Continuity and change in preferred provider organizations

This paper presents the results from a national survey of preferred provider organizations (PPOs) that was conducted in 1988. It is based on telephone interviews conducted by the authors with executives in over 170 PPOs in the United States. We compare the survey results with those obtained from similar surveys conducted in 1985 and 1986, allowing us to assess the extent to which PPOs have grown and changed. We found that PPOs have continued to grow at an extremely rapid rate. During the Summer and Fall of 1988, the time in which the survey took place, 37.6 million people were eligible to use PPO benefits, compared to the 16.5 million figure we obtained two years earlier. We did not find, however, that PPOs are moving in the direction of providing more innovative forms of health care cost containment. Most PPOs still rely on discounts from providers and utilization review to achieve savings. There is little trend towards using incentive reimbursement techniques and choosing preferred providers that have shown themselves to be cost-efficient. We conclude that in the coming years PPOs must demonstrate the ability to control rising health care costs. To accomplish this, they will need to put more pressure on providers to use resources more sparingly. Otherwise, they may lose their market share to other forms of managed care.

The use, cost, and economic burden of nursing-home care in 1985

Nursing-home expenses constitute one of the greatest financial risks for elderly Americans. This study, based largely on the 1985 National Nursing-Home Survey, examines the economic burden posed by nursing-home care during 1985. The results indicate that nursing-home expenses constitute by far the largest out-of-pocket burden of all health care services. It was found that nursing-home care expenses constituted 82.5% of the out-of-pocket expenditures among the elderly who incurred $3,000 or more in such expenditures during 1985. Surprisingly, though, it was found that the frequency in which those in nursing homes "spend-down" their assets and income, thus becoming eligible for Medicaid, is much lower than others have calculated. This may be due in part to the fact that a large proportion of the elderly are already eligible for Medicaid when they begin their nursing-home stays.

Cardiovascular risk factors in a French-Canadian population: resolution of genetic and familial environmental effects on blood pressure by using extensive information on environmental correlates

Genetic and environmental influences on systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial blood pressure (MBP) were examined in 371 French-Canadian families by using path analysis. Familial environment was estimated with environmental indices constructed from as many as 14 (of a pool of more than 100) correlates of blood pressure (BP). Approximately 20% of the variance in BP can be accounted for by the composite index, and the types of variables and the direction of their effects vary as a function of age and of the multivariate context. Path analysis of the family data suggests that genetic heritability is relatively high in children (from 0.49 for SBP to 0.56 for MBP) but much smaller in adults (from 0.08 for DBP to 0.18 for SBP). The proportion of variability explained by familial environment is estimated to be the same in children and adults and is much higher than reported to date (from 0.30 for SBP to 0.42 for DBP). In addition, sibships share significant nontransmitted environmental effects, and there is no evidence to suggest specific maternal effects in the aggregation of BP. Two unique findings emerge from this study. First, unlike in most earlier studies, we were able to arrive at the same parsimonious model for each of the BP variables. Second, the familial environment accounts for a substantial proportion of the variability in BP, which has been considerably underestimated in earlier studies.

Multivariate path analysis of specific cognitive abilities in the Colorado Adoption Project: conditional path model of assortative mating

A multivariate path model of genetic and environmental transmission employing a conditional path representation of assortative mating was fitted to specific cognitive abilities data from the Colorado Adoption Project and evaluated using a maximum-likelihood estimation procedure. In agreement with results obtained from a previous analysis of a smaller data set, significant genetic covariation among the cognitive variables was indicated and evidence for a general genetic factor was found. However, cultural transmission parameters are nonsignificant and environmental correlations among the measures are relatively small.

Cardiovascular risk factors in a French Canadian population: resolution of genetic and familial environmental effects on blood pressure using twins, adoptees, and extensive information on environmental correlates

Genetic and environmental influences on systolic (SBP), diastolic (DBP), and mean arterial (MBP) blood pressure were examined using an expanded version of a path model in which parents and their singleton, twin, and adopted offspring were incorporated, and which also included an environmental index as an estimate of the underlying familial environmental component. Estimates of genetic heritability are lower in parents (10-15%) than in offspring (40-50%). Cultural heritability was significant for SBP (0.31) and MBP (0.40), and an intergenerational effect was found for DBP, with higher estimates in parents (0.42) than in offspring (0.21). Marital resemblance was significant, and no support was found for differential maternal and paternal cultural transmission. Two novel results arising from this study are 1) gender-specific sibling effects, with greater female than male resemblance for SBP and MBP and the opposite pattern for DBP, and 2) the suggestion of extra twin resemblance arising on account of additional shared environments and resulting in greater like-sex than opposite-sex twin resemblance. The major conclusions drawn from this study are that 1) parameter estimates are stable with or without the use of extensive environmental indices, and 2) the addition of twins and adoptees did not significantly impact the results, with the exception of a possible influence of the adoptees in estimates of cultural heritability for DBP. Combining both these features (i.e., extended relatives and environmental indices) enables testing for additional sources of familial aggregation, which is not possible using the traditional nuclear family approach and results in a more accurate assessment of the relative roles of heredity and environment on blood pressure than has been previously possible.

