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Doing away with uncompensated care of the uninsured.

As more people lose their health insurance, an increasing volume of uncompensated care is absorbing billions of dollars of limited resources of the nation's hospitals, health systems, and other provider organizations. As yet, no provider organization has developed a comprehensive management approach to address this growing problem. Currently, the money spent on uncompensated care is viewed as a drain on institutional bottom lines rather than as a fund dedicated to improving the health of uninsured patients and prospective patients. If an accountable executive were made responsible for managing this problem by paying for all of this care on a case-by-case basis as third parties do, uncompensated care could be eliminated. Payment for each case would come from the institutional resources no longer required for uncompensated care. There is reason to hypothesize that with effective management, a significant amount of the resources currently absorbed by uncompensated care could be shifted from excessive inpatient care to more productive, innovative community initiatives. This paper outlines a six-point management program designed to increase the income and decrease the expense currently associated with uncompensated care, while improving quality, patient satisfaction, and outcomes. The program can be carried out by an individual provider organization, or as a collaborative program involving two or more organizations. Recommended are demonstration projects to test the feasibility and net cost or cost savings of such an approach, preferably starting in one-hospital towns.

Community Health Services↗

[Instruments for quality assurance in centers for medical rehabilitation].

In 1994, the German statutory pension insurance scheme started to develop a quality assurance programme in rehabilitation clinics, involving scientists giving support to the project. Established as a routine in 1998, the programme is based on the integrated use of different instruments relating to structural, procedural as well as outcome quality. Analysis and evaluation of data follow a concept of clinic comparisons, assessing particular groups of clinics of similar structure. The specific instruments used are described, their development is outlined and their application explained.

Chronic Disease↗

Nutritional status of pre-school children and women in selected villages in the Suvannakhet Province, Lao PDR--an intervention trial.

A project to promote the health and nutritional status of women and pre-school children was started from 1995 to 1997 in three villages in Suvannakhet Province, Lao PDR. One village served as control. In 1995, for the baseline survey, 456 females, and in 1997, for the final evaluation, 363 females from the four villages volunteered for further investigations. An attempt was made to involve all females in the reproductive age residing in the villages. At the same time also the nutritional status of 321 and about 540 randomly selected pre-school children respectively was also assessed through physical examination and anthropometric measurements. Intervention measures included introducing growth charts and taking regular anthropometric measurements of women in the reproductive age and of pre-school children. Training in nutritional aspects such as giving colostrum to new-borns, prepare proper weaning food and supplementary feeding, animal-raising and home gardening was also introduced and provided to health personnel, village leaders and in women clubs. Special attention was given to the control of acute infectious diseases. The conventional EPI program was enforced as well. Health education in matters of mother and child health care was also provided. The proportion of undernourished women was rather high at about 15%. For pre-school children, the proportion of wasting was around 5%, and of stunting 50% and above. Intervention did not improve the nutritional status either of the women or of the children. It was concluded that the time span of two years is too short for a decrease in the proportion of undernourishment to be observed. An improvement was achieved for some indicators of mother and child health care. This seems to indicate the population's willingness to follow suggestions to improve their health. Most probably, if attempts to improve the nutritional status were continued, an improvement in this aspect could also be observed, if the population can be encouraged to take actions and develop initiatives by themselves.

Adolescent↗

Abbreviated report of the WHO Western Pacific Region Workshop on National Plans of Action for Nutrition: key elements for success, constraints and future plans.

