Guidelines for management of the jaundiced term and near-term infant

Factors believed to have contributed to the reemergence of kernicterus in the United States during the 1990's are discussed: these include decreased concern about toxicity of bilirubin in term and near-term infants, increased prevalence of breastfeeding, and increasingly shortened postnatal hospital stays. The rationale for a universal predischarge bilirubin measurement at the time of the routine predischarge metabolic screen is presented: the hour-specific level of bilirubin at discharge, plotted on an Hour-Specific Bilirubin Nomogram, improves prediction of risk of excessive jaundice postdischarge and facilitates safe, cost-effective follow-up. This minimizes repeat bilirubin measurements and maximizes recognition of confounding variables and risk of hyperbilirubinemia so that timely, minimally invasive, preventive therapy can be instituted if needed.

Is community-based treatment an add-on or a substitution for hospital treatment of alcoholism? Some evidence from Canada

OBJECTIVES

This study determined whether the development of community treatment of alcohol problems acted as an add-on or a substitution for the utilization of inpatient hospital services in Ontario.

METHODS

Complex modelling and graphic analyses using econometric multiple regression techniques were performed on data for the 48 counties of Ontario (Canada) for the period 1972 to 1988, combining both cross-sectional and time series analysis.

RESULTS

After controlling for differences in alcohol consumption, in health care characteristics such as the supply of physicians or hospital occupancy rates, and in socioeconomic characteristics of the population, when community treatment became available, hospital utilization for the treatment of alcohol problems decreased and community services were substituting for hospital treatment. In addition, nonresidential services had an overall greater importance in producing this effect (elasticities at the mean of -0.11 to -0.14 depending on the region) than community-based residential treatment. The effect was larger in the southern than in the northern counties of Ontario. Testing of the modelling techniques showed statistically significant and satisfactory modelling of the forces at work.

CONCLUSIONS

Where community-based treatment was available, it was used in preference to inpatient hospital treatment; however, there may be a slightly more complex relationship present in the southern urban counties (which contain the larger metropolitan areas) than in the northern and southern rural counties..

Effects of post-hospital Medicare home health and informal care on patient functional status

OBJECTIVE

To examine the effect of post-hospital Medicare home health and informal care on the functional status of 755 Medicare beneficiaries six weeks after hospital discharge for treatment of stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hip procedures, and hip fractures.

STUDY SETTING/DATA SOURCES

Consecutive patients enrolled in the study between March 1988 and February 1989 prior to discharge from one of 52 hospitals in three cities. Data sources included patient interviews, medical records, and the Medicare Automated Data Retrieval System (MADRS).

ANALYSIS

The effect of the two types of care on patients' subsequent functional status was estimated using a selectivity corrected least squares regression of functional status six weeks post-discharge on hours of informal care, Medicare home health expenditures, and patient prior functional and cognitive status.

DATA COLLECTION/EXTRACTION METHODS

Patients were interviewed before hospital discharge and six weeks later. The patient's primary caregiver was interviewed by telephone six weeks post-discharge. Patient data included demographic characteristics, illness severity, cognitive status, functional status at discharge and six weeks later, post-discharge expenditures for Medicare home health, and hours of informal care.

PRINCIPAL FINDINGS

More informal care after discharge was associated with greater patient functional impairment six weeks later. The amount of Medicare home health that patients used had a nonsignificant effect on subsequent functional status.

CONCLUSIONS

Post-acute home care may maintain the patient at home and compensate for functional limitations, rather than promote restoration of function. Future studies are needed to examine the effects of specific types of care, services, and providers as well as factors that mediate their effects on patient functional outcomes.

Determinants and costs of Medicare post-acute care provided by SNFs and HHAs

Provisions in the 1997 Balanced Budget Act affecting Medicare skilled nursing facility (SNF) and home health agency (HHA) services heighten the importance of knowing more about beneficiary, market, and policy factors that impact use of post-acute care and the costs of such services. This study used data from the Medicare Current Beneficiary Survey and other sources to address these issues. Findings shed light on responses that need to be monitored in light of the recently mandated policies and other SNF and HHA options that are being considered.

