Follow-up contact bias in evaluation of substance abuse treatment programs.

This study examined the problem of follow-up contact bias in evaluation of substance abuse treatment programs using administrative data sets. Completed discharges in Iowa were compared to clients contacted 6 months after treatment. The percent of clients reporting no substance use doubled between admission to treatment and follow-up. Unemployment, arrests, and number of days of work or school missed declined. However, clients included in the follow-up sample were significantly different in terms of risk factors for adverse outcomes. The authors conclude that improvements in social functioning 6 months after discharge cannot be generalized to the entire population of clients treated, since those not found have a different combination of risk factors.

Iowa Case Management for rural drug abuse. Preliminary results.

The Iowa Case Management Project (ICMP) was developed to evaluate the effectiveness of a comprehensive, solution-focused model of case management with rural clients in drug abuse treatment. For this preliminary report, 483 clients who were admitted to residential or outpatient treatment at a local facility volunteered to participate and were randomly assigned to one of four research conditions. Clients in three of the conditions received Iowa Case Management (ICM), while clients in the fourth condition received standard treatment services and served as the control group. Clients were assessed regarding psychosocial characteristics at intake and three additional times during the subsequent 12 months.

Regionalization of tertiary care: impact of safe cardiovascular volumes in Iowa.

The outcomes of cardiovascular care for individual patients are known to be better when treatment is provided in hospitals where the volume of such care is greater. We examined the impact of establishing safe volume thresholds on hospitals now performing such procedures in the state of Iowa by analysing the relationship between various volume thresholds and the number of hospitals that would continue to provide the service if the thresholds were enforced. Four procedures performed in hospitals in Iowa in 1990 were studied: coronary artery bypass graft surgery, vascular surgery, cardiac valve surgery, and cardiac catheterization. The analysis was conducted assuming current per capita procedure rates and repeated assuming reduced procedure rates. The study finds that the 12 hospitals now performing coronary artery bypass graft surgery in Iowa could be reduced to two, providers of vascular surgery could be reduced to as low as four from the current 33, the 10 providers of cardiac valve surgery might be reduced to one, and catheterization could be provided at two rather than 22 hospitals.

Reinventing a medical specialty. Using anesthesiology as a model for change.

In only a decade, anesthesiology has reversed its fortunes from an underrepresented specialty in the 1980 Graduate Medical Education National Advisory Committee report to "a specialty in trouble" featured in The Wall Street Journal. This article focuses on anesthesiology and its work force dilemma as an evolving specialist model for change. What is happening to anesthesiology will not be unique--managed care competition will affect all physicians. Most specialties will have to reshape curricula and redesign education programs and academic delivery systems concentrating on fewer trainees. What are the options for coping with physicians grieving over lost dreams, such as autonomy and solo practice, while redesigning a medical specialty? The authors untangle fact from fear, mission from myth, and offer strategic thinking and solutions.

Effect of centralized intake on outcomes of substance abuse treatment.

OBJECTIVE: State governments are exploring the potential of various forms of case management to control the costs of substance abuse treatment programs. This report describes an experimental program in one Iowa county in which clients are assessed and referred elsewhere if treatment is needed. Outcomes of clients in that county are compared with those of clients served elsewhere in the state. METHODS: All claims submitted by provider agencies to the Iowa Department of Public Health for substance abuse treatment of eligible clients in 1994 were analyzed to test the effect of the experimental intake-and-referral program on clients' utilization of outpatient treatment, rate of treatment completion, and rate of abstention at discharge from treatment. RESULTS: In the county with the experimental program, 27 percent of clients recommended for treatment actually attended, compared with 48 percent in other counties. Clients who used the experimental program were also less likely to complete treatment. These differences persisted after adjusting for baseline differences in client characteristics. CONCLUSIONS: Lower utilization arising from failure to attend recommended treatment may reduce treatment costs but is not the intended outcome of the intake-and-referral program. Failure to complete treatment also is an adverse outcome. Outcomes of various types of case management programs should be carefully evaluated before statewide implementation is considered.

The new health care civilization: integration of physician land and manageria.

Changes occurring in health care demand that physicians expand their professional knowledge and skills beyond the medical and behavioral sciences. Subjects absent from traditional medical education curricula, such as the economics and politics of health care, practice management, and leadership of professional organizations, will become important competencies, particularly for physicians who serve in management roles. Because physicians occupy a central role in planning and allocating medical care services and other health care resources, they must be better prepared to work with other health care professionals to create a new civilization, even if this means leaving the cloistered domain of "physician land" to serve as interface professionals between the delivery of medical services and the management of health care. Our research findings and conclusions strongly suggest that economic, management, and leadership competencies need to be incorporated into the professional development of physicians, especially in postgraduate and continuing education curricula.

Anesthesiologists in North Carolina: a survey reflecting emerging subspecialization.

