Managed care and public health departments: who is responsible for the health of the population?

This review examines changes over the past decade in the delivery of health care in the United States, specifically the move toward managed care and capitation. Over 77 million Americans are now enrolled in health maintenance organizations, and the health care delivery system is reorganizing into large group practices and integrated health systems. Examined here are the implications of this shift on the interaction between managed care and public health agencies. How will a population-based system of health care be achieved in light of managed care organizations' responsibility only for their enrolled population, in contrast to the responsibility of the public health service for the entire population? Where does the responsibility of MCOs end and that of public health begin? Should certain public health functions be absorbed by managed care organizations? What are the prospects for partnership between these two systems?

Firearm ownership and health care workers.

OBJECTIVE: Health professionals have increasingly become aware of the public health hazards caused by firearms. This study was designed to determine the firearm ownership and storage practices of a group of health care workers. METHODS: All 6436 nonphysician employees of a large health maintenance organization were surveyed as part of an ongoing effort to enhance the organization's effectiveness. Two questions regarding firearm ownership and storage practices were included in the 85-question survey instrument. A total of 4999 surveys were returned, for a response rate of 78%. RESULTS: Forty-two percent of the health workers surveyed reported keeping a firearm in their home, and 35% of firearm owners stored that firearm loaded. Men were more likely than women to report having a firearm in the home. Firearm ownership and storage of a loaded firearm decreased with higher levels of education in both sexes. A measure of increased alcohol consumption was related to higher rates of firearm ownership and storage of loaded firearms in men. CONCLUSIONS: A substantial number of health care workers had firearms in their homes and did not store them safely. Counseling regarding the risks associated with easy access to firearms should be considered for inclusion in employee health programs as well as in employee assistance and alcohol treatment programs.

Firearm injury risk among primary care patients.

BACKGROUND: Firearm injuries are the eighth leading cause of death in the United States. Evidence suggests that availability of guns in the home is associated with an increased risk of homicide, suicide, and unintentional injuries and fatalities. Our study examined five demographically diverse primary care practices in Oregon to determine the extent to which patients and members of their households might be at risk for firearm injuries. METHODS: Six hundred and four consecutive English-speaking patients who were at least 18 years old and seeking care at the five different practices were surveyed. Participants were asked about the presence of firearms in the home, methods of storage, history of firearm safety training, and history of firearm counseling by their physicians. RESULTS: Forty-two percent of respondents reported having at least one firearm in the home. In homes with firearms, 48% contained at least one firearm that was stored unlocked, and 26% contained at least one firearm stored loaded. Twenty percent of homes with children contained at least one unlocked firearm, and 10% contained a loaded firearm. Forty-five percent [corrected] of those homes with both children and firearms had at least one gun that was stored unlocked, and 25% [corrected] contained at least one loaded firearm. Those who reported having had formal firearm safety training were no more likely to store their firearms safely than those without such training. Only 3% of respondents reported that their physician had ever talked with them about gun safety. CONCLUSIONS: Our data indicate that a substantial number of patients cared for by primary care physicians are at risk for firearm injuries.

Community-acquired invasive group A beta-hemolytic streptococcal infections in Zuni Indians.

BACKGROUND: Outbreaks of invasive group A beta-hemolytic streptococcal (GABS) infections have recently been reported. We observed a high incidence of invasive GABS disease among Native Americans at a small rural community hospital between 1982 and 1991. METHODS: A retrospective chart review was performed, and all cases of invasive GABS disease were studied for their clinical features. RESULTS: Sixteen cases of invasive GABS infection were identified during the 10-year study period. The rate of invasive GABS infection was 13.3 cases per 100,000 population per year. Mortality was 25%. Nearly half of the patients presented with systemic signs of sepsis without any obvious source of infection. CONCLUSIONS: Our experience documents a high rate of invasive GABS infections in a defined Native American population. To determine whether this population has a unique susceptibility to GABS disease requires further study.