RESUMEN
OBJECTIVE: To determine the financial impact of a nursing home practice on an academic medical center. DESIGN: Retrospective cohort design. SETTING: Middle-sized Midwestern community with fee-for-service Medicare population. SAMPLE: One hundred seventy-six nursing home residents followed by faculty and residents of a medical school department of family and community medicine. MEASUREMENTS: Billings and collections for professional and hospital services delivered by the academic medical center during fiscal year 1998. RESULTS: One hundred forty-four patient-years of service resulted in over 1 million dollars in billed charges. For every 1 dollar billed by family medicine, consulting physicians billed 2 dollars and the hospital billed 10 dollars. This amounted to over 4000 dollars per patient per year in reimbursement. This practice generated a wide variety of clinical problems (37 different diagnosis-related groups (DRGs) for the 61 admissions to the hospital). CONCLUSIONS: There is a significant downstream financial effect of a nursing home practice on an academic health center. For this and other reasons, this practice may be worthy of institutional support.
RESUMEN
OBJECTIVES: To describe views of attending physicians regarding nurse assistants as part of a multidisciplinary seminar on nurse assistants at the 1997 American Medical Directors Association (AMDA) Annual Symposium. DESIGN: Mailed survey. PARTICIPANTS: AMDA members. MEASUREMENTS: Attitudes regarding nurse assistants and the role of attending physicians with regard to enhancing the role of nurse assistants. RESULTS: Respondents rated the importance of quality nurse assistants with a mean of 4.85 and a mode of 5 (5 being very important). They also thought it was important for the medical director attending physicians to support, train, or otherwise assist in the professional development of nurse assistants (mean 4.07, mode 5). Respondents recommended enhanced training, reduced workload, increased salary and benefits, and building more effective relationships as strategies for improving the quality of care provided by nurse assistants. CONCLUSION: Physicians can be important in enhancing the role of the nursing assistant. Some activities may include acknowledging the nurse assistant, providing support and feedback, and supporting policy changes that enhance continuity, nonhierarchical management, and creative training programs.
RESUMEN
By using relevant clinical practice guidelines for end-of-life care and by incorporating meaningful quality indicators into an effective continuous quality improvement program, nursing facilities can provide quality end-of-life care for their residents while complying with state and federal regulations.
Asunto(s)
Casas de Salud , Calidad de la Atención de Salud , Cuidado Terminal , Anciano , Financiación Gubernamental , Regulación Gubernamental , Adhesión a Directriz , Humanos , Casas de Salud/normas , Cuidados Paliativos , Guías de Práctica Clínica como Asunto , Cuidado Terminal/normas , Estados UnidosRESUMEN
OBJECTIVES: To describe the prescribing and use of antiepileptic drug (AED) therapy in nursing facility residents. DESIGN: A retrospective, multicenter drug use evaluation. SETTING: A total of 85 nursing facilities (average size, 119 beds) in five states. PARTICIPANTS: 1132 residents of the total 10,168 residents screened were prescribed at least one AED. MEASURES: Demographic information, primary indication for AED, comorbid conditions, prescribing physician's specialty, concomitant medications, and AED dosage regimen information were collected. Laboratory tests obtained in the most recent 6 months and seizure occurrence and seizure-related diagnostic assessments made in the most recent 3 months were also recorded. RESULTS: Of 1132 residents receiving AED therapy, 892 (78.8%) were prescribed AED therapy for a seizure-related diagnosis although 86% of seizure types were unspecified. Another 215 residents (19.0%) were prescribed AEDs for nonseizure diagnoses, and 25 (2.2%) had no indication for AED therapy. AEDs most frequently prescribed were phenytoin (56.8%), carbamazepine (23.0%), phenobarbital (15.6%), and valproic acid (13.1%). For residents with a seizure diagnosis, the most frequently prescribed monotherapy agents were phenytoin (52.0%), carbamazepine (12.2%), and phenobarbitol (7.1%). Almost 25% of residents with a seizure diagnosis took a combination of AEDs; more than 50% of all combinations included phenobarbital. About 9% of residents with a seizure diagnosis had one or more documented seizures during a 3-month review period. CONCLUSION: Among the substantial percentage of residents treated with AEDs, the lack of diagnosis of seizure type has serious implications for the choice of AED therapy. Opportunities exist for prescribing physicians, consultant pharmacists, and nursing staff to improve the medical management of nursing facility residents with seizures and of others receiving AEDs.
