Painless dentistry. Fact or fiction?

The complex chronic health problems and functional limitations common in the elderly population place them at risk for complicated hospitalizations and discharge planning. The purpose of this study was to investigate the effectiveness of a discharge planning protocol in identifying elderly patients' home care needs. The sample in this quasiexperimental study consisted of 507 hospitalized patients age 65 years or older. The control group received the usual hospital discharge planning protocol. In the experimental group, nurse/social worker teams coordinated the discharge planning process, using an adapted form of the Discharge Planning Questionnaire (DPQ) to identify the home care needs of elderly patients. Thirty days after hospital discharge, both patient groups participated in a telephone survey to obtain information about health care problems they experienced during home recovery and their use of health care resources. The findings indicated that the majority of the elderly patients had functional dependencies, which required the help of another person to carry out daily household duties and provide assistance with basic needs, especially ambulation. These functionally dependent patients only received home care referrals about 50% of the time. These findings raise questions about current reimbursable services. Logistic regression analysis indicated that patients with increased functional dependency and patient problems during home recovery had a greater likelihood of rehospitalization and emergency department usage. This information about the home care of elderly patients after hospitalization supports the need for comprehensive functional assessment as part of discharge planning. This study also suggests that the nurse/social worker team can provide effective screening and discharge planning coordination of home care. Physician involvement and effective communication networks must be in place.     

The diffusion of new hospital technologies in the United States

Increases in the real resources used in hospital care have been an important cause behind rising hospital costs in the United States. Many of these resources have taken the form of new hospital technologies, and this paper begins by reviewing the trends in adoption of new hospital technologies over the years 1950-1974. The resource requirements, costs , and to the extent possible the patient benefits, of two of these technologies are then discussed in more detail: intensive care, a widespread facility with many variations, has been a major contributor to hospital costs; radiotherapy has been characterized by a succession of competing technologies. Regulatory efforts such as certificiate-of-need reviews would be more effective if they viewed hospitals as flexible collections of such technologies-with the costs and patient benefits of each to be weighed separately-rather than primarily in terms of numbers of beds. A national center to collect information on the separate technological functions of hospitals and make it available to interested groups would make a useful contribution to hospital regulation.     

Hospital-based advanced home-care, models from Eken?s, Finland

In 1995, advanced home treatment services were introduced at V?stra Nyland district hospital in Finland. For selected patients the new services constitute an alternative where hospitalisation would otherwise be necessary. Some of the hospital bed resources were moved to the patients' homes together with a trained team with immediate responsibility for the patients and providing 24-hour care, backed up by access to hospital resources in terms of specialised knowledge and sophisticated technology. Two years' experience of 500 patients so treated showed their diseases to have represented the complete spectrum of specialists fields. The most common diagnoses were oncological and infectious diseases. Although preliminary assessment suggests advanced home care to be a cheaper alternative than hospitalised care, the preeminent advantage from the patients' point of view was improved quality of life.     

Deconstructing the Columbia/HCA investigation

Every issue raised by the current investigation into the business practices of Columbia/HCA serves as a signpost for the progress and problems inherent in market-driven health care reform. Actions against Columbia/HCA by regulators reveal deeply rooted resistance to the profit-motivated reforms embodied in the company's philosophy: the public's reluctance to accept necessary reductions in excess hospital capacity; the legal and cultural obstacles to the overdue alignment of physician and hospital economic interests; and the myriad reimbursement and accounting problems involved in the vertical integration of health care delivery. The investigation also underscores the antiquation of the reimbursement mechanisms and control systems in place for financing the delivery of care to Medicare beneficiaries.     

Rural and urban differences in physician resource use for low-risk obstetrics

OBJECTIVE: To explore the hypothesis that rural obstetricians (OBs) and family physicians (FPs) utilized fewer resources during the care of the low-risk women who initially booked with them than did their urban counterparts of the same specialties. DATA SOURCES/STUDY DESIGN: A stratified random sample of Washington state rural and urban OBs and FPs was selected during 1989. A participation rate of 89 percent yielded 209 participating physicians. The prenatal and intrapartum medical records of a random sample of the low-risk patients who initiated care with the sampled providers during a one-year period were abstracted in detail and analyzed with the physician as the unit of analysis. Complete data for 1,683 patients were collected. Resource use elements (e.g., urine culture) were combined by standardizing them with average charge data so that aggregate resource use could be analyzed. Intraspecialty comparisons for resource use by category and overall were performed. FINDINGS/CONCLUSIONS: Results show that rural physicians use fewer overall resources in caring for nonreferred low-risk-booking obstetric patients than do their urban colleagues. Resource use unit expenditures showed the hypothesized pattern for both specialties for total, intrapartum, and prenatal care with the exception of FPs for prenatal care. Approximately 80 percent of the resource units used by each physician type were related to hospital care. No differences were shown in patterns of care for most clinically important aspects of care (e.g., cesarean delivery rates), and no evidence suggested that outcomes differed. The overall differences were due to specific components of care (e.g., fewer intrapartum hospital days and less epidural anesthesia).     

