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PubMed1988

Integrating and evaluating online bibliographic searching with clinical experiences of third year medical students.

In this paper, we describe the Clinical Health Information Retrieval Project (CHIRP), a trial program which provided online access to MEDLINE for third year students on medicine and pediatrics clerkships at The University of North Carolina School of Medicine. We present the project evaluation plan, report data from student questionnaires and interviews with the chief residents, clerkship directors, and clerkship coordinators, identify problems encountered, and address considerations for extension of the project.

Attitude of Health Personnel↗
PubMed1987

Postoperative complications necessitating right lower lobectomy in a heart-lung transplant recipient with previous sternotomy.

Heart-lung transplantation for treatment of end-stage cardiopulmonary disease continues to be plagued by many problems. Three primary ones are the technical difficulties that can be encountered, particularly in those patients who have undergone previous cardiac operations, the additional restriction on donor availability imposed by the lack of satisfactory preservation techniques, and the need for lung size compatibility. Two of these difficulties and others surfaced postoperatively in a heart-lung transplant recipient who presented a series of unique operative and therapeutic challenges. A 42-year-old woman with chronic pulmonary hypertension and previous atrial septal defect repair underwent a heart-lung transplantation in August 1985. The operative procedure was expectedly complicated by bleeding from extensive mediastinal adhesions from the previous sternotomy and bronchial collateralization. Excessive chest tube drainage postoperatively necessitated reoperation to control bleeding from a right bronchial artery tributary. Phrenic nerve paresis, hepatomegaly, and marked abdominal distention caused persistent atelectasis and eventual right lower lobe collapse. Arteriovenous shunting and low oxygen saturation necessitated right lower lobectomy 15 days after transplantation, believed to be the first use of this procedure in a heart-lung graft recipient. Although oxygenation improved dramatically, continued ventilatory support led to tracheostomy. An intensive, psychologically oriented physical therapy program was initiated to access and retrain intercostal and accessory muscles. The tracheostomy cannula was removed after 43 days and gradual weaning from supplemental oxygen was accomplished. During this protracted recovery period, an episode of rejection was also encountered and successfully managed with steroid therapy. The patient continued to progress satisfactorily and was discharged 83 days after transplantation. She is well and active 20 months after discharge.

Adult↗
PubMed1988

Use of a preferred provider by employees of the preferred provider.

Little is known about the use of services in a preferred provider organization. We studied Pacific Medical Center (PMC) in Seattle which offered a preferred provider arrangement to its employees who selected a Blue Cross-Blue Shield type of plan. PMC offered to waive copayments and reduce deductibles for those employees when they (or their dependents) used PMC. PMC was thus a preferred provider. In the first 16 months of this program, 632 subjects made at least one claim; of these, 444 (70 percent) used the preferred provider at least once. The use of PMC was highest for male employees (84 percent had at least one visit), next for female employees (74 percent), and lowest for dependents (58 percent). Approximately one-third (32 percent) used PMC exclusively, 30 percent used other providers exclusively, and 37 percent used a combination of PMC and other providers. These may be thought of as best-case estimates, since the subjects--particularly the male employees--had a high level of familiarity with the program and ease of access, while the dependents had high familiarity but less convenient access. Female employees may have used PMC less because of relationships already established with other physicians. Outpatient and inpatient charges were more than twice as high for those who used both PMC and other providers as for those who used one provider exclusively. It may be that the preferred provider arrangement encourages higher charges or, alternatively, that it provides additional flexibility for those who have the most need for care.

Adolescent↗
PubMed1983

An evaluation of criteria to designate urban health manpower shortage areas.

In the United States, federally designated health manpower shortage areas (HMSAs) have been eligible for a variety of programs intended to improve access to health services. Before 1978, HMSAs were predominantly rural. The Health Professions Educational Assistance Act of 1976 (P.L. 94-484) mandated that the criteria for designating HMSAs be revised to facilitate designation of urban areas. The most recent version of the HMSA criteria was published in 1980. This study applied the 1980 criteria to two Canadian urban areas. In general, the criteria did not succeed in distinguishing areas with relatively poorer access from those with relatively better access.

