Long-term outcome of children surviving massive burns.

CONTEXT: Major advances in treatment of burn injuries in the last 20 years have made it possible to save the lives of children with massive burns, but whether their survival comes at the cost of impaired quality of life is unknown. OBJECTIVE: To investigate the long-term quality of life in children who have survived massive burns. DESIGN AND SETTING: Retrospective, cross-sectional study conducted in a regional pediatric burn center. PATIENTS: Eighty subjects who were younger than 18 years at the time of injury, who survived massive burns involving > or =70% of the body surface, and who were admitted to the burn center between 1969 and 1992 were evaluated an average (SD) of 14.7 (6.0) years after injury. MAIN OUTCOME MEASURES: Short Form 36 (SF-36) scores of the 60 patients aged at least 14 years were compared with national norms and the impact of clinical variables on individual domain scores was assessed. RESULTS: The SF-36 domain scores of the study patients, who had survived massive burns at a mean (SD) age of 8.8 (5.5) years, were generally similar to the normal population). However, 15% and 20% of the burn patients had scores in the physical functioning and physical role domains, respectively, that were more than 2 SDs below the relevant norm, indicating that a few patients had continuing serious physical disability. Better functional status of the family predicted a higher score in physical role (P = .04). The child's early reintegration with preburn activities predicted higher scores in general health (P = .03), physical functioning (P = .003), and physical role (P = .01). Children followed up consistently in the multidisciplinary burn clinic for 2 years had higher physical functioning (P = .04). CONCLUSIONS: In this study, while some children surviving severe burns had lingering physical disability, most had a satisfying quality of life. Comprehensive burn care that included experienced multidisciplinary aftercare played an important role in recovery.

Contribution of education to cost-effective care of microcytic, hypochromic anemia.

Through a handbook, a seminar, and multiple opportunities for reinforcement in clinical settings, faculty in family medicine conducted an educational program that presented cost-effective practice standards for the care of anemia patients to resident physicians. A comparison of the quality and cost of anemia care by the residents before and during the program ascertained its value. The quality of patient care by residents rose significantly during the program. In addition, the residents' utilization of tests, therapy, and clinic visits and attendant costs reached more appropriate levels. These results should encourage faculty to respond to the current national need for the development of educational materials on cost-effective care of patients with common health problems.

Reimbursing for residency training: how many times?

Through an investigation of charges generated for 105 patients treated for congestive heart failure, three issues of reimbursement policy for graduate medical education are examined: 1) reimbursement policy by third parties for resident salaries and for the portion of teaching physicians' time devoted to graduate medical education; 2) the level of involvement for physicians in dual roles as attending physicians for private patients when simultaneously engaged in graduate medical education and supervising patient care delivered by residents; and 3) the greater utilization of hospital resources in teaching units. The results demonstrate that the reimbursement policy, as presently practiced, ignores the basic differences in the level of involvement between teaching and nonteaching physicians. The data also show for the first time the incremental effect of graduate medical education in a teaching hospital. Several alternatives are suggested to eliminate the deficiencies.

Quality assurance in undergraduate medical education at the Medical College of Ohio.

This paper reports a four-year experience in teaching evaluation of care at a three-year medical school, the Medical College of Ohio at Toledo. Informal patient care evaluation evolved to more structured medical care evaluation in seminars and by chart audits. The introduction of professional standards review organizations prompted the teaching and evaluation of the quality and cost of primary care, especially as it applies to learning clinical tasks.

Teaching students the relationship between quality and cost of medical care.

The usefulness of hospital charges as a means of teaching medical students the relationship between the quality of the cost of medical care provided by primary care physicians (internists and family physicians) is presented. The comparative role of these two types of primary care physicians as "generators of costs" is described. The cost of hospital care provided by primary care physicians is also compared with the cost of care provided by the cardiologist, a prototype of the highest quality of secondary and tertiary care for cardiovascular diseases. Data indicate that internists generated hospital costs that were consistently higher than family physicians. Moreover, a comparison of costs generated by internists, family physicians, and cardiologists in managing patients with cardiovascular diseases revealed that cardiologists generated lower costs than the other two types of specialists. It is believed that case studies such as this will provide evidence that will enable undergraduate medical students to reflect upon their own attitudes toward their developing role as "generators of cost".