Cost-savings analysis of using a portable coagulometer for monitoring homebound elderly patients taking warfarin

The authors present a prospective cost-savings analysis to determine how the use of portable coagulometers in the home health setting affects medical expenditure. Thirty-five elderly patients (mean age 67 years) receiving cardiac home health care and long-term oral anticoagulation were evaluated with paired measurements of the international normalized ratio by both a traditional, laboratory-based prothrombin time and a point-of-care coagulometer (CoaguChek, Roche Diagnostics, Basel, Switzerland). Costs for materials, procedures, transportation, and labor were summed for both methods, and it was found that cost of international normalized ratio determination by the portable coagulometer was significantly less than the traditional method ($6.85 vs. $17.30; p< 0.001). The authors conclude that by saving on the costs of transporting and processing traditional international normalized ratio specimens, use of point-of-care coagulometers by home health nurses could reduce medical expenditure. The cost savings and potential improvement in quality of care argue for equipping home health nurses with portable coagulometers.     

RX FOR HEALTH CARE COSTS:

The literature on addictions treatment cost offsets suggests that resolving addictive disorders in the general medical setting will drive down the demand for health care, promote more efficient use of care by both patients and their families, and preserve scarce resources that can be deployed more wisely elsewhere. The demand to reduce waste and trim health care expenditures challenges the historic gulf between general medical practice and the management of addictive behaviors. An example of an addiction treatment technology developed in medical settings for use by medical personnel, brief intervention , is reviewed, with reference to its cost-saving potential under health care reform.     

The generalist health care workforce

The generalist health care workforce in the United States is best characterized as those practitioners who deliver primary care services. These include most family physicians, general internists, general pediatricians, nurse practitioners, osteopathic family physicians, and physician assistants. Based on a variety of factors, including health care needs, managed care/HMO hiring practices, international comparisons, and health care costs, the case for increasing the amount and proportion of generalist providers is compelling. Projections strongly suggest a worsening shortfall of generalists if no change is made. Changing the career choices of medical students to promote generalism, even significantly, will take 20 years or more to have a meaningful impact. Therefore, retraining specialist physicians in oversupply to practice as generalists is an important option to consider. To best meet the nation’s health care needs, three issues need to be addressed in the context of health care reform: the creation of a “system” of generalist care that integrates into a coherent and collaborative framework the scopes of practice of the various generalist disciplines; the pursuit of a workable short-term model to convert specialist physicians into generalist physicians, led jointly by family medicine, general internal medicine, and general pediatrics; and a significant change in the medical education process to produce an ample supply of well-trained generalists.     

Internal medicine and the training of international medical graduates: a time for open discussion and new approaches.

The number of foreign national medical graduates entering internal medicine residency training programs in the United States has doubled since 1986. A rigorous, standardized preresidency evaluation of the basic clinical skills and language abilities of international medical graduates should be implemented. Those found to have significant deficits should undertake a preparatory curriculum designed to meet special educational needs before entry into the formal training program. A relevant curriculum might include formal lectures, reading assignments, physical diagnosis sessions, language classes, patient encounter sessions, and a tutorial on U.S medical culture that includes medical ethics and the basics of the our health care system. All or only some of these may be required for any given individual. The Educational Commission for Foreign Medical Graduates (ECFMG) could provide many of the methods needed for an evaluation program and work collaboratively with program directors. This new approach to training of international medical graduates will require an evaluation system to to measure its effectiveness. Important questions about the funding of graduate medical education for international medical graduates must also be addressed.     

Terrorism and the ethics of emergency medical care

The threat of domestic and international terrorism involving weapons of mass destruction-terrorism (WMD-T) has become an increasing public health concern for US citizens. WMD-T events may have a major effect on many societal sectors but particularly on the health care delivery system. Anticipated medical problems might include the need for large quantities of medical equipment and supplies, as well as capable and unaffected health care providers. In the setting of WMD-T, triage may bear little resemblance to the standard approach to civilian triage. To address these issues to the maximum benefit of our patients, we must first develop collective forethought and a broad-based consensus that these decisions must reach beyond the hospital emergency department. Critical decisions like these should not be made on an individual case-by-case basis. Physicians should never be placed in a position of individually deciding to deny treatment to patients without the guidance of a policy or protocol. Emergency physicians, however, may easily find themselves in a situation in which the demand for resources clearly exceeds supply. It is for this reason that emergency care providers, personnel, hospital administrators, religious leaders, and medical ethics committees need to engage in bioethical decision making before an acute bioterrorist event.     