Asunto(s)
Anticonvulsivantes/administración & dosificación , Cuidados a Largo Plazo , Casas de Salud , Convulsiones/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Comorbilidad , Revisión de la Utilización de Medicamentos , Estudios de Evaluación como Asunto , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Convulsiones/clasificación , Convulsiones/diagnóstico , Estados UnidosRESUMEN
OBJECTIVE: To describe the characteristics of physicians attending Medicaid recipients in Missouri's certified nursing homes (NH). DESIGN: Retrospective survey of multiple data sources. SETTING: Missouri's certified nursing homes. PARTICIPANTS: 1,339 physicians attending 22,452 Medicaid recipients. MEASUREMENTS: Physician characteristics were determined by reviewing a roster of medical directors of NHs compiled by the Missouri Department of Social Services' Division of Aging and physician directories compiled by the Missouri State Board of Registration for the Healing Arts, the AMA, the AOA, the ABFP, and the ABIM. Physician clinical activity was determined by examining NH inspection of care reports compiled by the Missouri Department of Social Services' Division of Aging. RESULTS: Each physician attended a mean of 16.8 and a median of six Medicaid recipients in the nursing home. The skewed distribution is reflected by 426 (31.8%) of the physicians attending only one or two residents, and 28 (2.1%) of the physicians attending 100 or more residents. Twenty-seven percent of the state's licensed osteopaths (DOs, 362) attended nursing home patients, compared with 11% of allopathic physicians (MDs, 977). Significantly more DOs than MDs attended more than the median number of patients (57% vs 45%, P < 0.001). Half were attended by the 605 (45%) physicians without board certification. Of those who were board certified, family physicians were more likely to include Medicaid nursing home patients in their practices than internists (43% vs 18%, P < 0.001). Physicians licensed for 11 to 20 years and rural physicians had the heaviest patient loads. CONCLUSIONS: Many doctors are caring for very few nursing home residents while a few doctors may be caring for too many patients. In addition, half the Medicaid recipients residing in Missouri's nursing homes in 1988 were attended by physicians without board certification, and almost one-third were attended by physicians who may be retiring between 2000 and 2010.
Asunto(s)
Medicaid , Casas de Salud , Médicos/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Certificación/normas , Certificación/estadística & datos numéricos , Demencia/epidemiología , Femenino , Predicción , Médicos Graduados Extranjeros/estadística & datos numéricos , Humanos , Medicina Interna/normas , Medicina Interna/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Licencia Médica/estadística & datos numéricos , Masculino , Missouri/epidemiología , Medicina Osteopática/normas , Medicina Osteopática/estadística & datos numéricos , Ejecutivos Médicos/estadística & datos numéricos , Médicos/normas , Médicos/provisión & distribución , Médicos de Familia/normas , Médicos de Familia/estadística & datos numéricos , Médicos de Familia/provisión & distribución , Ubicación de la Práctica Profesional/estadística & datos numéricos , Jubilación/estadística & datos numéricos , Jubilación/tendencias , Estudios Retrospectivos , Salud Rural , Estados Unidos , Salud Urbana , Recursos Humanos , Carga de Trabajo/estadística & datos numéricosRESUMEN
This study reports the economic contributions of nursing home practice to an academic department of family practice as well as the fiscal impact of referrals from nursing home practice on an academic medical center. Payment to primary physician faculty for nursing home service did not fully compensate for faculty effort. Nevertheless, these services did result in significant revenues to consulting physicians and the University Hospital. In aggregate, an average nursing home visit was associated with $33 in charges for the visit by the primary physician, $15 for additional primary care services in the clinic and hospital, $72 for services by consulting physicians, and $307 in charges by the University Hospital. The average nursing home patient provided $3,744 in charges and $2,403 in income to the academic medical center per year, with $1,813 going to the hospital and $331 to consulting physicians. Even though primary care is not well reimbursed, a relatively small number of patients have the capacity to create substantial income for consulting physicians and the hospital. The study does not address whether these nursing home referrals to the hospital utilized disproportionately high hospital resources.
