Dipstick urinalysis screening of asymptomatic adults for urinary tract disorders. I. Hematuria and proteinuria

We review evidence on the value of dipstick urinalysis screening for hemoglobin and protein in asymptomatic adults. In young adults, evidence from five population-based studies indicates that fewer than 2% of those with a positive heme dipstick have a serious and treatable urinary tract disease, too few to justify screening and the risks of subsequent workup. For older populations, evidence is contradictory and no recommendation can presently be made for or against hematuria screening. A population-based randomized, controlled trial of hematuria screening in the elderly is urgently needed. Proteinuria screening is not recommended in any healthy, asymptomatic adult population, since four population-based studies have found that fewer than 1.5% of those with positive dipsticks have serious and treatable urinary tract disorders.

Dipstick urinalysis screening of asymptomatic adults for urinary tract disorders. II. Bacteriuria

Using criteria adopted by the US Preventive Services Task Force, we evaluated use of the dipstick urinalysis to screen for bacteriuria. When the leukocyte esterase and nitrite dipstick tests are combined, the positive predictive value for detecting bacteriuria exceeded 12% in groups with a 5% or higher prevalence of bacteriuria: women who are pregnant, diabetic, or over 60 years of age and all institutionalized elderly. Conventional antimicrobial regimens for asymptomatic bacteriuria have proved efficacious only for pregnant women. We conclude that pregnant women should be screened for bacteriuria, but with the more sensitive urine culture, because treatment prevents serious fetal and maternal sequelae. Dipstick screening may be justified in women who are over 60 years of age or diabetic. The prevalence of bacteriuria in other groups is too low to justify screening.

A national health program for the United States. A physicians' proposal

Our health care system is failing. Tens of millions of people are uninsured, costs are skyrocketing, and the bureaucracy is expanding. Patchwork reforms succeed only in exchanging old problems for new ones. It is time for basic change in American medicine. We propose a national health program that would (1) fully cover everyone under a single, comprehensive public insurance program; (2) pay hospitals and nursing homes a total (global) annual amount to cover all operating expenses; (3) fund capital costs through separate appropriations; (4) pay for physicians' services and ambulatory services in any of three ways: through fee-for-service payments with a simplified fee schedule and mandatory acceptance of the national health program payment as the total payment for a service or procedure (assignment), through global budgets for hospitals and clinics employing salaried physicians, or on a per capita basis (capitation); (5) be funded, at least initially, from the same sources as at present, but with all payments disbursed from a single pool; and (6) contain costs through savings on billing and bureaucracy, improved health planning, and the ability of the national health program, as the single payer for services, to establish overall spending limits. Through this proposal, we hope to provide a pragmatic framework for public debate of fundamental health-policy reform.

Ideology in medical science: class in the clinic

The class character of medicine is most easily discerned in the inequitable organization of health services. Capital's shaping of the patterns of disease and our medical/scientific responses is less apparent but equally strong. We illustrate this point by reviewing some recent history of cardiovascular diseases and therapies. Hitherto unknown afflictions have become commonplace. Our diagnostic and therapeutic concepts are the crystallization of a long history of scientific effort--an effort dominated and directed by capitalist imperatives. The work of the clinician rests on this scientific substrate, and recognition or rejection of its class nature provides a potential basis for a new medical science but not the needed results. The socialist transformation of medicine will require a recognition of the capitalist specificity of current science, and the painstaking construction of alternative modes of thought.

The Jackson National Health Program

In this position paper we outline the major problems that exist in the U.S. health care system and present a proposal for addressing them. This paper contains the major health proposal put forward by the Jesse Jackson 1988 Campaign, calling for the establishment in the United States of a universal and comprehensive National Health Program (NHP) that will be federally funded and administered and be equitably financed. We also discuss how the NHP will affect patients, unions, corporations and employers, practitioners and other health workers, hospitals, and the insurance industry. Specific proposals are made for the transition from the current system to the proposed NHP, with a discussion of the major differences between national health proposals put forward by the two major Democratic contenders for the U.S. Presidency. This position paper also includes a brief appendix sketching some of the major differences between the U.S. and the Canadian medical care systems.

