Intensity Of Medical Care Research Articles

Predicting future medical needs and mortality risk in geriatric long-term care patients : Development and validation of the Nascher score and revised Nascher score.

Choosing the right intensity of medical care is ahuge challenge particularly in long-term geriatric care. The Nascher score was developed to assess future medical care needs. The aim of this study was to determine whether the Nascher score and arevised version can predict future medical needs. In this retrospective cohort study, 396 residents in long-term care hospitals, who were admitted over a period of two years and followed up to two and a half yeare, were analysed. Outcome parameters were: (1)number of medication changes, (2)number of ward doctor documentations and (3)number of acute illnesses treated with antibiotics, and mortality risk. Based on the first results, an alternative scoring of the Nascher score with 12instead of 26items was developed, called the revised Nascher score. The Nascher score significantly correlated with the number of medication changes, the number of ward doctor documentations, and the number of acute ilnesses treated with antibiotics with Spearman correlation coefficients of 0.30, 0.26, and 0.15, respectively. The revised Nascher score showed ahigher correlation with correlation coefficients of0.36, 0.26, and 0.21, respectively. Residents with aNascher score in the highest quartile had asignificantly higher mortality risk than residents in the lowest quartile (hazard ratio, HR 2.97, 95% confidence interval, CI 1.80-4.34). The corresponding values for the revised Nascher score were HR 3.03, 95% CI 2.03-4.54 in the highest and HR 1.80, 95% CI 1.24-2.60 in the middle quartiles. The Nascher score and even more so the revised Nascher score are well suited to predicting the various parameters of future medical needs and mortality risk.

Medication use in patients with functional seizures from a public and a private hospital

PurposeCurrently, we have limited knowledge of any potential differences among patients with functional seizures (FS), otherwise known as psychogenic non-epileptic seizures (PNES), from different socioeconomic backgrounds. Investigating medication use among these patients may provide insight into the quality and intensity of medical care they receive. Thus, we aimed to assess and compare the frequency and quantity of antiseizure medications (ASMs), and psychiatric and other medications used among patients with FS from a private and public epilepsy monitoring units (EMUs) in Cape Town, South Africa. MethodsOnly video-electroencephalographically (video-EEG) confirmed patients with FS with no comorbid epilepsy were eligible for the study. For this retrospective case-control study we collected data on patients’ medication-taking histories using digital patient records, starting with the earliest available digital patient record for each hospital. ResultsA total of 305 patients from a private hospital and 67 patients from a public hospital were included in the study (N=372). Patients with FS attending the public hospital had lower odds of taking any ASMs at presentation (aOR=0.39, 95% CI [0.20, 0.75]) and ever taking psychiatric medications (aOR=0.41, 95% CI [0.22, 0.78]) compared to FS patients from the private hospital. They did, however, have higher odds of being discharged with an ASM (aOR=6.60, 95% CI [3.27, 13.35]) and ever taking cardiovascular medication (aOR=2.69, 95% CI [1.22, 5.90]) when compared to the private hospital patients. With every additional presenting ASM (aOR=0.63, 95% CI [0.45, 0.89]) and psychiatric medication (aOR=0.58, 95% CI [0.40, 0.84]) the odds of being from the public hospital decreased. However, they increased with every additional discharge ASM (aOR=3.63, 95% CI [2.30, 5.72]) and cardiovascular medication (aOR=1.26, 95% CI [1.02, 1.55]). ConclusionStandard approaches to pharmacological treatment for patients with FS differed between the public and private hospitals and may indicate a gap in quality of care.