Adult↗
PubMed1982

Design and implementation of a prototype Human Protein Index.

This paper describes information-handling aspects of the TYCHO I analysis system (Clin, Chem. 27: 1807--1820, 1981), which analyzes two-dimensional electrophoresis gels, matches the individual protein spots with those in a reference pattern, and stores various information--including spot measurements, identifications, treatment profiles, set memberships, and comments--in a computerized database. This and additional information such as amino acid composition and cellular localization is then accessible from an interactive program that includes a pictorial user interface and presents much of the data in graphical form. Use of the TYCHO I system is illustrated by examples drawn from analyses of gel patterns from human leukocytes.

Blood Proteins↗
PubMedDate not supplied

The denturism initiative.

Denturism, an organized movement by dental laboratory technicians to increase their control over the provision of denture services to the public, has generated a great deal of controversy among members of organized dentistry, the National Denturist Association, the Federal Trade Commission, consumer groups, and prepaid dental plans.Denturism is currently legal in Arizona, Colorado, Maine, and Oregon. In the first three States, the denturist must practice under the supervision of a dentist, but in Oregon the denturist is able to enter independent practice.The American Dental Association has held that a denturist is educationally unqualified to provide denture services directly to the consumer, Representatives of organized dentistry have characterized denturists as untrained and unskilled persons who would endanger the public's health and return one phase of dentistry to the apprentice system. They see denturism as constituting a major step backward in health care delivery and having an adverse effect on preventive dental care.The National Denturist Association, however, defines a denturist as a highly skilled person who specializes in the making of full and partial dentures. Denturists maintain that the dentist is an unnecessary middleman in the provision of denture services and is the primary cause of the high cost of dental prostheses. They contend that State dental laws providing that only dentists may render denture services have led to the high cost of these services without contributing significantly to the health and safety of the public.Organized dentistry in the United States has been fighting denturism in a number of ways. One that has met with considerable success has been the establishment of programs to provide people access to dental care, especially denture services, at lower costs. A second alternative under consideration is to license denturists but require them to practice under the supervision of a dentist. A third alternative under discussion is to expand the duties of existing dental auxiliary personnel.The final decision on denturism, however, will not be made by the dental profession or the denturists, but by the voting public and their elected representatives, based on the evidence they have before them.

American Dental Association↗
PubMed1994

The medical/surgical nurse program. A flexible response to the changing patient care environment.

The medical/surgical nurse program at Stanford University Hospital was designed to provide patient care units with clinical professional support to manage emergency or other unpredictable situations in a challenging healthcare environment. As a result of this program, staff members have access to clinical nursing experts who provide valuable support to improve patient care services in the most cost-effective manner.

California↗
PubMed1995

Measuring outcomes: why now?

Intense scrutiny of the American healthcare paradigm will alter the activities of patients, providers, and payors. Government reform and marketplace-driven managed care programs create uncertainty. Quality, access, and cost concerns also drive change. Quality is conformity to requirements, and specification of requirements creates policy debate. Variability in utilization creates an accountability chasm between payors and providers that cannot be bridged without understanding the uncertainties in "appropriateness" research. Quality and access appear secondary to cost. Cost discussions must differentiate cost and charge. Inappropriate charge benefit analyses may temporarily benefit a specific organization but are unlikely to create long-term societal benefit. Multiple transitions have begun, including a shift from disease care to healthcare, provider mentality to consumer mentality, and provider autonomy to collaboration and accountability. Laboratories will be expected to provide outcomes, not tests; income will be related to covered lives, not volume, and profit will shift from "piecework and efficiency profit" to "prevention profit." Only good "outcomes" measurement can reduce uncertainty. The laboratory contribution to value in care processes remains unclear. What information is added by each result? How can results help prevent the need for future services? These are our challenges.

Chemistry, Clinical↗
PubMedDate not supplied

[Geriatric assessment: possibilities and limits].