Asunto(s)
Centros Médicos Académicos/economía , Medicina Familiar y Comunitaria/economía , Casas de Salud/economía , Afiliación Organizacional/economía , Medicina Familiar y Comunitaria/educación , Honorarios y Precios , Geriatría/economía , Geriatría/educación , Departamentos de Hospitales/economía , Missouri , Atención Primaria de Salud/economía , Derivación y ConsultaRESUMEN
For decades Vitamin B12 injections have been administered to patients with no documented deficiency. A previous study identified a cohort of patients who described vitamin B12-responsive symptoms despite lack of cobalamin deficiency as measured by conventional laboratory tests. These patients have been studied further and, when compared with controls, were found to have had more prescriptions for psychoactive drugs (P less than .001) and to have had more hospitalizations related to symptoms suggestive of neuropsychiatric problems (P less than .01). To confirm these findings and to determine national estimates for vitamin B12 use, an analysis of the 1985 National Ambulatory Medical Care Survey (NAMCS) was conducted. This analysis supports a significantly higher frequency of neuropsychiatric complaints among patients who received vitamin B12 injections (P less than .001). In addition, the NAMCS analysis indicates that of the calculated 2,516,564 vitamin B12 injections given in 1985, only 376,488 were for a diagnosis compatible with a cobalamin deficiency state (a 7:1 observed over expected ratio). According to the national data set analysis, vitamin B12 injections are given most frequently in the rural south by a doctor of osteopathy in solo practice.
Asunto(s)
Fatiga/tratamiento farmacológico , Trastornos Mentales/epidemiología , Vitamina B 12/uso terapéutico , Anciano , Medicina Familiar y Comunitaria , Fatiga/complicaciones , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Trastornos Mentales/complicaciones , Trastornos Mentales/tratamiento farmacológico , Medio Oeste de Estados Unidos/epidemiología , Psicotrópicos/uso terapéutico , Estudios Retrospectivos , Población RuralRESUMEN
A review of the records of patients attending a rural family practice clinic indicated that 13% had received "cold shots" (lincomycin with or without chlorpheniramine). The providers who assumed management of the clinic when the previous physician retired judged these injections inappropriate, but patients believed that they were effective and expected to continue to receive them. This study included 51 consecutive patients seen in the clinic for treatment of a cold and compared those who expected an injection with those who did not. Thirty-four patients (67%) expected an injection but instead received education about upper respiratory tract infections and symptomatic treatment. Half of these patients (17) were not satisfied with this alternative, and 10 reportedly went to another provider for an injection. Compared with patients who did not expect an injection, patients who did were older (P less than .001), had longer duration of symptoms (P less than .02), and were more likely to have tried nonprescription remedies (P less than .001). Analysis of the 1985 National Ambulatory Medical Care Survey indicates that the administration of lincomycin is not uncommon (an estimated 800,000 injections were given in 1985) and that lincomycin is more likely to be administered by a rural solo physician practicing in the north central or southern regions of the United States.