A workshop on National Plans of Action for Nutrition: Constraints, Key Elements for Success, and Future Plans was convened and organized by the WHO Regional Office for the Western Pacific in collaboration with the Institute for Medical Research Malaysia and co-sponsored with FAO and UNICEF from 25-29 October 1999. It was attended by representatives of 25 countries in the region and resource persons, representatives from WHO and other international agencies. The objectives of the workshop were to review the progress of countries in developing, implementing and monitoring national plans of action for nutrition (NPANs) in the Western Pacific Region and to identify constraints and key elements of success in these efforts. Most of the countries have NPANs, either approved and implemented or awaiting official endorsement. The Plan formulation is usually multisectotal, involving several government ministries, non-governmental organizations, and international agencies. Often official adoption or endorsement of the Plan comes from the head of state and cabinet or the minister of health, one to six years from the start of its formulation. The NPAN has stimulated support for the development and implementation of nutrition projects and activities, with comparatively greater involvement of and more support from government ministries, UN agencies and non-governmental agencies compared to local communities, bilateral and private sectors and research and academic institutions. Monitoring and evaluation are important components of NPANs. They are, however, not given high priority and often not built into the plan. The role of an intersectoral coordinating body is considered crucial to a country's nutrition program. Most countries have an intersectoral structure or coordinating body to ensure the proper implementation, monitoring and evaluation of their NPANs. The workshop identified the constraints and key elements of success in each of the four stages of the NPAN process: development, operationalization, implementation, and monitoring and evaluation. Constraints to the NPAN process relate to the political and socioeconomic environment, resource scarcity, control and management processes, and factors related to sustainability. The group's review of NPAN identified successful NPANs as those based on recent, adequate and good quality information on the nutritional situation of the country, and on the selection of strategies, priorities and interventions that are relevant to the country and backed up by adequate resources. Continued high level political commitment, a multisectoral approach, and adequate participation of local communities are other key elements for success. The participants agreed on future actions and support needed from various sources for the further development, implementation, monitoring and evaluation of their NPANs. The recommendations for future actions were categorized into actions pertaining to countries with working NPAN, actions for countries without working NPAN and actions relevant to all countries. There was also a set of suggested actions at the regional level, such as holding of regular regional NPAN evaluation meetings, inclusion of NPAN on the agenda of regional fora by the regional organizations, and strengthening of regional nutrition networks.

Guideline Adherence↗

[Para-membrane neurofilament structures of cerebral cortex synapses during ischemia and in the early postischemic period].

Using PTA-method, the structure of para-membrane neurofilament density of interneuronal synapses and PTA-positive contacts in neocortical molecular layer were studied in rats during ischemia and postischemic period. Marked reduction of definite contacts (by 25.4%) was recorded by min 90 of ischemia. However, reorganization of asymmetric contacts started during ischemia and continued in postischemic period. Changes in neurofilament density of synapses (primarily, dense projections of presynaptic grid) underlie the early reorganization of synapse architectonics.

Animals↗

["...that subsequently homeopathy will become nowhere as common as in veterinary medicine"--the history of veterinary homeopathy in Germany].

The subject of this article is the historical development of veterinary homoeopathy in Germany until 1945. Turning away from drastic healing methods around 1800, Samuel Hahnemann started to develop his homoeopathic system which since the 1820ies was also applied in the treatment of animals, especially by laymen. The number of homoeopathically-oriented veterinarians remained small. This is also true for veterinary-homoeopathic articles claiming to be scientific while there was a considerable number of popular articles to be found. The professors of the veterinary teaching institutions rejected homoeopathy. At the end of the 19th century hardly anything was heard about veterinary homoeopathy, at least among the professionals. Scientific success in human and veterinary medicine pushed Hahnemann's teachings and those of his successors into the background. In the 1920ies homoeopathy was revived and the position of the renowned surgeon August Bier played an important part in that. Members of the "Studiengemeinschaft für tierärztliche Homöopathie" (Study Group for Veterinary Homoeopathy) which was founded in 1936 started to investigate the effects of homoeopathic drugs systematically. The war put an end to this project. The present situation of veterinary homoeopathy in Germany can be described as follows: Neither have allopathy and homoeopathy been united, as it had been predicted, nor has classical medicine accepted homoeopathy as a scientific discipline. Hahnemann's demand to make his teachings a part of the veterinary studies remains unfulfilled until today.

Animals↗

How to select the right practice management system.

With health care "reforms" looming, physicians who plan to automate their practices--or upgrade an existing system--will want to start now. Otherwise, physicians who wait until the dust settles may find themselves facing two major projects: government mandated changes and computerization.

Health Care Reform↗

[Alcohol, lipid metabolism and coronary heart disease].

Numerous epidemiological studies have unequivocally proven a protection from the development of coronary heart disease by moderate long-lasting alcohol consumption. During the past 20 years studies in different ethnic groups starting from an American cohort and spanning to the recently performed analysis in the MONICA-project gave evidence for a decreased morbidity and mortality from coronary heart disease at 1 to 3 drinks a day when compared to total abstainers. A part of the protection is thought to be mediated through alcohol effects on plasma lipoprotein metabolism. Substantial increases in high-density lipoprotein cholesterol and its subfractions occur and are believed to be responsible for as much as half of the alcohol-mediated benefits. In addition, moderate decreases in low-density lipoprotein cholesterol and probably also in lipoprotein(a), established cardiovascular risk factors, may contribute accordingly. Furthermore, antioxidants like flavonoids and polyphenols found in red wines by protecting low density lipoproteins from oxidative modification may explain the "French paradox", the decreased incidence of coronary heart disease in France despite a high consumption of saturated fats. Also, alcoholic vasodilation, decreases in platelet aggregability, changes in prostacyclin/thromboxane ratios and increased fibrinolytic activities are to be considered as additional benefits caused by moderate alcohol consumption.