Treatments of geriatric syndrome

Aging is often seen as disadvantageous in human history. However, longevity reduces medical costs of the whole life compared with that of short life. Therefore, in order to reduce medical costs, we have to take care of the elderly in order to promote health and longevity. Health problems in the elderly should be solved by both medical and elderly care facilities. However, few studies have analyzed the health problems of the elderly. In this presentation, based on the pathophysiology of the health problems of the elderly we describe the recent advances for treatments for the geriatric syndrome.     

Management of Haemophilia in Developing Countries: Challenges and Options

There are significant challenges in managing haemophilia patients in developing countries. These challenges are (i) Lack of proper health care infrastructure and human resources suitable for haemophilia care (ii) Competing health care priorities of the government. (iii) Lack of penetrance of medical insurance in the population. (iv) Lesser visibility of the haemophilia patients in health care system (v) Low awareness across the medical profession, population and the policy makers about the condition (vi) Non availability of factor concentrates (vii) Inadequate utilization of knowledge for reducing factor concentrate use. (viii) Inadequate pain relief (ix) Challenges due to inhibitor developing (x) Viral hepatitis & (xi) Lack of research publications relevant to the country are some of the challenges faced by PWH for their management in developing country. The solutions are not easy but development of a strong patient organization with linkages with World Federation of Haemophilia is an important initial step. Following that internal and international twinning, use of internal sources, strong advocacy programme targeting government, doctors, opinion makers will solve many of the challenges in the time to come.     

On the medical edge: preparation of expatriates, refugee and disaster relief workers, and Peace Corps volunteers

Travelers to extreme environments and those who spend long periods of time in settings with limited health care resources need to have more detailed pretravel screening and education than the routine short-term traveler. Expatriates, relief workers, and Peace Corps volunteers need to receive careful pretravel medical, dental, and psychologic screening before deployment. Knowledge of special risks associated with the environment in which they will be stationed is necessary to provide effective education about ways to reduce or eliminate the risk of illness and death. The travel medicine practitioner should also provide detailed, region-specific recommendations regarding emergency care while traveling in remote regions. Information on foreign medical facilities and practitioners should be gathered in advance and regularly updated. Many fee-for-service directories of overseas medical centers are often out of date and do not include emergency contact information. Once deployed, systems should be in place to ensure the traveler's continued personal safety and maintenance of good health. Although these systems are generally beyond the scope of work of travel medicine providers, it is important for the long-term traveler to be aware of the need to be prepared to deal with unexpected medical events. In the event of an overseas emergency, the travel medicine specialist may be called on to facilitate ground or air medical evacuation to the most appropriate medical center, to communicate treatment priorities and pertinent medical details to foreign medical providers, and to facilitate international air evacuation or repatriation if necessary. In each of these cases, the experience for the patient and the travel health professional is dramatically improved by adhering to risk-reduction measures, such as pretravel screening, pretravel health and safety education, and preparing for emergencies in advance.     

Critical care rationing: international comparisons

Every country has finite resources that are expended to provide citizens with social "goods," including education, protection, infrastructure, and health care. Rationing-of any resource-refers to distribution of an allotted amount and may involve withholding some goods that would benefit some citizens. Health-care rationing is controversial because good health complements so many human endeavors. We explored (perceptions regarding) critical care rationing in seven industrialized countries. Academic physicians from England, Spain, Italy, France, Argentina, Canada, and the United States wrote essays that addressed specific questions including: (1) What historical, cultural, and medical institutional features inform my country's approach to rationing of health care? (2) What is known about formal rationing, especially in critical care, in my country? (3) How does rationing occur in my ICU? Responses suggest that critical care is rationed, by varying mechanisms, in all seven countries. We speculate that while no single "best" method of rationing is likely to be acceptable or optimal for all countries, professional societies could serve international health by developing evidence-based guidelines for just and effective rationing of critical care.     