Asunto(s)
Comportamiento del Consumidor , Lincomicina/uso terapéutico , Pautas de la Práctica en Medicina , Infecciones del Sistema Respiratorio/tratamiento farmacológico , Salud Rural , Virosis/tratamiento farmacológico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Interpretación Estadística de Datos , Estudios de Evaluación como Asunto , Femenino , Educación en Salud , Humanos , Lactante , Recién Nacido , Inyecciones Intramusculares , Lincomicina/administración & dosificación , Masculino , Persona de Mediana Edad , Missouri/epidemiología , Estudios Prospectivos , Infecciones del Sistema Respiratorio/epidemiología , Infecciones del Sistema Respiratorio/etiología , Estados Unidos/epidemiología , Virosis/complicaciones , Virosis/epidemiologíaRESUMEN
A review of the literature of the 1980s reveals that women living in rural American are at risk for receiving inadequate prenatal and maternal care. Documented risk factors include poverty and concomitant lack of medical insurance, residence in the most restrictive Medicaid states, and loss of local services including the closure of obstetric units of rural hospitals and the decision by local physicians to discontinue obstetrics. A prominent factor in a physician's decision to stop providing maternity care is the escalating cost of medical liability insurance; however, other forces are also at work, including interference with personal and family activities, disruption of other aspects of professional life (e.g., office schedule), inadequate reimbursement, and an inability to keep up with advancing technology. A research agenda for the 1990s should be consistent with previous recommendations and must stimulate the development of new programs that will induce the maximum number of providers to again offer high quality perinatal care to rural women. Other items on the 1990s research agenda include: (1) the clarification of the impact of lost perinatal services in rural areas, (2) the effects of travel time and distance on perinatal outcomes and cost of care, (3) the effect of loss of obstetric services on other health care services for women and children, and (4) comparisons of regionalized versus centralized systems for the provision of perinatal services.
Asunto(s)
Investigación sobre Servicios de Salud , Salud Rural , Niño , Demografía , Femenino , Hospitales Rurales/organización & administración , Humanos , Servicio de Ginecología y Obstetricia en Hospital/normas , Pobreza , Embarazo , Atención Prenatal , Estados Unidos/epidemiologíaRESUMEN
Family and general practitioners have historically provided a substantial portion of obstetric care in rural parts of the United States, including Missouri. The authors surveyed 328 rural general physicians to determine their participation in obstetrics. Their findings show a dramatic loss of physician obstetric services in rural Missouri and suggest that the dilemma is not likely to be easily remedied.
Asunto(s)
Obstetricia , Médicos de Familia/provisión & distribución , Salud Rural , Adulto , Humanos , Seguro de Responsabilidad Civil/economía , Persona de Mediana Edad , MissouriRESUMEN
To identify predictors of mortality, the records of 133 elderly patients with pneumonia admitted to a small rural midwestern hospital were examined using a retrospective cohort design. All recorded clinical information available to the patient's physician within the first hours of admission was reviewed. Twenty-one (15.8%) patients died during the hospitalization. Patients with preexisting coronary heart disease, dementia, urinary incontinence, and impaired mobility were more likely to die. Impaired mental status, absence of fever, rapid respiratory rate, hypotension, cyanosis, and diffuse abnormalities on chest examination were also associated with mortality. Logistic regression analysis revealed five predictive indicators of mortality: impaired level of consciousness (odds ratio [OR] = 11.3), tachypnea (OR = 10.8), temperature lower than normal (OR = 14.2), white cell count higher than 20 X 10(9)/L (20,000 mm-3) (OR = 12.2), and cyanosis (OR = 8.6). A risk score based on this regression model demonstrated that 1 of 95 patients with a score lower than 3 (1%), 7 of 22 with a score of 3 (32%), and 13 of 15 patients with a score higher than 3 (87%) died during their hospitalization. The validity of this risk-scoring system was confirmed in another sample of 40 patients. Studies such as this may be useful in identifying information of important prognostic value that enables physicians, patients, and family members to make more effective decisions.
