A claims data approach to defining an episode of care.

OBJECTIVE: To utilize health services research techniques in developing an episode of care using an administrative data set. This method is demonstrated for an episodic clinical condition, migraine. DATA SOURCES: Medicaid administrative data set of 3,372 patients with a diagnosis of migraine (ICD-9-CM 346.0, 346.1) in the state of Pennsylvania between May 1990 and March 1992. STUDY DESIGN: The duration of a migraine episode was measured by assessing the magnitude of resource utilization and the proportion of patients with charges in the period after the index migraine as compared to the period before the index migraine. A confidence interval (CI) was developed around each measure using bootstrap techniques. DATA COLLECTION METHODS: All charge data were extracted daily for a 113-day observation period surrounding each index migraine in order to observe the duration of impact of a migraine diagnosis on resource utilization. PRINCIPAL FINDINGS: The lower limits of both the 95% and 99% CIs for the difference in charges are greater than 0 for three weeks. The lower limits of both CIs for the difference in the proportion of patients with charges are above 0 for six weeks. CONCLUSIONS: Our analysis demonstrates that a health services research framework can be used to define an episode of care for a chronic disease category such as migraine. This method can be used to evaluate episodes of care for clinical studies of limited or episodic conditions and to complement clinical expertise in developing time horizons for clinical trials.     

Rapid opioid detoxification during general anesthesia: a review of 20 patients

BACKGROUND: Opioid addiction therapy includes successful detoxification, rehabilitation, and sometimes methadone maintenance. However, the patient may have physical, mental, and emotional pain while trying to achieve abstinence. A new detoxification technique that incorporates general anesthesia uses a high-dose opioid antagonist to compress detoxification to within 6 h while avoiding the withdrawal. METHODS: After Institutional Review Board approval and detailed informed consent, 20 patients, American Society of Anesthesiologists status I-II, addicted to various opioids underwent anesthesia-assisted rapid opioid detoxification. After baseline hemodynamics and withdrawal scores were obtained, anesthesia was induced. After testing with 0.4 mg intravenous naloxone, 4 mg nalmefene, was infused over 2 to 3 h. After emergence, severity of withdrawal was scored before and after administration of 0.4 mg intravenous naloxone. After 24 h, patients began outpatient follow-up treatment while taking oral naltrexone. RESULTS: All 20 patients were successfully detoxified with no adverse anesthetic events. After the first post-treatment test dose of 0.4 mg naloxone, 13 of 20 patients had no signs of withdrawal and hemodynamic changes were minimal. Withdrawal scores were always very low and similar before and after detoxification. Three of 17 patients (18%) available for follow-up have remained abstinent from opioids since treatment (< or = 18 months). Four other patients are clean after brief relapses. CONCLUSIONS: Anesthesia-assisted opioid detoxification is an alternative to conventional detoxification.     

Depletion of Vbeta4 TCR does not induce resistance to EAN--further evidence for diversity of TCR usage

In EAN, TCR variable (V) gene usage is still controversial. A dominant usage of a TCR Vbeta4-associated idiotype has been reported. To assess the role of TCR Vbeta4 positive T-cells in susceptibility to induction of EAN, we suppressed the selection of this idiotype by neonatal treatment of Lewis rats with anti-TCR Vbeta4 monoclonal antibody (mAb). Anti-Vbeta4 treatment had no effect on development of clinical disease after immunization with the neuritogenic P2-peptide amino acids (aa) 53-78. Furthermore, lymph node cells from anti-Vbeta4 treated animals isolated after immunization with P2-peptide did not exhibit a reduced proliferative response towards whole P2-protein or P2-peptide. Our results indicate that T-cells utilizing other TCR V chains can functionally replace the neuritogenic cell population, which is dominant in stable T-cell lines.     

What drives Medicare managed care growth?

We conducted case studies of four markets--Los Angeles, New York City, Portland (OR), and Tampa-St. Petersburg--to learn more about why Medicare managed care develops differently across the country even when capitation rates are similar. Our analysis highlights the importance of prior managed care history, beneficiary characteristics, supplemental coverage patterns, the form of provider organization, practice patterns, care expectations, and other market characteristics to the development of Medicare managed care. Policymakers seeking to expand Medicare managed care need to go beyond national statistics to understand how local market forces affect its growth.     

