The Impact of Health Maintenance Organization Care Authorization Policy on an Emergency Department before California's New Managed Care Law

Objective: To examine the effect on patient care of HMO–mandated calls for authorisation prior to ED evaluation. The study examined this phenomenon prior to implementation of a California law that discourages such calls.
Methods: Concurrent data were collected for patients who presented to the ED and who had authorization calls made to their HMOs prior to their ED evaluations during the period September through December 1994. Data collected included: 1) the number of authorization calls made, 2) the frequency that ED care was deemed unnecessary by the HMO, 3) the outcomes of patients denied authorization, and 4) the time and personnel involved in completing calls. Follow–up phone calls were made to patients who left the ED after the HMO denied authorization for payment.
Results: The total ED census was 19,935 patient visits for the four–month period. Authorization calls were made for 4,642 (23%) of the ED visits. There were 545 patients (12%) in this group who had authorization denied and only 29 (5%) chose to remain in the ED for continued evaluation. The total time required to complete a call ranged from 20 minutes to 2.6 hours. Authorization calls and denials caused the following problems: 1) patients for whom calls were made were subject to delays in ED care; 2) at least seven patients referred to HMO clinics were referred back to the ED because the patient was too sick to receive clinic care; 3) patients were inconsistently asked to sign an against–medical–advice form when they chose to leave with unstable conditions; and 4) high–risk patients denied authorization included patients with final diagnoses of ectopic pregnancy, acute myocardial infarction, pulmonary embolus, respiratory failure, and sepsis.
Conclusions: Calls for payment authorization prior to ED patient evaluation delay patient care and place some patients' health and safety in jeopardy.     

A Health Promotion Intervention for Families in a Medicaid Managed Care Plan

OBJECTIVE: To determine whether implementation of an intervention based on a model of health promotion will encourage patients to seek care from their primary care provider (PCP) and reduce visits to the pediatric ED (PED) for minor illness. METHODS: Prospective, randomized, controlled study in the PED of an urban children's hospital (CH). Children <13 months old, enrolled in a Medicaid managed care plan, who identified the CH as their site for primary care and presented to the PED for evaluation of minor illness were enrolled after being seen by the triage nurse, before being seen by a physician. Subjects were randomly assigned to the intervention (I) group or control (C) group. Parents of all enrollees completed a survey about health care utilization habits. Each family in the I group received health promotion teaching from a single investigator. The intervention consisted of a review of the child's medical record with the parents, an explanation of what to expect at future well-child visits, and a discussion of the role of the PCP. A follow-up appointment was also provided prior to discharge from the PED. The C group received usual care. Use of health care by all subjects was tracked for one year by medical record review and phone interviews at six and 12 months. RESULTS: 102 subjects in the I group and 93 in the C group (mean +/- SD ages 6.4 months +/- 3.8 and 7.2 months +/- 3.9, respectively, p = 0.15) were enrolled from March 1996 to November 1996. The two groups were similar with respect to demographics and overall health status at enrollment. At study entry: 94 of 102 (92%) subjects in I and 87 of 93 (94%) in C had made at least one visit to the PED in the previous 12 months (p = 0.11); 95 of 102 (93%) in I and 75 of 93 (81%) in C had seen their PCP at least once for well-child care (p = 0.24). Twelve-month follow-up by medical record review was completed for all subjects; phone interviews were completed in 90 of 102 (88%) in I and 80 of 93 (86%) in C. At 12-month follow-up: 84 of 102 (82%) in I and 73 of 93 (78%) in C had made at least one visit to the PED (p = 0.59); 81 of 102 (79%) in I and 77 of 93 (83%) in C had made at least one visit to their CH PCP (p = 0.54). CONCLUSIONS: There was no difference in health care utilization between the intervention and control groups at 12-month follow-up. The health promotion intervention did not alter utilization habits.     

Quantifying Client Need for Care in the Community: A Strategy for Managed Care

The Community Health Intensity Rate Scale (CHIRS) is a tool that provides an index of a client's need for care. Emphasis in healthcare has shifted from episodes of illness to covered lives and managed care. CHIRS contains all the elements for holistically determining the intensity of a client's need for care and the environmental, psychosocial, and health behaviors of the client. The CHIRS has been utilized with a variety of community health populations. Each application of CHIRS provided feedback to the researchers for use in revising CHIRS. This article reports the findings of a study which tested the validity and reliability of the refined version of CHIRS. The validity and reliability needed further refinement at the indicator level. The study produced a more practical tool for determining intensity of need for clients in the community.     

