Home care past, present, and future: opportunities and challenges in a managed care environment

This article describes the history of Medicare-based home care and the changing requirements of the home care industry as the reimbursement models continue to evolve. Medicare-based home care was once seen as an ancillary service of the hospitals. Now, with the advent of managed care, home care provides new options and opportunities and is facing new challenges at both the local and the national levels. Current proposals in Washington, such as bundling, co-pays, and a Prospective Payment System, will have farreaching effects on the industry. This article discusses the various reimbursement models, including Medicaid, Medicare HMOs, managed care, and capitation, and identifies key areas and opportunities for home care in the future.     

Evolution of transitional care settings: past, present, future

The use of intravascular stents as an adjunct for percutaneous transluminal revascularization is limited by two principal factors, acute thrombosis and neointimal proliferation, resulting in restenosis. To overcome these limitations, we have investigated the potential of microporous bioresorbable polymer stents formed from poly(L-lactic acid) (PLLA)/poly(epsilon-caprolactone) (PCL) blends to function both to provide mechanical support and as reservoirs for local delivery of therapeutic molecules and particles to the vessel wall. Tubular PLLA/PCL stents were fabricated by the flotation-precipitation method, and helical stents were produced by a casting/winding technique. Hybrid structures in which a tubular sheath is deposited on a helical skeleton were also generated. Using a two-stage solvent swelling technique, polyethylene oxide has been incorporated into these stents to improve hydrophilicity and water uptake, and to facilitate the ability of these devices to function as drug carriers. Stents modified in this manner retain axial and radial mechanical strength sufficient to stabilize the vessel wall against elastic recoil caused by vasoconstrictive and mechanical forces. Because of the potential of direct gene transfer into the vessel wall to ameliorate thrombosis and neointimal proliferation, we have investigated the capacity of these polymer stents to function in the delivery of recombinant adenovirus vectors to the vessel wall. In vitro, virus stock was observed to readily absorb into, and elute from these devices in an infectious form, with suitable kinetics. Successful gene transfer and expression has been demonstrated following implantation of polymer stents impregnated with a recombinant adenovirus carrying a nuclear-localizing betaGal reporter gene into rabbit carotid arteries. These studies suggest that surface-modified polymer stents may ultimately be useful adjunctive devices for both mechanical support and gene transfer during percutaneous transluminal revascularization.     

Asbestos: past, present and future

Owing to its particular properties asbestos has been widely used for the production of insulating material, for fire proofing, and for strengthening to other materials such as cements and plastics, and thus the story of this mineral was one of progressive commercial success until the middle of this century. However, serious health hazards were realized early: around the turn of the century a progressive form of diffuse fibrosis (asbestosis) in asbestos workers was observed and in 1950 an excess risk of lung cancer, while in 1960 the causal relationship between asbestos and mesothelioma were confirmed. In view of the known potential risks of asbestos and its widespread use in the building industry, more recently asbestos has caused considerable public concern and anxiety. Based on numerous experimental and epidemiological observations, present knowledge of the pathogenic effects of asbestos is sufficient for a number of broad conclusions to be drawn. (1) The amphibole types of asbestos are too dangerous for use as industrial material, and should be banned. (2) Chrysotile can probably be used safely if there is strict control of the workers' dust exposure. (3) It is very unlikely that the general public is at any measurable risk from asbestos in buildings. Exceptions are people working regularly on maintenance tasks involving removing or cutting of asbestos in buildings; such people are properly classified as asbestos workers and should be protected accordingly.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hydroxychloroquine: past, present, future

OBJECTIVE: To examine the trends in motor vehicle exhaust gas suicides since 1970 and to investigate the impact of catalytic converters. DESIGN: Australia-wide database analyses and a retrospective stratified series of 100 Victorian cases. DATA SOURCES: Australian Bureau of Statistics, 1970-1995; Australian Institute of Health and Welfare, National Injury Surveillance Unit, 1991/92-1995/96; Victorian Coroner's files, 1994-1996. RESULTS: There were 509 motor vehicle exhaust gas suicides in Australia in 1995, representing 22% of total suicides. Since the 1986 requirements for reduced carbon monoxide emissions from new vehicles (and thus the use of catalytic converters), the absolute numbers and rates of such suicides have increased, and they have come to represent a larger percentage of total suicides. Of 75 Victorian victims' vehicles traced, 36% were manufactured during or after 1986, showing that exhaust gas suicides have occurred in vehicles with catalytic converters. Blood carboxyhaemoglobin levels did not differ between victims using vehicles with or without catalytic converters. Between 1976 and 1991 exhaust gas suicides increased at a faster rate than motor vehicle registrations. Australian hospital admissions for exhaust gas suicide attempts have increased substantially since 1991-1992. CONCLUSION: Catalytic converters and the associated lower CO emission limits of 9.3 g/km had not, by 1995, resulted in a reduction in numbers, rates or percentages of exhaust gas suicides in Australia.     

