[Integrated case fees in cardiosurgery--a pilot project for fast-track rehabilitation]

BACKGROUND

Lengthy recovery and treatment times following cardiosurgical interventions were the motivation for introducing a pilot procedure to integrate acute and rehabilitative treatment structures. The advantage of such a pilot procedure is the medico-economic link between direct transition from acute care to rehabilitation treatment and cutting average case costs. With this in mind, shared case fees for patients following cardiosurgery are being agreed in a pilot project between health insurance companies, acute-care hospitals and rehabilitation clinics. The aim of this study was thus to investigate whether rehabilitation directly after cardiosurgery without prior transferral to an acute-care hospital is comparable with the conventional procedure involving acute care.

METHODS

A total of 221 patients were included in the investigation. The pilot project group comprised 159 patients (mean age 70 +/- 6 yrs, 117 men and 42 women) who were transferred directly to rehabilitation following cardiosurgery. The control group, comprising 62 patients (mean age = 71 +/- 6 yrs, 42 men and 20 women), was transferred to an acute-care hospital following cardiosurgery before commencing rehabilitation. Sociodemographic and clinical data were comparable between the two groups.

RESULTS

At the end of rehabilitation, the mean maximum ergometric performance in the pilot group was 96 +/- 33 W, significantly higher than the control group's performance of 81 +/- 31 W. One difference between the two groups related to complications. During rehabilitation, complications occurred more frequently within the pilot group. In the pilot group, compared to the control group, postcardiotomy syndrome occurred in 45.3 versus 25.8% and impaired wound healing in 10.1 versus 4.8% of cases. Despite these results, the pilot group demonstrated a significantly shorter overall hospital stay of 39.5 +/- 7.5 days compared to the control group stay of 45.7 +/- 9.7 days.

CONCLUSION

Compared to the control group, the pilot group was at no disadvantage with regard to clinical or performance data by the end of rehabilitation. Cardiac complications occur more often during rehabilitation taking place directly after cardiosurgery than with the conventional procedure. These can be viewed, however, as complications occurring directly in temporal conjunction with the operation and as to be expected. Complications attributed directly to fast-track rehabilitation can be excluded. In the pilot group the overall hospital stay was thus shortened. In an environment of legislative restructuring within the healthcare sector, this shows that adequate treatment of cardiosurgical patients is still guaranteed with fast-track rehabilitation.

[Coverage of preventive health activities in a Chilean region, calculated using the preventive medicine index]

BACKGROUND

Preventive activities of the public health system in Chile are not integrated and there is no parameter assessing the whole population that is benefited with these activities.

AIM

To develop and implement a mathematical measure of the coverage of preventive health activities, provided to different age groups.

MATERIAL AND METHODS

Data was gathered from the monthly statistical reports of the women, children, teenager, adult and elderly health programs in 30 communities of the Seventh Chilean Region. The preventive medicine index (PMI) was calculated as the ratio between the population that was ascribed to each program and the population that was a potential beneficiary of such program.

RESULTS

In the studied region, the global coverage of preventive medicine, calculated using the PMI, increased from 0.229 in 1999 to 0.370 in 2003. This represents a 61% increment. However, there are important inequalities in the access to preventive health in the different communities of the region.

CONCLUSIONS

The PMI revealed a substantial increment in preventive health activities in the studied region.

[Critical analysis of the progressive performance of low vision in Benjamin Constant Institute]

PURPOSE

To evaluate effectiveness of the Low Vision the Benjamin Constant Institute (BCI) and confirm the real necessity of an Institute like BCI in the present inclusion policy.

METHODS

Ecological study, analyzing 3 periods of Low Vision Assistance at the Benjamin Constant Institute from October 1, 1990 to December 20, 2002: a) 1991--starting assistance; b) 1995--medical pedagogic integration; c) 2002--present-day situation. We considered in this analysis as indicators: I--Low Vision Assistance, II--Low Vision sector in the Benjamin Constant Institute, III--Associates.