Diabetes and dementia in older people: a Best Clinical Practice Statement by a multidisciplinary National Expert Working Group

Both dementia and diabetes mellitus are long‐term disabling conditions and each may be a co‐morbidity of the other. Type 2 diabetes is associated with a 1.5‐ to 2‐fold higher risk of dementia. Diabetes also may occur for the first time in many individuals with mental ill health, including cognitive impairment and dementia, and this may complicate management and lead to difficulties in self‐care. Case finding is often poor for cognitive impairment in medical settings and for diabetes in mental health settings and this needs to be addressed in the development of care pathways for both conditions. Many other deficiencies in quality care (both for dementia and diabetes) currently exist, but we hope that this Best Clinical Practice Statement will provide a platform for further work in this area. We have outlined the key steps in an integrated care pathway for both elements of this clinical relationship, produced guidance on identifying each condition, dealt with the potentially hazardous issue of hypoglycaemia, and have outlined important competencies required of healthcare workers in both medical/diabetes and mental health settings to enhance clinical care.     

A Marxist view of medical care.

Marxist studies of medical care emphasize political power and economic dominance in capitalist society. Although historically the Marxist paradigm went into eclipse during the early twentieth century, the field has developed rapidly during recent years. The health system mirrors the society's class structure through control over health institutions, stratification of health workers, and limited occupational mobility into health professions. Monopoly capital is manifest in the growth of medical centers, financial penetration by large corporations, and the "medical-industrial complex." Health policy recommendations reflect different interest groups' political and economic goals. The state's intervention in health care generally protects the capitalist economic system and the private sector. Medical ideology helps maintain class structure and patterns of domination. Comparative international research analyzes the effects of imperialism, changes under socialism, and contradictions of health reform in capitalist societies. Historical materialist epidemiology focuses on economic cycles, social stress, illness-generating conditions of work, and sexism. Health praxis, the disciplined uniting of study and action, involves advocacy of "nonreformist reforms" and concrete types of political struggle.     

Descriptive analysis of the process and quality of oral anticoagulation management in real-life practice in patients with chronic non-valvular atrial fibrillation: the international study of anticoagulation management (ISAM)

BACKGROUND/OBJECTIVES: Expert oral anticoagulation management is the key to good outcomes and is performed variably in different health care systems throughout the world. We set out to assess the quality of anticoagulation management in five countries in patients receiving vitamin K antagonists (VKAs) for stroke prophylaxis in chronic non-valvular atrial fibrillation (NVAF), and to compare the anticoagulation management practices in these countries. METHODS AND RESULTS: This was a retrospective, multi-centre cohort study in the United States, Canada, France, Italy, and Spain. About 1,511 patients were randomly recruited from representative practices (routine medical care (RMC) in the US, Canada, and France; anticoagulation clinics in Italy and Spain) and data pertaining to their oral anticoagulation care were abstracted from their medical records. The predominant anticoagulant in use was warfarin in the US, Canada, and Italy; acenocoumarol in Spain; and fluindione in France. Documentation of care was poor in the US, Canada, and France, countries where RMC was studied. Percent INRs or time-in-therapeutic range was greater in the two anticoagulation clinic samples compared with the RMC samples. CONCLUSION: Oral anticoagulation care varies considerably from country to country. Findings suggest that anticoagulation clinic care (ACC) may provide better outcomes as assessed by international normalized ratio (INR) time-in-range. Physicians tend to under treat more than over treat. Finally, documentation of care is often inadequate. Condensed Abstract Oral anticoagulation management (routine medical care or anticoagulation clinic care) was retrospectively assessed in 5 countries using a uniform, structured assessment tool. Major management differences were detected, especially between anticoagulation clinic care and routine care. Documentation was often a problem in the latter setting. Less time in therapeutic INR range was noted in routine medical care. Findings suggest that anticoagulation clinic care may provide better outcomes as assessed by international normalized ratio (INR) time-in-range. Physicians tend to under treat more than over treat. Finally, documentation of care is often inadequate.     

Conceptual basis of international health

International health is becoming an important field of study and practice due mainly to the increasing complexity of international relationships which imply both changes in the epidemiologic profile of the population, and transformations of health care delivery systems. At the same time, the character of health problems does not recognize the geographical boundaries of nations; instead, it may open or reinforce new areas of cooperation or conflict in the international arena. The many interactions between international relations and health impose the need to build and consolidate an academic and intellectual tradition of international health, which supports its efforts to generate knowledge and leads its practical applications. International health is experiencing important conceptual and strategic changes which have to be taken into account if educational programs, research projects, and national, binational and multinational health actions are to be comprehensive in their approach, scope, and focus. This article identifies those conceptual and strategic changes, proposes basic definitions, the universe for action, and the disciplinary base of the new international health. In short, the article proposes the transition towards a new international health concept and practice.     