Adult↗

How to lower perinatal mortality? Perinatal care in Japan.

OBJECTIVE: To review the 30-year history of perinatal medical care in Japan, and the recently initiated regionalization system of perinatal centers, new technologies and treatments in obstetric and neonatal medicine developed in Japan. STATISTICAL DATA: Maternal and neonatal health statistics of Japan released by the Ministry of Health and Welfare, Japanese Society of Obstetrics and Gynecology, Japanese Pediatric Society, and Tokyo Women's Medical University. LABORATORY DATA: Serological assay and immunohistochemical staining employing TKH-2 antibody for the diagnosis of amniotic fluid embolism, and assaying granulocyte elastase as a specific inflammatory marker in mucous samples from the uterine cervical canal for the prediction of preterm labor or premature rupture of membranes. TREATMENTS: Urinary trypsin inhibitor (Urinastatin) for the prevention of preterm delivery, and a double-blind, placebo-controlled, randomized trial of antithrombin-III therapy in severe preeclampsia. CONCLUSION: Over the last 30 years, the statistical data of perinatal health care, such as maternal and perinatal mortality rates, have markedly improved in Japan. These results are supported by the advanced technologies and newly developed treatments in obstetric and neonatal medicine. The regionalization of perinatal centers, a national project in order to assure a systematic collaboration among primary, secondary, and tertiary centers, has just started in Japan. It also aims at systematization of the function of perinatal centers on the national level through the informative promoting action.

Female↗

[Rehabilitation management categories. A new approach to case mix in medical rehabilitation].

Creating typical treatment case groups in medical rehabilitation, in short: Rehabilitee Management Categories (RMKs, Rehabilitanden-Management-Kategorien), is a key issue for quality assurance within the frame of modern concepts of Total Quality Management (TQM), not least utilizing current organization and management concepts (Managed Care). So far, the problem of creating highly homogeneous case groups has remained unsolved on the basis of the present methodological framework. Critical prerequisites for any further scientific work on this problem are being established in the field of medical rehabilitation with the help of the Classification of Therapeutic Services (CTS) as well as development of instruments documenting therapy plans for typical rehabilitation case groups, process-relevant quality features and definitions of therapy goals as a basis for quality screening under the Pension Insurance quality assurance programme in medical rehabilitation. These developments have clearly contributed to expanding the theoretical foundations as well as the prerequisites for empirical grounding of Rehabilitee Management Categories in medical rehabilitation under the Pension Insurance scheme. A project for determination of rehabilitation case groups which is based on these developments, is due to start at the Humboldt University and Technical University, Berlin in the near future within a rehab promotion initiative of the German Pension Insurance system in cooperation with the Federal Ministry of Research and Technology. Conceptually, the determination of Rehabilitee Management Categories by far exceeds all previous approaches as (1) it will be generated by an iterative process of empirical service descriptions and theoretical consensus building among experts, (2) not only static parameters but also process-related details will be recorded, and (3) quality requirements will be defined for the rehabilitation process and outcome. As a result, rehabilitation-relevant case groups are to be created, which will include a definition of process- and outcome-oriented quality standards. Unlike previous case group concepts, the new approach encompasses quality management issues as an integral part of its development. Since this concept for determination of Rehabilitee Management Categories incorporates the definition of quality standards, i.e., guidelines, prerequisites will be created for integrating these standards into quality management concepts, as well as service management across the interfaces of the German service delivery system (Managed Care).

Diagnosis-Related Groups↗

A comparative study of Chinese cosmology cum-humorology with eight elements.

