Biomedical subjects
Publications and source records attributed to J G Kaplan.
Managed care organizations are evaluating doctors, but how well are these organizations being evaluated themselves? This proposal for a report card identifies the necessary features of competent and sophisticated managed care enterprises. It is designed so that purchasers, providers, and patients may appreciate the more substantive issues associated with success in health care management.
Report cards on health plans and on physicians are becoming an increasingly important way of comparing health care quality from the perspective of consumers and the government. In the conclusion of a two-part article, the author suggests another side of the coin: physicians' own rating of health plans to guide their choices in health plan contracting.
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In the initial installment of a two-part article, the author suggests that report cards must evolve further before they can become truly useful measures of health plans or providers. They are a beginning, however, and some decisions can be made based on the claims data and process-based measures available today.
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A 24-year-old woman with a history of hereditary spherocytosis and oral contraceptive use presented with a spontaneous, isolated loss of great toe extension. She had clinical and electrodiagnostic evidence of a localized lesion affecting the nerve supply to the extensor hallucis longus (EHL). Full clinical recovery was apparent within 6 months with nonoperative therapy. Isolated EHL weakness may occur as a rare neurologic complication of procedures such as high tibial osteotomies, but, to our knowledge, this has not been reported in the absence of trauma or surgery. While the coexistence of hereditary spherocytosis and a peripheral neuropathy may have been purely coincidental, it is plausible that the isolated lesion in this patient was due to ischemic changes from underlying rheologic conditions, possibly in association with a variation in the neural or nutrient vessel supply to the EHL.
A major obstacle in the quest for health care quality improvement is physician acceptance of clinical practice guidelines. Typically objective and autonomous, physicians do not readily "buy-in" to standards that challenge their judgement. In this article, the authors identify the necessary conditions for physician acceptance if not active participation in the development and promulgation of these living documents.
The gatekeeper is the ambassador of managed care, a cost-effective, quality advocate. The gatekeeper is one of the most effective management tools available to managed care organizations and patients today. However, there is little evidence proving this positive cost-benefit. Furthermore, managers lack the understanding and information about how gatekeepers operate and why certain decisions are made. The authors discuss what they believe is the real promise of managed care.
Defining business objectives is never easy. However, with market reform exceeding any realizable promise of governmental reform, the rapid evolution of health care may seem daunting. The Table presented by the author helps conceptualize where we are and where things seem to be moving. It incorporates issues of interest to the health care business manager, developer, provider, and informed consumer.
The only logical way to avoid unnecessary future costs and improve quality is to analyze the past, providing input for the present. The informational management strategies are ready. There is continuous quality improvement, profiling with case-mix adjustment, and other techniques that will help us manage care and caring. But these strategies all rely on the customer being empowered to make truly informed decisions (the ethical principle of autonomy) and for us to advocate for patients (beneficence). Translating relevant data into information is the concentration of medical informatics. Virtually everyone in medical management can attest to the fact that, competitive forces notwithstanding, it is time for us to recognize not only that we are in the information business, but also that this information belongs to a larger community. Clearly, it is time to collaborate!
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Chlorpyrifos (Dursban) is an organophosphate insecticide with extensive domestic and agricultural applications. It is regarded as safe for these purposes; one report of neurotoxicity is attributed to massive ingestion in a suicide attempt. We report eight people who developed peripheral neuropathy after exposure to exterminator-applied commercial Dursban; five also experienced memory loss and cognitive slowing. Evaluation failed to reveal other causes of neurologic dysfunction; symptoms recurred in one patient following accidental reexposure. We conclude that environmental contact with chlorpyrifos can cause sensory neuropathy and CNS dysfunction and that this agent should be used with caution.
We describe a patient with burning pain in both feet associated with local autonomic disturbances following bilateral traumatic sciatic mononeuropathies. The diagnosis of a sympathetically maintained pain was confirmed through a prompt response to sympathetic blockade. Although a mild alcohol-nutritional neuropathy was found, the clinical findings strongly suggested a diagnosis of bilateral causalgia. Clinical evaluation and quantitative sensory testing were performed prior to and after successive unilateral lumbar sympathetic nerve blocks. After unilateral blockade, bilateral improvement was recorded in measures of pain, sudomotor function, and foot temperature. Other measures of autonomic function showed variable responses to sympathetic blockade. Quantitative sensory testing revealed a dramatic alteration in the contralateral limb's thermal sense following unilateral block. This case underscores the potential for bilateral causalgia and provides additional evidence for a central mechanism operating in this disorder. The relationship between bilateral causalgia and the "burning feet syndrome" in alcoholic neuropathy is discussed.
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Our experience and review of the literature reveal that Sjogren's syndrome (SS) is an important, poorly recognized cause of peripheral neuropathy. Several forms of peripheral nerve dysfunction occur in SS including trigeminal sensory neuropathy, mononeuropathy multiplex, distal sensory neuropathy, distal sensorimotor peripheral neuropathy and a pure sensory neuronopathy syndrome. Rarely, chronic relapsing inflammatory polyneuropathy and multiple cranial neuropathies appear. Clinical evidence of glandular involvement is often minimal or absent when patients with SS develop peripheral neuropathy; and the diagnosis of the underlying condition is elusive. We review clinical and laboratory features of this disorder and suggest appropriate evaluation of patients with neuropathy and suspected SS.
Leptomeningeal metastasis (LM) of systemic malignancy often give rise to multifocal involvement of the central (CNS) and peripheral nervous system. Signs of CNS dysfunction such as seizures and confusion often overshadow radicular deficits. We report clinical and laboratory evaluations in 10 patients with LM who presented with isolated polyradiculopathy. Our data suggest that electromyography and late response studies are sensitive indicators of radicular dysfunction in patients with LM. These studies are helpful in the early documentation of root involvement when computerized tomography, MRI and myelography are normal.
We reviewed 63 cases of cytologically confirmed leptomeningeal metastases (LM). 31 (49%) had solid tumors 17 (27%) had leukemia and 15 (24%) had lymphoma. The most common presenting symptom was pain (76%) with radicular discomfort (58%), headache (32%), neck or back pain (17%). The predominant neurological signs were mental status abnormalities (49%), weakness (47%), seizures (14%). The mode of presentation varied with tumor type. Patients with leukemia (18%) and lymphoma (13%) tended to present frequently with LM without systemic involvement, or during periods of apparent remission (leukemia 35%, lymphoma 27%), while patients with solid tumors had established systemic metastases (90%) at time of presentation. Laboratory studies did not vary among the groups. 71% had positive cytology on the first lumbar puncture (LP) and only 8% required more than 2 LPs. The cell count was a poor predictor of positive cytology as 29% of LP's with positive cytology and 36% of all LP's had less than 4 cells/mm. We conclude that 1) LM presents with pain and seizures more frequently than has been previously recognized; 2) LM is frequently the mode of presentation in patients with leukemia and lymphoma and; 3) cytology is positive frequently in CSF specimens with normal cell counts and chemistries.