[Value of individually risk-adjusted after-care--economic management of oncologic effectiveness?]

The individual risk-adapted follow-up programme after R0-resection of colorectal carcinoma is a propatiently and favourable alternative. Controlled economic studies are required to examine further quantitative and qualitative modifications of the follow-up programme.

Psychiatric home care: clinically valid and cost effective

A lot can happen when a psychiatric home care program hooks up with patients' families, practitioners, and the community to ensure quality care. According to a recent study, one home care agency's experience demonstrates that psychiatric home care is not only cost effective, but also a clinical success.

Cost comparison of state hospital and community-based care for seriously mentally ill adults

OBJECTIVE

In 1989, Philadelphia began a bold experiment involving the total shutdown of a 500-bed state hospital. This study examines the service utilization and cost of treating individuals with serious mental illness in a community-based care system in which the state hospital was replaced with 60 extended acute care beds in general hospitals and 583 residential beds.

METHOD

A pre-post study design was used to determine the utilization and cost differences before and after the state hospital closed for individuals with a diagnosis of schizophrenia who required extended psychiatric hospitalization following an acute care crisis episode in a general hospital. The number and cost of days spent in general and in extended hospital and residential treatment were compared on an episode and an annual basis.

RESULTS

The results of this analysis showed that after the state hospital closed, the direct treatment cost of an episode of care increased from $68,446 to $78,929, and the average annual cost of care per patient increased from $48,631 to $66,794 because of an increase in acute care hospitalization.

CONCLUSIONS

This study suggests that an "admission" cohort of seriously mentally ill patients requires an optimal mix of acute care, extended care, and residential beds, as well as ambulatory services, in order for cost-efficient care to be delivered during a crisis period. Determining the appropriate allocation and supply of beds in different settings is essential if community mental health systems are to manage the care of individuals with serious mental illness outside of institutional settings.

Survivorship and the cancer follow-up clinic

In recent years there has been growing interest in the needs of those individuals who have survived cancer. It is now possible to describe the adjustments that these individuals will make, predict when such difficulties will arise, and identify those most vulnerable to adjustment difficulty. The value of the cancer follow-up clinic has also received scrutiny, drawing on work previously undertaken in the cancer screening clinic setting. Issues discussed in the literature include the purpose of follow-up, the most appropriate health care professional to undertake the follow-up clinic, and the financial cost of cancer follow-up. There exists an opportunity for cancer nurses at present to develop roles in the clinic setting, offering patient-centred and cost-effective alternatives to physician-led follow-up.

Randomised controlled trial of two models of care for discharged psychiatric patients

OBJECTIVE

To compare the clinical outcome and costs of care of psychiatric patients allocated to community multidisciplinary teams or to hospital based care programmes after discharge from inpatient care.

DESIGN

Randomised controlled trial.

SETTING

Inner London (Paddington and North Kensington) and outer London (Brent) psychiatric services.

SUBJECTS

155 patients with severe mental illness with a previous admission within the past 2 years.

MAIN OUTCOME MEASURES

Ratings of clinical psychopathology, depression, anxiety, and social functioning; comprehensive costs of health care.

RESULTS

Clinical outcomes were available for 133 patients and cost data for 144 patients after 1 year. The clinical outcomes of the two models of care were essentially similar, but admission to hospital was more likely in the hospital based care group and the costs of health care were 14% greater per patient than in the community group. This difference, however, was dwarfed by a twofold difference in the costs of care in the outer London services compared with those in inner London. This was explained largely by greater inpatient care for outer London patients (58 median bed days v 18 for inner London patients), more of which was provided by extracontractual referrals to other psychiatric hospitals as Brent had only 0.28/1000 beds available for acute adult patients compared with 0.82/1000 in Paddington and North Kensington over the period of the study.