RESULTS

This study demonstrated an increase in assistance, reaching a wider spectrum of patients after medical-pedagogic integration. Other indicators, such as physician capacitation, participation in Benjamin Constant Capacitation Courses, increase in orientation to institutions, schools and others and referrals to the Benjamin Constant Institute, and Rehabilitation also attest the effectiveness of the Low Vision sector of the Benjamin Constant Institute.

CONCLUSIONS

The Low Vision sector proved to be the interface between the Medical and Pedagogic Departments, and later on the Rehabilitation and Physical Education Coordination sectors. This has implied alterations in the way to manage the low-vision patient, not only regarding the regular Benjamin Constant Institute student as well as any other patient in the community. The Benjamin Constant Institute proved its importance as regards inclusion policy.

Achieving community membership through community rehabilitation provider services: are we there yet?

Findings from an analysis of the characteristics and services of community rehabilitation providers (CRPs) in the early years of the 21st century are presented. Services provided by CRPs can be categorized along two dimensions: purpose (work, nonwork) and setting (facility-based, community). The number of individuals with disabilities present provides a third perspective for analysis. The majority of CRPs provided both work and nonwork services, and the majority of those that provide employment services offered both integrated and facility-based employment. Individuals with developmental disabilities were most likely to be supported in facility-based work (41%), followed by nonwork services (33%), and integrated employment (26%). Despite some changes in CRP characteristics, the goal of community membership has not yet been widely achieved.

Assisted self-report of health-services use showed excellent reliability in a longitudinal study of older adults

OBJECTIVE

Seniors use a wide variety of health services delivered by numerous practitioners and organizations. Self-report is the most accessible and cost-effective method to collect information on their use. It is thus important to demonstrate the reliability of this approach.

STUDY DESIGN AND SETTING

As part of a longitudinal study on the effect of an integrated service delivery system, participants (or their proxies) were instructed to use a calendar to record their use of health services. Every 2 months, an interviewer collected use since the last phone contact. A subsample was recontacted by the same or another interviewer to estimate test-retest and interinterviewer reliability, respectively. Data collections were compared using delta and weighted kappa as well as intraclass correlation coefficients.

RESULTS

Almost perfect agreement was obtained for hospitalization, day surgery, visits to general practitioners and medical specialists, help for home maintenance, and use of voluntary services. Agreement was substantial for visits to the emergency room and home help for personal care. For visits to or by nurses and other health professionals, agreement can be qualified as moderate-to-substantial.

CONCLUSION

Assisted self-report of health-services use by older adults or their proxies through bimonthly phone calls is reliable.

Testing the validity of the Recovery Assessment Scale using an Australian sample

OBJECTIVE

Mental health services in Australia are increasingly becoming recovery orientated. However, there are varying meanings for recovery and few measures that specifically target recovery outcomes. The current study aimed to assess the construct and concurrent validity of a patient self-report measure, the Recovery Assessment Scale (RAS).

METHOD

Participants were 168 individuals with severe and persistent psychiatric disability who were participants in the Australian Integrated Mental Health Initiative (AIMhi) project. They completed self-report recovery and other mental health measures and their case workers completed the Health of the Nation Outcome Scales. Exploratory and confirmatory factor analyses were carried out to examine the factor structure of the RAS.

RESULTS

Exploratory factor analysis of the RAS produced five factors that were replicated using confirmatory techniques. Each factor has satisfactory internal reliability (Cronbach alpha range = 0.73-0.91). The factors displayed convergent validity with positive and significant correlations with other recovery measures. Concurrent validity was demonstrated with significant but lower correlations with symptoms and clinician-rated measures of psychiatric functioning.

CONCLUSION

The factors of the RAS are consistent with the consumer literature on recovery. Correlations with other variable suggest that the RAS is measuring something different from traditional symptom or functional mental health measures. Further research is needed to clarify the extent to which the RAS is able to capture the range of recovery experiences that have been described by patients.