This North Carolina case study addresses the migration of anesthesiologists into subspecialty, clinical areas of anesthesiology over a 4-year period (1984 to 1987). Three hundred fourteen members of the North Carolina Society of Anesthesiologists (NCSA) were surveyed using a one-page questionnaire. The response rate was 93.6%. The questionnaire elicited data to characterize the magnitude of change in anesthesiologist manpower, to assess emerging subspecialization, to describe the flux of anesthesiologists entering and leaving practice, and to detail evolving modes of practice. Results indicated a net increase in manpower averaging 8.8% per year in academic programs, whereas clinical community practitioners increased physician positions at a rate three times the former (27% increase per year). Of 184 anesthesiologists recruited to North Carolina over 4 years, 75 different residency programs were represented; 48% of new anesthesiologists were from southern educational programs and 44% entered practice with fellowships (i.e., postgraduate year 4 to 5). The principal fellowship was cardiac (33%). Subspecialty areas were represented in all 53 reporting clinical practices. The principal practice mode emerging was hospital-based, same day surgery (85%) followed by pediatric anesthesia (81%), perioperative pain management (68%), obstetric anesthesia (63%), and an anesthesia "clinic" (54%). Respondents expected additional practice options over the next 3 years with anesthesia for ambulatory diagnostic and therapeutic modalities projected to emerge at the fastest rate. In conclusion, anesthesiologists in North Carolina seem to be filling unmet needs in obstetric and cardiac anesthesia, critical care, ambulatory surgery, and pain therapy units. These observations may represent a vignette of the national scene.

Cardiovascular effects of nondepolarizing relaxants employed for pretreatment prior to succinylcholine.

A pregnant woman with severe pre-eclampsia experienced a hypertensive crisis following a pretreatment dose (20 mg) of gallamine. That episode initiated a study to determine the cardiovascular effects of non-depolarizing muscle relaxants in 58 nonobese, ASA physical status I and II adults. Subjects were assigned randomly to one of five treatment groups as follows: gallamine (0.29 mg X kg-1), d-tubocurarine (0.04 mg X kg-1), metocurine (0.014 mg X kg-1), pancuronium (0.007 mg X kg-1), or normal saline (control). Baseline measurements of systolic, diastolic, mean arterial pressure, heart rate (HR) and rate pressure product (calculated RPP) were recorded at one-minute intervals while electrocardiogram, lead II, was recorded continuously. Statistically significant increases occurred in HR at minutes 2, 3 and 4; RPP at minutes 3 and 4; and per cent change in HR at minutes 2, 3 and 4 following gallamine pretreatment. The rise in RPP was predominantly due to the elevation in HR. These results suggest that even modest doses of gallamine should be avoided in clinical situations where lability of cardiovascular dynamics can be anticipated.

Inaccuracy of liquid crystal thermometry to identify core temperature trends in postoperative adults.

In 71 adult postsurgical patients, simultaneous measurement of core (tympanic membrane) and shell (liquid crystal adhesive temperature strip) cutaneous temperature was assessed on admission and every 15 minutes throughout the recovery room stay. Tympanic membrane sensors were inserted into the ear and adhesive temperature strips were applied to the forehead. Although temperature strip temperatures on admission to the recovery room were correlated significantly with tympanic membrane temperatures on admission to the recovery room (r = 0.61, p less than 0.001), subsequent readings 15, 30, 45, and 60 minutes after admission demonstrated decreasing correlation coefficients. Moreover, changes in temperature strip temperatures over the first 15, 30, and 45 minutes of monitoring in the recovery room did not correlate significantly with changes in tympanic membrane temperatures over the same time period. These data suggest that shell temperature (temperature strip) is not a reliable or valid trend indicator of core temperature (tympanic membrane) in postanesthetic adults.

Nursing care for the severely obese patient.

Care of the morbidly obese person (BMI greater than or equal to 30) during the perioperative period is specific and differs from routine nursing care. Effective communication, preplanning, and psychologic and physiologic assessment, with appropriate intervention (pulmonary and circulatory), result in positive care outcomes. Preoperative care emphasizes both psychologic and physiologic support concurrent with evaluation of vital signs, fluid status, teaching, and administration of preoperative medications (see Table 1). Intra- and postoperative care incorporates the necessity of additional personnel, transport precautions, physical protection, positioning, oxygenation, and early ambulation coupled with accurate arterial blood gas sampling, intraarterial line care, and cardiopulmonary and fluid status monitoring (see Tables 2 and 5). New information regarding hypothermia and shivering documented to occur in the recovery room underlines the need for accurate core temperature monitoring (see Tables 3 and 4; Figs. 1 and 2). An assessment tool (see Fig. 3)--an effective reminder of important aspects of patient care in the recovery room and until hospital discharge--provides a systematic guide to facilitate nursing care, recording, and reporting.

Postoperative hypothermia in adults: relationship of age, anesthesia, and shivering to rewarming.

Frequency, magnitude, and duration of hypothermia (core body temperature less than 36.0 C) in the recovery room (RR) were determined in 198 adults. In addition, the influence of age, anesthetic technique, and shivering on the rewarming process was assessed. Tympanic membrane temperatures were recorded on admission to the RR and every 15 minutes thereafter until discharge from the RR. Sixty percent of the subjects had temperatures less than 36.0 C on admission to the RR. Elderly subjects (greater than or equal to 60 yr) had lower RR admission and discharge temperatures and experienced longer duration of hypothermia than did younger patients. General anesthesia was associated with a significantly more rapid rate of increase in postoperative temperature and a shorter duration of hypothermia than was regional anesthesia. The incidence of shivering and the incidence of hypothermia were significantly related 30 and 45 minutes after admission to the RR. Duration of hypothermia varied with different operative procedures.