Integrated delivery networks: a detour on the road to integrated health care?

This paper reviews the rationales and evidence for horizontal and vertical integration involving hospitals. We find a disjunction between the integration rationales espoused by providers and those cited in the academic literature. We also generally find that integration fails to improve hospitals' economic performance. We offer seven lessons from hospitals' efforts to integrate and then suggest four alternative models for achieving integrated delivery of health care services.     

Short echo time MR spectroscopic imaging of the lung parenchyma

PURPOSE: To perform short echo time MR spectroscopic imaging of the lung parenchyma on normal volunteers.MATERIALS AND METHODS: A short echo time projection-reconstruction spectroscopic imaging sequence was implemented on a commercial 1.5T whole body MRI scanner. Images and spectra of the lung parenchyma were obtained from five normal volunteers. Breath-held spectroscopic imaging was also performed.RESULTS: Spectroscopic imaging of short-T2* species allows visualization of different anatomic structures based upon their frequency shifts. A characteristic peak from the parenchyma was seen at three ppm from water frequency.CONCLUSION: Short echo time MR spectroscopic imaging of the lung parenchyma was demonstrated in normal volunteers. This method may improve proton imaging of the lungs and add specificity to the diagnosis of pulmonary disease.     

Characterization and reduction of the transient response in steady-state MR imaging.

Refocused steady-state free precession (SSFP) imaging sequences have recently regained popularity as faster gradient hardware has allowed shorter repetition times, thereby reducing SSFP's sensitivity to off-resonance effects. Although these sequences offer fast scanning with good signal-to-noise efficiency, the "transient response," or time taken to reach a steady-state, can be long compared with the total imaging time, particularly when using 2D sequences. This results in lost imaging time and has made SSFP difficult to use for real-time and cardiac-gated applications. A linear-systems analysis of the steady-state and transient response for general periodic sequences is shown. The analysis is applied to refocused-SSFP sequences to generate a two-stage method of "catalyzing," or speeding up the progression to steady-state by first scaling, then directing the magnetization. This catalyzing method is compared with previous methods in simulations and experimentally. Although the second stage of the method exhibits some sensitivity to B(1) variations, our results show that the transient time can be significantly reduced, allowing imaging in a shorter total scan time. Magn Reson Med 46:149-158, 2001.     

Adenylyl cyclase activity is increased in younger, but decreased in older, alcoholic patients after detoxification

Acute and chronic administration of ethanol leads to alterations of the adenylyl cyclase (AC) signal transduction pathway. This study examined whether the formation of cAMP by AC in lymphocytes correlates with age in alcoholic patients and in healthy controls. Blood was drawn for preparation of lymphocyte membranes and for determination of basal, GTPgammaS-stimulated, and forskolin-stimulated AC activity from 68 actively drinking alcoholic patients (age, mean +/- SD: 45 +/- 10; range: 26-69 years) after ethanol detoxification. The patients' AC activity correlated negatively with age. In contrast, no effect of age was observed in the healthy controls (age, mean +/- SD: 42 +/- 11; range: 24-65 years). The age-related decrease in AC activity of alcoholic patients could not be attributed to the duration of regular alcohol intake. It was partly due to the large variance of AC activity in younger and middle-aged alcoholics.     

Inflammatory reactions in primary osteoarthritis of the hip and total hip prosthesis loosening

Summary In 14 patients [9 with loosened total hip arthroplasty (THA), 5 with primary osteoarthritis], the inflammatory cell infiltrate was characterized in cryostat tissue sections using antibodies against subsets of macrophages and lymphocytes. In all patients the abundance of a mature type macrophage (25F9+) was observed, whereas 27E10+ macrophages, characteristic of acute inflammatory reactions, were not seen in primary osteoarthritis but were found in 4 out of 9 patients with THA loosening. The RM3/1+ macrophage phenotype was seen in some of both sets of patients (osteoarthritis 4/5; THA loosening 4/9). The markers MRP8 and MRP14 typical of immature macrophages, were found in all patients with osteoarthritis and in some (4/9 and 8/9 respectively) of those with THA loosening. IOT4+ T-helper cells were only present in 1/5 5 patients with osteoarthritis and in 2/9 patients with THA loosening. IOT8+ T-suppressor lymphocytes were more frequently present (in 4/5 and 5/9 respectively). The data reveal remarkable differences between the two groups of patients. While the inflammatory infiltrate in patients with osteoarthritis lacks the characteristics of acute inflammation, in patients THA loosening the inflammatory process seems to be determined by periods of acute reactions. The occasional presence particularly of T-helper cells suggests that the inflammatory process is less T-cell but rather macrophage-driven.     

Mean circadian cosinors of vital signs, performance of blood and urinary constituents in patients with leprosy.

We have herewith examined the characteristics of circadian rhythms in patients with lepromatous leprosy, active or inactive, allowing a comparison with corresponding properties of rhythms in healthy subjects mapped earlier. Group results were illustrated by cosinor plots, produced directly on microfilm by computer. Eventually such reference standards in the form of cosinors, among other displays, notably of waveform, may be individualized and carried on a person's health record. Such a quantitative assessment of an individual's rhythms in health may serve for rigorous comparison with any changes accompanying increased susceptibility or occult or overt disease.     

Synergism of stimulating capacity of pooled lymphocytes in the mixed lymphocyte reaction

One-way mixed lymphocyte reactions in cultures of responding cells from a single subject and a pool of stimulating cells from two or more donors exhibited a synergistic response. Increased activity of the responding cells showed a positive correlation with the pool size. Treatment of the responding cells, stimulating cells or both with neuraminidase significantly increased the response.     

Access to conventional medical care and the use of complementary and alternative medicine

The use of complementary and alternative medicine (CAM) in the United States has greatly increased during the past decade. Using survey data from the 2002 National Health Interview Survey (NHIS), we show that adults who did not get, or delayed, needed medical care because of cost in the prior twelve months were also more likely than all other adults to use CAM. Recent increases in CAM use could be the result of not only the desire for individual empowerment and patient dissatisfaction with conventional medicine, as has been claimed, but also of increases in the relative cost of conventional health care.     

How to present the business case for healthcare quality to employers

Many employers in the US are investing in new programmes to improve the quality of medical care and simultaneously shifting more of the healthcare costs to their employees without understanding the implications on the amount and type of care their employees will receive. These seemingly contradictory actions reflect an inability by employers to accurately assess how their health benefit decisions affect their profits. This paper proposes a practical method that employers can use to determine how much they should invest in the health of their workers and to identify the best benefit designs to encourage appropriate healthcare delivery and use. This method could also be of value to employers in other countries who are considering implementing programmes to improve employee health. The method allows a programme that improves workers' health to generate four financial benefits for an employer - reduced medical costs, reduced absences, improved on-the-job productivity, and reduced turnover - and uses accurate estimates of the benefits of reducing absences and improving productivity.