Roles of the federal and state governments in outcomes assessment.

Both federal and state governments have mandates to collect, analyze, and disseminate health care information. The federal government is the single largest payer for health care and health services research. Its agencies, the Healthcare Finance Administration (HCFA) and the Agency for Healthcare Policy Research (AHCPR) play a major role in shaping information strategies for all health care stakeholders. State governments are among those stakeholders and are fertile grounds for experimentation, change, and learning. Building effective federal-state partnerships and public-private partnerships can help foster innovation in health data collection and analysis, as well as identify new strategies for information dissemination.

Public reporting of clinical outcomes--the data needs of health care stakeholders.

The Pennsylvania Health Care Cost Containment Council (PHC4) was created by the Pennsylvania legislature to promote cost constraint and assure quality of care by providing public information about the performance of health care providers. Today the Council is challenged by the information needs of multiple users including business, labor, insurers, managed care organizations, hospitals, physicians, and the public. Each of these interest groups has different priorities for the types of activities and reports of the Council. PHC4 must carefully balance the information needs of each of these stakeholders. All stakeholders believe that an assessment of the impact of changes currently underway within the delivery system must occur. PHC4 must continue to provide meaningful and more timely outcomes information and also find an appropriate role to augment data from other sources regarding the implications of the movement toward managed care.

A MEDLINE feasibility study.

A MEDLINE feasibility study was conducted with the Northeastern Consortium for Health Information (NECHI) and sponsored by the New England Regional Medical Library Service. It is based on the theory that most potential users and supporters of MEDLINE within hospitals are unaware of its usefulness and applications, and that there exists a need for expanding MEDLINE services to more hospital libraries. The purpose of the study was to provide NECHI with an evaluation of MEDLINE as a feasible service by ascertaining the need and by evaluating the usefulness, satisfaction, and costs of the system. The study demonstrated sufficient use of MEDLINE to justify implementation within NECHI and it provided useful data to determine the future of MEDLINE in each institution. It documented that utilization improved rapidly with publicity and the presence of the system within an institution, that MEDLINE can be an effective and economical complement to the traditional reference services used to support information needs in hospitals, and that more hospital libraries should be able to implement MEDLINE to their advantage once potential users and supporters have been exposed to the system.

Phenothiazine analgesia--fact or fantasy?

Double-blind clinical trials involving the use of phenothiazines as analgesics or potentiators of analgesics (aspirin, meperidine, morphine sulfate) and adverse effects of phenothiazines are reviewed and evaluated. Promethazine, promazine and propiomazine were not found to possess analgesic or potentiating properties. One chlorpromazine study contained important design and reporting deficiencies which precluded a recommendation for use of chlorpromazine in the treatment of pain. Methotrimeprazine was determined by numerous authors to have analgesic properties; however, most of the studies also were deficient in design or data presented, or both. Adverse reactions to phenothiazines, including hypotension, sedation, drowsiness, extrapyramidal symptoms, tardive dyskinesia, cardiac toxicity and agranulocytosis, are often more common and severe than those attributed to narcotic analgesics. Because of the lack of data supportive of analgesic activity and the adverse reactions associated with phenothiazines, use of these agents in the management of pain should be discouraged. The prophylactic use of phenothiazine for narcotic analgesic-induced emesis also is, in most cases, a questionable practice.

Osteogenic sarcoma of the maxilla: neutron therapy for unresectable disease.

Purpose. To present a case study involving the use of fast neutron therapy to treat an extensive unresectable osteogenic sarcoma arising from the left maxilla.Patient. A 14-year-old male presented with a massive tumor producing severe distortion of his facial structures. He had already received six courses of chemotherapy, which had reduced his pain, but had not measurably reduced the tumor.Methods. The patient was treated with 66 MeV fast neutrons to a dose of 20.4 Gy in 13 fractions over 35 days.Results. CT assessments indicate gradually increasing calcification and noticeable reduction of soft-tissue disease in the frontal sinus, orbit and maxillary antrum.There has been some recontouring of the facial structures.The boy conducts an active life, has no pain, and feels well. He was 17 years old at the last follow-up.Discussion. Fast neutrons have a greater biological effectiveness than conventional photon beams. Their use has been associated with improved chance for local control of unresectable disease.This case illustrates their effectiveness in controlling an unusual and aggressive osteogenic sarcoma of the facial bone and sinuses.