Chronisch krank - chronisch vergessen? - Kommunikation/Mobilität/Alltag

In the course of the recent years, the policy for the needs of disabled people has started a fundamental paradigm shift. Central elements of the current policy for the needs of disabled people are prevention, rehabilitation and integration. Self-determination instead of care forms the guiding principle. An indistinct definition of chronic disease makes it difficult to obtain a general idea of structures in the care and support for people with chronic diseases. The following compilation examines requirements in social legislation and questions the quality of life by means of the three exemplary aspects: communication, mobility and everyday life. Here the question remains whether the current focus on health neglects any relevant components of chronic diseases. It turns out that people with a chronic illness, although social legislation has improved, are neglected the more support they need. Care as an elementary social principle must be discussed on an interdisciplinary basis and in the context of the whole society.

The organisation, form and function of intermediate care services and systems in England: results from a national survey

This paper reports the results of a postal survey of intermediate care coordinators (ICCs) on the organisation and delivery of intermediate care services for older people in England, conducted between November 2003 and May 2004. Questionnaires, which covered a range of issues with a variety of quantitative, tick-box and open-ended questions, were returned by 106 respondents, representing just over 35% of primary care trusts (PCTs). The authors discuss the role of ICCs, the integration of local systems of intermediate care provision, and the form, function and model of delivery of services described by respondents. Using descriptive and statistical analysis of the responses, they highlight in particular the relationship between provision of admission avoidance and supported discharge, the availability of 24-hour care, and the locations in which care is provided, and relate their findings to the emerging evidence base for intermediate care, guidance on implementation from central government, and debate in the literature. Whilst the expansion and integration of intermediate care appear to be continuing apace, much provision seems concentrated in supported discharge services rather than acute admission avoidance, and particularly in residential forms of post-acute intermediate care. Supported discharge services tend to be found in residential settings, while admission avoidance provision tends to be non-residential in nature. Twenty-four-hour care in non-residential settings is not available in several responding PCTs. These findings raise questions about the relationship between the implementation of intermediate care, and the evidence for and aims of the policy as part of National Health Service modernisation, and the extent to which intermediate care represents a genuinely novel approach to the care and rehabilitation of older people.

Health service use and outcome: comparison of low charge, integrated, comprehensive services with usual health care

We examined the effects of use of low charge, integrated and comprehensive health care services (Veterans Administration (VA) health care system) on health care service use and health-related outcomes. Data came from the 10-year (1986/87-1996/97) Duke Established Populations for Epidemiologic Studies of the Elderly, with 159 men aged 65-85 who primarily used VA health services compared with 1,100 men aged 65-85 who did not. In controlled analyses, no differences were found between the two groups on number of OTC medications used, or in speed or likelihood of entering a nursing home. However, veterans who primarily used the VA health care system reported more outpatient visits and prescription drugs, and increased likelihood of using an adjunct health care provider; entry into a hospital was quicker, and number of hospitalizations was greater. Although health status was controlled, because of eligibility requirements it remains possible that veterans were sicker. Nevertheless, no differences were found in health outcome (functional status or mortality). Readier access to better integrated health services appears to result in increased use of health services controlled by the health care provider, but not of services requiring the recipient's relocation, while functional status and mortality attained equivalence.

Cross-country measures for monitoring epilepsy care

PURPOSE

The International League Against Epilepsy (ILAE) Commission on Healthcare Policy in consultation with the World Health Organization (WHO) examined the applicability and usefulness of various measures for monitoring epilepsy healthcare services and systems across countries. The goal is to provide planners and policymakers with tools to analyze the impact of healthcare services and systems and evaluate efforts to improve performance.

METHODS

Commission members conducted a systematic literature review and consulted with experts to assess the nature, strengths, and limitations of the treatment gap and resource availability measures that are currently used to assess the adequacy of epilepsy care. We also conducted a pilot study to determine the feasibility and applicability of using new measures to assess epilepsy care developed by the WHO including Disability-Adjusted Life Years (DALYs), responsiveness, and financial fairness.

RESULTS

The existing measures that are frequently used to assess the adequacy of epilepsy care focus on structural or process factors whose relationship to outcomes are indirect and may vary across regions. The WHO measures are conceptually superior because of their breadth and connection to articulated and agreed upon outcomes for health systems. However, the WHO measures require data that are not readily available in developing countries and most developed countries as well.