The impact of physician involvement in managed care on efficient use of hospital resources

OBJECTIVES: This research assesses the impact of managed care on the physician's efficient use of hospital resources. It examines three questions. (1) Does a higher percentage and volume of managed care patients in the physician's hospital practice lead to more efficient utilization? (2) Do physicians shift cost to nonmanaged care patients in an effort to compensate for lower reimbursement for managed care patients? (3) Are there threshold effects in the percentage and volume of managed care patients treated by physicians? METHODS: The study combines patient discharge data from the state of Arizona with physician and hospital data for a 2-year period. Random effects maximum likelihood (REML) regressions were performed for four different diagnosis classifications to examine the effect of the physician's managed care caseload on mean-adjusted charges and length of stay. RESULTS: The findings suggest that physicians with high percentages and volumes of managed care patients in their hospital practice are more efficient in using hospital resources. The findings also suggest that physicians may compensate for the lower reimbursement from managed care patients by increasing their resource use among non-health maintenance organization patients. CONCLUSIONS: Finally, there appears to be a threshold effect of managed care activity on the physician's hospital utilization in one of the conditions studied.     

Innovative service redesign and resource reallocation: responding to political realities, mental health reform and community mental health needs

General hospital mental health programs in large inner city communities face challenges in developing responsive services for populations facing high rates of serious mental illness, substance abuse, homelessness, and poverty. In addition provincial political pressures such as Mental Health Reform and hospital restructuring have caused general hospital mental health programs to reevaluate how services are delivered and resources are allocated. This paper describes how one inner city mental health service in a university teaching setting developed successful strategies to respond to these pressures. Strategies included: (a) merging two general hospital mental health services to pool resources; (b) allocating resources to innovative care delivery models consistent with provincial reforms and community needs; (c) fostering staff role changes, job transitions, and the development of new professional competencies to complement the innovative care delivery models; and (d) developing processes to evaluate the effects of these changes on client.     

The perinatal assessment of psychosocial risk

Although evaluation of psychosocial risk factors prior to perinatal hospital discharge has been advocated, the means for accomplishing such an evaluation are not well established. This article reviews several major psychosocial risk factors together with instruments that have been utilized to assess them during the perinatal period. Formal constructs reviewed include anxiety, depression, self-concept, general attitudes, life events, stress, adaptation, social support, marital and family functioning, and the home environment. Ongoing assessment of psychosocial status using formal instruments during routine perinatal care may provide a more complete picture of the psychosocial needs of the individual mother and her family, allowing for more appropriate, timely intervention and utilization of social and health care resources.     

Deinstitutionalization and schizophrenia in Finland: I. Discharged patients and their care

Finland has experienced one of the most rapid psychiatric deinstitutionalization processes in the world. Since 1980, the use of psychiatric beds has decreased about one-third. The effects of this deinstitutionalization were studied in the national Discharged Schizophrenia Patient Project. The study used three representative samples of patients with schizophrenia who were discharged from mental hospitals in 1982, 1986, and 1990, and followed them for 3 years. Patients with schizophrenia discharged at the beginning of the 1990s were older and more disturbed, and had been ill for a longer time than patients discharged at the beginning of the 1980s. The use of outpatient care increased and that of hospital care decreased, but because of the increased residential outpatient care, the total amount of residential care did not change during the study period. However, readmissions to the hospital increased. In patients with a long duration of illness, the increase in readmissions was exceptionally high; these patients also seemed to be losing their share of the residential outpatient services. On the whole, from the point of view of the psychiatric treatment system, deinstitutionalization seemed to have proceeded fairly successfully. The system proved able to redirect and use the available resources more effectively and to modify the structure of services according to the changing needs of patients discharged from hospitals. The well-developed social services have also supported this adaptation to the decreasing use of mental hospital beds.     

The state of the state mental hospital 1996

OBJECTIVES: This analytical review is intended to update the author's earlier writings on the position of the state mental hospital within the spectrum of services for long-term mental patients and to provide perspective for the next generation of service planners. METHODS: Findings and commentary are organized around four major questions. First, what is the prevailing view of state mental hospitals today, and how does it compare with the view that existed in the first half of this century? Second, what individuals tend to be served in state mental hospitals today? Third, what has been the fate of mentally ill persons who are no longer served in state mental hospitals? Fourth, what is an appropriate role for the state mental hospital in today's uncertain and rapidly changing systems of care? Source material consists of periodical articles suggested in MEDLINE searches, plus newspaper reports, recent books on mental health service systems, and a variety of writings found in the "fugitive" literature generally not indexed in traditional archives. RESULTS AND CONCLUSIONS: Individual state mental hospitals vary in the composition of their resident populations, the content of their services, and the overall quality of their care. Although they have been superseded by community-based service structures in some places, they continue in general, as the result of their multifunctionality, to occupy a critical place in systems of care. Renewed efforts to integrate them as full partners within those systems must be undertaken.     

