TThe Syva MicroTrak Chlamydia enzyme immunoassay (EIA; Syva Company, San Jose, Calif.) with cytospin and direct fluorescent-antibody assay (DFA) confirmation was evaluated on 43,630 urogenital specimens over a 1-year period in the Provincial Laboratory in Regina, Saskatchewan, Canada. This was a two-phase study intended to define a testing algorithm for Chlamydia trachomatis that would be both highly accurate and cost-effective in our high-volume (> 3,000 tests per month) laboratory. The prevalence of C. trachomatis infection in our population is moderate (8 to 9%). In phase 1, we tested 6,022 male and female urogenital specimens by EIA. All specimens with optical densities above the cutoff value and those within 30% below the cutoff value were retested by DFA. This was 648 specimens (10.8% of the total). A total of 100% (211 of 211) of the specimens with optical densities equal to or greater than 1.00 absorbance unit (AU) above the cutoff value, 98.2% (175 of 178) of the specimens with optical densities of between 0.500 and 0.999 AU above the cutoff value, and 83% (167 of 201) of the specimens with optical densities within 0.499 AU above the cutoff value were confirmed to be positive. A total of 12% (7 of 58) of the specimens with optical densities within 30% below the cutoff value were positive by DFA. In phase 2, we tested 37,608 specimens (32,495 from females; 5,113 from males) by EIA. Only those specimens with optical densities of between 0.499 AU above and 30% below the cutoff value required confirmation on the basis of data from phase 1 of the study. This was 4.5% of all specimens tested. This decrease in the proportion of specimens requiring confirmation provides a significant cost savings to the laboratory. The testing algorithm gives us a 1-day turnaround time to the final confirmed test results. The MicroTrak EIA performed very well in both phases of the study, with a sensitivity, specificity, positive predictive value, and negative predictive value of 96.1, 99.1, 90.3, and 99.7%, respectively, in phase 2. We suggest that for laboratories that use EIA for Chlamydia testing, a study such as this one will identify an appropriate optical density range for confirmatory testing for samples from that particular population.
During the past century, long-term care in the United States has evolved through five cycles of development, each lasting approximately twenty years. Each, focusing on distinct concerns, produced unintended consequences. Each also added a layer to an accumulation of contradictory approaches--a patchwork system now pushed to the breaking point by increasing needs and financial pressures. Future policies must achieve a better synthesis of approaches inherited from the past, while addressing their unintended consequences. Foremost must be assuring access to essential care, delivery of high-quality services in an increasingly deinstitutionalized system, and a reduction in social and economic disparities.
OBJECTIVE: This long-term follow-up recorded the prevalence, aetiology and treatment of hard-to-heal leg and foot ulcers, and an estimated nurses' time spent providing care, for the years 1994-2005. METHOD: A questionnaire was sent to all district and community nurses in the county of Blekinge, Sweden, during one week in 1994, 1998, 2004 and 2005. Calculating the costs of hard-to-heal leg and foot ulcer care was not a primary aim, but the reduction in prevalence and time spent on wound management suggested it was important to illustrate the economic consequences of these changes over time. RESULTS: Estimated prevalence of hard-to-heal leg and foot ulcers reduced from 0.22% in 1994 to 0.15% in 2005. Treatment time decreased from 1.7 hours per patient per week in 1994 to 1.3 hours in 2005. Annual costs of leg and foot ulcer care reduced by SEK 6.96 million in the study area from 1994 to 2005. CONCLUSION: Improved wound management was demonstrated; leg and foot ulcer prevalence and treatment time were reduced. The results could be attributed to an increased interest in leg and foot ulcer care among staff, which was maintained by repeated questionnaires, continuous education, establishment of a wound healing centre in primary care and wound management recommendations from a multidisciplinary group. The improved ulcer care reduced considerably the annual costs of wound management in the area.
This paper uses hospital separation abstracts to assess trends in acute care hospital utilization in British Columbia over the first 18 years of publicly funded health insurance in the province. Between 1969 and fiscal year 1987-88, the overall separation rate decreased by 16%, accompanied by a 23% decrease in average length of stay. For the elderly, the separation rate increased by 14% and three quarter of this increase was for surgical procedures, mostly new high-technology procedures. For the nonelderly, separation rates decreased by 25%. Lengths of stay decreased in both age groups. Over the last two decades overall separation rates in British Columbia were higher than or equal to separation rates in the United States, and lengths of stay were consistently higher in British Columbia. Since access to hospitals by the elderly is similar in the two countries, lower hospital costs in Canada result from factors other than lower overall hospital utilization or decreased access for the elderly.
