The influence of organizational structure on physician satisfaction: findings from a national survey.

BACKGROUND: The term managed care encompasses a variety of organizational arrangements between physicians and health plans. At one extreme, physicians are plan employees; at the other, physicians have contracts with multiple plans. How these arrangements affect physicians' satisfaction with managed care is not well known. OBJECTIVE: To explore the effect of organizational structure on physician satisfaction. DESIGN: Telephone survey of 751 practicing internists. The response rate for the 15-minute survey was 64%. SAMPLING STRATEGY: The random sample was taken from the membership of the American College of Physicians-American Society of Internal Medicine. Federal employees, retirees, physicians, and students who spent less than half of their time in patient care were excluded. RESULTS: 689 Physicians indicated that they were affiliated with a managed care plan: 9% were salaried employees, 6% had an exclusive contract with one plan, and 85% had a variety of nonexclusive arrangements with multiple plans. Among plan employees, 32% reported they were very satisfied with the managed care organization in which they worked. The corresponding figure was 19% among physicians with an exclusive contract and 5% among those with multiple contracts. A similar pattern of responses was seen when physicians were asked about their perception of the commitment of managed care to quality. Although 64% of plan employees responded that there was a great deal of commitment, the corresponding figure was 35% among physicians with an exclusive contract and only 7% among those with multiple contracts. CONCLUSIONS: Physicians who are salaried employees of a staff- or group-model HMO report the highest satisfaction with managed care.

Area agency on aging outreach and assistance for households with older carers of an adult with a developmental disability.

A demonstration project was undertaken in the state of New York to assess how area agencies on aging (AAAs) would approach outreach and direct aid to families caring for someone with a developmental disability. It was found that AAAs organized their outreach and direct-aid efforts using three main approaches: direct operation, contract operations, and multi-organizational. They generally organized staff time so that about two days per week of effort was devoted to undertaking outreach activities, conducting community education, and providing casework and referrals for target families. Four major distinctions were identified that differentiated work with older carers of persons with a developmental disability from that with other kinds of carers: complexity of problems presented by households identified, vagaries of fiscal resources, diverse household composition, and planning for eventualities. It was concluded that targeting AAAs for outreach and providing help to these carers was effective and productive and should be replicated throughout the United States.

Glossopharyngeal schwannoma, an uncommon posterior fossa tumor: diagnostical and therapeutical aspects: a case report.

Among posterior fossa tumors, schwannomas arising from glossopharyngeal nerve are rare; only about 30 cases of glossopharyngeal neuroma have been described. Though a typical 'jugular foramen syndrome' has been described for tumors of this region, the clinical onset may often closely resemble that of acoustic neuromas thus misleading the diagnosis. Because of its different surgical implications, such a rare condition must be clearly recognised preoperatively. A new case is hereby reported with particular focus on clinical and surgical management.

Inter-hemispheric scissure, a rare location for a traumatic subdural hematoma, case report and review of the literature.

Subdural interhemispheric hematomas (ISH), though not really rare, are quite an uncommon complication of head traumas. This condition is more frequent in childhood, where it is generally considered as a part of a more complex syndrome, called 'Shaken Children Syndrome', usually pointing out child abuse. Although a head injury is very often considered the cause (in about 80-90% of the cases), possible predisposing factors such as coagulopathies, alcohol abuse or anticoagulant therapy can also be considered. Furthermore, as the rupture of an intracranial aneurysm has also occasionally pinpointed as a possible cause, this event should be kept in mind in order to be able to address exactly both the diagnostic and therapeutical procedures. A new conservatively managed case is thereby described. A review of the literature with particular attention drawn to the diagnosis and the different therapeutical possibilities is also elaborated.

Ischemic stroke syndromes in childhood.

The ischemic stroke syndrome is very broad and encompasses a wide range of underlying conditions. Its identification is of great importance in clinical routine, in particular in the management of young patients who have acute neurologic deficits. The introduction of CT, MR and ultra-sound demonstrating lesions of the brain and in certain degree of the cerebral arteries has in general eliminated the need for angiography as a first examination. The most common underlying anomaly found with thrombotic or embolic stroke is congenital or acquired heart disease. Thus, it is essential that patients with cerebral ischemia be submitted to a complete cardiac examination. Children tend to show more recovery after a stroke than adults do.

The 10 essential activities of the quality assurance unit.