CONCLUSION

The epilepsy field should consider adopting the WHO measures in country assessments of epilepsy burden and healthcare performance whenever data permit. Efforts should be made to develop the data elements to estimate the measures.

Factors identifying high-frequency and low-frequency health service utilization among substance-using adults

Understanding why substance-using patients seek care at emergency departments (EDs) and who utilizes such service at high rates is important in tailoring and targeting interventions. We conducted a retrospective/prospective cohort study of 326 medically ill substance-using adults to identify factors associated with 12-month high-frequency utilization of ambulatory care, ED, and inpatient medical care. The majority were actively using heroin (74.6%), cocaine (62.4%), and alcohol (54.4%); 94.8% had a chronic medical condition; and 53.8% reported a chronic mental health condition. High-frequency use of ED (> or = 3 visits) was independently associated with being female (adjusted odds ratio [AOR] = 1.88; 95% confidence interval [95% CI] = 1.12, 3.17), being African American (AOR = 2.36; 95% CI = 1.30, 4.29), being homeless (AOR = 2.07; 95% CI = 1.08, 3.96), a history of > 1 substance abuse treatment episode (AOR = 4.10; 95% CI = 3.28, 10.87), and > or = 1 ambulatory care visit (AOR = 8.94; 95% CI = 3.28, 24.41). However, the combination of having certain chronic conditions (seizure disorder, hepatitis B, and hepatitis C) and accessing ambulatory care was protective against high-frequency use of ED. In contrast, high-frequency use of ambulatory care (> or = 3 visits) was independently associated with having insurance (Medicare/Medicaid: AOR = 2.39; 95% CI = 1.31, 4.69), having HIV/AIDS (AOR = 3.15; 95% CI = 1.70, 5.85), and receiving substance abuse treatment during the study period (AOR = 3.58; 95% CI = 1.61, 7.98) Efforts to redirect medical care to more subacute settings will likely require both capacity building and addressing a client's underlying needs, including homelessness, access to substance abuse treatment, and chronic disease management.

SA HealthPlus: a controlled trial of a statewide application of a generic model of chronic illness care

SA HealthPlus, one of nine national Australian coordinated care trials, addressed chronic illness care by testing whether coordinated care would improve health outcomes at the cost of usual care. SA HealthPlus compared a generic model of coordinated care for 3,115 intervention patients with the usual care for 1,488 controls. Service coordinators and the behavioral and care-planning approach were new. The health status (SF-36) in six of eight projects improved, and those patients who had been hospitalized in the year immediately preceding the trial were the most likely to save on costs. A mid-trial review found that health benefits from coordinated care depended more on patients' self-management than the severity of their illness, a factor leading to the Flinders Model of Self-Management Support.

Challenges associated with the integration of endovascular repair of abdominal aortic aneurysms in a community hospital

PURPOSE

There has been considerable debate regarding the proper place for endovascular repair (ER) of abdominal aortic aneurysms (AAAs) versus traditional open repair (OR). Our study compared preoperative patient demographics and outcomes for elective, asymptomatic AAA repairs performed at our center over a 33-month period.

METHODS

For this study, we selected 342 consecutive elective infrarenal AAA repairs performed between July 1, 2000, and March 31, 2003, at Riverside Methodist Hospital. The patients underwent either ER or OR, depending on patient and surgeon collaborative determinations. Ruptured and symptomatic AAAs were excluded from our study. Preoperative demographics, anesthesia, complications, and discharge status for the 2 groups were analyzed, and statistical analysis was done to determine statistically significant differences.