CONCLUSION

Aftercare by community teams for psychiatric patients with severe mental illness has a similar outcome to hospital based aftercare but with fewer admissions to hospital. When psychiatric bed requirements are insufficient for a population, however, neither form of aftercare is effective as greater use of hospital beds elsewhere swamps any advantage of community care programmes, with disintegration and discontinuity of psychiatric services leading to escalating costs.

[Follow-up of women treated for breast cancer. State of the art]

The intensive follow up of breast cancer patients is not safer than a minimalist policy for breast cancer surveillance. The survival rate is not modified by the use of expensive exams. Follow up program are stressful, delay the patient rehabilitation and are useless because in 75% of cases the patient discovered the relapse by herself. A good clinical examination, including gynecological examination and a mammography are sufficient for a good follow up practice. The guide lines for the follow up of breast cancer patients include self examination of the breast monthly, clinical examination twice a year and an annual mammography during five years and an annual clinical examination and a mammography after. The radio therapist, the surgical or medical oncologist should be involved with the general practitioner for this follow up.

Effect of a patient management system on outcomes of total hip and knee arthroplasty

Five hundred fifty-three patients undergoing hip and knee reconstructive procedures in one institution that used a patient management system were compared with a retrospective group of 340 patients undergoing similar procedures in the same institution. All procedures were performed by one surgeon and the same patient management team. Measures of length of stay, discharge disposition, and hospital charges were recorded for all patients in each subgroup of total hip arthroplasty, revision total hip arthroplasty, total knee arthroplasty, revision total knee arthroplasty, unicompartmental knee arthroplasty, and bilateral procedures. The length of stay and hospital charges were reduced significantly in all groups, whereas the percentage of patients discharged to home was unchanged. There was no significant difference in complication rates between the two groups.

[Ambulatory surgery clinic in a public general hospital. Organization and results]

In surgery a day care clinic is defined as an institution in which patients undergo elective operations the day of their admission and are discharged within 24 h after surgery. An important goal of day care surgery is to avoid unnecessary hospitalisations however providing the patient with the same quality of treatment and personal satisfaction. This presentation describes the patients selection, information and follow-up, the organization of the day care system, the computerized quality control and the medical outcome. Our experience is based on a 2-year period of day care surgery in a general community hospital. The results of 581 consecutively operated, not selected, patients are presented. Quality control was performed for all patients during their stay at the day care unit, and for 98.5% as follow-up control by the General Practitioners. The most frequent operations were: arthroscopies, meniscectomies, removals of implants after osteosynthesis, decompressions of peripheral nerves, large excisions of skin-tumors, bursectomies, reconstructions of torn ligaments, hernial repairs, strippings of varicose veins, hemorrhoidectomies and operations of the anal and genital region. We present the patients age, the type of anesthesia, the type of operation, eventual complications (in clinic, 24 hours after discharge and at the end of the treatment), the medical results as well as the costs of the after-treatment.

Ethical issues in long-term psychiatric management

Two general ethical problems in psychiatry are thrown into sharp relief by long term care. This article discusses each in turn, in the context of two anonymised case studies from actual clinical practice. First, previous mental health legislation soothed doubts about patients' refusal of consent by incorporating time limits on involuntary treatment. When these are absent, as in the provisions for long term care which have recently come into force, the justification for compulsory treatment and supervision becomes more obviously problematic. Second, Anglo-American law does not normally allow the preventive detention of someone who may be dangerous but has not actually committed any crime. The justification for detaining a possibly dangerous user of mental health services without his or her consent can only be based on risk assessment, but this raises issues of moral luck. Is the psychiatrist who decides not to take out a supervision order for a possibly dangerous patient with an initial psychotic diagnosis morally at fault if that person harms someone in the community, or himself? Or is the psychiatrist merely unlucky?

