patients who developed disseminated zygomycosis by Absidia corymbifera during the aplastic phase by antineoplastic chemotherapy. RESULTS: In both cases, the first symptom was high fever unresponsive to broad spectrum antibiotics neither fluconazole. Initial sites of infection were sinonasal region in one case and bowel in the other one. The diagnosis was confirmed by culture of nasal swab and peritoneal fluid respectively. One patient was early diagnosed and he received prolonged amphotericin B therapy but no surgical debridement. The other one had a postmortem diagnosis at autopsy. None of them survived. Death was directly related to the fungal infection. CONCLUSIONS: Although this infection is infrequent, it must be suspected in high-risk patients because early diagnosis and quick combined therapy appear to improve the prognosis.     

Impact of the BBA on Medicare HMO payments for rural areas

The Balanced Budget Act (BBA) of 1997 radically changed the way Medicare risk plans are paid, replacing the adjusted average per capita cost (AAPCC) system with one in which county payment rates are set as the highest of (1) a local/national blended rate; (2) a national payment floor; or (3) a 2 percent minimum update from the prior year's rate. This DataWatch presents results of simulations of the likely impact of these changes throughout the BBA implementation period ending in 2003. The assessment considers urban/rural differences in payment levels, year-to-year rate volatility, the types of rates paid, and budget-neutrality issues.     

The pattern of acute poisonings with pesticides in Poland during the periods 1989-1990 and 1994-1995

Pesticide constitute a large group of commonly used chemicals with diverse chemical structure and toxicity. They are intended mostly to protect plants and plant products from the activity of various harmful organisms but they can also be used as biocides. Pesticide poisonings may be due to suicidal attempts or accidental ingestion associated with improper storage in unlabelled containers. Severe cases are treated at the regional poison units while others in the in-patient and out-patient clinics all over the country. The study made us draw the conclusion that poisonings with organophosphates and dipyridyl derivatives pose an essential toxicological problem. They are usually severe and require long hospitalisation. The highest morality rate was noted also for the poisonings with organophosphates and dipyridyl derivatives. Suicidal attempts constitute the most frequent cause of the poisonings. The results of the analysis imply a necessity to replace the most harmful organophosphate and dipyridyl pesticides with others of a lower toxicity class. It should be underlined that in order to avoid an accidental misuse, pesticides should be stored in the original, labelled containers.     

Paralytic poliomyelitis (1989-1994): report from a sentinel center

OBJECTIVE: To study the trends of paralytic poliomyelitis in pre Pulse Polio Immunization period. SETTING: Hospital based sentinel surveillance. METHODS: Analysis of 6704 line-listed poliomyelitis cases from January 1989 to December 1994 attending the Department of Physical Medicine and Rehabilitation. RESULTS: 85% of all cases reported in Delhi were from this center. A decline in alternate year peaks was observed from 1621 cases in 1990 to 1062 cases in 1994. There was an increase in proportion of cases with poliomyelitis in fully vaccinated children from 14% to 22.9%. Polio type I virus was the commonest isolated virus in all the years except 1993, when type II was isolated in 38.7% of cases. CONCLUSION: Despite improvement in immunization coverage, the study reveals that a large number of children (67.2%) who suffer from poliomyelitis are unvaccinated. This stresses need to intensify and sustain high level of immunization coverage with effective vaccine.     

Incidence of primary central nervous system cancers in South and East Netherlands in 1989-1994

About 2,000 patients with primary CNS cancers, as defined by the ICD-O, were registered in four adjacent cancer registries in South and East Netherlands in 1989-1994, covering a population of more than 5 million people. About 85% of the patients were registered through pathological laboratories, concentrated in four centers for neurosurgery. Patients with a clinical-radiological diagnosis only (about 50% in the age-group of 75 years and older) were mainly identified through medical records of hospitalized patients. World-standardized incidence rates of 6.5 and 4.4 per 100,000 person-years for males and females, respectively, were similar to those reported in other European cancer registries. Eighty-five percent of histologically verified primary CNS cancers were of glial origin, 6% were lymphomas and 4% embryonal tumors. Gliomas were mainly of astrocytic (about 85%) and oligodendroglial or mixed type (about 10%). Without additional review most astrocytic tumors could be classified into high-grade (70-75%) and low-grade astrocytomas (20-25%). Different grading systems were used for gliomas, but the dichotomy of astrocytomas according to differentiation grade seemed to correspond well with the definition of the WHO. Age-specific incidence rates for low-grade astrocytomas were remarkably constant. The incidence of high-grade astrocytomas increased sharply with age and declined after the age of 70, whereas the incidence of clinically diagnosed tumors continued to increase. Male/females-ratios were relatively high for these tumor types (1. 6-1.7). We conclude that the registration of primary CNS cancers in the Netherlands may be almost complete and valid for gliomas, embryonal tumors and lymphomas.     