Medical care costs at the end of life among older adults with cancer: a national health insurance data-based cohort study

ObjectiveAlong with aging, the elderly population with cancers is increasing. The costs of end-of-life (EOL) care are particularly high among cancer patients. The purpose of this study was to investigate the trends in medical costs in the last year of life among older adults with cancer.Design, setting, and participantsUsing the Health Insurance Review and Assessment Services (HIRA) database for the period 2016–2019, we identified older adults aged ≥ 65 years who had a primary diagnosis of cancers and high-intensity treatment at least once in the intensive care unit (ICU) of tertiary hospitals.Main outcomes and measuresHigh-intensity treatment was defined as receiving at least one of the following treatments: cardiopulmonary resuscitation, mechanical ventilation, extracorporeal membrane oxygenation, hemodialysis, and transfusion. The EOL medical treatment costs were calculated by dividing periods 1, 2, 3, 6, and 12 months from the time of death, respectively.ResultsThe mean total EOL medical expense per older adult during the year before death was $33,712. The cost of EOL medical expenses for three months and one month before subjects’ death accounted for 62.6% ($21,117) and 33.8% ($11,389) of total EOL costs, respectively. Among subjects who died while receiving high-intensity treatment in the ICU, the costs associated with medical treatments that occurred during the last month before death were 42.4% ($13,841) of the total EOL expenses during the year.ConclusionThe findings indicate that EOL care expenditures for the older population with cancer are highly concentrated until the last month. The intensity of medical care is an important and challenging issue in terms of care quality and cost suitability. Efforts are needed to properly use medical resources and provide optimal EOL care for older adults with cancer.

Impact of Specialized Versus General Palliative Care on the Intensity of Medical Care at the End of Life in Adolescents and Young Adults with Cancer: A Population-Based Cohort Study

Impact of Specialized Versus General Palliative Care on the Intensity of Medical Care at the End of Life in Adolescents and Young Adults with Cancer: A Population-Based Cohort Study

Supportive and palliative care in hemato-oncology: how best to achieve seamless integration and subspecialty development?

While recent medical advances have led to cure, remission, or long-term disease control for patients with hematologic malignancy, many still portend poor prognoses, and frequently are associated with significant symptom and quality of life burden for patients and families. Patients with hematological cancer are referred to palliative care (PC) services less often than those with solid tumors, despite higher inpatient mortality and shorter interval between first consultation and death. The complexity of individual prognostication, ongoing therapeutic goals of cure, the technical nature and complications of treatment, the intensity of medical care even when approaching end of life, and the speed of change to a terminal event all pose difficulties and hinder referral. A modified palliative care model is an unmet need in hemato-oncology, where PC is introduced early from the diagnosis of hematological malignancy, provided alongside care of curative or life-prolonging intent, and subsequently leads to death and bereavement care or cure and survivorship care depending on disease course. From current evidence, the historical prioritization of cancer care at the center of palliative medicine did not guarantee that those diagnosed with a hematological malignancy were assured of referral, timely or otherwise. Hopefully, this article can be a catalyst for debate that will foster a new direction in integration of clinical service and research, and subspecialty development at the interface of hemato-oncology and palliative care.

Factors associated with emergency department use for mental health reasons among low, moderate and high users

ObjectivesThis study identified factors associated with frequency of emergency department (ED) use for mental health (MH) reasons in Quebec during 2015–2016. MethodsParticipants (n = 115,066) were categorized as: 1) low (1 visit/year; 76%); 2) moderate (2 visits/year; 14%); and 3) high (3+ visits/year; 10%) ED users. Independent variables included predisposing, enabling and needs factors based on the Andersen Behavioral Model. Variables significantly associated with frequency of ED use were entered into a multinomial logistic regression. ResultsPatients with mental illness (MI), especially substance-related disorders (SRD) and schizophrenia spectrum disorders; bipolar, depressive, anxiety or personality disorders; and those with severe chronic physical illness (needs factors) were more likely to use ED for MH reasons, as were male participants 18–64 years old, and those living in metropolitan areas with high social or material deprivation (predisposing factors). Regarding enabling factors, consultations with outpatient psychiatrists and not seeing a general practitioner (GP) in the year prior to ED visit were associated with high ED use. ConclusionThe severity of MI/SRD contributed most to frequent ED use, while social and material deprivation in metropolitan areas, and intensity of medical care also influenced ED use for MH reasons.

