Perioperative care: preoperative care

With a subject as vast as preoperative care its is impossible in an article of this length to do more than sketch in the broad outlines of assessment and preparation, using a few examples to illustrate certain aspects. Unfortunately the pressure of work in most hospitals is such that the standard of preoperative care is not as high as it might be. Many authors have stressed its values not only in making anaesthesia safer but especially in reducing the incidence of postoperative morbidity--a field that has received too little attention for too long.     

Cancer care. Palliative care. The last days of care

The government has promised a further 12m pounds over three years for end-of-life care, on top of the 50m pounds a year for palliative care. A framework developed by Macmillan Cancer Relief has identified seven gold standards of care including communication, coordination, control of symptoms, carer support and care in the dying phase. The government has committed to doubling the number of palliative care consultants by 2015.     

Managed care as health care rationing

This article is based on the author's presentations to the New York State Governor's Health Care Advisory Board's Task Force on the President's Health Care Plan, November 22, 1993, and to a hearing of the New York State Attorney General on the experience of consumers with health insurers and health maintenance organizations, September 20, 1993. His comments deal with the effects of the Clinton health care reform proposal and other forms of managed care on those most in need of care. Particularly interesting are his suggestions for protecting the rights of health care consumers.     

When the care giver needs care

Case studies are used to illustrate family dysfunction that can occur when the wife and/or mother who has assumed the role of primary care giver is diagnosed and treated for cancer. These women were treated by the liaison psychiatrist and social workers at a large cancer center. The cases are discussed from a framework of family systems theory. Treatment implications for social workers in health care are also presented.     

Health care, not sick care

Senator Tom Harkin announces his introduction of the HeLP (Healthy Lifestyles and Prevention) Act. This comprehensive legislation provides incentives to stimulate health promotion in workplace, school, and community settings, with specific programs for disabled people, food marketing, Medicare reimbursement for preventive services, and research on obesity, and creation of a National Health Promotion Trust Fund to pay for programs by penalties on tobacco companies that fail to cut smoking rates among children, ending federal subsidies for tobacco advertising, and closing other tax loopholes.     

Managed care and integrated health care

Managed care and integrated care may be viewed as stages in the evolution of the U.S. health care system. The authors discuss the essential characteristics of an integrated delivery system, including patient satisfaction, maintenance of clinical skills, cost-effective practice, and professional reputation.     

Quality of care for primary care patients with depression in managed care

OBJECTIVE: To evaluate the process and quality of care for primary care patients with depression under managed care organizations. METHOD: Surveys of 1204 outpatients with depression at the time of and after a visit to 1 of 181 primary care clinicians from 46 primary care clinics in 7 managed care organizations. Patients had depressive symptoms in the previous 30 days, with or without a 12-month depressive disorder by diagnostic interview. Process indicators were depression counseling, mental health referral, or psychotropic medication management at index visit and the use of appropriate antidepressant medication during the last 6 months. RESULTS: Of patients with depressive disorder and recent symptoms, 29% to 43% reported a depression-specific process of care in the index visit, and 35% to 42% used antidepressant medication in appropriate dosages in the prior 6 months. Patients with depressive disorders rather than symptoms only and those with comorbid anxiety had higher rates of depression-specific processes and quality of care (P < .005). Recurrent depression, suicidal ideation, and alcohol abuse were not uniquely associated with such rates. Patients visiting for old problems or checkups received more depression-specific care than those with new problems or unscheduled visits. The 7 managed care organizations varied by a factor of 2-fold in rates of depression counseling and appropriate anti-depressant use. CONCLUSIONS: Rates of process and quality of care for depression as reported by patients are moderate to low in managed primary care practices. Such rates are higher for patients with more severe forms of depression or with comorbid anxiety, but not for those with severe but "silent" symptoms like suicide ideation. Visit context factors, such as whether the visit is scheduled, affect rates of depression-specific care. Rates of care for depression are highly variable among managed care organizations, emphasizing the need for process monitoring and quality improvement for depression at the organizational level.     

Quality palliative care in long-term care settings

It is paramount that physicians and midlevel practitioners who care for residents in long-term care facilities be able to provide high-quality comfort care to their patients, the majority of whom are frail and suffering from chronic and progressive diseases. Physicians must be knowledgeable in the assessment, prevention, and relief of patients' physical, emotional, and spiritual distress, as well as develop appropriate attitudes, knowledge, and skills to care for patients who are in the last years of life. The provision of high-quality palliative care is the essence of long-term care medicine.     

Health care without managed care in Japan

The best gross health indices in the world and universal coverage with no overt signs of rationing characterize the Japanese health care system. The delivery system, which consists primarily of private physicians and private hospitals, is functionally independent, but the financing system is strictly regulated. The author argues that this combination is the key to the system's unique success.