HIV infection among male prisoners in South Australia, 1989 to 1994

The prevalence of human immunodeficiency virus (HIV) in male prisoners in South Australia from July 1989 to June 1994 was ascertained from a repeated cross-sectional study. We also compared the criminological and demographic characteristics and histories of drug use of 39 HIV-infected prisoners and a randomly selected sample of 86 uninfected prisoners admitted at the same time. The numbers of HIV-infected prisoners in prison in any month ranged from 4 to 12. Prevalence among the total prison population ranged from 0.4 per cent to 1.4 per cent, and among the subpopulation of injecting drug users from 1.25 per cent to 4.36 per cent. Many HIV-infected prisoners continued after their diagnosis to have lifestyles that resulted in imprisonment. Infected prisoners were significantly older, had spent longer in prison and were more likely to be users of heroin (OR = 13.1) and methadone (OR = 25.4) than controls. Infection with HIV among South Australian prisoners has been continuous since at least the mid-1980s. The recidivism among many of the infected prisoners contributes to the variation in prevalence but also raises concerns about their management. Greater effort to minimise the recidivism of the HIV-infected prisoners could reduce the prevalence of HIV in the prison population.     

Population-based analysis of treatment of pancreatic cancer and Whipple resection: Department of Defense hospitals, 1989-1994

BACKGROUND: The influence of hospital experience and referral patterns on the operative mortality rate of pancreaticoduodenectomy was studied in a worldwide hospital system. METHODS: We analyzed computerized data on pancreatic cancer patients from U.S. Department of Defense (DOD) hospitals from 1989 to 1994. RESULTS: Six hundred ninety-eight patients had pancreatic cancer, and 130 Whipple operations (105 for pancreatic and 25 for other cancers) were performed with an 8.5% 30-day operative mortality rate. Although most resections were done in teaching hospitals performing more than 1 Whipple procedure per year, their results were not superior to smaller, lower volume nonteaching hospitals. Patients transported for resection were younger than patients undergoing resection at their local DOD hospital but had similar outcomes. The operative mortality rate was higher after unusual resections and with increasing age; the tumor stage had no effect. Unresected patients undergoing combined radiation and chemotherapy had the longest survival times. Radiation therapy was associated with significantly longer survival times in patients without distant metastases, but chemotherapy was associated with a longer survival time when metastases were present. CONCLUSIONS: This mortality rate 8.5% for Whipple resections matches that from other large populations. Equivalent results were obtained in DOD teaching hospitals and smaller, community-type institutions. Because the DOD medical system minimizes financial and logistic barriers to transfer, the even distribution of DOD pancreatectomy mortality suggests that these barriers may favorably influence single institutional outcomes.     

The National Cancer Data Base report on Hodgkin''s disease for 1985-1989 and 1990-1994

OBJECTIVE: Terbutaline, a selective beta2-agonist, is a frequently used tocolytic known to affect maternal metabolism. The purpose of this study was to evaluate the effect of oral terbutaline on maternal glucose metabolism and energy expenditure. STUDY DESIGN: Six healthy pregnant women with normal glucose tolerance were evaluated between 30 and 34 weeks' gestation. Oral terbutaline was administered to determine the effects on hepatic glucose production with [6-6(2)H2] glucose tracer, insulin sensitivity (hyperinsulinemic-euglycemic clamp), and energy expenditure (indirect calorimetry). Terbutaline, insulin, and glucagon levels were also obtained. Subjects were randomly assigned to either oral terbutaline 5 mg every 6 hours for 24 hours or no medication. Repeat studies were conducted 1 week apart, each subject serving as her own control. RESULTS: In the basal state terbutaline was associated with a trend toward increased basal glucose levels (81.6 +/- 6.6 vs 93.7 +/- 12.0 mg/dl, p = 0.06) but no significant increase in hepatic glucose production (3.2 +/- 0.3 vs 3.6 +/- 0.4 mg/kg fat-free mass/min, p = 0.23). However, there was a significant increase in basal insulin concentration (17.6 +/- 9.2 vs 25.6 +/- 10.4 microU/ml, p = 0.02). There was a 28% decrease in insulin sensitivity as measured by the glucose infusion rate during the euglycemic clamp plus residual hepatic glucose turnover (5.78 +/- 1.91 vs 4.16 +/- 1.49 mg/kg fat-free mass/min, p = 0.005). Glucagon concentration was significantly decreased both in the basal state (163 +/- 26 vs 144 +/- 27 pg/ml, p = 0.0007) and during the clamp (144 +/- 27 vs 133 +/- 27 pg/ml, p = 0.003). Basal oxygen consumption increased 9% (270 +/- 49 vs 294 +/- 50 ml oxygen/min, p = 0.007) and caloric expenditure 14% (1.32 +/- 0.23 vs 1.50 +/- 0.31 kcal/min, p = 0.025) or 260 kcal/day with terbutaline. CONCLUSION: Decreased peripheral insulin sensitivity, and to a lesser degree increased endogenous glucose production, may represent the pathophysiology of abnormal glucose tolerance observed in many women treated with oral terbutaline. Common side effects such as tremors and tachycardia experienced by many women on a regimen of terbutaline are consistent with our finding of a significant increase in basal energy expenditure.     