As agriculturist, man recognized Earth, Heat and Water as essential to plant life and projected them as cosmic elements. Pastoral man observed animals multiply due to reproduction. He realized that reproduction resulted from the union of opposites as male and female. Projecting reproduction, he conceived creation, which then resulted as the union of the cosmic pair of opposites. Heaven and Earth. The Chinese conceived of creation as starting with creative energy in its latent form, as Thai-Chi, meaning the absolute existence. Later, it assumed its dynamic form called Chhi. It was dual-natured with the opposites called Yang (light) and Yin (darkness). The reproductive power was projected as creative energy called Chhi and male and female opposites were projected as the universal pair of opposites as Yang and Yin. Creative energy produced the cosmic elements which in turn produced all creation. The cosmic elements of Chinese cosmology were Wood, Fire, Water, Earth and Metal. They also included the factors of humorology when the following elements had, as contents, items belonging to humorology, Wood-contained Air, Earth.....Moisture; Metal.......Dryness. By assigning dual-sense to three cosmic elements, Chinese humorology came into existence but has incorporated it in its cosmology. It is easy to equate Air = Vayu of Tridosha doctrine of India, Moisture = Kapha, Dryness = Pitta. Then with five elements of cosmology including three with dual-sense, as belonging to humorology, we have eight elements in all as cosmology-cum-humorology. It is obvious that Air, so important in the cosmologies of India and Greece, is no where explicit in Chinese cosmology.(ABSTRACT TRUNCATED AT 250 WORDS)

History, 20th Century↗

Computer-assisted LISS plate osteosynthesis of proximal tibia fractures: feasibility study and first clinical results.

Fluoroscopy is the most common tool for the intraoperative control of long-bone fracture reduction. Limitations of this technology include high radiation exposure for the patient and the surgical team, limited visual field, distorted images, and cumbersome verification of image updating. Fluoroscopy-based navigation systems partially address these limitations by allowing fluoroscopic images to be used for real-time surgical localization and instrument tracking. Existing fluoroscopy-based navigation systems are still limited as far as the virtual representation of true surgical reality is concerned. This article, for the first time, presents a reality-enhanced virtual fluoroscopy with radiation-free updates of in situ surgical fluoroscopic images to control metaphyseal fracture reduction. A virtual fluoroscopy is created using the projection properties of the fluoroscope; it allows the display of detailed three-dimensional (3D) geometric models of surgical tools and implants superimposed on the X-ray images. Starting from multiple registered fluoroscopy images, a virtual 3D cylinder model for each principal bone fragment is constructed. This spatial cylinder model not only supplies a 3D image of the fracture, but also allows effective fragment projection recovery from the fluoroscopic images and enables radiation-free updates of in situ surgical fluoroscopic images by non-linear interpolation and warping algorithms. Initial clinical experience was gained during four tibia fracture fixations that were treated by LISS (Less Invasive Stabilization System) osteosynthesis. In the cases operated on, after primary image acquisition, the image intensifier was replaced by the virtual reality system. In all cases, the procedure including fracture reduction and LISS osteosynthesis was performed entirely in virtual reality. A significant disadvantage was the unfamiliar operation of this prototype software and the need for an additional operator for the navigation system.

Adult↗

Structural genomics in Europe: slow start, strong finish?

Structural genomics in Europe is slowly coming off the ground. So far, European Commission funding is restricted to methods development projects, whereas structural genomics programs are funded from national sources. The research outlook is more toward techniques for high-throughput structure analysis than toward a systematic coverage of protein fold space. At present, there is little European coordination of the structural genomics effort.

Animals↗

Expanding screening for rare metabolic disease in the newborn: an analysis of costs, effect and ethical consequences for decision-making in Finland.

AIM: Currently, the only metabolic disorder that newborns are screened for in Finland is congenital hypothyroidism. A proposal to start a pilot study on screening for other rare metabolic diseases using tandem mass spectrometry prompted a health technology assessment project on the effect and costs of expanded newborn screening programme options. METHOD: A modelling study using data from current published studies, healthcare registers and expert opinion. RESULTS: The annual running cost of screening 56,000 newborns for the chosen five disorders (congenital adrenal hyperplasia, medium-chain acyl-CoA dehydrogenase deficiency [MCADD], long chain 3-hydroxyacyl-CoA dehydrogenase deficiency [LCHADD], phenylketonuria [PKU] and glutaric aciduria type 1 [GA 1]) was estimated to be euros 2.5 million or euros 45 per newborn when starting costs were included. The costs per quality-adjusted life year (QALY) gained are a maximum of euros 25,500. Prevention of severe handicap in one newborn would reduce the costs to a maximum of euros 18,000 per QALY gained. CONCLUSIONS: Expanding the Finnish neonatal screening programme would require a new organization. The cost-effectiveness, resources, ethics and equity need to be considered when deciding in favour of or against starting a new screening programme.