A randomized trial of early discharge and nurse specialist transitional follow-up care of high-risk childbearing women

In a randomized clinical trial, quality of health care as reflected in patient outcomes and cost of health care was compared between two groups of high-risk childbearing women: women diagnosed with diabetes or hypertension in pregnancy. The control group (N = 52) was discharged routinely from the hospital. The intervention group (N = 44) was discharged early using a model of clinical nurse specialist transitional follow-up care. During pregnancy, the intervention group had significantly fewer rehospitalizations than the control group. For infants of diabetic women enrolled in the study during their pregnancy, low birth weight (< or = 2,500 g) was three times more prevalent in the control group (29%) than in the intervention group (8.3%). The postpartum hospital charges for the intervention group were also significantly less than for the control group. The mean total hospital charges for the intervention group were 44% less than for the control group. The mean cost of the clinical specialist follow-up care was 2% of the total hospital charges for the control group. A net savings of $13,327 was realized for each mother-infant dyad discharged early from the hospital.

Multiple primary melanomas: implications for screening and follow-up programs for melanoma

BACKGROUND

Once individuals are diagnosed with malignant melanoma, they are at an increased risk of developing another melanoma when compared with the normal population.

METHODS

To determine the impact of an intensive follow-up protocol on the stage of disease at diagnosis of subsequent primary melanomas, a retrospective query was performed of an electronic medical record database of 2,600 consecutively registered melanoma patients.

RESULTS

Sixty-seven patients (2.6%) had another melanoma diagnosed at the time of presentation to the clinic or within 2 months (synchronous) and another 44 patients (1.7%) developed a second primary melanoma during the follow-up period (metachronous). For the 44 patients diagnosed with metachronous lesions, the Breslow mean tumor thickness for the first invasive melanoma was 2.27 mm compared with 0.90 mm for the second melanoma. The first melanomas diagnosed are thicker by an average of 3.8 mm (p = 0.008). The mean Clark level for the initial melanoma was greater than the mean level for subsequently diagnosed melanomas (p = 0.002). Twenty-three percent of the initial melanomas were ulcerated, whereas only one of the second primary lesions showed this adverse prognostic factor (p = 0.002).

CONCLUSIONS

Once individuals are diagnosed with melanoma, they are in a high-risk population for having other primary site melanomas diagnosed and should be placed in an intensive follow-up protocol consisting of a complete skin examination.

Staging evaluation and surveillance for melanoma patients in a fiscally restrictive medical environment. A commentary

Although few objective data are available from which to derive strict and definitive guidelines for both staging of newly diagnosed patients and surveillance following treatment, rational recommendations can be offered that can minimize patient morbidity and costs.

Recommendations on follow-up of breast cancer patients following primary therapy

Follow-up of breast cancer patients who have completed their primary therapy has not been standardized. The literature is reviewed and it is proposed that "minimal" follow-up with history and physical examination is the most appropriate procedure. Data show that more expensive imaging studies be carried out only in patients who are symptomatic from their disease, otherwise such an intensive follow-up schedule is not cost effective.

Clinical usefulness of an aftercare worker for psychotic patients discharged from half-way houses in Hong Kong

BACKGROUND

The aim was to assess the clinical usefulness and economic viability of an aftercare worker for psychotic patients discharged from half-way houses in Hong Kong.

METHOD

A sample of 32 chronic psychotic patients was provided with a full-time aftercare worker. A matched control group received no such service.

RESULTS

The experimental group was found to have greater and better employment prospects, better mental status with less hospitalisation and less law-breaking behaviour than the control group. Some of these benefits were converted into economic terms and the tangible costs incurred in the project were calculated.

CONCLUSIONS

The provision of an aftercare service is clinically useful and economically viable.

Colon surveillance after colorectal cancer surgery

PURPOSE

This study was performed to determine cost-effective colonoscopy guidelines for patients with prior colorectal adenocarcinoma.

METHOD

A retrospective review was performed of patients who had been treated for colorectal adenocarcinoma and later underwent follow-up colonoscopy from 1984 to 1994.

