Effects of the September 11th attacks on urgent and emergent medical evaluations in a Northern California managed care plan

PURPOSE: To determine whether the terrorist attacks on September 11, 2001, affected the health of persons far from the attacks, we studied rates of urgent and emergency medical evaluations among the 3 million persons enrolled in a managed care plan in Northern California. METHODS: Using a computerized database of all urgent care and emergency department evaluations, we monitored physician diagnoses made during the 6 weeks before and after September 11, 2001, at 16 hospitals in the Kaiser Permanente Medical Care Program. Actual rates of evaluations and diagnoses were compared with expected rates based on similar periods in 1998, 1999, and 2000. RESULTS: There were 4260 fewer urgent and emergent medical evaluations than expected during the 6 weeks beginning September 11, 2001 (-4%; 95% confidence interval [CI]: -3% to -5%; P <0.0001; N = 95,603). Emergency department visits occurred at the expected rate (-1%; 95% CI: -2% to 1%; P = 0.34), but urgent care visits were reduced (-9%; 95% CI: -8% to -11%; P <0.0001). Evaluations were particularly less frequent during the week beginning September 11 (-7%; 95% CI: -4% to -9%; P <0.0001), but a decrease persisted afterwards. Compared with expected rates, injuries (P <0.0001) and ill-defined/symptom-related diagnoses (P <0.0001) were less frequent, while gastrointestinal diagnoses (P = 0.01) were more frequent, during the 6 weeks after the attacks. Total urgent and emergent evaluations were mostly unchanged on September 11; only diagnoses associated with cardiac ischemia were more frequent (+70%; 95% CI: 10% to 163%; P = 0.02). CONCLUSION: Total urgent and emergent medical evaluations in a California managed care plan were reduced during the 6 weeks after the September 11th attacks. These results may help in allocation of resources during national disasters.     

The effect of variable health insurance deductibles on the demand for physician visits

In order to contain cost in the health care sector, the introduction of consumer incentives in health insurance has been suggested and realized in many countries. The Swiss health system reform of 1996 introduced a choice of deductible for health services in the mandatory basic health insurance. This paper estimates the effect of this choice on physician service utilization. A generalized method of moments (GMM) estimator is applied to take account of the endogeneity of the choice of the deductible in the estimation of the number of physician visits. This paper finds that most of the observed reduction in the number of physician visits among individuals who choose a higher deductible seems to be a result of self-selection of individuals into the respective insurance contracts, and not to induced changes in utilization behaviour.     

Worker Decisions to Purchase Health Insurance

Studying worker health insurance choices is usually limited by the absence of price data for workers who decline their employer's offer. This paper uses a new Medical Expenditure Panel Survey file which links household and employer survey respondents, supplying data for both employer insurance takers and decliners. We test for whether out-of-pocket or total premium better explains worker behavior, estimate price elasticities with observed prices and with imputed prices, and test for worker sorting among jobs with and without health insurance. We find that out-of-pocket price dominates, that there is some upward bias from estimating elasticities with imputed premiums rather than observed premiums, and that workers do sort among jobs but this does not affect elasticity estimates appreciably. Like earlier studies with less representative worker samples, we find worker price elasticity of demand to be quite low. This suggests that any premium subsidies must be large to elicit much change in worker take-up behavior.     

Issues of intervention aimed at preventing prospective surplus of physicians in Japan

OBJECTIVES: In Japan, regulatory intervention aimed at preventing a prospective surplus of physicians is an important medical issue. The study committees organized by the Ministry of Health and Welfare (MHW) in 1986, 1993 and 1998, concluded that the number of physicians would exceed demand for their services in the future. As a result, the government planned to reduce the number of medical students. However, MHW has not been successful in the intervention so far, as shown by the fact that their initial plan for a 10% reduction in the number of students enrolled in medical school has not been attained. In this paper, we examine why the MHW policy failed. METHODS: We reviewed those forecasts performed by past MHW study committees and examined whether the government policy of controlling physician training was appropriate. Additionally, we did a preliminary projection of specialty-specific demand for physician services as a reference for future physician manpower policies in Japan. RESULTS: We found that both conflicts among various interest groups and a lack of precise projections of physician services hampered the proper formation and implementation of a physician manpower policy in Japan. CONCLUSIONS: It might be necessary to examine the appropriateness of the MHW policy in reducing the overall number of students enrolled in medical schools. As a first step in formulating and implementing a physician manpower policy, we should begin to consolidate the necessary data to conduct precise and proper projections of future physician demand.     