Intensity of medical care in internal medicine: impact on outcomes from a trend analysis over six years

In large acute medical wards treating heterogenous and complex patients, intensity of patient care should be graduated according to clinical severity. We conducted a retrospective observational study on all unselected admissions (8838) to the internal medicine ward of the Santa Chiara Hospital of Trento from 2012 to 2017. During 2012 and 2013, a standard organizational model (SMC) was in place, while an organizational model for intensity of medical care (IMC) was introduced in 2014. In SMC, patient admission was performed according to bed availability only. In IMC, patients were allocated to three different ward settings (high, medium and post-acute care) based on the stratification of clinical instability. The National Early Warning Score (NEWS) was used for the stratification, together with the clinical judgment. The implementation of the IMC model led to a decrease of mortality and urgent transfers for clinical deterioration to Intensive Care Unit and to an increase of admissions from Intensive Care Unit and from regional spoke hospitals. Redesigning delivery processes based on IMC can play a pivotal role in improving patient outcomes and bed management.

A model based on intensity of medical care may improve outcomes for internal medicine patients in Italy.

BackgroundIn medical wards, to guarantee safe, sustainable and effective treatments to heterogeneous and complex patients, care should be graduated into different levels of clinical intensity based on a standardised assessment of acute-illness severity. To support this assumption, we conducted a prospective observational study on all unselected admissions of 3,381 patients to a medium size internal Italian Medicine Unit by comparing Standard Medical Care model (SMC) to a new paradigm of patient admission based on Intensity of Medical Care (IMC).MethodsThe SMC operated during 2013, while an IMC organizational model started in 2014. In SMC, patient’s admission was performed according to bed availability only. In IMC, after the stratification of clinical instability performed using the National Early Warning Score (NEWS) and clinical judgment, patients were allocated to three different ward areas (high, middle, and post-acute medical care). We compared clinical and organizational outcomes of IMC patients (2015) to SMC patients (2013), performing adjusted logistic regression model.ResultsWe managed 1,609 and 1,772 patients using SMC and IMC, respectively. The IMC seemed to be associated to a lower risk of clinical worsening for patients. Comparing IMC to SMC, the odds ratio (aOR) for urgent transfers to intensive care units was 0.69 (p = 0.03), and for combination of urgent transfers and early deaths was 0.68 (p<0.01).ConclusionsRedesigning the configuration of internal medicine ward to support urgency and competency of the clinical response by applying IMC paradigm based on the NEWS, improved outcomes in patients with acute illness and enhanced ward performances.

Adaptive immunity to fungi.

Life-threatening fungal infections have risen sharply in recent years, owing to the advances and intensity of medical care that may blunt immunity in patients. This emerging crisis has created the growing need to clarify immune defense mechanisms against fungi with the ultimate goal of therapeutic intervention. We describe recent insights in understanding the mammalian immune defenses that are deployed against pathogenic fungi. We focus on adaptive immunity to the major medically important fungi and emphasize three elements that coordinate the response: (1) dendritic cells and subsets that are mobilized against fungi in various anatomical compartments; (2) fungal molecular patterns and their corresponding receptors that signal responses and shape the differentiation of T-cell subsets and B cells; and, ultimately (3) the effector and regulatory mechanisms that eliminate these invaders while constraining collateral damage to vital tissue. These insights create a foundation for the development of new, immune-based strategies for prevention or enhanced clearance of systemic fungal diseases.

The effects of health information technology on the costs and quality of medical care

Information technology has been linked to productivity growth in a wide variety of sectors, and health information technology (HIT) is a leading example of an innovation with the potential to transform industry-wide productivity. This paper analyzes the impact of health information technology (HIT) on the quality and intensity of medical care. Using Medicare claims data from 1998 to 2005, I estimate the effects of early investment in HIT by exploiting variation in hospitals’ adoption statuses over time, analyzing 2.5 million inpatient admissions across 3900 hospitals. HIT is associated with a 1.3% increase in billed charges (p-value: 5.6%), and there is no evidence of cost savings even five years after adoption. Additionally, HIT adoption appears to have little impact on the quality of care, measured by patient mortality, adverse drug events, and readmission rates.

