Shared management of children with cancer.

OBJECTIVE: To determine the risks and benefits of university-based pediatric oncologists and community-based primary care physicians sharing the management of children with cancer. DESIGN: Physicians participating in shared management of children with cancer were surveyed, and the outcomes of the children were measured. SETTING AND PARTICIPANTS: One hundred thirty-seven community-based primary care physicians participated in the management of the 226 children with cancer in Iowa and western Illinois during the past 15 years. The survival of the 226 children was compared with that of 240 randomly selected children treated using the identical treatment protocols but treated only by pediatric oncologists. INTERVENTION: A 7-point Likert scale questionnaire was completed by 97 (71%) of the participating primary care physicians. RESULTS AND OUTCOME MEASURES: There were no differences in the survival of children using shared management compared with those treated only by pediatric oncologists. Primary care physicians believed that shared management is of economic and psychosocial benefit to patients, improves the treatment choices available to patients, does not require excessive time, and does not result in loss of practice income. The system strengthens the primary care physicians' relationships with oncologists and results in additional referrals to the university-based pediatric oncologists. It is of educational value, is personally satisfying, and provides relief from the stress associated with caring for these families. Primary care physicians would like to see this system expanded to include other children with special health care needs. CONCLUSION: The shared-management approach to care is a viable attractive option of health care provision for children.

Life-cycle models of saving and the effect of the timing of divorce on retirement economic well-being.

The long-term effect of the current high rate of divorce upon the future economic status of individuals has not been thoroughly analyzed. This study reviews the retirement, precautionary, and bequest motives for saving, then evaluates how marriage dissolution may (a) decrease the family's savings rate, (b) cause shifts in the family's portfolio to assets with lower rates of return, and (c) destroy or deplete existing family assets. Whether divorce interrupts the savings process or destroys assets, it is unlikely that most individuals will be able to save enough in later life to overcome the loss. The long-term effect may well be that, in future years, we will recognize a new category of elderly poor, those who have experienced the dissolution of their marriage.

"Risk" factors affecting readmission of the elderly into the health care system.

One hundred one patients, 70 years and older, who were discharged to the community from an acute-care hospital were followed for 1 year to isolate risk factors affecting the probability of readmission. A total of five interviews were conducted with each patient. Postdischarge outcome at any point in time was defined as either readmission to a health care institution or continuous survival in the community. At 1 year, 47 individuals had experienced at least one unplanned readmission. Logistic regressions were used to study risk factors influencing the probability of readmission at 6 weeks, 6 months, and 1 year after release from the hospital. In the short run, sex, being widowed, a weighted severity-of-illness factor, and life satisfaction were significant; previous hospitalization and admission and discharge location were additional variables significant in the long run. An explanation is offered for why some risk factors useful in postadmission studies do not function as well as risk factors in post-discharge studies.

Physician incentives for shared management of childhood cancer patients.

Four years' experiences of 69 primary care physicians who delivered more than 70% of the chemotherapy to 174 children with cancer were assessed. Five academic pediatric oncologists were responsible for diagnosis, assignment to a clinical trial protocol, and overall management. The academicians saw the patients at diagnosis and at regularly scheduled intervals but provided care for less than 30% of the outpatient visits. Factors examined included: (1) why the primary care physicians agreed to participate in the care of these patients, (2) how they thought their participation affected the patient and the patient's family, (3) how participation affected their personal and professional development, (4) how participation affected their practice, (5) what their perceptions were concerning the merits of traditional specialist management, and (6) their overall evaluation of the Iowa shared-management program. The initial agreement by primary care physicians to participate in shared management was related to their perception that it would improve the overall care of their patients. The physicians agreed that the program saved the family time and money, was of educational value, personally satisfying, and not economically detrimental to their practice. They did not identify areas where specialist management had clear advantages over shared management and none reported dissatisfaction with this management program.