When medical group and HMO part company: disenrollment decisions in Medicare HMOs

Medicare beneficiaries who enroll in "risk contract" Health Maintenance Organizations (HMOs) are covered for services only if they are provided or approved by the HMO. Thus, their enrollment decisions involve selecting a health care delivery system and may be influenced by whether the HMO has contracts with particular providers. Disenrollment decisions, in turn, may be influenced by breaks in contracts between the HMO and its medical groups. This study examines decisions made by Medicare HMO enrollees when their HMO terminated its relationship with a major medical group; the group then signed a contract with a competing HMO. Beneficiaries were forced to choose between remaining with their HMO and switching to another provider, and switching to the competing HMO where they could keep their provider. Beneficiaries demonstrated considerable loyalty to their providers; nearly 60% switched to the competing HMO. Previous research on health care coverage decisions has been based on models which did not address consumers' knowledge, options, and information sources. In this decision context, we found that knowledge and information sources were the most important determinants of beneficiary decisions.     

Revolution in Australian surgery, 1914-1994

Between 1914 and 1994, Australian surgery has undergone a period of unique growth and scientific revolution. It has been influenced by the effects of two world wars, two lesser engagements in Asia (Korea and Vietnam) and vast developments and social changes in the Australian Commonwealth. The pioneer surgeon, whose background was general practice, has evolved into today's member of a scientifically orientated professional body which is responsible for its own standards, training and management.     

Preperitoneal prosthesis implantation in surgical management of recurrent inguinal hernia. Retrospective evaluation of our results 1989-1994

Recurrent inguinal hernia represents a great problem in surgery given the frequency of this operation, with a recurrence rate of 0.5-8%. Re-recurrence after repair without implantation of a prosthesis occurs in 1-23% of cases. We analyzed our results of patients with recurrent inguinal hernia, operated according to the method of Stoppa. Between 1989 and July 1994 there were 58 operations upon 55 patients with an average age of 65 years, 79% of whom had unilateral and 21% bilateral hernias. 89% of all patients underwent surgery because of a recurrent inguinal hernia. A Marlex mesh was used in 79% of the case. All patients were followed up (mean 35 months, minimum 12 months). Early complications consisted in one hematoma (1.7%), which had to be drained, as well as one early recurrence (1.7%). No infections were observed. The overall recurrence rate was 12%. However, 60% of all recurrences occurred in the few first years after introduction of this technique at our clinic; with growing number of operations and experience with Stoppa's technique, we obtained a recurrence rate of 6-7% per year. In our opinion, supported by the results of other studies, Stoppa's technique is a successful method in the treatment of recurrent inguinal hernia.     

吴溪淳:关于进一步替代进口和加快淘汰落后产能问题

在7月31日召开的中国钢铁工业协会二届七次常务理事(扩大)会议上,中国钢铁工业协会顾问吴溪淳就如何加快替代进口产品开发和淘汰落后产能的问题作了讲话。     

Tracking small-firm coverage, 1989-1996

The presence of host inflammatory cells inside the spiral canal of all viable Taenia solium cysts obtained from naturally infected pigs is described. Cells can penetrate into the vicinity of suckers and rostellum, although most appear damaged, suggesting that conditions in the canal are deleterious for them. These observations extend the localization of host inflammatory infiltrate to this intricate microniche, which may offer new approaches for the treatment of cysticercosis, based on a scolex-targeted action. The presence of host cells in the canal of cysts also poses the problem of the resulting contamination with host materials in studies using cysts extracts. As an example, host DNA contamination is readily detectable in genomic DNA isolated from T. solium and Taenia taeniaeformis cysts, as demonstrated by polymerase chain reaction amplification and subsequent sequencing of a segment of the 18S ribosomal gene.     

