COSTING ACUTE MYOCARDIAL INFARCTION IN NEW SOUTH WALES,AUSTRALIA, BASED ON INCIDENCE RATHER THAN PREVALENCE METHODS

Estimating the economic costs of a disease is an important prerequisite to determining the costs and benefits of various preventive programs. For preventive programs, incidence-based costing is a more appropriate means of estimation than is prevalence-based costing. In this study the cost of acute myocardial infarction (AMI) in New South Wales has been estimated using an incidence-based approach. The calculated cost of AMI in 1979 was $301.0 million, made up of $32.3 million as direct costs and $268.7 million as indirect costs. In a sensitivity analysis, the cost was shown to be most sensitive to the incidence of AMI, the discount rate, and the assumption of a wage for housework. Both the direct costs and indirect costs per case are substantially higher in the United States than in Australia, and this reflects higher physician charges, higher hospital costs, and in the case of indirect costs, higher average weekly earnings.     

Soul City: a sustainable edutainment vehicle facilitating social change

This paper outlines the programming model employed by the Soul City Institute for Health and Development Communication, a South African NGO, in using ‘edutainment’ to facilitate social change. The paper refers to the intersection of this model and current thought on health promotion and various social change theories. It also discusses key challenges and factors contributing to sustainability over 12 years.     

Breast reconstruction by tissue expansion for congenital and burn deformities

We have used tissue expanders to treat 10 patients with breast deformities, 2 the result of burns and 8 congenital in origin. The expanders are placed in the subglandular plane and expanded incrementally until the desired amount of growth is obtained. In patients with congenital deformities, the desired size of the reconstructed breast (implant size) is determined during the expansion phase. Reconstructions of the nipple-areola complex are done either at the time of the exchange or as separate procedures. Patients with burn deformities present a variety of problems not seen with the congenital deformities. The expander is placed in the subglandular plane and filled to the desired volume. We have noted a marked permanent softening of the scar and grafts encasing the breast, which persists after the expander is removed and the breast reconstructed. The interval between expansion and definitive reconstruction is delayed for several months to allow scar softening to take place. If the parenchyma is not burned and pedicle tissue is not required, the expander can be deflated and the skin coverage observed to determine if it will remain soft. If it does, the expander can be removed and the breast reconstructed. In patients who require pedicle coverage in the reconstruction and who have unburned scar surrounding the breast, massive overexpansion is carried out. The pedicle skin is used to resurface the breast after removal of the appropriate areas of scar and skin grafts. In all burned patients, the inframammary fold must be reconstructed if the breast is to be protuberant. The nipple-areola complex also requires reconstruction. To date there has been great acceptance by patients with both congenital and burn deformities; however, we believe that tissue expansion techniques offer possibilities that have not as yet been fully explored.     

Management of cardiogenic shock complicating acute myocardial infarction: The Henry Ford Hospital experience and review of the literature.

Cardiogenic shock complicating acute myocardial infarction (MI) carries a high mortality which in some series prior to 1980 exceeded 80%. Neither the use of inotropic and vasopressor agents nor intraaortic balloon counterpulsation was found to improve survival in this group of patients. Intravenous thrombolytic agents improve survival in patients with acute MI, but their role in cardiogenic shock is unknown. Reports of the use of surgical and mechanical interventions in patients with severe left ventricular dysfunction were examined to determine if there was any benefit to be derived from restoring blood flow to ischemic areas of the myocardium. It was found that urgent placement of intraaortic balloon counterpulsation followed by coronary bypass surgery may improve survival rates and successful coronary angioplasty also appeared to benefit patients with cardiogenic shock. Similar improvement in survival has been reported after successful coronary reperfusion. In surgical series with predominantly nonmechanical causes of shock, survival has varied from 40% to 88%. Data from our five-year experience in the management of MI patients with cardiogenic shock suggest that coronary revascularization with coronary angioplasty or bypass surgery improves survival in patients with cardiogenic shock especially when performed within 24 hours of the onset of shock.     