It is certainly my pleasure to be here today. Several months ago, Pat Pomerleau invited me to be on your program. At the time, I had no idea that I would be speaking as Paul Lepore, private citizen, rather than Paul Lepore, regulator and bureaucrat. However, the Food and Drug Administration (FDA) made me an offer I could not refuse and, upon considerable thought, I retired effective September 30, 1994. Immediately, I called Pat for advice on how to deal with my planned presentation before you. Graciously, she said that she did not believe that I would forget all I knew about Good Laboratory Practice (GLP) over 1 weekend and that the Society would love to have me anyway. Today, I intend to discuss the 10 essential activities of a properly functioning quality assurance Unit (GAU). I will summarize the importance of records and documentation to the unit and I will close with some comments on achieving regulatory compliance. My remarks are intended to emphasize that an effective, active quality assurance unit is crucial for ensuring data quality, and that attention paid to day-to-day quality assurance activities will foster regulatory compliance.

"Experimental amnesia" induced by emotional items.

Tulving described an effect of retrograde amnesia in a free-recall task of word lists, produced by inserting items having priority in recall. Other authors confirmed the amnesic effect without giving instructions for priority both in recall and in recognition tasks. The effect was explained by Tulving as a premature termination of encoding processes. The similarity between these experiments and the researches aimed at reproducing amnesia by emotional trauma led us to hypothesize that the two phenomena might be due to the same functional mechanisms. We have organized a free-recall task of word lists into which emotional items were inserted. Our aim was to verify whether with these experimental conditions Tulving's results would be reproduced. The obtained data show amnesic effects in free recall; nevertheless, they do not seem to confirm closely the experimental hypothesis. Lastly, changes in primacy and recency effects produced by emotional items are analyzed.

Final report of the Color Additive Scientific Review Panel.

The Color Additives Scientific Review Panel considered whether there was information sufficient to perform a carcinogenic risk assessment on the colors D&C Red No. 19 (R-19), D&C Red No. 37 (R-37), D&C Orange No. 17 (O-17), D&C Red No. 9 (R-9), D&C Red No. 8 (R-8) and FD&C Red No. 3 (R-3) and to evaluate the assessments sent to FDA as part of the petitions for use of the colors for drug and external uses by the Cosmetic, Toiletry and Fragrance Association (CTFA). There is a lack of human data concerning the colors for making a human health assessment, so the assessments are based upon the extrapolation of animal data. The risk assessments are determined for exposure to single chemicals. Excluded from consideration are possible effects from exposure to multiple chemicals, such as co-carcinogenesis, promotion, synergism, antagonism, etc. In the light of recent efforts in establishing a consensus in risk assessment, the Panel has determined that the CTFA assessments for R-10, O-17, and R-9 are consistent with present acceptable usages, although it questions some of the assumptions used in the assessments. The Panel identified a number of general assumptions made, and discusses their validity, their impact on total uncertainty, and the potential options to address the gaps in understanding that necessitate the assumption. The Panel also derived revised risk estimates using more "reasonable" assumptions than "worst-case" situations, for 90th percentile and average exposure. For those assumptions that are easily quantifiable, the Panel's estimates are less than an order of magnitude lower than the CTFA risk estimates, indicating that the underestimates and overestimates of the CTFA risk estimates tend to balance each other. The impact of most of the assumptions is not quantifiable. The assessment for R-3 is complicated by the fact that there is no good skin penetrance study for this color. It was assumed that the penetrance is similar to that of another water-soluble xanthene color, R-19. It is expected that the absorption of the color is not likely to exceed that of the smaller molecule, R-19. Therefore, the risk estimates are similar to the CTFA estimates, but with different reasoning. The estimates for R-8 and R-37 are different from the others in that there is a lack of any exposure or toxicological information on these colors.(ABSTRACT TRUNCATED AT 400 WORDS)

Regulation of animal care and research. The final order on Good Laboratory Practices.

On June 20, 1979, the Food and Drug Administration (FDA) enacted all aspects of its Good Laboratory Practices (GLP) program. The program was instituted to ensure the quality and integrity of the safety data submitted to FDA in support of the approval of regulated products, including human and animal drugs, food additives, biologicals, radiation-emitting products and human medical devices. Moreover, these considerations include all safety data submitted to support applications for research and marketing permits. These steps were taken in response to the appalling circumstances uncovered in a limited series of inspections of laboratories that was performed during 1975. FDA found careless experimentation, improperly trained employees, unreviewed data, omitted data, improper laboratory and animal care procedures and improperly monitored contract studies, including the failure of sponsors to validate the data appearing in the final study reports. The Congress responded to this situation by allocating FDA 600 new positions and .$16 million to remedy the problems that were evident. In their final form, the GLP's represent regulations fine tuned to assure proper safety testing with a minimum of increased cost. It is hoped that these regulations will increase public confidence in FDA decision making and will help to ensure that safe products are approved for marketing.