The corporate compromise: a Marxist view of health maintenance organizations and prospective payment

Recent developments in health care are strikingly congruent with a Marxist paradigm. For many years small scale owner producers (physicians) dominated medicine, and the corporate class supported the expansion of services. As health care expanded, corporate involvement in the direct provision of services emerged. This involvement is reflected not only in the rise of for-profit providers, but also in the influence of hospital administrators, utilization review organizations, insurance bureaucrats, and other functionaries unfamiliar with the clinical encounter, but well versed on the bottom line. Corporate providers' quest for increasing revenues has brought them into conflict with corporate purchasers of care, whose employee benefit costs have skyrocketed. This intercorporate conflict powerfully shapes health policy and has caused the rapid proliferation of health maintenance organizations and other forms of prospective payment. Corporate purchasers of care favor the incentives under prospective payment for providers to curtail care and its costs. For corporate providers, prospective payment has allowed increased profits even in the face of constrained revenues, because reimbursement is disconnected from resource use. Unfortunately, this corporate compromise serves patients and physicians poorly. Alternative policy options that challenge corporate interests could save money while improving care.

Free care: a quantitative analysis of health and cost effects of a national health program for the United States

We estimate the health and cost effects of instituting a National Health Program (NHP) in the United States that would provide universal, comprehensive free care. Based on empiric studies of the relationship of health service use to cost and health outcomes, we estimate that an NHP would increase use of health services by 14.6 percent and save between 47,000 and 106,000 lives annually. Because the United States faces a growing surplus of hospital beds and physicians, additional services could be provided at low cost. Simplifying the health bureaucracy that currently enforces unequal access to care would also result in substantial savings. Consequently, an NHP would actually decrease costs 2.4 percent, $10.2 billion annually, since the $35.7 billion spent for additional services would be offset by $45.9 billion saved on bureaucracy.

Reverse targeting of preventive care due to lack of health insurance

We analyzed patterns of receipt of preventive services among middle-aged women, with particular attention to health insurance coverage, based on data from the National Health Interview Survey. Lack of insurance was most prevalent among socioeconomically disadvantaged women at high risk for disease and was the strongest predictor of failure to receive screening tests. The relative risk of inadequate screening for uninsured compared with insured women was 1.60 (95% confidence interval [Cl], 1.40 to 1.83) for blood pressure checkups, 1.55 (95% Cl, 1.43 to 1.68) for cervical smears, 1.52 (95% Cl, 1.41 to 1.63) for glaucoma testing, and 1.42 (95% Cl, 1.33 to 1.51) for clinical breast examination. Controlling for demographic and health status variables did not diminish the effect of insurance coverage. We conclude that inadequate insurance coverage leads to "reverse targeting" of preventive care--that is, populations at highest risk are least likely to be screened. This compromises both the effectiveness and the cost-effectiveness of screening.

Will cost effectiveness analysis worsen the cost effectiveness of health care?

Cost effectiveness analysis is increasingly advocated as a basis for health policy. Analysts often compare expensive interventions with highly cost-effective programs such as hypertension screening, implying that if the former were curtailed resources would be reallocated to the latter and the efficiency of health care would improve. However, in practice, savings are unlikely to be targeted in this way. We present refined policy models that take into account actual patterns of resource allocation in the United States, and provide more realistic estimates of the likely uses of savings. We illustrate the implications of these models in an analysis of the effects of diverting funds from an expensive but effective practice. Eliminating such a practice would actually worsen the overall cost-effectiveness of U.S. health care unless there are radical changes in health policy. Cost effectiveness analysis incorrectly predicts health and cost outcomes of policy initiatives because it ignores the political constraints to health care decision-making.