RESULTS

The preoperative status of the ER and OR patient groups were essentially similar. There were only 3 significant differences between the 2 groups: alcohol use was higher for the OR group than for the ER group (12.0% versus 5.2%; P = .04), and the incidence of type II diabetes mellitus and peripheral vascular disease were lower for the OR group compared with the ER group (6.7% versus 13.4% [P = .04] and 18.3% versus 30.6% [P = .008], respectively). The OR group used more general anesthesia than the ER group (99% versus 86%; P < .001) and had more complications, including dysrhythmia (8.65% versus 1.59%; P = .005), ileus (13.94% versus 0.79%; P < .0001), infection (8.17% versus 0.0%; P = .0007), respiratory complications (12.50% versus 1.59%; P = .0003), and renal complications (5.29% versus 0.79%; P = .032). The ER group had a higher rate of wound hematoma (4.76% versus 0.48%; P = .007). ER patients also had significantly less blood loss (379 mL versus 1930 mL; P < .001), a better independent discharge status (P < .0001), a shorter length of stay (1.8 days versus 8.2 days; P < .001), and a lower mortality rate (0.75% versus 3.85%; P = .0954).

CONCLUSIONS

From our study we cautiously continue to encourage the consideration of the ER of AAAs in our patient population while being mindful of its limitations.

Models of health: A survey of practitioners

PURPOSE

Models of health influence providers' practice and delivery of health care. This study surveyed a random sample of providers to determine if health care providers from mainstream medicine (MM), integrative medicine (IM), and complementary and alternative medicine (CAM) hold mutually exclusive models of health or combine notions from models thought to be contradictory.

METHODS

A survey was created through qualitative research, piloted, and mailed to a wide variety of MM, IM, and CAM health care professionals.

RESULTS

All providers combined various models and definitions of health. Most utilized the biomedical approach to some extent. Balance (holistic model) and functioning in daily life were essential to most respondents' models of health, disease, and healing. Close communication between MM and CAM systems was preferred over complete separation or a single system.

CONCLUSIONS

Many providers of all types combine widely disparate components in their definitions of health, providing keys for improving communication.

On-site medical care in methadone maintenance: associations with health care use and expenditures

To evaluate whether long-term drug treatment with on-site medical care is associated with diminished inpatient and outpatient service use and expenditures, we linked prospective interview data to concurrent Medicaid claims of drug users in a methadone program with comprehensive medical services. Patient care was classified as follows: long-term (>/=6 months) drug treatment with on-site usual source of medical care (linked care), long-term drug treatment only, or neither. Multivariate analyses adjusted for visit clustering within patients (n = 423, with 1,161 person-years of observation). After adjustment, linked care participants had more outpatient visits (p < .001), fewer emergency department (ED) visits (24% vs. 33%, p = .02) and fewer hospitalizations (27% vs. 40%, p = .002) than the "neither" group. Ambulatory care expenditures in the linked group were increased, whereas expenditures for other services were similar or reduced. Long-term drug treatment with on-site medical care was associated with increased ambulatory care, less ED and inpatient care, and no net increase in expenditures.

Breast cancer treatment of older women in integrated health care settings

PURPOSE

A substantial literature describes age-dependent variations in breast cancer treatment, showing that older women are less likely to receive standard treatment than younger women. We sought to identify patient and tumor characteristics associated with the nonreceipt of standard primary tumor and systemic adjuvant therapies.

PATIENTS AND METHODS

We studied 1,859 women age 65 years or older with stage I and II breast cancer diagnosed between 1990 and 1994 who were cared for in six geographically dispersed community-based health care systems. We collected demographic, tumor, treatment, and comorbidity data from electronic data sources, including cancer registry, administrative, and clinical databases, and from subjects' medical records.

RESULTS

Women 75 years of age or older and women with higher comorbidity indices were more likely to receive nonstandard primary tumor therapy, to not receive axillary lymph node dissection, and to not receive radiation therapy after breast-conserving surgery (BCS). Asian women were less likely to receive BCS, and African American women were less likely to be prescribed tamoxifen. Although nonreceipt of most therapies was associated with a lower baseline risk of recurrence, an important minority of high-risk women (16% to 30%) did not receive guideline therapies.

CONCLUSION

Age is an independent risk factor for nonreceipt of effective cancer therapies, even when comorbidity and risk of recurrence are taken into account. Information regarding treatment effectiveness in this age group and tools that allow physicians and patients to estimate the benefits versus the risks of therapies, taking into account age and comorbidity burden, are critically needed.

