Dilemmas in the acute pharmacologic treatment of uncontrolled atrial fibrillation

A recently conducted observational study of the prehospital treatment of uncontrolled atrial fibrillation brought to light therapeutic inconsistencies by emergency providers in dealing with this dysrhythmia. A review of the literature suggests that digoxin lacks efficacy in controlling ventricular rate in atrial fibrillation and that the slow onset of digoxin makes its use in the emergency setting questionable. Because of their demonstrated ability to rapidly slow ventricular rate, the calcium channel blocker, diltiazem, or the beta-adrenergic blocker, esmolol, should be the preferred agents for treating rapid atrial fibrillation in the emergency department or the paramedic ambulance.

Impact of a worker's compensation practice guideline on lumbar spine fusion in Washington State

OBJECTIVES

In the face of escalating medical costs for injured workers, the Washington State Department of Labor and Industries (L&I), which pays for most workers' compensation costs in the state, established guidelines for elective lumbar fusion as part of its inpatient utilization review program. The guidelines were tied to reimbursement strictures. The authors attempt to assess the effects of these guidelines, which were introduced in November 1988, upon subsequent L&I fusion procedures.

METHODS

Discharge data from the Comprehensive Hospital Abstract Reporting System and algorithms using International Classification of Diseases, Version 9, Clinical Modification diagnosis and procedure codes were used to identify lumbar surgical cases. Population estimates were from the 1990 US Census Bureau.

RESULTS

During the period of years 1987 through 1992, the lumbar fusion rate for the state showed a 26% decline compared with a 3% decrease for all lumbar operations. After November 1988, when the guidelines went into effect, the state fusion rate declined 33%, whereas rates for nonfusion operations essentially were unchanged. The sharpest decline corresponded in time to implementation of the guidelines. Prior to the initiation of L&I guidelines, the proportion of fusions among L&I patients was higher than among non-L&I patients. The opposite was true by the end of 1992, and the L&I proportion decreased more rapidly than the non-L&I proportion. Time series analysis revealed that both the decline in Washington state lumbar fusion rates and the decline in the proportion of lumbar fusion among L&I patients were statistically significant.

CONCLUSIONS

The data suggest that the L&I lumbar fusion surgery criteria and reimbursement standards implemented in 1988 contributed to a decline in rates of performing that procedure. The utilization review aspect of the guidelines as well as the process of involving surgeons in the preparation and dissemination of guidelines also may have been contributory.

Emergency medical systems in Czechoslovakia

The year 1987 witnessed the "velvet revolution" of Vaclav Havel and the beginning of democratic reform in Czechoslovakia. As the country struggles to build a market-based economy, it maintains a well-developed socialist system of health care that is patterned after the former Soviet system and is free to all (Am J Emerg Med 1984; 2:455-456). Formal private medical practice does not exist. Non-emergency care is provided by multispecialty, primary-care oriented clinics (polyklinka) where after-hours visits are possible due to the presence of on-call physicians. In small towns such an on-call doctor would be a general practitioner, but in large cities an internist, pediatrician, and surgeon might all be available.