Heterogeneity in the biological and cultural determinants of high-density lipoprotein cholesterol in five North American populations: the Lipid Research Clinics Family Study

Heterogeneity in the source of familial resemblance for high-density lipoprotein (HDL) cholesterol in 5 different Lipid Research Clinics (Cincinnati, Iowa, Minnesota, Oklahoma and Stanford) was assessed using a general linear model for cultural and biological inheritance. No evidence of heterogeneity was found in any of the parameters of the model. Under the most parsimonious hypothesis, using data pooled over all clinics, genetic and cultural heritability were both significant and were estimated to be 0.52 +/- 0.04 and 0.09 +/- 0.02, respectively; there was cultural transmission but no maternal effects; marital and nontransmitted sibship environmental resemblance were significant.

AIDS Nurses to be better protected

HIV-positive nurses will be better protected at work after last week's publication of guidelines drawn up by the Government's Expert Advisory Group on Acquired Immune Deficiency Syndrome.

Role of radiation therapy in small cell lung cancer: a bio-clinico-pathological review and perspective

The role of radiotherapy in small cell carcinoma of the lung is unsettled; however, the radiosensitivity of this neoplasm is unquestioned. The ability of radiotherapy to cure or improve patients with this disease is still undergoing study. A review of this challenging subject is presented.

Schnyder's dystrophy. Progression and metabolism

In the first long-term cohort study of Schnyder's corneal dystrophy the authors examined affected and unaffected members of two unrelated families in 1975 and 1976 respectively, and again in 1984. They identified carriers, catalogued changes in the diffuse and crystalline corneal opacities which characterize this dystrophy and analysed the patient's lipid metabolism. Corneal opacities never regressed. Progression was more frequent in diffuse than in crystalline opacities. Both crystalline and diffuse opacities reappeared and progressed following penetrating keratoplasty. Mean cholesterol levels in the carrier group were above normal and six had a moderate type IIa dyslipoproteinemia; conversely, two carriers had low apo B. The degree of corneal opacification showed no relationship to dyslipoproteinemia. Schnyder's corneal dystrophy appears to involve the corneal lipid metabolism only and not to be a systemic disease.

Consumer knowledge of Medicare and supplemental health insurance benefits

In this article, data from a recent study funded by the Health Care Financing Administration are used to examine the level of knowledge about health care insurance coverage among Medicare beneficiaries. Two related categories of this knowledge are analyzed: knowledge of the Medicare program itself and knowledge of supplemental health insurance policies owned by program beneficiaries. The results indicate that Medicare beneficiaries typically do not have high levels of knowledge either about Medicare or about their supplemental health insurance. Also analyzed are the factors that affect knowledge levels.

Preferred provider organizations: issues for employers

The preferred provider organization (PPO), an alternative delivery system currently embraced by the employer sector, has been growing at a phenomenal rate for the past few years. It is necessary to examine the issues an employer should consider when deciding whether to offer a PPO option, and to look at organizational issues such as PPO structure, quality, utilization review mechanisms, and benefits design.

Increased risk of gastrointestinal perforations in neonates mechanically ventilated with either face mask or nasal prongs

Twenty cases of gastrointestinal perforations not associated with necrotizing enterocolitis or a bowel obstruction (GPNN) were reviewed. Fifteen infants suffered perforations during cycle ventilation. Perforations were localized in the stomach, duodenum, ileum, and jejunum. To determine if the type of mechanical ventilation used (ie, face mask, nasal prongs, or endotracheal tube) was associated with GPNN, a matched case-control analysis was performed. Case and control infants were matched by means of Apgar scores, gestational age, and length of time on ventilatory support. The Mantel-Haenszel estimate for estimating odds-ratios was used to determine that infants ventilated with nasal prongs or face mask were more likely to develop a gastrointestinal perforation than control infants ventilated with endotracheal tubes (odds-ratio greater than or equal to 29.6). This risk was associated with both upper gastrointestinal perforations (odds-ratio greater than or equal to 21.0) and lower gastrointestinal perforations (odds-ratio greater than or equal to 15.3). Routine use of mechanical ventilation with either nasal prongs or face mask appears to be associated with an unacceptable risk of gastrointestinal perforations in sick neonates.

"PALS for life!" A required trauma-oriented pediatric advanced life support course for pediatric and emergency medicine housestaff

While advanced cardiac life support (ACLS) and advanced trauma life support (ATLS) courses have become accepted standards for physicians who care for the critically ill and injured patient, only recently have pediatric advanced life support (PALS) courses been developed. The American Academy of Pediatrics has shown renewed interest in pediatric cardiopulmonary arrest after impressive gains made in adult resuscitation. The American Heart Association filled a void by including new chapters on Pediatric and Neonatal Resuscitation in the Textbook of Advanced Cardiac Life Support, 1981. A joint committee of AHA and AAP is seeking to unify course objectives and materials for standard curriculum. Because trauma is the most common cause of death and disability in children, pediatric trauma life support measures should be incorporated into any program directed toward emergency physicians and pediatricians who function in an emergency department or rural primary care setting. The Department of Pediatrics and Surgery and its division of Emergency Medicine has developed and implemented a PALS curriculum which is different from most other programs in that emphasis has been placed on pediatric trauma in addition to traditional cardiac (ACLS) resuscitation. This 20-hour program combines a modified ACLS curriculum with specific pediatric trauma lectures and laboratory sessions. It includes a canine surgical procedure lab and modified ATLS skill stations. At the completion of the course, students are eligible for ACLS certification. In the two years in which the course was given, 39 pediatric houseofficers were enrolled in the course.(ABSTRACT TRUNCATED AT 250 WORDS)