Asunto(s)
Hospitales Rurales/estadística & datos numéricos , Hospitales/estadística & datos numéricos , Neumonía/mortalidad , Anciano , Temperatura Corporal , Enfermedades Cardiovasculares/complicaciones , Estudios de Cohortes , Demencia/complicaciones , Femenino , Estudios de Seguimiento , Hospitales con menos de 100 Camas , Humanos , Masculino , Persona de Mediana Edad , Missouri/epidemiología , Modelos Estadísticos , Neumonía/complicaciones , Neumonía/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Población RuralRESUMEN
We studied 65 rural hospitals in Missouri that provided obstetric services in 1986. The hospitals were divided into three groups on the basis of their physician obstetric staff: family or general practitioners only (38 hospitals), family practitioners and obstetricians (22 hospitals), and obstetricians only (five hospitals). From birth certificate data, we detected a decline in the mean number of births in all groups of rural hospitals comparing 1980-1983 with 1984-1987. Births in family practice only hospitals declined most over the past four years (35%), whereas there was only a 4 percent decline in the number of births to rural Missouri women. In 1987, 10 of the 38 family practice only hospital obstetric units closed due to loss of physician services, whereas none of the other hospitals stopped providing obstetric care (X2 = 8.40, p less than 0.005). These findings suggest that rural hospitals with family and general practitioners exclusively on their obstetric staffs are at significant risk of closing their obstetric units.
Asunto(s)
Instituciones de Salud , Clausura de las Instituciones de Salud , Accesibilidad a los Servicios de Salud , Departamentos de Hospitales/provisión & distribución , Hospitales Rurales/organización & administración , Servicio de Ginecología y Obstetricia en Hospital/provisión & distribución , Estudios de Evaluación como Asunto , Femenino , Hospitales , Humanos , Entrevistas como Asunto , Missouri , Médicos de Familia , Embarazo , RiesgoRESUMEN
As family and general practitioners who provide a substantial portion of the obstetric care in rural areas quit their obstetric practice, small rural hospital obstetric units are at risk of closing. Using a case study design, we examined the impact of the loss of obstetric services at a small rural hospital in Missouri. This unit was the site of delivery for less than one-half of the infants born to women living within its service area. However, it was the most likely source of care for women who were young, undereducated and unmarried (p less than 0.01). Evidence derived from birth certificates showed that women who delivered there had good perinatal outcomes compared with local women who delivered at larger hospitals. A gradual decline in the number of physicians providing obstetric care preceded the closing of the hospital unit. Women from the hospital service area who presented late for prenatal care were twice as likely to have had a low birthweight infant in the year after the local hospital unit closed (16.7% versus 7.4%), although this difference and other comparisons of outcomes were not statistically significant.
Asunto(s)
Instituciones de Salud , Clausura de las Instituciones de Salud , Accesibilidad a los Servicios de Salud , Departamentos de Hospitales/provisión & distribución , Hospitales Rurales/organización & administración , Servicio de Ginecología y Obstetricia en Hospital/provisión & distribución , Estudios de Evaluación como Asunto , Femenino , Hospitales , Humanos , Missouri , Médicos de Familia , EmbarazoRESUMEN
We reviewed the records of 1222 patients who attended a newly acquired rural satellite clinic and found that 120 (10%) had been receiving regular cyanocobalamin injections, but that only 4 (3%) met accepted criteria for its administration. Open-ended interviews with 48 of these patients revealed that they had been receiving cyanocobalamin injections for a mean of 9.9 years for 3.3 symptoms each and with a mean effectiveness rating of 2.9 (scale, 0 to 4). After receiving education regarding the appropriate indications for cyanocobalamin injections, 25 (52%) of the patients were willing to stop receiving them at least temporarily. However, 18 patients (38%) who were younger and who reported greater symptom relief would actively seek a physician who would continue to administer cyanocobalamin. Our findings suggest that some patients who have been receiving cyanocobalamin injections but who do not have a documented deficiency will stop receiving the injections when presented with reasonable alternatives.
