Cost-effectiveness of Veterans Administration hospital-based home care. A randomized clinical trial.

A randomized design was used to examine the cost-effectiveness of a Veterans Administration hospital-based home care program that case managed inpatient and outpatient care. Patients (N = 419) with two or more functional impairments or a terminal illness were randomized to hospital-based home care (n = 211) or customary care (n = 208). Functional status, satisfaction with care, and morale were measured at baseline and at 1 and 6 months after discharge from the hospital; health care utilization was tracked for 6 months. Findings included significantly higher (0.1 on a three-point scale) patient and caregiver satisfaction with care at 1 month and lower Veterans Administration and private sector hospital costs ($3000 vs $4245) for the experimental group. Net per person health care costs were also 13% lower in the experimental group. We conclude that this model of hospital-based home care is cost-effective and that its expansion to cover these two patient groups throughout the Veterans Administration system can improve patient care at no additional cost.

Cost-effectiveness of home care.

Home health care is uniformly accepted by patients, caregivers, health professionals, policymakers, and the public as a desirable way to provide care to disabled individuals and the frail elderly. Given the lack of positive impact of home care upon functional status, cost, and nursing home use, as well as documented additional cost, future research must focus upon positive aspects from past experiences. Careful targeting of patients most likely to benefit from this care has produced better results. Satisfaction with care has been shown consistently. Managed home health care may have the potential, especially the impact of physician involvement with team care on hospital use, to contain costs. The intuitive belief that home care is beneficial and a worthwhile expense, held by policymakers and health care professionals alike, needs to be fully researched by studies that carefully examine the wide spectrum of home care benefits for disabled or chronically ill individuals in relation to varying cost levels that the population and health care system can absorb. The challenge is here, and those who believe in home care need to make use of the results of these previous, rather nonsupportive studies. Additional research is needed to measure the impact of active physician participation in the team care provision of home care services and the impact of managed home care on the cost of hospital care in the population most at risk for recurrent hospitalization. This same research must document not only more effective targeting of individuals, but also the maintenance of increased satisfaction with care--strongest motive for the need to prove the cost-effectiveness of home care.

Integrating management concepts into licensed practical nurse and associate degree in nursing student clinical experiences.

In an associate degree nursing program in which students have the option to take the practical nurse licensing examination at the end of the first year, management concepts and experiences are introduced during the second semester. Many students work as licensed practical nurses and are expected to manage care for groups of clients. Using this model, students work together to practice time management and leadership skills.

Is There a Predisposition Gene for Ewing's Sarcoma?

Ewing's sarcoma is a highly malignant tumor of children and young adults. The molecular mechanisms that underlie Ewing's Sarcoma development are beginning to be understood. For example, most cases of this disease harbor somatic chromosomal translocations that fuse the EWSR1 gene on chromosome 22 with members of the ETS family. While some cooperative genetic events have been identified, such as mutations in TP53 or deletions of the CDKN2A locus, these appear to be absent in the vast majority of cases. It is therefore uncertain whether EWS/ETS translocations are the only consistently present alteration in this tumor, or whether there are other recurrent abnormalities yet to be discovered. One method to discover such mutations is to identify familial cases of Ewing's sarcoma and to then map the susceptibility locus using traditional genetic mapping techniques. Although cases of sibling pairs with Ewing's sarcoma exist, familial cases of Ewing's sarcoma have not been reported. While Ewing's sarcoma has been reported as a 2nd malignancy after retinoblastoma, significant associations of Ewing's sarcoma with classic tumor susceptibility syndromes have not been identified. We will review the current evidence, or lack thereof, regarding the potential of a heritable condition predisposing to Ewing's sarcoma.

Antibody responses to influenza vaccination in patients with chronic renal failure.

A bivalent type A inactivated influenza virus vaccine containing both sets of H3N2 and Hsw1N1 antigens was given to patients with chronic renal failure and to control subjects. The patients were divided into an azotemic group in whom dialysis was not yet required and a hemodialyzed group. Hemagglutination-inhibition (HI) antibody responses were measured at time intervals of 1,3, and 4 weeks after vaccination. We found that the mean postvaccination HI titers against both sets of antigens in the patients as a group did not differ significantly from those found in the control subjects as a group. The proportion of responders showing a fourfold or greater increase in post-vaccination antibody responses over prevaccination antibody values for either set of antigens was similar in both groups of patients and the group of control subjects. In general, an inverse correlation was found between prevaccination antibody levels and postvaccination antibody responses in both patients and control subjects. The only exception to this trend was the response of two of the azotemic patients to the H3N2 antigens who failed to respond despite low prevaccination antibody levels. These were the patients with the highest serum creatinine values.