Comparison of two systems for stroke rehabilitation in a general hospital.

This study was designed to compare the effectiveness of stroke rehabilitation therapy in a specialized Stroke Unit with that provided on the medical service of a general hospital (Rhode Island Hospital). The 8-bed Stroke Unit is staffed by a multidisciplinary team, and a weekly conference is held for evaluation and planning. On the basis of data obtained from the hospital records, two groups of patients were studied: 224 who were treated in the Stroke Unit, and 110 who were evaluated and approved for admission to the Unit but were not accommodated. A rigid "first come, first served" policy for admission to the Unit was observed. Hypothesis testing was performed with reference to the patient's medical condition, socioeconomic status, demographic characteristics, and difficulties during hospital stay to determine whether the groups were comparable. A patient was considered to have improved if his condition decreased in severity between the time of admission to therapy and the time of discharge. Severity was rated as: mild (level one), moderate (level two), severe (level three), and profound (level four). No significant difference in rehabilitation results was found between the two treatment systems at severity levels two (moderate) and four (profound). However, the Stroke Unit attained significantly better results with level-three patients (severe stroke). This group received more sessions of physical therapy and remained in the hospital longer than did the level-three patients treated on the general medical service. Physicians referred patients selectively to the Stroke Unit, althoug the Unit had no policy of screening patients for admission, and this may have had some influence on the achievement of better results with level-three patients. Level-four patients did not do well in either setting.

Assessment of thrombogenicity of prothrombin complex concentrates in a porcine model.

Infusion of prothrombin complex concentrates into pigs resulted in evidence of disseminated intravascular coagulation manifested by positive fibrin monomer tests, depletion of coagulation factors and platelets, and the presence of fibrin in small blood vessels at autopsy. All of the nine prothrombin complex concentrates were found to be thrombogenic. The response appeared to be dose-related, and the two activated materials were more thrombogenic than the non-activated products. In contrast, a purified factor IX concentrate resulted in minimal transient changes in only 2 of 5 animals tested, and autopsy findings were negative for fibrin deposition in all. Four of these animals received 200 factor IX units/kg, which was twice the dose used for any of the other products. Control animals received human plasma or albumin with no evidence of coagulation changes or fibrin deposition at autopsy. The porcine model is more sensitive than other animal models for detection of the thrombogenic effects of prothrombin complex concentrates and may be useful for testing new products found to be non-thrombogenic in other test procedures.

How successfully can academic faculty practices compete in developing managed care markets?

The author investigated the range of competitive options available for academic faculty practices and their associated academic medical centers located in health care markets with relatively limited development of managed care plans. Using personal and telephone interviews, he studied two such markets in 1994, one in Philadelphia, Pennsylvania, and one in Atlanta, Georgia. Representatives of faculty practices in these cities were asked to assess whether their practices would be attractive or unattractive for contracting with managed care providers; eight attributes of faculty practices (e.g., specialist physicians' availability within the group; prices of services offered by the group) were used as criteria. Similarly, representatives of local managed care plans were asked to use the same criteria to indicate what they would consider attractive or not in their local faculty practices when considering a physician services contract with such a practice. In both markets, the image of the academic medical center was generally considered to be a strong asset to the faculty practices. But all sectors also agreed that the nature of practices' utilization management and what was seen as their excessive use of resources in the academic environment were causes for concern. Also, the difference between the practice patterns of managed care physicians and academic faculty physicians was regarded as a cultural one in which traditional patterns of academic training are considered inimical to fostering the prudent management of patients. The findings strongly suggest that opportunities for faculty practices to negotiate with managed care plans and help shape their areas' future health care environments still exist in developing markets throughout the United States. But even those practices with such opportunities cannot succeed without significant internal restructuring to transform themselves to successfully deal with the new world of managed care.

Organizational models for medical school-clinical enterprise relationships.

Changes in the organization, financing, and delivery of health care services have prompted medical school leaders to search for new organizational models for linking medical schools, faculty practice groups, affiliated hospitals, and insurers-models that better meet the contemporary challenges of governance and decision making in academic medicine. However, medical school leaders have relatively little information about the range of organizational models that could be adopted, the extent to which particular organizational models are actually used, the conditions under which different organizational models are appropriate, and the ramifications of different organizational models for the academic mission. In this article, the authors offer a typology of eight organizational models that medical school leaders might use to understand and manage their relationships with physicians, hospitals, and other components of clinical delivery systems needed to support and fulfill the academic mission. In addition to illustrating the models with specific examples from the field, the authors speculate about their prevalence, the conditions that favor one over another, and the benefits and drawbacks of each for medical schools. To conclude, they discuss how medical school and clinical enterprise leaders could use the organizational typology to help them develop strategy and manage relationships with each other and their other partners.

Organizational models of medical school relationships to the clinical enterprise.