RESULTS

During this study period, 389 patients previously treated for colorectal adenocarcinoma underwent follow-up colonoscopy. All patients had perioperative colon evaluation for other neoplasms. Ages ranged from 26 to 89 (mean, 65.8) years, and 46.8 percent were female. Recurrent or metachronous cancer or a neoplastic polyp constituted a positive examination. Results of 389 first follow-up colonoscopies were compared with 259 second (66.6 percent), 165 third (42.4 percent), and 83 fourth (21.3 percent) follow-up examinations. Median interval between all colonoscopies was 13 months. Positive examination rates for the first two yearly examinations were 18.3 and 18.5 percent, respectively. Slightly lower, third-year and fourth-year positive examination rates were 16.4 and 14.5 percent, respectively. Four-year examinations yielded the following: first year--1 carcinoid, a new adenocarcinoma, and 100 polyps; second year--1 anastomotic recurrence and 68 polyps; third year --55 polyps; and fourth year--1 recurrent cancer and 17 polyps.

CONCLUSIONS

These data suggest that 1) annual follow-up colonoscopy for two years after colorectal cancer surgery is beneficial for detecting recurrent and metachronous neoplasms and 2) the interval between subsequent examinations may be increased depending on the result of the most recent examination.

Patterns and costs of post-acute care: a longitudinal study of people aged 60 and over in Dubbo

Declining length of stay of older people in hospital has caused concern about shifting of costs from acute to community care services. Because the two types of care are funded through different programs and from different jurisdictions, the coordination of acute and post-acute care has become the major issue. There is, however, little information available on patterns of use and costs of post-acute care either in Australia or elsewhere. In an existing longitudinal community study of older people in Dubbo, New South Wales, data on use of services by people aged 60 years and over for 12 months of hospitalisations was collected by linkage to the records of Home and Community Care providers. Only a quarter of older people received any type of Home and Community Care service in the 12 weeks after discharge and two-thirds of these received only one type of service. While less than 5 per cent received a service from an occupational therapist, physiotherapist or speech therapist, 78 per cent visited a general practitioner after discharge. The average cost of all Home and Community Care services received after hospital discharge was around $12.50 per week per person discharged. The predictors of higher costs of service use were: living alone, and the interactions of high levels of disability with owning a house. Results on service coordination, the identification of post-acute services, cost consequences of program funding, assessment and discharge planning are related to debates emerging from the Commonwealth Heads of Government.

Description and evaluation of a program for the early discharge of infants from a neonatal intensive care unit

The effect of a cost-containment program focused on decreasing the lengths of hospital stay of high-risk neonates was assessed by comparison of discharge weights and lengths of stay for 257 study infants, discharged from a neonatal intensive care unit (NICU) after an early-discharge program began, with those of 477 control infants discharged during a prior 1-year period. Demographic data and costs, as well as data on emergency department use and hospital readmissions, were included in the comparisons. There was a significant decrease in mean discharge weight and length of stay for infants in the study group. During a 7-month period, an estimated 2073 days of hospital care and approximately $2,700,000 in hospital charges were saved, or $10,609 per infant discharged. The cost of instituting and maintaining the program was $120,413, or $468 per infant. Seven visits were made to the emergency department by the study infants during the first 14 days after discharge. One infant was readmitted for a 4-day hospital stay for suspected sepsis. Significantly earlier discharge of high-risk neonates produced a decrease in hospital charges without causing excessive morbidity. The success of the program was coincident and presumed related to the institution of multiple elements focused toward family support through early-discharge planning. The reduction in hospital charges was 30 times higher than program expenses.

Postal follow up of patients with epilepsy

BACKGROUND

Epilepsy services in India are mostly located in urban areas and are often overcrowded. It is difficult, therefore, to organize long term management programmes. We report our experience at a tertiary referral centre on follow up of patients with epilepsy through regular postal review.

METHODS

One hundred consecutive patients with epilepsy (63 men, 37 women, mean age 17 years) who had only seizures were followed up by post using a questionnaire, instead of reviewing them in a clinic. The safety, utility and efficiency of this system were evaluated.