Selective cytotoxicity of two rodent T cell lymphomas to rat yolk sac tumours involves a retroviral envelope protein expressed by the lymphoma

OBJECTIVE: To test a model for the study of inequalities in hospitalizations in the city of Ribeirao Preto (SP), understanding them to be due both to the social position of inpatients and also to health care policies in Brazil. MATERIAL AND METHOD: Using a hospital information system in existence for more than 25 years in the city of Ribeirao Preto-SP, 56.293 hospitalizations of municipal inhabitants occurring in some of the 12 general hospitals in 1993, were studied. Using the Brazilian occupancy classification for mortality, these inpatients were grouped on 6 occupational levels, as in the British classification: professional, intermediate, qualified non manual, qualified manual, partially qualified and unqualified. RESULTS AND CONCLUSIONS: Two-thirds of the inpatients had no place in the i.e. did not belong to the economically active population--and consisted of housewives, pensioners, children and students--and one third had some economic activity and thus belonged to the economically the active population. A close association was found between social strata and the classification of the hospital financing system into private, private group clinic and public health system patients. There were differences in hospital parameters as well as in morbidity patterns between these groups. The inequalities relating to average age, average age of hospital deaths, mean lengths of stay, hospital mortality, re-internment and frequency of diseases are discussed. This model allows the social position of the inpatient to be estimated using the hospital financing system, including also those patients with no economic activity, which covers the majority of the population. Social mechanisms created to compensate for inequalities in the welfare state do not cancel out the social differences.     

Issues in patient-focused care for the respiratory care practitioner

Patient-focused care is the redesign of patient care so that personnel and resources are organized around the patient instead of departments. The reasons are many but usually involve cost reductions and improvement in the customer's perception of quality. Goals for this process include grouping patients by diagnosis, decentralizing services, and cross-training staff. The respiratory care practitioner is well prepared to fit into the patient-focused care model. Recent surveys show the impact of hospital restructuring on respiratory care to be rather positive.     

Improving patient outcomes through CQI: vascular access planning

AIM: The aim of the study was to describe and analyse the hospital delivery system for patients recovering from myocardial infarction, applying the offering and value concepts from service management theory. BACKGROUND: In Nordic hospital care patients traditionally played a minor role. But changes have taken place. By means of information giving and systematic education from the staff many chronically ill patients are now taking a significant part in their treatment and care. METHOD: The method was a case study including 12 individual interviews. CONCLUSIONS: The principal conclusion is that the short and intense periods of hospital inpatient stay make it advantageous to consider the patient a member of the health care team taking an active part in the caring process.     

Legal liability and managed care.

In attempts to reduce the cost of mental health treatment, health insurers are turning to mechanisms for intensive oversight that fall under the rubric of managed care. These approaches have implications for the potential liability of clinicians and managed care entities. Clinicians may be confronted with legal duties to appeal adverse decisions, to disclose the impact of managed care on patients' treatment, and in some circumstances, to continue treatment after payment has been denied. Managed care entities are being held to duties to conduct review in a reasonable fashion, and may also have a duty to disclose the limitations managed care may place on patients' access to treatment, and to select appropriate providers of care. The law in this area is in an early stage of development and is likely to be refined. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Rationing: a transatlantic perspective

Despite the differing mechanisms of health care delivery and financing in the United Kingdom and the United States many of the issues faced by the two countries are similar, most notably the increasing financial pressures. In both countries there have been recent changes in the allocation of resources and the mechanisms of decision making. Different criteria for determining resource allocation have been tried in the two health care systems. These developments change long traditions of rationing decisions at the individual patient level in the US, and of centralised government decision making in the UK.     

Treatment of granulating wounds with silastic foam dressings

We have examined the usefulness of a Silastic foam dressing in the management of open granulating wounds in 55 outpatients. It is an acceptable and comfortable dressing, which allows earlier discharge from hospital. The method of making the dressing, and the daily care of the wound are described. Improved wound care is achieved by providing two dressings, so that when one is in place the other is being thoroughly cleaned. This technique has been shown to reduce bacterial contamination of the wounds and to improve wound healing (p less than 0.02).     

Rehabilitation psychology practice, ethics, and a changing health care environment.

