Down's syndrome. Recent trends in the United States

The crude incidence of Down's syndrome (DS) in the United States is currently about 1/1,000 births. Reduction in the proportion of births to women 35 years and older can account for a halving of the estimated percentage of DS births to this age group and a drop in the estimated crude incidence of DS from 1.33/1,000 births in 1960 to 0.99/1,000 births in 1978. Epidemiologic studies suggest that among women 35 years and older, the risk of having a child with DS has not changed. With the present distribution of maternal ages, prenatal diagnosis among women 35 years and older can result in no more than a 20% decrease in the crude incidence of DS. With continued use of prenatal diagnosis among older gravidas, upward of 80% of DS births will occur to younger mothers.     

Recent trends in cesarean birth and trial of labor rates in the United States

A national probability survey was conducted to evaluate changes since 1979 in cesarean delivery and trial of labor rates after a previous cesarean delivery. Questionnaires were mailed to 538 hospitals and 87% responded. In 1979, of women with a prior cesarean birth 2.1% (+/- 0.3%) were given a trial of labor. By 1984, the rate increased fourfold to 8.0% (+/- 0.7%). Trials of labor increased dramatically with the size of the delivery service. The rates ranged from 2% in smaller hospitals to 25% in larger hospitals. More than 50% of the trials of labor were successful. However, the fraction of hospitals with no trials of labor remains high (54%). Cesarean birth rates increased from 14.1% (+/- 0.1%) in 1979 to 19.0% (+/- 0.2) in 1984. Hospitals with fewer births had a larger variation in cesarean birth rates; the fifth and 95th percentiles were 5% and 33%, respectively, for hospitals with fewer than 500 deliveries per year, and 14% and 31% for hospitals with 1000 deliveries or more per year. Fetal distress accounted for a larger proportion of primary cesarean deliveries in 1984 (21%) compared with 1979 (14%). The observed increase in the rate of trial of labor does not seem to be large enough to stem the rising cesarean delivery rate. This survey and other national surveys provide no evidence that the cesarean delivery rates are leveling off or decreasing.     

Recent trends in disability and functioning among older adults in the United States: a systematic review

Context  Several well-publicized recent studies have suggested that disability among older Americans has declined in the last decade. Objectives  To assess the quality, quantity, and consistency of recent evidence on US trends in the prevalence of self-rated old age disability and physical, cognitive, and sensory limitations during the late 1980s and 1990s and to evaluate the evidence on trends in disparities by major demographic groups. Data Sources  We searched MEDLINE and AGELINE for relevant articles published from January 1990 through May 2002 and reviewed reference lists in published articles. Study Selection  From more than 800 titles reviewed, we selected 16 articles based on 8 unique repeat cross-sectional and cohort surveys of US prevalence trends in disability or functioning among persons generally aged 65 or 70 years or older. Data Extraction  We evaluated survey quality according to 10 criteria, ranked the surveys as good, fair, or poor, and calculated for each outcome the average annual percent change. Data Synthesis  Among the 8 surveys, 2 were rated as good, 4 as fair, 1 as poor, and 1 as mixed (fair or poor, depending on the outcome) for assessing trends. Analyses of surveys rated fair or good showed consistency of declines in any disability (-1.55% to -0.92% per year), instrumental activities of daily living disability (-2.74% to -0.40% per year), and functional limitations. Surveys provided limited evidence on cognition and conflicting evidence on self-reported ADL (changes ranged from -1.38% to 1.53% per year) and vision trends. Evidence on trends in disparities by age, sex, race, and education was limited and mixed, with no consensus yet emerging. Conclusions  Several measures of old age disability and limitations have shown improvements in the last decade. Research into the causes of these improvements is needed to understand the implications for the future demand for medical care.      

National-scale clinical information exchange in the United Kingdom: lessons for the United States

Over the last four decades, the UK has made large investments in healthcare information technology. The authors conducted interviews and reviewed published and unpublished documents to describe national-scale clinical information exchange in England, how it was achieved, and the problems experienced that the USA might avoid. Clinical information exchange in the UK was accomplished by establishing a foundation of policy, infrastructure, and systems of care, by creating and acquiring clinical computing applications and with strong use of financial and clinical incentives. Many software and hardware vendors played a part in this effort; they participated in a national framework created by the NHS in which standards for exchange are specified and their applications designed to make clinical information exchange part of normal practice. Great potential exists for cost reduction, increased safety, and greater patient involvement as a result of clinical information exchange.     

Implementing pay-for-performance in Australian primary care: lessons from the United Kingdom and the United States

We identify key lessons learned from the international experience of pay-for-performance and use them to formulate questions for Australia to consider before such a scheme is introduced. Discussion of lessons learned is based on a narrative review of the literature. We examined international evidence on factors to consider when designing pay-for-performance schemes, and the impact of these schemes on primary care practitioner behaviour and on primary care funding. Pay-for-performance schemes evolve over time, and usually involve several complex interventions including accreditation, education, quality improvement programs, investment in information technology and data collection systems, professional support and regional structures. These are all necessary conditions for linking financial incentives to quality of care. There is a strong argument for changing the existing service incentive payments program and investing the resources into revised outcome payments that provide rewards for annual improvements in numbers of patients receiving completed cycles of care. If pay-for-performance is to be introduced in Australia, several key lessons should be learned from the experiences of other countries. Pay-for-performance should be used as part of a wider strategy for quality improvement; it should not be seen as a panacea. Pay-for-performance should be used to drive quality improvement, not simply to reward those who are already providing high-quality care.     

首位留学美英的医生黄宽

黄宽是我国第一位留学美国,学习西医于英国的医生。在美国盂松学校学习基础科学知识,两年后在英国爱丁堡大学接受医学教育并获得医学学位。他是我国早期杰出的外科医生。在传播西方医学方面作出重要贡献,在当时他被称为好望角以东最负盛名之良外科。他的业绩自当永垂中国医学史。     

Occupational hazards for operating room-based physicians. Analysis of data from the United States and the United Kingdom

Comparative analysis of data from three large retrospective surveys in the United States and the United Kingdom reaffirms an increased incidence of spontaneous abortion among female physicians working in the operating room. The live-born children of female physicians exposed in the operating room also had substantially more congenital abnormalities. Male anesthetists, compared with nonanesthetist physicians, had an increased incidence of hepatic disease; there was also an increased frequency of congenital abnormality in their children. The incidence of spontaneous abortion in wives of male anesthetists and in the rate of cancer among exposed male anesthetists was similar to control. Despite differences in survey methods and analysis, there was remarkable agreement in conclusions to be drawn from the independent studies.