Abstract 338: High Quality Medical Care: A Key Component in Access to Vascular Care for Patients with Lower Extremity PAD

Objectives: Prior work has demonstrated that patients at risk for amputation often have limited access to vascular care. We hypothesized that patients at risk for amputation may also have poor access to medical care related to their peripheral arterial disease (PAD). Therefore, we studied the intensity of medical care provided to patients at risk for amputation, and its relationship to access to vascular care. Methods: We identified a cohort of 52,505 Medicare patients at risk for amputation (pre-existing diabetes, PAD, and foot ulceration) who required hospital admission for leg or foot cellulitis. Using the 307 hospital referral regions defined in the Dartmouth Atlas, we determined the proportion of patients that received appropriate, high quality medical care within 1 year (before or after) hospital admission. High-quality medical care was defined as evidence of (1) hemoglobin A1C testing (2) podiatric care, and (3) non-invasive vascular testing. Then, using regression analysis at the regional level, we assessed relationships between the use of high quality of medical care and access to diagnostic or therapeutic lower extremity vascular procedures. Results: Across the United States, only 36% of diabetic patients with PAD and tissue loss received all three components of high quality medical care; 76% received 2 of 3 components. A non-invasive vascular study was absent in 41%. Provision of high-quality medical care varied across regions, from 4% of patients in Mason City, Iowa to 58% of patients in Sun City, Arizona. Regions that provided high quality medical care were significantly more likely to provide vascular care (R=0.30, p&lt;0.001). Across quintiles of medical care quality, those regions most likely to provide high quality medical care were 24% more likely to provide invasive vascular care and revascularization (p&lt;0.001, Figure). Conclusions: Fewer than 4 out of 10 Medicare diabetics with PAD and tissue loss receive high-quality, appropriate medical care. Quality improvement efforts at limiting amputation need to incorporate multidisciplinary strategies and involve primary care providers, as high quality medical care is an important determinant of access to vascular care and limb preservation.

Personalized end-of-life care: Associations between patient preferences and treatment intensity near death

6516 Background: Medical treatment at the end-of-life (EOL) should be responsive to patient values, but research shows it may instead reflect the regional supply of health services and/or physician practice patterns. We sought to determine whether patients' preferences are associated with EOL medical care and place of death. Methods: Coping with Cancer is an NCI/NIMH-funded, multi-site prospective, longitudinal cohort study of patients with advanced cancer, conducted from September 2002-February 2008. Analyses were based upon 317 deceased patients interviewed at baseline and followed until death, a median of 4.4 months later. EOL care was obtained from chart review, and regressed on patients' baseline preferences for life-extending therapy. Analyses were adjusted for significant confounds; i.e., socio-demographics, cancer type, patient denial, EOL discussion, do-not resuscitate (DNR) order, and treatment center. A sub-analysis examined EOL care within three different medical centers to determine whether patients' preferences and treatment intensity varied by region/practice type. Results: 90 of 317 patients (28.4%) reported a desire to receive life-extending therapy at baseline. Patients' preferences did not differ by proximity to death or performance status, but patients who preferred life-extending therapy had higher rates of denial (75.0% vs. 55.6%, p = 0.002) and were less likely to report having an EOL conversation (24.4% vs. 48.9%, p = 0.0002) or a DNR order (24.4% vs. 48.9%, p &lt; 0.0001). These patients were more likely to undergo ICU admission (AOR 4.6, 95% CI 1.9–11.1) and ventilation (AOR 3.0, 95% CI 1.2–7.3), and die in an ICU (AOR 6.7, 95% CI 2.4–18.7) instead of at home (AOR 0.6, 95% CI 0.3–0.9). A sub-analysis of patients treated at Yale, Parkland, and New Hampshire Oncology-Hematology confirmed that patients' preference for life-extending treatment was associated with higher rates of ICU admission in all three centers. Conclusions: Advanced cancer patients' treatment preferences may play a more important role in determining the intensity of medical care at the EOL than previously recognized. Future research should determine whether these preferences are informed and thus reflect patients' true values for EOL care. No significant financial relationships to disclose.