A national diabetes care and education programme: the Ghana model

An account is given of how a national diabetes care and education programme was developed in Ghana, a developing country, through international collaboration of medical schools, industry and government health care institutions. The approach is by way of trained diabetes teams consisting of physicians, dietitians and nurse educators at two tertiary institutional levels (teaching hospitals) who in turn trained teams consisting of physicians, dietitians or diettherapy nurses, nurse educators and pharmacists at regional and district/sub-regional levels to offer care and education to patients and the community. In three years all regional and about 63% of sub-regional/district health facilities had trained diabetes health care teams, run diabetes services and had diabetes registers at these institutions. Additionally a set of guidelines for diabetes care and education was produced. All programme objectives with the exception of one (deployment of diabetes kits) were met. Distances to be travelled by persons with diabetes to receive diabetes care had been reduced considerably. The success of the project has given an impetus to the collaborators to extend the programme to the primary health care level. The continuing prohibitive prices of diabetes medications and supplies however, could be addressed by removing taxes on such supplies. The Ghana diabetes care model, a 'top-down' approach, initially involving two diabetes centres is recommended to other developing countries, which intend to incorporate diabetes care and education into their health care system.     

Ethnicity,self-care,and use of medical care among the elderly with joint symptoms

Elderly individuals with self-reported joint symp-toms representing three ethnic groups (i.e., blacks [n = 105], Hispanics[n = 100], and whites of Eastern European origin [n = 112] answered questions about their use of self-care and medical care for these symptoms. Ethnic groups differed in both self-care practices and their use of medical care for joint symptoms. Multiple regression analyses demonstrated that arthritis-specific and general health status were better predictors than ethnicity of the tendency to rely on self-care and medical care. There was no evidence that self-care served as a substitute for medical care.     

Care for older people

Aging is often seen as disadvantageous in human history. However, longevity reduces medical costs of the whole life compared with that of short life. Therefore, in order to reduce medical cost, we have to take care of the elderly in order to promote health and longevity. Health problems in the elderly should be solved by both medical and elderly care facilities. However, few studies have analyzed the care problems of the elderly. In this review, we describe the recent methods of care for the elderly.     

Algorithm for the treatment of status epilepticus: an Australian perspective

Convulsive status epilepticus (SE) is a medical emergency where successful treatment is associated with timely intervention and the use of a protocol has been recommended to provide the highest quality of care. Despite this, there is no nationally available protocol for the treatment of SE in adults in Australia. Treatment is therefore variable and often based on international guidelines or familiarity with certain medications. We have developed an Australian‐based algorithm for the treatment of SE, focusing on simplifying management while delivering the safest possible care. We believe this algorithm is suitable for all health practitioners, regardless of training or experience.     

Health care for older persons: a country profile-Korea

The Korean healthcare system is faced with a crisis caused by rapidly changing social values tending toward westernization, increasing insurance benefit requests for elder health care, financial instability of the National Health Insurance (NHI) program, and a lack of social infrastructure for the elderly. The demand for health care for the elderly has increased markedly, because of a rapidly aging population, growing female participation in the labor market, elevated expectations for health care, and a change in the pattern of medical conditions in the elderly from acute illness to chronic disability. NHI lacks the finances to meet the benefit request for long-term care (LTC). Only 0.39% of the elderly can be accommodated in LTC beds. Consequently, the chronically disabled elderly overflow to acute care beds in general hospitals, which places an undue burden on the already strained NHI system in terms of longer stays and higher cost of treatment in hospitals compared with care specific to the elderly in LTC facilities. It is clear that the Korean healthcare system does not have the facilities to meet such challenges and is in a state of disorder. Korea has failed to predict and prepare for population needs before they arise, including financing and the development of appropriate care models, particularly concerning the adequate provision of LTC. This paper advocates the necessity of international discussion of the prospects for developing health care for aging populations and encourages the sharing of differing national experiences concerning care for the elderly.