Rapid changes in the health care environment have brought about ethical and professional challenges for rehabilitation and rehabilitation psychology. The response of rehabilitation psychologists to the threats and opportunities of these challenges will have an impact on the welfare of persons with disabilities and the future of the profession. Managed care organizations have focused their efforts on the management of acute illness. Ethical concerns are being raised about patient access to care, self-determination, confidentiality, provider accountability, and marketing in managed care systems. Rehabilitation psychologists' skills in program development and outcome evaluation place them in a key position to influence the changes in the health care environment. To be effectual, however, fundamental changes must be made in research psychology practice, education and training, research focus, and professional activities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Elevated serum level of thioredoxin in patients with hepatocellular carcinoma

BACKGROUND: Acute infant bronchiolitis is a frequent seasonal disease which peaks in December. It often requires hospital care in Paris and in its surroundings. The exceptional bronchiolitis epidemic of December 1991 brought about a temporary saturation of hospital bed space at the Assistance Publique-H?pitaux de Paris (AP-HP). Hereafter, in order to organize care more efficiently, an epidemiological observation network called ERBUS was set up. METHODS: Thanks to daily reports of emergency pediatric admissions through the Minitel network, it has been possible to get real time information on the course of the past five epidemics in each of the 11 AP-HP hospitals with pediatric emergency units. RESULTS: Globally the results point to a similar situation every year: approximately 60% boys, 35% babies under 6 months; the ratio of very young patients who are admitted to hospital is multiplied by 1.5 at the mid-point of and at the end of the epidemic compared with the beginning; 70% of the babies under 3 months are admitted to hospital. The ratio of patients who come and are admitted to hospital has been on the decrease every year since 1991: globally from 36.8% down to 28.6% in five years (from 75.1% down to 65.3% among babies under 3 months). The rhythm and intensity of the epidemic have risen sharply: in five years, the number of patients has increased by 119% and that of patients admitted to hospital by 69%, while the epidemic peaks are earlier and higher. CONCLUSION: These statistics have actually been used to allocate additional resources in AP-HP hospitals during the epidemics. To avoid the saturation of bed space in the future, ambulatory care of patients not admitted to hospital should be favored.     

Overview of the rectus abdominis myocutaneous flap in head and neck reconstruction

OBJECTIVES: To examine the current in-patient respite service in terms of the type of patient served, whether their care could be provided satisfactorily outwith hospital and whether hospital resources could be used more efficiently. DESIGN: Multi-disciplinary assessment of subjects and completion of recording form. SETTING: Inverclyde and Renfrew, Scotland (population 288,000). SUBJECTS: All elective respite admissions to Merchiston Hospital during the period 1.1.93 to 31.12.93. RESULTS: Twenty-six patients received respite care in the period studied. Seventy-three per cent had severe/profound handicap, and all had at least one additional problem to their learning disability. We found the majority (73%) would require extra nursing care in hospital. Current social work respite placements do not cater for this level of disability. Respite bed occupancy rates are lower during the week than at the weekend. CONCLUSIONS: Most patients receiving respite care in our hospital are a highly dependent group whose needs cannot be met by local social work services. There is a need for more accurate planning of respite provision to maximise the efficient use of beds.     

Ethics of allocating intensive care unit resources

ICU clinicians commonly make decisions that allocate resources. Because of the high cost of ICU care, these practitioners can expect to be involved in the growing dilemma of trying to meet increasing demand for healthcare services within financial constraints. In order to participate meaningfully in a societal discussion over fairness in allocating scare and expensive resources, ICU practitioners should have more than a superficial knowledge of the principles of distributive justice. Distributive justice refers to fairness in the distribution of limited resources and benefits. Fairness refers to giving equal treatment to all those who are the same with regard to certain morally significant characteristics and treating in a different manner those who are not the same. Although theoretical issues remain unresolved as to which characteristics should be most significant, the United States has a strong cultural value that regards individuals as inherently valuable and having equal social worth. From this, it is likely that only an egalitarian approach to allocation of lifesaving healthcare resources will be acceptable. Studies of how ICU resources have been allocated during times of scarcity indicates that, in general, when beds are scarce, the average severity of illness of those admitted to the ICU increases. However, in some hospitals, political and economic factors appear to play important roles in determining who has access to scarce ICU beds. Of great concern is documentation of a widespread pattern in which fewer hospital resources, including ICU resources, are provided to seriously ill patients of minority status or with low levels of insurance reimbursement. How society's values get translated into allocation decisions is another unresolved issue. One recent example of how this occurred is the Oregon Medicaid Plan. This plan extended Medicaid coverage to additional people in poverty, despite the same amount of state and federal funds. This was accomplished by not reimbursing what were regarded as marginally beneficial services on the basis of medical and community input. Portents of how society might be involved in the future of health care are illustrated by the argument that society should limit access to all therapies except palliative care solely on the basis of advanced age. Until an open consensus develops in U.S. society about how to allocate scarce healthcare resources, the delivery of ICU care will continue to be at risk of covert, de facto rationing based on ability to pay, race, or other nonmedical personal characteristics.