Gender issues in newspaper coverage of people with disabilities: a Canada-Israel comparison

This research compared how over a three-month period Canadian and Israeli newspapers wrote about females and males with disabilities. The results showed that in both countries there was significantly greater coverage of males than females. In addition, different (and stereotypical) types of details were used to describe the two groups, and females were associated with different kinds of problems than males, including a higher incidence of violence and victimization. There were also some significant differences between the male and female journalists in this study, and evidence of sexism within the newspaper industry. This paper concludes with some ideas for altering the images of disabled women in the media.     

The changing US health care system: challenges for responsible public policy

The "managed care backlash" arguably topped the list of media and policy concerns in 1998. Yet, against the background of the highly charged environment in which the future of our health care system continues to be debated, there is a dearth of concrete, "objective" facts on the nature of the changes, the reasons for them, and their meaning. An analysis of five important themes that emerged from a review of the recent literature on health system change concludes that an inherent tension exists between the interest in rapidly driving down health care costs through organizational change and the long time frames that are required to make fundamental changes in structure, process, and orientation. Unfortunately, in an environment in which purchasers are driven to seek cost savings and the political will supports a pluralistic and mixed public/private system, the health system may chart an alternative course, with the result that purchasers may rely increasingly on individual cost sharing and continue to cut back the amount of coverage they are willing to offer. The real challenge for public policy makers is to confront the issues directly, avoiding political incentives to adopt easy and fast solutions for these complex matters.     

Use-dependent block of atrial sodium current by ethylisopropylamiloride.

Ethylisopropylamiloride (EIPA) is a potent inhibitor of Na(+)-H+ exchange in many tissues and is frequently used to study cellular regulation of pH, but the electrophysiologic effects of EIPA on cardiac cells have not been studied previously. The use-dependent effects of EIPA on the sodium current (INa) of cultured embryonic chick atrial myocytes were investigated using standard whole-cell patch-clamp techniques. With 150-ms depolarizations from -140 to 0 mV, applied at 1-3 Hz in the presence of 10 microM EIPA, a decrement in INa was observed. This use-dependent reduction equaled 31 +/- 6% of control INa at steady state during 1-Hz stimulation. Inhibition increased with stimulation rate and with depolarization of the holding potential to -100 mV, but there was no effect of pulse duration on the EIPA-induced inhibition over the range of 20-500 ms. Moreover, repetitive depolarizations to potentials that did not activate macroscopic current but that did yield pronounced channel inactivation did not result in a decrement in INa. The effect of EIPA increased over the concentration range of 1-30 microM so that with 3-Hz stimuli steady-state inhibition increased from 3 +/- 1 to 85 +/- 5%. Amiloride, which slows repolarization of the cardiac action potential, was at least 100-fold less potent than EIPA in reducing INa. We conclude that EIPA is an "open-channel" blocker of the cardiac sodium current at concentrations comparable to those of many type I antiarrhythmic agents.     

Alcohol and recreational drug use by HIV-seropositive homosexual men

The objectives of this study were to describe the patterns of alcohol and recreational drug use of HIV-seropositive homosexual men and to determine the effect of alcohol use on HIV risk-taking behaviour. Of particular interest was the effect of knowledge of HIV status on these behaviours. Information on alcohol and drug use was obtained from 485 HIV-seropositive homosexual and bisexual men presenting to a HIV-antibody testing and medical management clinic. Heavy alcohol use was common, with 46.2% reporting consumption of six or more standard drinks on one day recently. Men who knew that they were HIV infected drank significantly more than those men who had yet to learn of their HIV status at the time of interview. There was clear evidence in this study for a role of alcohol use in HIV risk-taking behaviour. Almost one-third (27%) of the HIV-seropositive men reported unprotected anal intercourse during the previous 3 months with approximately one-third of these (27/76, 35·5%) nominating alcohol as contributing to their high HIV-risk behaviour.