农村患者就医流向的变化趋势分析

根据国家的卫生统计提要数据以及有关国家卫生服务调查数据,对农村患者就医流向的变动趋势进行描述性统计分析,指出了有关的现状和原因,并提出了相应的政策建议。     

青岛市围绝经期妇女保健需求现状

目的 了解青岛市围绝经期妇女对围绝经期的认识程度和保健需求，为制定保健措施提供依据。方法 采用整群随机抽样方法，选取青岛市区及城郊的各400名共1600名35—59岁的妇女作为调查对象，进行围绝经期妇女保健需求调查。结果保健需求排在前五位的有：定期全面查体（54．56％）、围绝经期咨询（50．88％）、预防骨质疏松（42．56％）、预防老年痴呆症（39．19％）、保护关节功能（38．25％）；只有16．56％的妇女了解围绝经期保健知识；知识主要来源于媒体（38．60％）、同事朋友（35．92％）、医疗机构（25．48％）；围绝经期妇女HT的使用率4．13％，青岛市区的HT使用率明显高于城郊（χ^2=22．73，P〈0．01）。结论围绝经期妇女对保健需求较迫切，保健知识贫乏，应深入开展健康教育，普及推广HT的相关知识。     

国内心理健康服务从业者继续教育培训的需求现状及相关因素

目的:调查国内心理健康服务从业者继续教育培训需求的现状和相关因素.方法:用自编培训需求和影响因素问卷,按方便抽样法抽取国内29个省份1391名心理健康从业者,调查其培训需求现状和影响因素.结果:从业者继续教育培训的需求可概括为督导评估、相关知识和实践技能3类;从业者对实践(4.2±1.0)和技能(4.1±1.0)培训的需求最高.受教育程度低、工作时间短、参加知识培训多者,3类培训需求均高 [如,对督导评估培训的需求,大专(14.9±3.9),博士(13.1±3.9),P=0.006];女性对督导评估培训需求高于男性[(14.8±3.7)vs.(14.3±3.4),P=0.026],社会取向者对督导评估培训需求高于教育和临床取向者[(15.2±3.6)vs.(14.4±3.6),(14.4±3.6);P=0.018, 0.009];兼职、参加培训次数少、参加技能培训者对实践技能培训需求高[如,兼职(8.4±1.6),专职(8.1±1.8),P=0.010].结论:国内心理健康从业者对实践技能培训的需求最高;其需求情况与性别、年龄、受教育程度、从业取向、从业长短、已参加培训次数及内容等因素有关,表现出层次性和偏好特点.     

Is the efficacy of successful infliximab induction therapy maintained for one year lasting without retreatment in different behavior types of Crohn's disease?

The high cost of infliximab inhibits the regular retreatment of all patients in Hungary with Crohn's disease (CD) after beneficial induction therapy. This study is set out to evaluate the medium-term efficacy of induction therapy with infliximab without retreatment in CD patients with chronic activity and/or fistulae refractory to conventional therapy.MethodsA retrospective 1-year review was undertaken of all CD patients with successfully induced remission or fistula closure with 3 infusions of infliximab. Infliximab was administered in a dose of 5 mg/kg 3 times, in weeks 0, 2 and 6. Clinical remission was defined as symptom resolution and an estimated Crohn's Disease Activity Index (CDAI) < 150 and complete fistula closure. We evaluated the clinical response, the estimated CDAI, the number of draining fistulae, the dosages of steroid and immunosuppressive drugs at 6 and 12 months after the last infusion, and the needs for hospitalization and surgical intervention during this period. Breslow (Generalized Wilcoxon) test was used as the statistical method.ResultsThe data of the 50 patients (19 luminal, 31 fistulizing disease; average age 29. 3 [13–59] years, disease localization: 23 colon, 13 ileum, 13 ileocolon, 1 duodenum) were suitable for analysis. Infliximab induction therapy without retreatment resulted in a beneficial effect lasting for at least 1 year in 22 of the 50 patients (44%). 11 of the 19 patients (57.9%) with luminal disease remained in steroid-free complete remission, while the fistulae persisted closed in only 11 of the 31 patients (35.5%) (p < 0.05).ConclusionInfliximab induction therapy alone may result in sustained remission mainly in patients with luminal disease. These results suggest the need for maintenance therapy with infliximab after successful therapy induction in patients with fistulae, while luminal CD patients could possibly participate in regular retreatment only if needed. If these data are confirmed, this modification of the therapeutic procedure could well increase the cost-effectiveness of infliximab.