Auditing outcomes and costs of integrated complementary medicine provision--the importance of length of follow up

A retrospective audit was carried out on 58 patients with chronic health problems who were referred by 22 general practitioners (GPs) for acupuncture, aromatherapy, homeopathy, massage and osteopathy, or a combination. Costs of GP consultations, prescriptions, secondary care referrals, and diagnostic tests from records of 33 of these patients were compared pre (24 months), during (mean 4.3 months) and post (mean 5.7 months) complementary medicine (CM) treatment. Patient centred outcome data included the Measure Yourself Medical Outcome Profile (MYMOP) and content analysis of patient and practitioner comments. Costs of GP consultations/patient/month were significantly higher during (20.10 pounds, p<0.001) and post (17.53 pounds, p<0.01) CM treatment compared with pre-treatment costs (11.27 pounds). Total prescription costs were not significantly higher during and post-treatment than pre-treatment. Prescription costs for referred conditions were lower during (2.26 pounds) and higher post-treatment (3.75 pounds) compared with costs pre-treatment (3.24 pounds). Pre- and post-treatment MYMOP scores indicated significant improvements in health and well-being. Longer follow up, is required in order to demonstrate significant cost savings related to CM provision. Cost comparisons with conventional medicine should consider quantitative and qualitative data to capture the wider benefits experienced by patients.

Inter-state variations in integration of leprosy services into general health system in low/ moderately endemic states of India

The objective of the study was to analyse inter-state variations in integration of leprosy services into the general health system, covering broad categories of structure integration, training of health functionaries, availability of MDT services and record maintenance, in 24 low/moderately endemic states. Multi-stage random sampling technique was used to select 9 states, 86 health facilities (including district hospitals, community health centres, primary health centres) and 108 sub-centres. Information from each level was collected on a pre-tested form by officers of three leprosy institutions of the Government of India. The results showed wide inter-state variations on each aspect. Redeployment of vertical staff was complete (100%) in Tamil Nadu and Tripura. Assam reported a higher level of training (97%) of medical officers in leprosy. Training of health supervisors and multipurpose workers was better than that of medical officers in most of the states. Tripura reported negligible training of all the health functionaries because of specific local problems. In Assam, Maharashtra and Sikkim, all the urban and rural health facilities were providing MDT. Three months' stock of all types of MDT blister packs was available only in one health facility in Andhra Pradesh and in Goa. Assam and Haryana had lower availability of MDT stocks. In Assam and Maharashtra, medical officers in all health facilities were diagnosing and treating leprosy cases, as compared with Himachal Pradesh where the value was 30%. Involvement of sub-centres in MDT delivery was more at 92% and 100% in Tamil Nadu and Maharashtra respectively in comparison to none in Himachal Pradesh and Tripura. Use of the Simplified Information System (SIS) 2002 guidelines and formats was universal. However, lower involvement of GHS staff in recording and reporting was noted in Assam (0%), Andhra Pradesh (10% and 30%). The study emphasized the need for further tailor-made follow-up studies to suit local problems.

Impact of program services on treatment outcomes of patients with comorbid mental and substance use disorders

OBJECTIVE

This study examined the outcomes of individuals with co-occurring disorders who received drug treatment in programs that varied in their integration of mental health services. Patients treated in programs that provided more on-site mental health services and had staff with specialized training were expected to report less substance use and better psychological outcomes at follow-up.

METHODS

Participants with co-occurring disorders were sampled from 11 residential drug abuse treatment programs for adults in Los Angeles County. In-depth assessments of 351 patients were conducted at treatment entry and at follow-up six months later. Surveys conducted with program administrators provided information on program characteristics. Latent variable structural equation models revealed relationships of patient characteristics and program services with drug use and psychological functioning at follow-up.

RESULTS

Individuals treated in programs that provided specific dual diagnosis services subsequently had higher rates of utilizing mental health services over six months and, in turn, showed significantly greater improvements in psychological functioning (as measured by the Brief Symptom Inventory and the RAND Health Survey 36-item short form) at follow-up. More use of psychological services was also associated with less heroin use at follow-up. African Americans reported poorer levels of psychological functioning than others at both time points and were less likely to be treated in programs that provided mental health services.