A recent meta-analysis has shown that comprehensive geriatric assessment can reduce mortality, increase survival at home, and improve functional status in elderly patients. Despite their high effectiveness, geriatric assessment programs have not yet been widely introduced into clinical practice. This review discusses the following four factors potentially explaining the limited spread of geriatric assessment programs. 1) There is a lack of accepted targeting criteria to select patients who need evaluation and management in costly in patient geriatric units. 2) There are effectiveness gaps in current knowledge on modifiable disability risk factors. 3) Geriatric assessment programs have been insufficiently integrated into the continuity of primary care. 4) More data are needed for evaluating the cost of geriatric assessment. Interdisciplinary research might help to optimize geriatric assessment programs and, at the same time, might ensure access of elderly patients to appropriate geriatric assessment programs despite current restraints in health care costs.

Activities of Daily Living↗
PubMed1994

Encrypting personal identifiers.

STUDY SETTING. A statewide patient discharge database contained only one unique identifier: the social security number (SSN). A method was developed to transform (encrypt) the SSN so that it could be made publicly available, for purposes of linking discharge records, without revealing the SSN itself. The method of encrypting the SSN into a Record Linkage Number (RLN) is described. PRINCIPAL FINDINGS. The same RLN will always result from the same SSN; it is highly improbable that the same RLN would be produced by two different SSNs; the SSN cannot be derived from the RLN, even given access to the encryption program; the encryption method cannot be determined through knowledge of a number of SSN/RLN combinations; and the method can be described, evaluated, and adapted for use by other researchers without compromising confidentiality of the RLNs resulting from the method.

Abstracting and Indexing↗
PubMed1995

Adolescent suicide: implications for primary care.

A number of factors associated with teen suicide have been elucidated in recent years. Relevant clinical and research issues are reviewed: victim characteristics including psychopathology and warning signs; social influences including the effects of music and the media, the role of imitation and access to firearms; prevention programs; and implications for practice including professional education, primary care interventions, response to threats, commitment, and post-intervention.

Adolescent↗
PubMed1996

Motivation for tattoo removal.

BACKGROUND AND DESIGN: Motivational issues surrounding tattoo removal are important to understand because tattooing is flourishing, thus creating many requests for tattoo removal. A descriptive study and a 67-item survey were used to examine characteristics of tattooed patients seeking laser therapy for tattoo removal. The setting was the Laser Dermatology Center, Massachusetts General Hospital in Boston, a large metropolitan ambulatory clinic. Patients queried were 64 tattooed males and 41 tattooed females between the ages of 17 and 62 years with a wide variety of vocational and professional occupations. We assessed risk factors surrounding tattooing decisions and experiences that might later influence their motivation to have the tattoos removed by laser therapy. RESULTS: Motivation, treatment, and cost, in terms of money, pain, and risk of disfigurement all entered into the decision making to have the tattoos removed. Strong elements of purchase and possession risks were documented as well as an improved sense of self and maturity. The patient's maturation was in contrast to the notion of a waiting room filled with ill-behaved stereotypical tattooed individuals. Most participants impulsively obtained their tattoos for internal expectations of self-identity at an early age and were still internally motivated to dissociate from the past and improve self-identity. CONCLUSIONS: Poor decision making and subsequent personal regret seem to be frequent motivations for tattoo removal, thus viable methods and accessibility to tattoo removal programs are important. In addition, educational programs for adolescents about tattooing to reduce risks and promote dissuasion should be implemented.

Adolescent↗
PubMed1996

Efficacy of 2-month total parenteral nutrition in AIDS patients: a controlled randomized prospective trial. The French Multicenter Total Parenteral Nutrition Cooperative Group Study.

OBJECTIVE: To evaluate the efficacy of total parenteral nutrition in AIDS patients. DESIGN: A prospective, randomized, controlled, multicentre trial. METHODS: Over a period of 2 months, 31 malnourished and severely immunodepressed AIDS patients were assigned to receive either dietary counselling (n = 15) or home total parenteral nutrition (TPN; n = 16) via a central venous access after an educational program. Results were analysed by intent-to-treat basis. RESULTS: Bodyweight change was +8 kg (+13 +/- 3%) in the TPN group and -3 kg (-6 +/- 2%) in the control group (P < 0.0006). Lean body mass increased in the TPN group (+9 +/- 3%) and decreased in the control group (-5 +/- 3%; P < 0.004) while body cell mass increased in the former (+15 +/- 4%) and decreased in the latter (-12 +/- 6%; P < 0.002). Nutritional subjective global assessment, subjective self-reported health feeling and Karnofsky index were also improved by TPN. Infection line sepsis incidence remained low (0.26 per 100 patient-days). However, no difference in survival rate was exhibited between the two groups by the log-rank test. CONCLUSION: We conclude that home TPN is an efficient treatment of malnutrition in severely immunodepressed AIDS patients.