Review of a Basal Insulin Regimen in Long-term Care

Diabetes management continues to present challenges in the long-term care setting. Hypoglycemia, poor glycemic control, and high costs are associated with use of sliding-scale insulin. Evidence supporting the use of basal insulin in combination with prandial bolus and or oral agents is now available, but actual guidelines for practice are lacking for long-term care residents. Best practices are essential to achieve glycemic control and reduce costs associated with diabetes and diabetic complications in the elderly long-term care resident. A basal-bolus insulin regimen is presented that can improve management of diabetes and be cost-effective.     

Effect of Ethnicity on Denial of Authorization for Emergency Department Care by Managed Care Gatekeepers

OBJECTIVE: After a pilot study suggested that African American patients enrolled in managed care organizations (MCOs) were more likely than whites to be denied authorization for emergency department (ED) care through gatekeeping, the authors sought to determine the association between ethnicity and denial of authorization in a second, larger study at another hospital. METHODS: A retrospective cohort design was used, with adjustment for triage score, age, gender, day and time of arrival at the ED, and type of MCO. RESULTS: African Americans were more likely to be denied authorization for ED visits by the gatekeepers representing their MCOs even after adjusting for confounders, with an odds ratio of 1.52 (95% CI = 1.18 to 1.94). CONCLUSIONS: African Americans were more likely than whites to be denied authorization for ED visits. The observational study design raises the possibility that incomplete control of confounding contributed to or accounted for the association between ethnicity and gatekeeping decisions. Nevertheless, the questions that these findings raise about equity of gatekeeping indicate a need for additional research in this area.     

The Cost-Benefit of a Randomized Trial to a Health Care Organization

Clinicians and patients make many decisions in situations where optimal treatment is uncertain. Despite well-published advantages of clinical trials for reducing such uncertainties, a trial may not be conducted because the sample size indicated by classical, hypothesis-testing methods is so large that no one institution could afford to sponsor the trial. By explicitly taking into consideration the costs and benefits of a trial, Bayesian statistical methods permit estimation of the value to a health care organization conducting a randomized trial instead of continuing to treat patients in the absence of more information. This paper describes a method for calculating the cost-benefit to a health care organization conducting a clinical trial, and the expected sample size to adequately resolve the uncertainties about which treatment is better. The method is illustrated in the case of a proposed clinical trial of a drug to prevent multiorgan system failure and death in patients admitted to the Stanford University surgical intensive care unit. This method should permit health care organizations to evaluate a proposed trial's expected cost-benefit and the expected sample size that will resolve the question of interest, and thereby assist in the process of deciding whether to conduct the trial.     

Predictors of Peritonitis,Hospital Days,and Technique Survival for Peritoneal Dialysis Patients in a Managed Care Setting

♦ Introduction: Many clinicians perceive that peritoneal dialysis (PD) should be reserved for younger, healthier, more affluent patients. Our aim was to examine outcomes for PD patients in a managed care setting and to identify predictors of adverse outcomes.♦ Methods: We identified all patients who initiated PD at our institution between 1 January 2001 and 31 December 2010. Predictor variables studied included age, sex, race, PD modality, cause of end-stage renal disease (ESRD), dialysis vintage, Charlson comorbidity index (CCI) score, education, and income level. Poisson models were used to determine the relative risk (RR) of peritonitis and the number of hospital days per patient-year. The log-rank test was used to compare technique survival by patient strata.♦ Results: Among the 1378 patients who met the inclusion criteria, only female sex [RR: 0.85; 95% confidence interval (CI): 0.74 to 0.98; p = 0.02] and higher education (RR: 0.77; 95% CI: 0.60 to 0.98; p = 0.04) were associated with peritonitis. For hospital days, dialysis vintage (RR: 1.11; 95% CI: 1.04 to 1.18; p = 0.002), CCI score (RR: 1.06; 95% CI: 1.02 to 1.20; p = 0.002), and cause of ESRD (RR for glomerulonephritis: 0.59; 95% CI: 0.43 to 0.80; p = 0.0006; and RR for hypertension: 0.69; 95% CI: 0.55 to 0.88; p = 0.002) were associated with 1 extra hospital day per patient-year. The 2-year technique survival was 61% for patients who experienced at least 1 episode of peritonitis and 72% for those experiencing no peritonitis (p = 0.0001). Baseline patient age, primary cause of ESRD, and PD modality were the only other variables associated with technique survival in the study.♦ Conclusions: Neither race nor socio-economic status predicted technique survival or hospital days in our study. Female sex and higher education were the only two variables studied that had an association with peritonitis.     