CONCLUSIONS

Study findings support continued efforts to provide specialized services for individuals with co-occurring disorders within substance abuse treatment programs as well as the need to address additional barriers to obtaining these services among African Americans.

Early experiences with e-health services (1999-2002): promise, reality, and implications

BACKGROUND

E-health services may improve the quality and efficiency of care; however, there is little quantitative data on e-health use.

OBJECTIVE

The objective of this study was to examine trends in e-health use and user characteristics.

RESEARCH DESIGN

This was a longitudinal study of e-health use (1999-2002) within an integrated delivery system (IDS). We classified 4 e-health services into transactional (drug refills and appointment scheduling) and care-related (medical and medication advice) services.

SUBJECTS

Approximately 3.3 million members of a large, prepaid IDS.

MEASUREMENTS

Amount and frequency of e-health use over time and characteristics of users.

RESULTS

The number of members registered for access to e-health increased from 20,617 (0.7% of all members) in Q1 1999 to 270,987 (8.6%) in Q3 2002. Between Q1 and Q3 2002, 42,845 members (1.3%) used the drug refill service and 55,901 (1.7%) used the appointment scheduling service compared with 10,756 members (0.3%) who used the medical advice service and 3069 (0.1%) who used the medication advice service. Over the same period, transactional service users averaged 3.5 uses/user versus 1.6 uses/user among care-related service users. Members most likely to use e-health services had a high level of clinical need, a regular primary care provider, were 30 to 64 years old, female, white, and lived in a nonlow socioeconomic status neighborhood. These findings were consistent across e-health service types.

CONCLUSIONS

Although use of all e-health services grew rapidly, use of care-related services lagged significantly behind use of transactional services. Subjects with greater clinical need and better ties to the health system were more likely to use both types of e-health services.

Interprofessional referral patterns in an integrated medical system

OBJECTIVE

To determine the interreferral patterns among physicians and complementary and alternative medicine (CAM) providers in an independent practice association integrated medical system.

METHOD

Data from a 1-year period were collected on referral patterns, diagnosis, number of visits, cost, and qualitative aspects of patient care. The independent practice association provided care for approximately 12,000 patients.

RESULTS

In the selected integrative network, there are those primary care physicians (PCPs) who refer and those who do not. Among those PCPs that refer to CAM, a preference is shown for a limited number of providers to whom they refer. Although doctors of chiropractic get more referrals, they are also more concentrated among selected providers than are doctors of oriental medicine.

CONCLUSION

This study shows the interreferral patterns among the PCP and CAM providers working within an integrated medical system. One effect of being in the network for doctors of chiropractic and doctors of oriental medicine might be the possible interreferrals between each other.

[Psychiatric care in South Tyrol -- an example of coordination]

The Tyrol's division after the two World Wars cut the South Tyrol off from every relevant aspect of psychiatric care. First attempts towards a community psychiatric system weren't sufficiently sustained by politicians. Only in the 90 ty's was the association of relatives of mentally ill people able to sensitize public and politicians to the need for an adequate psychiatric care system. Since 1996 an excellent psychiatric plan has been in existence, 80 % of which has to date been able to be put into practice. Since 1997 mentally ill people have founded their own self-help-organization and influenced the planning process.

[Integrated Health Care in cardiology: substitution or addition of new tools?]

On the basis of broad statistical information about procedures and operations in German cardiology, the author discusses probable and already evident effects of emerging Integrated Health Care projects. Among those expectations, possibly a new group of services will emerge that adds rather than substitutes already existing services. By this effect no cost-containment, which is one of the legislative purposes for Integrated Health Care, will be achievable. Besides this pessimistic view, Integrated Health Care in cardiology has the potential to allocate financial funds in a more appropriate way than it is presently usual. For example, procedures that can be performed in outpatients, no longer need to be performed on inpatients for the only reason that hospitals are not entitled to do outpatient services.