RESULTS

Sixty patients had generalized seizures, 30 had complex partial seizures and 10 had other types of seizures. The indication for shifting to postal review was good control of seizures in 87 cases and economic reasons in the remaining. Postal review constituted 60% of the total follow up period in 55 cases. Sixty-six patients could be maintained on postal review which was suspended or discontinued in 34 patients. Of these 34, 16 were returned to it after being seen in the clinic on a further occasion. Poor control of seizures, fresh medical or social problems, lack of confidence or a combination of these were the reasons for discontinuing the postal review. The economic benefit to a patient by way of savings in travel, incidental expenses and lost wages was estimated to be Rs 750 per annum. The work load in the epilepsy clinic was decreased by 40%. No serious medical problems or mortality were reported in the study population.

CONCLUSION

Systematic postal review is a cost-effective alternative to clinic review in the long term follow up of a certain group of patients with epilepsy.

The continuum of care for older people

The introduction of casemix in hospitals has increased concerns about cost-shifting to community services. There has been little evidence with which to test claims about shifting balances in the continuum of care, in particular for major user groups like older people. These matters have come into greater prominence with the Council of Australian Governments Communique which agreed in April to radical reforms of health and community services. We used an existing longitudinal study of people aged 60 years and over in the community of Dubbo, New South Wales, to study hospital and aged care service use over 50 months. Fifty-five per cent of those studied were hospitalised but only 1.7 per cent were admitted to nursing homes over the period. In the 12 weeks after hospital discharge, 24 per cent received Home and Community Care services, while 78 per cent visited a general practitioner. All post-acute community services over 12 weeks after discharge cost an average of $150. In the light of this new evidence, current proposals for structural reform are critically discussed.

Management of suicide attempters: what are the routines and the costs?

The services offered to a consecutive series of 97 suicide attempters (36 men and 61 women) at a general hospital were registered by a participating observer. All but one case were subjected to psychiatric consultation for suicide risk assessment, but only 34% were evaluated by a psychiatric specialist. Fifty-seven percent were admitted to psychiatric inpatient care. The length of inpatient care varied, the average duration was 5 days for men and 14 days for women. Repeaters were admitted more often than nonrepeaters. The short-term compliance was satisfactory. The direct cost for management was evaluated based on the detailed quantification of care provided for each subject. The care at the hospital equalled 6.4% of the total budget for psychiatric inpatient care.

Community psychiatric nurse teams: cost-effectiveness of intensive support versus generic care

BACKGROUND

Part of the community psychiatric nurse (CPN) service was reorganised into a community support team (CST), with staff acting as case managers. An economic evaluation ran parallel to the comparison with generic CPN care.

METHOD

Eighty-two clients were randomly allocated to experimental and control groups. Costs were comprehensively measured over a pre-referral period (three months), and then at 6, 12, and 18 months.

RESULTS

The economic evaluation found a cost difference between the groups. Generic group costs averaged 89 pounds per patient per week more than CST group costs. The difference was only significant for the first six months. Changes in the burden of cost across agencies were observed.

CONCLUSIONS

Although CPN inputs and costs were higher for the CST group, there was a significant short-term reduction in total cost. Beyond the short term, the CST did not confer cost or cost-effectiveness advantages.

[Cost saving after-care in infra-inguinal vascular reconstruction]

To assess the indications for routine colour flow duplex surveillance, 43 infrainguinal autogenous vein grafts were prospectively entered into a surveillance protocol. Screening consisted of measurements of ankle brachial indices (ABI) and colour flow duplex imaging of the entire graft length. All grafts at risk had a serial fall in resting ABI of more than 0.1. This study suggests that resting ABI measurements are a very sensitive and non-expensive primary screening procedure, provided that all grafts with ABI changes of more than 0.1 are further evaluated. About 60% of ABI-screened grafts needed further evaluation because of ABI changes of greater than 0.1, incompressibility of arteries or extension of the graft to the ankle or pedal arteries. Colour flow duplex scanning was very useful in excluding of identifying and localising graft problems and deciding on further invasive diagnostic and therapeutic procedures.

Discharge destinations of Medicare patients receiving discharge planning: who goes where?