Viral hepatitis in the US Air Force, 1980-1989

Viral hepatitis and its acute and chronic complications continue to pose significant threats to the readiness of military personnel. Knowledge about the specific viral agents and their routes of transmission are important in developing prevention strategies. A recent analysis of hepatitis in the US Navy for the period 1975-1984 is reviewed. In order to better characterize the risk of viral hepatitis among US Air Force personnel, a comprehensive review of inpatient and quarters data for hepatitis A, B and 'non-A, non-B' were reviewed from Air Force medical treatment facilities worldwide for the period 1980-1989. Following a discussion of the study methodology, preliminary data and hepatitis type-specific demographic risk variables are discussed. Preliminary results from a hepatitis serosurvey (A, B and C antibody with use of a supplemental validating assay) of the subset of the study cohort who are currently on active duty are briefly reviewed.     

Occupational burns in Washington State, 1989-1993

Occupational burns cause significant morbidity in the United States each year; however, there are few studies that report industries or workplaces where workers are at an increased risk of burn injuries. Washington State's Department of Labor and Industries (L and I) computerized workers' compensation database was used to describe work-related burns over 5 years. From 1989 to 1993, L and I accepted 27,323 claims for occupational burns, 71.4% of them thermal burns and 26.8% chemical burns. The most common sources of injury were cooking oils (14%) and hot water/steam (13%). Workers involved in food preparation or food handling accounted for the highest proportion of injured workers (30%). Industries involved in the smelting, sintering, or refining of ore had the highest rate for thermal burns, with a rate of 15.0 burn injuries per 100 full-time equivalent workers per year, followed by paper, pulp, or wood fiber manufacturing, with a rate of 5.8, then roof work, with a rate of 4.3. Industries involved in hazardous waste landfill clean-up had the highest rate for chemical burns, with a rate of 4.9, followed by portable cleaning and washing, with a rate of 3.5, and paper, pulp, and wood fiber manufacturing, with a rate of 2.6. Further study is needed to identify work practices that result in burn injuries in order to decrease the incidence of this preventable occupational injury.     

Worldwide trends in suicide mortality, 1955-1989

Expression of keratin K5 (and K14) in multilayered epithelia occurs predominantly in the basal layer of proliferating keratinocytes. When a keratinocyte becomes committed to terminal differentiation, it moves out of the basal layer towards the epithelial surface. As part of this program of terminal differentiation, the expression of K5 (and K14) is downregulated in suprabasal cells, and new pairs of differentiation-specific keratins are expressed. To define the cis-acting DNA sequences required for K5 cell-type- and differentiation-specific expression, chimeric gene fusions between portions of the bovine keratin K5 locus and the Escherichia coli lacZ gene were used to generate transgenic mice. In the genomic fragment consisting of 5.3 kb of 5' flanking sequences, 6.1 kb corresponding to the body of the gene and 4.5 kb of 3' flanking sequences, the subfragment extending from -5300 bp to +138 bp was the smaller region that directed lacZ expression to stratified epithelia in a manner analogous to the endogenous keratin K5. Proximal sequences from -1300 bp to +138 bp were inactive. We also determined the expression pattern of keratin K5 during mouse development using an antiserum specific for mouse keratin K5. Expression was first detected in ectodermal cells of 11.5 days postcoitum embryos, and from day 13.5 postcoitum onwards K5 was detected in the precursors of most epithelia and organs which express K5 at adult stages. This pattern was reproduced, with few differences, by the construct with sequences from -5300 bp to +138 bp fused to the lacZ gene. These findings identify sequences between -5.3 kb and -1.3 kb of the bovine K5 gene as being important for cell-type- and differentiation-specific gene expression both during mouse development and in the adult.     

Hospital employment trends in California, 1982-1994

During the 1980s California hospitals responded to selective contracting, growth in managed care, and the Medicare prospective payment system (PPS) by controlling their level of spending. This DataWatch examines whether these hospitals achieved these savings by changing the number and/or the mix of hospital employees. We examined employment trends because wages represent the largest component of hospital budgets and because the number and mix of personnel can be changed in the short run. Analysis of the California Health Facilities Cost Report data shows that employment increased steadily during 1982-1994. There is no evidence that hospitals responded to growing competition by altering the rate of growth in hospital personnel and only weak evidence that they altered the mix of personnel by hiring a greater proportion of nonclinical staff. We conclude that increased competition had only a minor effect on hospital employment decisions.