Care for the Adult Family Members of Victims of Unexpected Cardiac Death

More than 300,000 sudden coronary deaths occur annually in the United States, despite declining cardiovascular death rates. In 2000, deaths from heart disease left an estimated 190,156 new widows and 68,493 new widowers. A major unanswered question for emergency providers is whether the immediate care of the loved ones left behind by the deceased should be a therapeutic task for the staff of the emergency department in the aftermath of a fatal cardiac arrest. Based on a review of the literature, the authors suggest that more research is needed to answer this question, to assess the current immediate needs and care of survivors, and to find ways to improve care of the surviving family of unexpected cardiac death victims. This would include improving quality of death disclosure, improving care for relatives during cardiopulmonary resuscitation of their family member, and improved methods of referral for services for prevention of psychological and cardiovascular morbidity during bereavement.     

女性压力性尿失禁行无张力尿道悬吊术的护理

目的：探讨采用经阴道无张力尿道悬吊术（TVT）治疗女性压力性尿失禁的护理。方法：我院对8例压力性尿失禁的女性患行TVT术。术前充分准备，避免一切可能引起腹内压升高的诱因；术后密切观察，预防出血和感染。结果：所有患术后临床症状明显好转或痊愈，未发生并发症。结论：术前准确避免引起术后腹内压升高以及术后密切观察预防出血和感染在TVT术的护理中至关重要。     

Bleeding as an Outcome Among Patients With Nonvalvular Atrial Fibrillation in a Large Managed Care Population

Background

Patients with nonvalvular atrial fibrillation (NVAF) are at increased risk for stroke and bleeding events, but bleeding as an outcome has not been extensively studied in this patient population.

Objectives

The goal of this study was to estimate the incidence of bleeding events among patients with NVAF enrolled in managed care, investigate the relationships between bleeding incidence and bleeding and stroke risks, and estimate health care costs for patients who had a major bleeding event.

Methods

Adults with commercial insurance or Medicare Advantage coverage and health care claims related to AF between January 2005 and June 2009 but with no evidence of valvular disease were included in this retrospective claims data analysis. Baseline stroke risk (CHADS₂ [Congestive Heart Failure, Hypertension, Age >75 Years, Diabetes Mellitus, and Prior Stroke or Transient Ischemic Attack]) and bleeding risk (HAS-BLED [Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratios, Elderly, Drugs/Alcohol]) were estimated. Bleeding events were identified during the variable follow-up period, which lasted from the date of the first qualifying AF visit until the earlier of death, disenrollment from the health plan, or June 30, 2010. Bleeding events were classified as major, serious nonmajor, or minor. Health care costs for patients with major bleeding events were calculated.

Results

Among 48,260 patients with NVAF (mean age, 67 years), 34% had an incident bleeding event during a mean (SD) follow-up period of 802 (540) days. Incidence rates for bleeding events of any severity and major events were 29.6 and 10.4 per 100 patient-years, respectively. Bleeding incidence rates increased with greater CHADS₂ and HAS-BLED risk scores. All-cause health care costs for patients during a major bleeding event averaged $16,830. Average costs per patient with a major event increased from approximately $52 per day in the prebleeding period to approximately $63 per day in the postbleeding period. Costs for patients who did not experience a major bleeding event averaged approximately $38 per day.

Conclusions

Bleeding incidence among patients with NVAF in a real-world setting was high and increased with greater stroke and bleeding risk scores. Health care costs for patients with major bleeding events were elevated. All rights reserved.     

EPOCH方案在非霍奇金氏淋巴瘤病人化疗中的应用及护理

复发性、难治型的非霍奇金氏淋巴瘤 (NHL)的临床治疗方案较多 ,有效率在 40 %～ 80 %之间 ,但远期效果不佳。近年来 ,EPOCH方案在临床中越来越广泛地用于中、高度复发性NHL的治疗 ,并取得良好的疗效 ,是目前公认的治疗效果较好的挽救方案[1] 。1　临床资料　　　 2 0 0 1年 6月— 2 0 0 2年 6月间我科住院的复发或难治的中高度NHL病人共 3 2例 ,其中男 2 3例 ,女 9例 ,年龄为 15岁～71岁 ,全身功能状态评分 (ECOG) 0分～ 2分 ,外周血白细胞计数 >3 .5× 10 9/L ,血小板 >10 0× 10 9/L ,肝肾功能正常 ,预计生存期大于 6个月。2　化…