Economies of scale, physician volume for urology patients, and DRG prospective hospital payment system

Diagnosis Related Group (DRG) hospital payment has begun to squeeze hospitals financially and is likely to do so in the future. This study analyzed the relationship between the volume of urologic procedures by an individual urologist, hospital costs per patient, and outcome. We used a three-year DRG database of urology patients (N = 2,980) at an academic medical center to analyze these. Low-volume urologists (arbitrarily defined by us) had higher hospital costs per patient, financial losses versus profits under DRGs, and a poorer outcome when compared with high-volume urologists. Pearson correlation showed a positive relationship between cost per patient and physician volume for nonemergency patients (-0.129, p less than 0.0001) and emergency patients (-0.368, p less than 0.0001). This may have been explained (in part) by a greater severity of illness for patients of low-volume urologists. These findings suggest, however, that the volume of urologic procedures per urologist may be related to hospital resource consumption. The health care financing environment of the future should provide substantial interest in this finding for those involved in the consumption of urologic services.     

Benign intracranial hypertension and recombinant growth hormone therapy in Australia and New Zealand

Benign intracranial hypertension (BIH) is reported in three children from Australia and one from New Zealand, who were being treated with recombinant human growth hormone (rhGH). Three males and one female, aged between 10.5 and 14.2 y, developed intracranial hypertension within 2 weeks to 3 months of starting treatment. A national database, OZGROW, has been prospectively collecting data on all 3332 children treated with rhGH in Australia and New Zealand from January 1986 to 1996. The incidence of BIH in children treated with growth hormone (GH) is small, 1.2 per 1000 cases overall, but appears to be greater with biochemical GHD (<10IUml ^-1), i.e. 6.5/1000 (3 in 465 cases), relative risk 18.4, 95% confidence interval 1.9-176.1, than in all other children on the database. The incidence in patients with Turner's syndrome was 2.3/1000 (1 in 428 cases). No cases in patients with partial GHD (10–20 IUml ^-1) or chronic renal failure were identified. Possible causative mechanisms are discussed. The authors'practice is now to start GH replacement at less than the usual recommended dose of 14IUm-² week^-1 in those children considered to be at high risk of developing BIH. Ophthalmological evaluation is recommended for children before and during the first few months following commencement of rhGH therapy and is mandatory in the event of peripheral or facial oedema, persistent headaches, vomiting or visual symptoms. The absence of papilledema does not exclude the diagnosis.     

Effects of intracavernosal trazodone hydrochloride: animal and human studies

Trazodone hydrochloride is an oral antidepressant agent which has been associated with the improvement of erections in impotent men and the development of prolonged erections or priapism in potent men. An in vivo study in animal and human subjects was performed to gain experience with the effect of intracavernosal trazodone. In the anesthetized New Zealand White rabbit, intracavernosal trazodone or its major metabolite m-chlorophenylpiperazine (m-CPP) produced full penile erection in 76% and 84% of animals studied respectively with doses ranging from one to 15 mg. On the other hand, intracavernosal administration of five mg. papaverine resulted in a prolonged erection in 90% of animals studied. In 13 selected volunteer patients, intracavernosal trazodone caused tumescence but not full penile erection with corporal body pressures of 28.2 +/- 5.8 mm. Hg. Intracavernosal papaverine or papaverine and phentolamine in these subjects resulted in significantly higher corporal body pressures of 58 +/- 18 mm. Hg (p less than .05). Intracavernosal administration of alpha adrenoceptor agonists but not normal saline resulted in complete detumescence of trazodone- or m-CPP-induced prolonged erection in the animal studies. Intracavernosal trazodone results in erectile activity that appears in part based on its local alpha blocking activity but like other intracavernosal alpha-blocking agents is not as effective in initiating penile erections as are intracavernosal agents that directly induce smooth muscle relaxation.