The authors analyzed existing relationships between medical schools and clinical enterprises in order to develop models of these relationships. The conceptual framework for the models uses three variables to assess the nature of the relationships: (1) high academic control-high clinical enterprise control; (2) high academic influence-low academic influence; and (3) self-contained system-open system (i.e., the extent to which the resources needed for clinical education are provided by the relationship between the clinical enterprise and the medical school). The authors present four conceptual models of the relationship between the medical school and the clinical enterprise: (1) The "single ownership; owned integrated system" is characterized by a closed clinical delivery system owned or controlled by the academic institution. (2) The "general partner" organization emphasizes an open clinical environment in which the medical school forms alliances with clinical entities, and the school is a dominant partner. (3) The "limited partner" organization operates with an open clinical delivery system that the school relates to through affiliations and contractual relationships, and the school is a less dominant partner. (4) The "wholly owned, subsidiary" organization operates in a controlled clinical environment in which the medical school is a subsidiary of the larger integrated delivery system. Each model is presented in its pure organizational form, then augmented with descriptions of the different ways that the medical school and other components may relate to each other. Also, the advantages and disadvantages of each model for the medical school are discussed. The authors emphasize that no model is superior to the others; instead, the best choice for a medical school depends on the history, local circumstances, and leadership of the school and other organizations. The authors' intent is to assist the leaders of medical schools as they design strategies for the future relationships of their institutions.

Ontogeny of bovine hemostasis.

Ontogeny of selected hemostatic system components was studied in 120 bovine fetuses which had been divided into eight monthly gestational age groups. Fetal blood was subjected to the following tests: platelet count, partial thromboplastin time, prothrombin time, thrombin time, fibrinogen quantitation, and assays for prothrombin and factors V and VIII. Platelet numbers corresponding to adult numbers were in fetal blood at least as early as gestation day 60, and their numbers varied only slightly thereafter. Bovine blood was incapable of in vitro coagulation at gestation day 90, with all samples coagulating by gestation day 150. Fetal coagulation screening test times (partial thromboplastin time, prothrombin time, and thrombin time) shortened during gestation and were near times of adults at birth. Of the four individual coagulation factors tested, only factor VIII reached adult values in the fetus in utero. Amounts of fibrinogen, prothrombin, and factors V and VIII in the neonate exceeded that of normal adult cattle.

Esophageal/gastric leiomyoma in the laboratory Beagle.

In a colony of 306 laboratory Beagles, gastric leiomyoma was diagnosed at necropsy (n = 69) and by biopsy (n = 1). The prevalence in males and females was nearly identical (23% and 22%, respectively). The neoplasm was strongly age related (P less than 0.001) and was seen in 82.4% of dogs aged 17 to 18 years. In contrast to malignant gastric tumors that generally are found in the distal two thirds of the stomach, the leiomyomas were found at the esophageal/gastric junction in 94% of cases. Clinical signs could not be specifically attributed to these masses, though their recognition was important in the differential diagnosis from other more serious gastric neoplasms.

Health care as a social good: trauma care and the "kindness of strangers".

Urban trauma centers have been shown in the medical literature to be effective resources for dealing with traumatic injury in a manner which results in demonstrated increases in survival rates. Given that much debate exists over the relative efficacy of various technological medical interventions, the acceptance and diffusion of a "proven" technology, such as trauma centers, should be assured. Yet, the significant investment of resources required to staff, equip, and maintain a trauma center, coupled with a perceived fiscal deterioration of the provision of these services, has resulted in a retreat from the concept through closure of the services.

Doctoral education in executive format, or fitting the Procrustean Bed: an exercise in organizational change.

Doctoral education in health administration has been heavily influenced by the model of the traditional academic research Doctor of Philosophy. This powerful traditional template has been appropriate for the advancement of research and scholarship in health systems administration, but not necessarily for the advancement of the field of practice. With the advent of executive doctoral programs that feature larger student cohorts, routinized curricula, and student bodies comprised of experienced professionals, the expectations for doctoral study in health systems administration are being tested as new models evolve. Faculty are reluctant to depart from the traditional doctoral forum, but will do so based upon demonstrated advantages in the area of publication opportunities, student responsiveness, and financial inducements. This paper examines the program in an executive format conforming to the existing degree offerings of the School of Public Health, and the process of balancing the traditional academic expectations with the executive format of content delivery.

Two-year quality of life after breast cancer surgery: a comparison of three surgical procedures.

PURPOSE: To analyze longitudinal changes in each subscale of a quality of life (QOL) measure and to explore their relationships to effective QOL predictors in breast cancer surgery patients. PATIENTS AND METHODS: This prospective study analyzed 172 patients at two tertiary academic hospitals. All patients completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its supplementary breast cancer measure (QLQ-BR23) at baseline and at 1 and 2 years postoperatively. The 95% confidence intervals for differences in responsiveness estimates were derived by bootstrap estimation. Scores derived by these instruments were interpreted by generalized estimating equation (GEE) before and after surgery. RESULTS: A 2-year follow-up survey of the examined population revealed significant (P < 0.05) improvement in each QOL subscale. In both postoperative surveys, effect size was largest in the QLQ subscales for patients who had received mastectomy with reconstruction and lowest in those who had received modified radical mastectomy. After adjusting for time effects and baseline predictors, GEE approaches revealed the following explanatory variables for QOL: time, type of surgical procedure, age, chemotherapy, radiotherapy, hormone therapy, and preoperative functional status. CONCLUSIONS: When evaluating QOL after breast cancer surgery, several factors other than the surgery itself should be considered. Patients should also be advised that their postoperative QOL might depend not only on the success of their operations, but also on their preoperative functional status.