A compendium of managed care: past, present, and hints of the future--Part II

This study was designed as a prospective clinical caries prevalence study starting with children at 1.5 years of age. The subjects were 374 children who were born between 1989 and 1991. All subjects visited a public health center in Kunitachi-city, Tokyo, at 1.5 years, 2 years, and 3 years of age. All the children and parents have followed preventive dental care guidance. Dental caries were always examined by one of the authors. The caries prevalences at 1.5 years, 2 years, and 3 years of age were 6.1%, 14.7%, and 31.8%, respectively. The mean dft at 3 years of age in children who developed caries before 2 years of age was significantly greater than that in children caries free at 2 years of age. The findings from the current study showed that children who develop caries before 2 years of age are at greater risk for dental caries.     

Pubovaginal slings: past, present and future

Renewed interest in the pubovaginal sling procedure for stress urinary incontinence has occurred in response to recent reports of poor durability and inconsistent efficacy associated with simple cystourethropexy. Many of the failures are felt to represent patients with an unrecognized component of intrinsic sphincteric deficiency. Historically slings have a favourable cure rate, but have been perceived as having unacceptably high rates of prolonged urinary retention and secondary detrusor instability. This article reviews the preoperative evaluation and indications for pubovaginal slings, describes the evolution of the current techniques, and discusses choice of sling material, surgical approach, results and complications. It is hoped that this review will stimulate interest in this versatile but technically challenging procedure.     

Cancer prevention: past, present, future

There are many examples of different types of cancers that have been prevented by appropriate measures in the past. Most of them were related to occupational, iatrogenic or accidental factors, often as the outcome of heavy exposure of humans to specific carcinogenic agents. Cancer is a disease of DNA, and is generally associated with multiple genetic alterations, these being produced in the typical case by exposure to various carcinogens, each of which exists at minute concentrations. Thus, the impact of carcinogenic factors, xenobiotics and autobiotics, is due to their actions in concert. However, a single mutation yielding genomic instability exerts a disproportionately large influence by resulting in a large number of secondary mutational events. Epigenetic changes can also not be disregarded especially from the view point of prevention of neoplasia. The occurrence of multiple primary cancers among survivors of initial primaries, and the presence of hereditary groups with a high risk of cancer development provide a strong stimulus for establishment of effective approach for cancer prevention, which should be, in principle, multi-faceted. Therefore, a holistic approach is essential with improvement in life style including choosing a balanced diet and avoidance of cigarette smoking and other sources of carcinogens, as integral elements.     

Defining epileptogenic foci: past, present, future

There is a direct relationship between the geometry (location, area, and orientation) of cortex-generating epileptiform discharges and resultant spike or seizure voltage fields at the scalp. Epileptogenic foci have been localized traditionally with EEG by identifying the negative field maximum (e.g., a phase reversal between adjacent bipolar channels). However, it is the shape of the entire voltage field over the head, including both negative and positive maxima, which provides information necessary to characterize the focus properly. Source location and orientation can be inferred from spike or seizure voltage topography, however, three-dimensional visualization can be obtained from mathematical source models, such as an equivalent dipole. Recent investigations have shown that dipole models can identify the location of epileptogenic foci with sub-lobar precision. Accuracy is enhanced by using additional electrodes, particularly on the lower half of the head, and by measuring their location. Realistic head models obtained from three-dimensional reconstructions of MR images can overcome errors introduced by simple spherical models of the cranium. Co-registering EEG voltage topography and source models with a patient's own cerebral anatomy will make EEG an unparalleled functional imaging technique for defining epileptogenic foci.     