Acquired Immunodeficiency Syndrome↗
PubMed1998

[Pharmaco-economics: a point of view of the mutualities].

In Belgium, the mutualities are responsible for their budgets. They are playing an important role in drug pricing and reimbursement procedures. This document aims at explaining our line of arguments for a critical evaluation and the place for a pharmacoeconomic evaluation in the Belgian social security system. The available economic data for each molecule or pathology are essential but insufficient. Economic evaluations could help to reveal the costs and benefits of different uses of medical therapies and could thereby enhance the resources allocation in a health care system. But this science is still in its infancy, and in practice, the methodological quality of this kind of study is often weak. Furthermore it is not easy to transfer those evaluations to the Belgian reimburse systems. The clinical efficacy and the transparency is price setting should remain the two most important criterions to build reimbursement rules in order to ensure right price, rational use of medicine and accessibility for all.

Belgium↗
PubMedDate not supplied

[Can plantar ulcers associated with leprosy be treated in the field. Results of experience in Senegal].

The introduction of a program for the treatment of plantar ulcers (PU) in field conditions in Senegal was studied. The program was complementary to the Health Education and Protective Footwear to Prevent Disability (POD) initiatives within the Senegalese anti-leprosy program. The wound care given in health centers was coded and simplified. Access to hospitals was made easier for those patients requiring surgery. More than 30% of patients with PU were treated each year, with a mean of 62% cured. An increasing number of leprosy patients have been admitted to regional hospitals for surgery. Never before have patients with signs of leprosy had access to general hospitals. This study emphasizes the need for regular supervision of the individuals treating wounds.

Foot Ulcer↗
PubMed1993

The delivery of Early and Periodic Screening, Diagnosis and Treatment Program services by NPs in a nursing center.

Enacted in 1967 as a required component of the Medicaid program, the Early and Periodic Screening, Diagnosis and Treatment Program combines outreach, health screening, follow-up care for detected conditions, and case management. This article describes the delivery of this program's services by nurse practitioners in an academic nursing center. Detailed are the Nursing Center's activities to develop a services contract for the Early and Periodic Screening, Diagnosis and Treatment Program and to improve client access. Issues discussed include protocol development, prescriptive authority and referral to health care providers accepting Medicaid. Services are evaluated by auditors, faculty, students and clients. The article concludes with suggestions for other providers or potential providers of the program.

Child↗
PubMedDate not supplied

Web-based education in family medicine predoctoral programs.

BACKGROUND AND OBJECTIVES: New technologies and widespread Internet access make Web-based education feasible for family medicine predoctoral programs. Offering educational activities and resources through the Web can support community-based education and improve communication. We assessed the status of Web-based education nationally and explored the interest and opportunities for collaboration. METHODS: A survey assessed the inclusion of Web-based educational methods in family medicine predoctoral programs and school-wide programs, the level of national interest in collaborative development, and common obstacles to progress. The survey was mailed to all US family medicine predoctoral directors. RESULTS: The response rate was 61%. Results showed nearly universal use of e-mail and Web pages. The most common educational use of the Internet was posting text information. One third of the responding programs used the Web for evaluation. Barriers to development of Web-based educational programs are faculty time and funding. Most respondents were interested in collaborative Web development and would value a national, Society of Teachers of Family Medicine-based network for this purpose. CONCLUSIONS: Web-based educational activities are commonly offered by family medicine programs. To realize the full potential of Web-based education, collaborative development of new methods and materials will be needed to overcome the limiting factors of faculty time and funding.

Computer-Assisted Instruction↗