Gas emissions, minerals, and tars associated with three coal fires, Powder River Basin, USA.

Ground-based surveys of three coal fires and airborne surveys of two of the fires were conducted near Sheridan, Wyoming. The fires occur in natural outcrops and in abandoned mines, all containing Paleocene-age subbituminous coals. Diffuse (carbon dioxide (CO(2)) only) and vent (CO(2), carbon monoxide (CO), methane, hydrogen sulfide (H(2)S), and elemental mercury) emission estimates were made for each of the fires. Additionally, gas samples were collected for volatile organic compound (VOC) analysis and showed a large range in variation between vents. The fires produce locally dangerous levels of CO, CO(2), H(2)S, and benzene, among other gases. At one fire in an abandoned coal mine, trends in gas and tar composition followed a change in topography. Total CO(2) fluxes for the fires from airborne, ground-based, and rate of fire advancement estimates ranged from 0.9 to 780mg/s/m(2) and are comparable to other coal fires worldwide. Samples of tar and coal-fire minerals collected from the mouth of vents provided insight into the behavior and formation of the coal fires.

The next stage in the health care economy: aligning the interests of patients, providers, and third-party payers through consumer-driven health care plans.

This article reviews employers' attempts over the past 25 years to address the cost and accessibility of health care services for their employees and the effect these efforts have had on U.S. health care delivery. The difficulties in aligning the interests of all parties in a third-party health beneficiary contract are examined. Many employers are considering consumer-driven health care plans as an alternative to managed care plans to both control health care costs and improve employee satisfaction. Such plans differ from fee-for-service and managed care models in terms of the economic alignment of the parties. Consumer-driven plans align the employer's economic interest with the employee/patient, and reduce health benefit costs by providing information, tools, and direct economic incentives to employees for self-management of health care dollars. Because these incentives are designed to reduce the consumption of services, providers are the party left out of economic alignment under the consumer-driven model.

Centralized oversight for clinical performance improvement: a pilot initiative at the Lexington VAMC.

BACKGROUND: In July 2000 the Lexington Veterans Affairs Medical Center (Lexington, Ky) centralized oversight of clinical performance improvement (CPI) activities by creating an office of clinical operations (OCO) to improve patient care and operational efficiency. The OCO was designed to eliminate redundancy of effort, correct resource underuse and overuse, and improve the communication of change initiatives and successes. Before 2000 no formal process existed for creating interdisciplinary CPI teams. Lack of organizational oversight for CPI activities had also led to duplication of effort, mixed accountability, and difficulty in remaining focused on organizational goals. CREATING THE OCO: OCO staff have led and facilitated numerous projects, all of which involved interdisciplinary teams consisting of physician and nurse leaders, users, and support staff. The OCO has also developed a utilization management plan for the entire medical center. The OCO formally interfaces with three major arenas of medical center operation: clinical processes, patient safety, and cost-efficiency. CHALLENGES AND LESSONS LEARNED: A major effort of OCO staff has been to learn about data availability and access and to determine how data can be used in a meaningful way to benefit CPI project teams. The creation of the OCO precipitated the typical cultural integration problems that are often encountered with the introduction of new organizational entities that lack existing turf.

Outcome report cards: a necessity in the health care market.

Measuring value (quality and cost) continues to be a major challenge in health care as providers respond to societal pressures (primarily from the payer) to standardize processes and patients assume the role of consumer. Relatively few studies report the extent to which report cards affect patient outcomes of care. Survey results indicate high levels of public distrust in report cards. The information that patients desire often is not what is reported because traditional indicators of quality often serve institutional needs rather than patient needs. Patients understand and value information framed as risk avoidance more so than as an opportunity for better health. Effective report cards are brief and simple. The model surgical report card for patients suggested herein includes ratings for patient satisfaction, functional status and well-being, specific symptom assessment, biologic indicators of disease progress, and costs. Successful report cards strike a balance between quality and cost that meets the needs of the stakeholder for whom they are intended.