Budget cuts and U.S. Poison Centers - regional challenges create a nationwide problem.

Federal funding of poison centers (PCs) in the United States was established in 2000 through the Poison Control Center Enhancement and Awareness Act. Unfortunately, the problems with financial stability of PCs that this legislation was intended to improve persist because of continued reliance on fragile local funding sources. In the past few months budget cuts have had an impact on PC activity and threaten the continued existence of a nationwide network of PCs in the United States. This commentary discusses the problems faced by PCs in this changing environment and illustrates the many competing tasks that the PC network performs for the U.S. population. PCs face continuing challenges in coming months and a unified approach at a national level may provide the best opportunity for a solution to this crisis.

The costs and outcomes of restricting public access to poison control centers. Results from a natural experiment.

OBJECTIVES: The authors examined the costs and outcomes resulting from a natural experiment during which direct public access to poison control centers was restricted and then restored. METHODS: Both societal and health care purchaser perspectives were used. Probability data were obtained from a natural experiment during which public callers from a large county in California were electronically blocked from directly accessing the poison control center. Callers were referred to 911, which had direct access to the poison control center, if they thought they had a poisoning emergency. We conducted telephone interviews of: (a) persons who attempted to call the poison control center for a child's poisoning exposure but who did not have direct access (n = 270) and (b) persons who called the poison control center after direct access was restored (n = 279). Cost data were obtained from primary data collection and from other sources. The outcome measure was the appropriateness of the treatment location (at home or at a health care facility). Caller-reported outcomes were also examined. RESULTS: The average additional cost per blocked call was $10.89 from a societal perspective, or $33.14 from a health care purchaser perspective. Fourteen percent of callers with restricted access were treated at an inappropriate location, compared with only 2% of callers with direct poison control center access. Also, 14% did not obtain any professional advice after they attempted to call the poison control center, although 66% of these cases involved potentially toxic substances. Results were robust across a range of sensitivity analyses. CONCLUSION: Restricting direct public access to poison control centers created additional costs to society, the health care sector, and callers.

Willingness to pay for poison control centers.

We used the willingness-to-pay (WTP) method to value the benefits of poison control centers when direct access was blocked, comparing WTP among: (1) blocked callers (n = 396), (2) callers after access was restored (n = 418), and (3) the general population (n = 119). Mean monthly WTP was $6.70 (blocked callers), $6.11 (non-blocked callers), and $2.55 (general population). Blocked and non-blocked callers had a significantly higher WTP than general population respondents (p < 0.001). We conclude that the WTP method measured benefits that are difficult to quantify; however, WTP surveys need to be carefully conducted to minimize bias. We discuss how this approach could be useful for other health care services.

Health care cost effects of public use of a regional poison control center.

Poison control centers in the United States are threatened with closure, and attempts at a cost-benefit analysis of these services have been indeterminate. The purpose of this study was to compare the operating costs of a regional poison control center resulting from public use of its telephone hotline services with those of hypothetical alternative sources of advice and care. We conducted a follow-up telephone survey among 589 public callers to the San Francisco Bay Area Regional Poison Control Center who had been managed at home without medical referral after an unintentional poisoning. All survey respondents were asked what alternative action they would have taken had the poison control center not been available to assist them by telephone consultation. We then surveyed emergency departments and physicians' offices cited as alternatives by the callers to determine their response and charges for evaluating a suspected poisoning case. A total of 464 (79%) of the callers surveyed would have sought assistance from their local emergency health care system had the poison control center not been available. We conservatively estimated that the total charges for such evaluations would be +71,900. Comparatively, the total actual operating cost of services provided by the poison control center for all 589 poisoning cases was +13,547. Most of the study subjects (429 [73%]) had private insurance coverage. Direct public access to these services probably reduces the use of emergency health care resources, thus lowering health care costs.

Venesection in haemoglobin Yakima, a high oxygen affinity haemoglobin.

High oxygen affinity haemoglobins result in polycythaemia and cardiovascular adaptation to maintain tissue oxygenation. The polycythaemia can cause symptoms of hyperviscosity and vaso-occlusive disease. We report a kindred with a high affinity haemoglobin (Haemoglobin Yakima) one of whose members gave birth to two infants with intra-uterine growth retardation and who suffered with symptoms of hyperviscosity which settled on reduction of the PCV by venesection.