Medicare managed care: budgetary and tax implications

The Medicare program is in precarious financial condition because of underfunding and structural defects in the way it pays providers of medical care. Given the prevailing anti-tax sentiment, the more promising route for attaining Medicare fiscal solvency would seem to lie on the expenditure side of the equation. This paper proposes a managed care model for reform that relies on an efficient and already-tested form of competitive bidding for the provision of medical care. It concludes with a discussion of short-run, intermediate-run, and long-run budgetary and tax implications for the Medicare program.     

Pertussis vaccines: past, present and future in Australia

In August 1997, a workshop was convened by the National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases to consider current issues in the use of pertussis vaccines and implications for the Australian immunisation schedule. Topics covered included the history, efficacy and reactogenicity of whole-cell and acellular vaccines and vaccine schedules. Acellular pertussis vaccine is preferred by the National Health and Medical Research Council for the primary course as well as the 18 month and 4-5 year old childhood doses. At the time of the workshop, a 3-component acellular vaccine (DTPa) had been approved (licensed) in Australia for all doses in the childhood schedule. It was the first vaccine subject to a cost-effectiveness evaluation under the new vaccine funding arrangements. Issues considered in the evaluation of the cost-effectiveness of the vaccine were discussed. These included comparative efficacy, adverse events and compliance, and the question of community as well as individual benefit from the use of the vaccine.     

Laboratory diagnosis of tuberculosis: past, present, and future

Resurgence of tuberculosis justifies extraordinary efforts to expedite TB diagnosis and susceptibility testing. This demands that laboratory support expand to a "second generation" of methods and procedures, including rapid availability of fluorochrome smears of concentrated specimens, faster techniques for detection (e.g., the BACTEC radiometric broth system and microcolony detection), quicker identification (e.g., high-pressure liquid chromatography, nonisotopic genetic probes), more rapid susceptibility testing methods (e.g., BACTEC), and reporting of these results as critical values. Guidelines have been established for turnaround time for results of smears, TB organism identification, and susceptibility testing to usual first-line drugs. A "third generation" of laboratory techniques soon will make testing not only more effective but also more efficient. These methods include direct testing of respiratory specimens through nonisotopic genetic probes as well as nucleic acid amplification techniques utilizing polymerase chain reaction (PCR) and other molecular procedures. These new procedures and protocols place heavy demands on laboratory test volume, technologist time and costs. For the healthcare system or clinical laboratory without the resources to deal with these new demands, referral of TB specimens represents a reasonable alternative, as long as transport is adequate to meet current CDC and other guidelines for turnaround time.     

Accuracy of anthropometric measurements: past, present, and future

Experience, based on anthropometric examination of over 1000 children with facial syndromes and more than 2400 healthy subjects of both sexes and various ages, has led me to diverge in some points from the more usual views found in the physical anthropologic literature. The purpose of this paper is to discuss the major controversial topics associated with anthropometric measurement. These include the problems associated with formation of a representative population sample, the relative validity of longitudinal and cross-sectional studies, the interpretation of intraobserver and interobserver testings, and the questionable judgments of mensurative skill in clinical practice. The factors influencing the accuracy of anthropometric measurements, definitions of both the consistent and less reliable measurements, and the duration of validity of anthropometric normative data are also discussed.     

Non-insulin dependent diabetes--the past, present and future

The aim of this investigation was to establish a new model for phototoxicity which is more advanced than the widely used cultures of yeasts, bacteria or cells of various origin, and at the same time to avoid animal testing. We studied the extraembryonal vasculature of the incubated hen's egg. This model was originally introduced by toxicologists as an alternative to the rabbit's eye irritation test (Draize test). In the photo hen's egg test, substances are applied to the embryo's yolk-sac blood vessel system at a non-toxic concentration and are irradiated with 5 J/cm2 ultraviolet A (UVA) (320-400 nm). Promethazine, haematoporphyrin, ciprofloxacin and 8-methoxypsoralen were tested in this system. Death of the embryo, membrane discoloration and haemorrhage are parameters for phototoxic damage, which were recorded during an observation period of 24 h. These well-known phototoxic substances induced pronounced damage of the yolk-sac membrane and blood vessels which was not found in the controls (test substance alone, UVA alone or untreated) using a 2 x 2 factorial test design. The photo hen's egg test serves as a valid screening model for substances supposed to be photosensitizers owing to a phototoxic mechanism.