This study aims to increase knowledge about factors affecting discharge destinations of Medicare patients leaving the hospital after receiving discharge planning services. Medical, social, financial, and demographic factors are tested in relation to three dispositions: home, nursing home, and rehabilitation unit. Polytomous logistic regression was used to assess the likelihood of going to one destination versus another. For both nursing home versus home and rehabilitation unit versus home, destination was a function of first medical and then financial factors, with social resources playing a lesser role in the models. The only demographic variable with a significant relationship to destination was race, with black patients less likely to enter nursing home settings.

[Para-clinical tests and follow-up of breast cancer: how do Quebec oncologists use them?]

To assess the use of complementary tests by oncologists during staging and follow-up of breast cancer patients, a study was performed comparing actual procedures with current literature recommendations. A survey concerning the use of biochemical, radiological and radionuclide tests was presented to a sample of 58 radiation oncologists and medical oncologists involved in the treatment of breast cancer patients, with a 71% response rate. During the post-treatment surveillance, respectively 3%, 24%, 37%, 76% and 96% of the physicians scheduled liver scans, liver ultrasounds, bone scans, chest roentgenograms or mammograms on a regular basis. The frequency of use of various procedures are reported with a reference to the cost-benefit ratio, a matter of current interest. Although most oncologists limit their use of diagnostic tests, some still rely on extensive work-up to detect early recurrences or metastases, an approach that remains controversial in today's literature.

A randomized study of telephone contact following completion of radiotherapy

The hypothesis tested was that routine contact by telephone might significantly improve the adequacy of support for patients during the potentially stressful period between completing radiotherapy and the first follow-up visit. The study was a randomized controlled trial in which 100 patients were allocated either to telephone contact (intervention arm) or usual care (control arm). Adequacy of support was assessed by a questionnaire administered at the first follow-up visit. There were no significant differences in the perceived adequacy of support between the two arms. Of the 72 patients who completed questionnaires, 76% of those in the intervention arm versus 61% in the control arm rated their support after radiotherapy as 'extremely adequate'. The 95% confidence interval (CI) for this 15% rate difference was -6- +36. Analysis by intention to treat showed a rate difference of only 4% (95% CI -17-(+)25) in favour of intervention. We conclude that, given the limited resources currently available, it is not possible to justify a policy of routine contact by telephone for all patients completing radiotherapy.

Post-hospital home health care for Medicare patients

Medicare patients in five diagnosis-related groups (DRGs) associated with heavy use of post-hospital care discharged from 52 hospitals in 3 cities were followed up at 6 weeks, 6 months, and 1 year to determine the factors associated with their being discharged home with or without home health care and the correlates of improvement in their functional status. Models correctly predicted those discharged home from those going to institutions in a range from 54 to 82 percent of cases. The amount of the variance in the change in function for those who went home (with or without home health care) explained by the models tested ranged from 19 percent to 73 percent. Total Medicare costs for the patients who went home were considerably less in the year subsequent to the hospitalization compared with those discharged to institutional care.

The intrauterine device in the present and future

Good counseling and better selection of candidates would result in the intrauterine device's (IUD) safer use. Age and parity of the IUD acceptor do not seem to be associated with an increased risk of pelvic inflammatory disease (PID). The newer generation of copper- and hormone-releasing IUDs are associated with improved safety and efficacy.

Changes in medical stability upon admission to a rehabilitation unit

The implementation of Medicare's prospective payment system in acute care has coincided with a steady increase in medically unstable admissions to our freestanding rehabilitation facility. We investigated the consequences of these admissions by collecting medical information regarding transfers beginning in 1983. Patients requiring transfer back to the acute setting within 1 day of admission were considered medically unstable and their charts were reviewed. The number of patients requiring transfer back within 1 day increased from 1.5% of all first admissions to 3.1% in 1988 (Mantel - Haenszel chi 2 = 8.03, (df = 1), p < .01), but the increase among Medicare patients alone was not significant. This progressive increase was most pronounced in the cerebrovascular accident and spinal cord injury populations. Beginning in 1988, an intensified preadmission evaluation program was implemented, resulting in a significant decline in unstable patient transfers from hospitals where our consultants were on staff. Physiatric consultations at referral institutions decreased the number of unstable patients at admission.