Development of hand preference in the Colorado Adoption Project

A longitudinal study of the development of hand preference in 152 adopted and 120 nonadopted (control) infants measured in natural behavioral situations at both 12 and 24 mo. of age is reported. Significant developmental trends were observed for both increasing strength and direction of handedness. Less than 10% of the infants exhibited a clear preference at 12 mo. of age, whereas about 30% were lateralized at 24 mo., with more boys than girls being left-handed. In contrast, over 90% of the parents of these children (both biological and adoptive parents of the adopted children and parents of the nonadopted children) were lateralized. Perhaps because so few infants were lateralized at either age, parent-offspring resemblances were inconsistent and the number of significant parent/child correlations was about that expected on the basis of chance alone.

Determinants of physician assignment rates by type of service

In this article, the determinants of physician assignment rates under the Medicare program are examined separately for medical, surgical, laboratory, and radiology services. Data for this study include copies of all Medicare claims submitted by over 1,200 Colorado general practitioners, internists, and general surgeons during the periods both before and after they experienced a substantial change in program reimbursement rates. The results indicate that there is a significant positive relationship between changes in reimbursement and changes in assignment rates for medical, laboratory, and radiology services, but the relationship for surgical service is not significant. Furthermore, for laboratory and radiology services, only the change in medical service reimbursement is significant--reimbursement rates for laboratory and radiology services are not.

Changes in Medicare reimbursement in Colorado: impact on physicians' economic behavior

In 1976 there was a change in Medicare reimbursement policy in the State of Colorado. This study analyzes the impact of that change on physicians' economic behavior. Through 1976, prevailing charges (one of the determinants of the level of physician reimbursement under Medicare) were computed separately within each of 10 regions of Colorado. Since then, they have been computed for the State as a whole, and thus, physicians in like specialties have had equal prevailing charges throughout the State. This change in reimbursement policy led to a relative increase in prevailing charges for physicians in small urban and nonurban areas of the State, and a relative decrease for physicians in the major urban areas. In this paper we analyze the impact of this change on several aspects of physician behavior. We found that physicians whose reimbursement rates declined as a result of the change--primarily those in the Denver/Boulder area--provided more-intensive medical services, had lower assignment rates, and charged lower prices than they would have in the absence of the change.

Clinical significance of tolerant strains of Staphylococcus aureus in patients with endocarditis

We have studied 50 cases of endocarditis and 54 cases of bacteremia due to Staphylococcus aureus to ascertain the clinical significance of the newly described phenomenon of tolerance. In 32 of the patients with endocarditis and 35 of those with bacteremia strains were classified as tolerant (minimum bactericidal concentration/minimum inhibitory concentration greater than or equal to 16). Patients with endocarditis due to a tolerant strain responded less favorably than did patients with a sensitive strain. A larger number of patients with a tolerant strain had prolonged fever (58% versus 19%), a higher mean number of complications (1.6 versus 0.73), a greater number of intensive-care unit admissions (66% versus 33%), and a higher mortality (25% versus 11%). In contrast there was no difference in response to therapy in bacteremic patients without endocarditis having sensitive and tolerant strains. We conclude that infection with a tolerant organism adversely influences the outcome of staphylococcal endocarditis.

Primary meningococcal pericarditis

We have described two patients with primary meningococcal pericarditis. The first patient required open surgical drainage. In the second patient, pericardiectomy was eventually required. Thirteen cases of primary meningococcal pericarditis have now been reported. All the patients survived, in contrast to purulent pericarditis of other causes.

The demonstration of angiogenic activity from ocular tissues. Preliminary report

Human, bovine, and rabbit retinal extracts are shown to be capable of stimulating (1) proliferation and thymidine uptake of bovine vascular endothelial cells in cultures and (2) neovascularization of the chick chorioallantoic membrane (CAM). Extracts of skeletal muscle, heart, and liver lack similar stimulatory activity. Vitreous aspirates from patients with proliferative diabetic retinopathy, in a preliminary study, were able to stimulate vascular endothelial cell thymidine uptake. Most vitreous samples from patients without intraocular neovascularization lacked similar stimulatory activity. Indirect evidence suggests the liberation of an angiogenic factor from the retina in several ocular disorders. The data contained in this report represent the first direct evidence of angiogenic activity from mammalian retina.

Orbital involvement by plasmacytoma. Report of two cases

Two patients with orbital involvement of plasma cell myeloma are presented. The first patient presented an isolated plasmacytoma in the orbit; the second patient had generalized plasma cell myeloma. In both cases X-rays and computed tomographic scanning gave valuable information and biopsy confirmed the diagnosis.