Bleeding diathesis coincident with chronic myelomonocytic leukaemia.

Two important haematological problems were found in an otherwise healthy 78 year old man: chronic myelomonocytic leukaemia; and a complex, acquired, hyperfibrinolytic bleeding disorder characterized by prolonged coagulation times, deficiency of coagulation factors V, X, and XI, anti-thrombin III and proteins C and S, with high concentrations of circulating tissue plasminogen activator, and low concentrations of plasminogen activator inhibitor. There may be a causal relation between the two conditions, with the peripheral blood monocytes mediating the hyperfibrinolytic process by the abnormal production of tissue plasminogen activator, though no previous description of a similar association has been reported.

Use of cytoplasmic 5'nucleotidase for differentiating malignant from benign monoclonal gammopathies.

Bone marrow smears from 15 patients with multiple myeloma, 15 patients with monoclonal gammopathy of undetermined significance (MGUS), and 15 control subjects were examined for the presence of cytoplasmic 5'nucleotidase (c5NT) in plasma cells. Plasma cell positivity for c5NT (mean and 95% confidence interval) in patients with multiple myeloma numbered 46.4% (38.0-54.8%), in those with MGUS it was 15.3% (11.1-19.6%), and in control subjects it was 1.2% (0.3-2.1%). These findings indicate that c5NT can be used to differentiate benign from malignant monoclonal gammopathies.

Multidisciplinary response of San Francisco General Hospital to the AIDS epidemic.

Acquired immunodeficiency syndrome (AIDS)-related services offered by San Francisco General Hospital (SFGH); programs to protect employees who are at occupational risk for infection with human immunodeficiency virus (HIV); and the legal, ethical, and economic implications of such infection are discussed. Support from public officials, health-care professionals, and the community has enabled SFGH to develop an extensive program of AIDS-related services. The program consumes 10% of SFGH's budget and was responsible for treating 1693 patients between January 1981 and June 1988. The hospital has two internationally recognized units dedicated to the care of AIDS patients. Many of the medical and support departments at SFGH contribute expertise directly; clinical and basic research are also conducted. Other services sponsored by the hospital include HIV testing and counseling; special training for physicians and nurses; assisting patients with finances, housing, and home care; emotional support; and community education. Expenses per patient are lower at SFGH than nationally because of contributions from the private and public sectors, but costs are not fully recovered. Hospital employees are protected by a body substance precautions program, a comprehensive needle-stick program, mandatory reporting and evaluation of all exposures, and enrollment in a study to document seroconversions. Confidentiality and compensation remain major concerns. San Francisco General Hospital has a model program of caring for patients with AIDS and protecting its workers, but the issue of compensating those employees who do become infected with HIV has not yet been resolved.

Detrimental effect of high-dose prostaglandin E1 in the treatment of ischemic ulcers.

Eight patients with ischemic lower extremity ulcers were entered into a randomized, controlled trial of intravenous prostaglandin E1 (PGE1) versus placebo. All ulcers had been stable or increasing in size for at least 3 weeks prior to the study. Each patient had rest pain assessment, Doppler pressure measurements, and ulcer measurements before and after infusion. Four patients received PGE1 and four received placebo. There were no significant preinfusion differences between groups. Rest pain remained stable or improved in all patients. In the placebo group the mean absolute ankle pressure decreased 5 +/- 14 mm Hg, but the mean ankle/arm pressure ratio increased 0.03 +/- 0.06. In the PGE1 group the mean absolute ankle pressure decreased 16 +/- 16 mm Hg and the mean ankle/arm pressure ratio decreased 0.05 +/- 0.06. Neither difference is statistically significant. Patients who received placebo had no change or decrease in ulcer size, but all patients who received PGE1 had an increase in ulcer size (P = 0.05, Wilcoxon rank sum test). One of the four placebo patients required extremity amputation during follow-up of 10.5 +/- 3.5 months. All four patients in the PGE1 group required amputation within 3.3 +/- 2.6 months. Despite theoretic benefits, intravenous PGE1 may be detrimental in the treatment of ischemic ulcers.