Cost-Benefit Analysis↗

UMIN--key information infrastructure for the Japanese medical community.

University hospital Medical Information Network (UMIN) was established in 1989 as a collaborative project of national university hospitals in Japan funded by the Ministry of Education, Science, Sports, and Culture, and it started its Internet-based service for medical professionals in 1995. Since then, many services including those for academic societies and research groups have been added. Currently, due to batch registration of the members of large academic societies, the number of registered users and Web accesses are rapidly increasing (about 87,000 registered users and 4,500,000 page views in November, 2000). More than one hundred homepages of academic societies and research groups (including forty- two member-only ones) and one thousand mailing lists are operated. More than one hundred thirty academic societies collect abstracts using the UMIN server. All the Internet-based clinical and epidemiological research projects in Japan are now under way using UMIN. The characteristics of UMIN are its large variety of services and large number of user accounts of medical professionals, which are beneficial to both users and information service providers. UMIN is now important for some medical specialties and will be so for further ones in the future. UMIN is, in fact, evolving into a collaborative project of the Japanese medical community and is considered as its key information infrastructure.

Hospitals, University↗

Preventing baby bottle tooth decay in American Indian and Alaska native communities: a model for planning.

Baby bottle tooth decay (BBTD) is a preventable dental disease which surveys have shown affects more than 50 percent of Native American children. An experimental program to prevent BBTD was implemented in 12 Native American communities. The project represented a cooperative effort by three Department of Health and Human Service agencies: Administration for Children, Youth, and Families, Head Start Bureau; Indian Health Service, Dental Program; and Centers for Disease Control, Dental Disease Prevention Activity. Intervention strategies included the training of parent volunteers, health professionals, and the tribal employees who counseled caretakers of young children and made group presentations. There was also a media campaign in each community that ran for a 3-year period. Numerous educational materials were developed including training manuals, counseling booklets, tippee cups, posters, and bumper stickers. The BBTD project's planners encouraged tailoring the education materials and strategies to fit each community. Preliminary results documented statistically significant decreases in the prevalence of BBTD at the pilot sites. This multidisciplinary, comprehensive intervention offers a model for organizing members of minority communities to prevent health problems.

Alaska↗

Education on health risks of smoking in Magadan, Russia.

PURPOSE: The purpose of this project was to educate young Russians on the health risks of smoking. METHOD: The American Cancer Society, Alaska Division, sponsored a project to deliver its teaching modules on the health risks of tobacco use to first- through third-graders in Magadan, Russia. Starting with a $4,400 (U.S.) contribution designated for this purpose, a young teacher, Irina Alishova, was contacted in Magadan in 1993. She translated the modules of the American Cancer Society oriented to the first- to the third-grade level. Irina also made contact with the Magadan school system, specifically the principal of Middle School Number 29, Alla Vakulyuk. Principal Vakulyuk encouraged the project and worked with the other schools in the Magadan school system. RESULTS: Throughout the 1993-94 school year, nearly all of the first- and second-grade classes and a portion of the third-grade classes received and participated in the 50-minute teaching module. An American representative for the American Cancer Society observed one of the classes and noted thoughtful and enthusiastic participation by the schoolchildren.

Adolescent↗

[Preliminary results of the pilot phase of neutron treatment in Essen (author's transl)].

In agreement with the EORTC Charged Particle Therapy Project Group, a pilot phase of neutron treatment was performed on 59 patients in 1978. All patients suffered from far-advanced tumours. Sixteen were treated with neutrons exclusively, while all the others had recurrences after chemotherapy, surgery, or combined surgery and photon- or electron therapy. 29 of them received reduced doses (10 to 14 Gy), thirty patients got a full neutron course of 16 Gy (Total Effective Dose). The observation time varied from 2 to 11 months. Serious side effects occurred in 11 cases. A complete tumour regression was achieved in 35 patients, and a partial regression in 17. Recurrences developed in 5 cases, no tumour regression was seen in 2 cases. These preliminary results encouraged us to start a randomized trial of head and neck tumours according to the protocols of the EORTC Charged Particle Therapy Project Group.

Humans↗