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Educación del Paciente como Asunto , Participación del Paciente , Vitamina B 12/administración & dosificación , Anciano , Anciano de 80 o más Años , Instituciones de Atención Ambulatoria , Fatiga/tratamiento farmacológico , Femenino , Humanos , Inyecciones Intramusculares , Masculino , Persona de Mediana Edad , Salud Rural , Deficiencia de Vitamina B 12/diagnóstico , Deficiencia de Vitamina B 12/tratamiento farmacológicoRESUMEN
Loss of a general surgeon in a rural community cna alter the referral patterns, the image and utilization of the local hospital, and even the market share of local primary care physicians. Prior research has not defined the necessary and/or sufficient conditions for a rural county to be able to support a local general surgeon. Based upon empirical analysis of 96 rural Missouri counties and the limited literature available on rural surgeons and physician referral rates, a first approximation of those conditions are offered. We conclude that a rural county with a hospital, a population base of more than 15,000 people, and at least 11 potential referring physicians has sufficient conditions to enable it to support a local general surgeon. Among those rural Missouri counties not meeting the above conditions but having a general surgeon in 1984, we estimate that 8 to 10 potential referring physicians appear to be the minimum necessary condition for supporting a rural general surgeon through patient referral. From those conclusions, we argue that any rural hospital currently without a surgeon should re-examine its situation. To prepare for a competitive future, such a hospital should take every opportunity to expand the referral base necessary to support a full-time local surgeon rather than place long-term reliance upon itinerant general surgeons.
Asunto(s)
Áreas de Influencia de Salud , Cirugía General , Hospitales Rurales/estadística & datos numéricos , Hospitales/estadística & datos numéricos , Cuerpo Médico de Hospitales , Administración de Personal , Admisión y Programación de Personal , Missouri , Ubicación de la Práctica Profesional , Derivación y Consulta , Población Rural , Estadística como Asunto , Recursos HumanosRESUMEN
Gene D5 is not only necessary for replication of bacteriophage T5 DNA and for shutoff of expression of some early genes, but has been found to be necessary also for the expression of late T5 genes. The polypeptide product of gene D5 has been identified, an intragenic map of gene D5 has been constructed, and the direction of transcription of gene D5 has been established. The polypeptide coded by gene D5 has been shown to be a DNA-binding protein with affinity for both double- and single-stranded DNA.
Asunto(s)
Colifagos/genética , ADN Helicasas/biosíntesis , ADN Viral/biosíntesis , Genes Virales , Proteínas Virales/biosíntesis , Colifagos/metabolismo , ADN Helicasas/fisiología , Biosíntesis de Proteínas , Proteínas Virales/fisiologíaRESUMEN
The change of infectivity of phage DNAs after heat and alkali denaturation (and renaturation) was measured. T7 phage DNA infectivity increased 4- to 20-fold after denaturation and decreased to the native level after renaturation. Both the heavy and the light single strand of T7 phage DNA were about five times as infective as native T7 DNA. T4 and P22 phage DNA infectivity increased 4- to 20-fold after denaturation and increased another 10- to 20-fold after renaturation. These data, combined with other authors' results on the relative infectivity of various forms of phiX174 and lambda DNAs give the following consistent pattern of relative infectivity. Covalently closed circular double-stranded DNA, nicked circular double-stranded DNA, and double-stranded DNA with cohesive ends are all equally infective and also most highly infectious for Escherichia coli lysozyme-EDTA spheroplasts; linear or circular single-stranded DNAs are about 1/5 to 1/20 as infective; double-stranded DNAs are only 1/100 as infective. Two exceptions to this pattern were noted: lambda phage DNA lost more than 99% of its infectivity after alkaline denaturation; this infectivity could be fully recovered after renaturation. This behavior can be explained by the special role of the cohesive ends of the phage DNA. T5 phage DNA sometimes showed a transient increase in infectivity at temperatures below the completion of the hyperchròmic shift; at higher temperatures, the infectivity was completely destroyed. T5 DNA denatured in alkali lost more than 99.9% of its infectivity; upon renaturation, infectivity was sometimes recovered. This behavior is interpreted in terms of the model of T5 phage DNA structure proposed by Bujard (1969). The results of the denaturation and renaturation experiments show higher efficiencies of transfection for the following phage DNAs (free of single-strand breaks): T4 renatured DNA at 10(-3) instead of 10(-5) for native DNA; renatured P22 DNA at 3 x 10(-7) instead of 3 x 10(-9) for native DNA; and denatured T7 DNA at 3 x 10(-6) instead of 3 x 10(-7) for native DNA.