Post-hospitalization followup appointment-keeping among the medically indigent

The purpose of this study was to measure followup appointment-keeping in patients discharged from a General Medicine Inpatient Service and to identify possible predictors of compliance. Patients were interviewed on hospital admission and all charts were reviewed on discharge. A subset of patients were interviewed by telephone an average of one month after first followup appointment date. The study was conducted in an urban public teaching hospital with hospital-based and community clinics. A convenience sample of 209 patients were selected from admissions to the General Medicine Inpatient Service over a three month period. Followup appointment-keeping was recorded on all 195 patients discharged alive. Seventy-five percent of patients had no medical insurance, public or private. A compliance rate of 60% (95% confidence interval: 53% to 67%) with first followup appointment was found. Variables associated with compliance and which retained independence on multiple logistic regression analysis, followed by adjusted odds ratios (95% confidence intervals) were: no copayment requirement, odds ratio 3.2 (1.6 to 6.3), single followup appointment 2.9 (1.4 to 5.9), apartment dwelling 3.2 (1.4 to 7.3) and non-primary care clinic appointment 2.3 (1.1 to 4.8). We conclude that health-care-delivery related factors such as no copayment requirements are strongly associated with appointment-keeping in a public hospital population.

The costs of returning home

AIMS

To measure the use, and the financial cost to the patient, of medical and domiciliary services, in an elderly population following discharge from hospital. To estimate the effect of recent changes in Accident Compensation Corporation (ACC), Disabled Persons Community Welfare Act (DPCW) interpretation and user part charges on those costs.

METHODS

Elderly patients discharged home from hospital were visited 3 months following their discharge. The use of medical services and pharmaceuticals, receipt of formal domiciliary support services and adaptive equipment was recorded, together with the cost to the patient of each.

RESULTS

Ninety-four (88%) of 106 eligible patients were visited. Fifty percent lived alone and 77% were solely reliant on state benefits for income. Forty (42%) received meals on wheels, 64 (68%) domestic help and 42 (45%) district nursing. Most (86%) required the use of a walking aid and 77 (82%) needed further adaptive equipment to return home. The mean cost to the patient was $541.40 for the first 3 months. Changes in the funding of community supports would add an average of $60.38 (11.2%) to this cost.

CONCLUSION

Elderly patients recently discharged from hospital are high users of domiciliary support services. Any changes to their funding need monitoring to determine the effects on utilisation, costs and health status for the patient.

Access to needed follow-up services. Variations among different Medicare populations

BACKGROUND

We developed a new approach to measuring access to care that examines post-hospitalization follow-up care. It reveals differences in receipt of follow-up care among different subsets of the Medicare population.

METHODS

Medicare administrative databases from 1986, 1988, and 1990 were used to construct three retrospective cohorts. Each cohort consisted of patients from a random 1% sample of Medicare beneficiaries admitted with selected conditions that almost always require timely follow-up care. Various "vulnerable populations" within these cohorts were defined on the basis of age, sex, race, and other demographic factors. Merged outpatient records were used to determine receipt of postdischarge follow-up physician services, follow-up services in outpatient departments, and any follow-up care for these different Medicare populations.

RESULTS

Beneficiaries aged 85 years or older, black beneficiaries, Medicaid/Qualified Medicare Beneficiaries, residents of urban core counties, residents of the highest-poverty ZIP codes, and residents of Health Professional Shortage Areas were less likely to receive follow-up physician services. Beneficiaries aged 85 years or older, black beneficiaries, residents of the highest-poverty ZIP codes, and residents of Health Professional Shortage Areas were less likely to receive any follow-up care.

CONCLUSIONS

This method identified some Medicare populations who failed to receive needed follow-up services, suggesting problems with access to care. This method may be useful in tracking changes in access under the new Medicare fee schedule.