Physicians for a National Health Program

A new organization called Physician's for a National Health Program (PNHP) is mobilizing physician support for a universal, comprehensive public system of health care for the United States. Recent changes in power relations within medicine (the so-called proletarianization of physicians) are prodding many physicians to abandon their traditional reactionary role in health policy. PNHP is working with elderly, labor, community, and health care activist groups to put a national health program (NHP) back on the U.S. health policy agenda. In this article, five key features of an NHP needed to simultaneously assure access, control costs, and minimize bureaucracy are noted.

Socialized medicine: a solution to the cost crisis in health care in the United States

Despite growing concern with cost containment, most health policy analysts have ignored vast potential savings on medically irrelevant spending for excess administration, profits, high physician incomes, marketing, and legal involvement in medicine. Indeed, many recent reforms encourage administrative hypertrophy, entrepreneurialism and litigation. A universal national health program could abolish billing and consequently the need for much of the administrative apparatus of health care, and decrease spending for profits and marketing. In this article we analyze the administrative savings that could be realized from instituting a Canadian-style national health insurance program or a national health service similar to that in Britain, and the potential savings from additional reforms to curtail profits, marketing and litigation. Our calculations based on 1983 data suggest that national health insurance would save $42.6 billion annually: $29.2 billion on health administration and insurance overhead, $4.9 billion on profits, $3.9 billion on marketing, and $4.6 billion on physician's incomes. A national health service would save $65.8 billion: $38.4 billion on health administration and insurance overhead, $4.9 billion on profits, $3.9 billion on marketing, and $18.6 billion on physician's incomes. Complete nationalization of all health related industries and reform of the malpractice system would save at least $87.2 billion per year. We conclude that a national health program, in addition to improving access to health care for the oppressed, could achieve cost containment without rationing of care.

Militarism and mortality. An international analysis of arms spending and infant death rates

Examination of data from 141 countries showed that infant mortality rates for 1979 were positively correlated with the proportion of gross national product devoted to military spending (r = 0.23, p less than 0.01) and negatively correlated with indicators of economic development, health resources, and social spending. In a multivariate analysis controlling for per caput gross national product, arms spending remained a significant positive predictor of infant mortality rate (p less than 0.0001), while the proportion of the population with access to clean water, the number of teachers per head, and caloric consumption per head were negative predictors. The multivariate model accounted for much of the observed variance in infant mortality rate (R2 = 0.78, p less than 0.0001), and showed good fit to similar data for the year 1972 (R2 = 0.80, p less than 0.0001). The model was also predictive of infant mortality rates in subgroup analysis of underdeveloped, middle developed, and developed nations. Analysis of time trends confirmed that an increase in military spending presages a poor record of improvement in infant mortality rate. These findings support the hypothesis that arms spending is causally related to infant mortality.

Medical care and mortality: racial differences in preventable deaths

We analyzed deaths of blacks and whites in Alameda County, California where previous studies have documented consistent racial inequalities in health services. We classified each death during 1978 as due to preventable and manageable conditions or as "non-preventable" according to lists compiled by the Working Group on Preventable and Manageable Diseases chaired by Dr. David Rutstein. The total death rate for blacks 0-65 years of age exceeded that of whites by 58 percent (p less than .01). Rates of death due to preventable and manageable conditions for persons aged 0-65 years were 77 percent higher for blacks than for whites (p less than .01). More than one-third of the excess total death rate of blacks relative to whites could be explained by the excess of potentially preventable deaths. Our findings suggest that inequalities in health services reinforce broader social inequalities and are in part responsible for disparities in health status. Improvements in the health and longevity of blacks and other oppressed groups might be achieved by improved access to existing medical, public health, and other preventive measures.

Elevated SGOT/SGPT ratio in alcoholic patients with acetaminophen hepatotoxicity

Two alcoholic patients with acetaminophen hepatotoxicity are described. Both patients had very high SGOT levels and SGOT/SGPT ratios. It is suggested that a high SGOT/SGPT ratio is not specific for alcoholic hepatitis. Extreme elevations of this ratio, especially in association with SGOT levels greater than five times normal, should suggest nonalcoholic causes of hepatocellular necrosis in alcoholic patients.