In October 1993, a survey of health care agency administrators was undertaken shortly after they had experienced two sudden reductions in public funding. The purpose of this investigation was to gain insight into the role of ethics in health administrator decision making. A mail questionnaire was designed for this purpose. Descriptive statistics and content analysis were used to summarize the data. Staff reductions and bed closures were the two most frequently reported mechanisms for addressing the funding reductions. Most administrators did not believe that these changes would have a negative public impact. In contrast, the majority indicated that future changes in reaction to additional funding reductions would have a negative public impact. Approximately one-third of the administrators reported ethics to be an element of recent administrative decision making, and one-half could foresee that ethics would be important in the future if reductions continued. These findings are discussed in relation to ethics. Issues for additional research are outlined.
This paper is an examination of the effectiveness of a programme (described in detail elsewhere) designed to admit whole families for short-term intensive assessment and treatment. The goals of this programme are to eliminate residential care for symptomatic children who are admitted with their families to this service, to decrease the length of stay of the symptomatic child in residential treatment, if this is required following admission of the whole family to this unit, and to provide these services at costs comparable to or less than that currently being spent with conventional residential treatment. Results stemming from a number of pre- and post-treatment measures indicate that one half of the children initially assessed and recommended for inpatient treatment had successfully avoided inpatient treatment for six months following admission of their family to this unit. For children recommended for residential care after admission of their families to the family unit, a reduction of approximately 35% of total time in residence occurred (when compared with a comparison group). A cost saving of over +12,000 per case was realized as a result of admission of the whole family when compared with residential treatment.
Rationing of health care is an inevitable correlate of living in a world of finite resources. It is morally necessary. The Hippocratic ethic commits clinicians to do whatever will benefit the patient and therefore must be abandoned in a world of moral rationing. After looking at some unacceptable preliminary strategies, two patient-centered adjustments in the Hippocratic ethic, adopting a more objective standard of patient benefit and adding a principle of patient autonomy, are defended. Still, however, cutting the fat out of the system will not be sufficient. A true social ethic of resource allocation will be necessary. A social contract approach supports a principle of equity as a necessary supplement to utility and cost-benefit analysis. It does not follow, however, that clinicians must take on these social ethical decisions. Clinicians should be exempt from normal social ethics so they are free to pursue the objective welfare of patients (provided they consent to such benefit). Administrators are in no better position to allocate scarce resources. What is needed is input from patients to (a) set categorical limits on their own care, (b) articulate principles for fine-tuning the allocation decisions, and (c) supervise professional agents who will make specific gatekeeping decisions for allocating a pool of resources legitimately thought to belong to the patient population. Neither administrators nor clinicians will be responsible for rationing decisions. In 1989 we spent $604.1 billion on health (U.S. Department of Health and Human Services 1990). That is almost $2 billion a day. Sometimes the benefits are dramatic: the pneumonia cured, the heart transplanted, the children spared from infectious diseases with immunizations that cost only pennies. Even so, the American health care system leaves much to be desired. Many other countries have higher life expectancy at birth. Infant mortality in the United States is far higher than countries like Japan and Sweden (United Nations Children's Fund 1990). If we look at the distribution of health status in the United States, the problems look even worse. Today, depending on the study, about 13 to 15 percent of the population has no health insurance at all (U.S. Bureau of the Census 1989; Short, Monheit, and Beauregard 1989). Another 13 percent is woefully underinsured (Farley 1985). Social variables such as income, education, and race reveal dramatically different health status (Short, Monheit, and Beauregard 1989; Farley 1985). To respond to these needs, rationing will be essential.(ABSTRACT TRUNCATED AT 400 WORDS)
Comment In: Front Health Serv Manage. 1991 Fall;8(1):31-310112249
Comment In: Front Health Serv Manage. 1991 Fall;8(1):34-610112250
Comment In: Front Health Serv Manage. 1991 Fall;8(1):37-4210112251