Classification of Complications Associated with Hemodialysis Vascular Access Procedures: A Position Statement from the American Society of Diagnostic and Interventional Nephrology

AbstractA procedure‐related complication is an unanticipated adverse event that requires therapy. In order to analyze frequency and severity of complications in the process of quality assurance, it is useful to have a classification of complications, indicating the type and severity. The Clinical Practice Committee of American Society of Diagnostic and Interventional Nephrology has developed a Classification of Complications relating to Hemodialysis Vascular Access Procedures, based on the system first proposed by Beathard in 2006. In this system, the “type” refers to the procedure being performed or vessel entered, and the “grade” is based on the intensity of medical care needed to address the complication. This publication describes 10 Types and 4 Grades of complications.

Weekend Worriers

Clinicians strive to provide care to patients every day of the week. Doing so entails effort, and people who work in hospitals (unlike those in many other lines of work) are not always compensated for taking the weekend shift. Casual observations of hospital parking lots suggest that staffing shortfalls may prevail, indicating that the intensity of medical care on weekends does not match that provided on other days of the week.The shortfall of weekend medical care is important because the consequences of adverse events cannot always be offset by working harder on subsequent days. For example, treatment of myocardial . . .

Di(2‐ethylhexyl)phthalate (DEHP): human metabolism and internal exposure – an update and latest results1

Di(2-ethylhexyl)phthalate (DEHP) is a reproductive and developmental toxicant in animals and a suspected endocrine modulator in humans. There is widespread exposure to DEHP in the general population. Patients can be additionally exposed through DEHP-containing medical devices. Toxicokinetic and metabolic knowledge on DEHP in humans is vital not only for the toxicological evaluation of DEHP but also for exposure assessments based on human biomonitoring data. Secondary oxidized DEHP metabolites like mono-(2-ethyl-5-hydroxyhexyl)phthalate (5OH-MEHP), mono-(2-ethyl-5-oxohexyl)phthalate (5oxo-MEHP), mono-(2-ethyl-5-carboxypentyl)phthalate (5cx-MEPP) and mono-[2-(carboxymethyl)hexyl]phthalate (2cx-MMHP) are most valuable biomarkers of DEHP exposure. They represent the major share of DEHP metabolites excreted in urine (about 70% for these four oxidized metabolites vs. about 6% for MEHP); they are immune to external contamination and possibly the ultimate developmental toxicants. Long half-times of elimination make 5cx-MEPP and 2cx-MMHP excellent parameters to measure the time-weighted body burden to DEHP. 5OH-MEHP and 5oxo-MEHP more reflect the short-term exposure. We calculated the daily DEHP intake for the general population (n = 85) and for children (n = 254). Children were significantly higher exposed to DEHP than adults. Exposures at the 95th percentile (21 and 25 microg/kg/day, respectively) scooped out limit values like the Reference Dose (RfD, 20 microg/kg/day) and the Tolerable Daily Intake (TDI, 20-48 microg/kg/day) to a considerable degree. Up to 20-fold oversteppings for some children give cause for concern. We also detected significant DEHP exposures for voluntary platelet donors (n = 12, 38 microg/kg/apheresis, dual-needle technique). Premature neonates (n = 45) were exposed to DEHP up to 100 times above the limit values depending on the intensity of medical care (median: 42 microg/kg/day; 95th percentile: 1,780 microg/kg/day).

Studienteilnahme verbessert Therapiestrategien und individuelle Patientenversorgung in teilnehmenden Zentren

Die ADEBAR-Studie ist eine prospektive multizentrische Phase III Studie, die überprüft, ob Hochrisiko-Mammakarzinompatientinnen (>4 befallene axilläre Lymphknoten) von einem sequenziellen Anthrazyklin-Docetaxel Regime (E90C-D: 4 Zyklen Epirubicin [E] 90mg/m2 KOF plus Cyclophosphamid [C] 600mg/m2 KOF q21d, gefolgt von 4 Zyklen Docetaxel [D] 100mg/m2 KOF q21d) gegenüber der Standard-Chemotherapie mit Anthrazyklinen (FE120C: 6 Zyklen E60mg/m2 KOF d 1+8, 5-Fluorouracil 500mg/m2 KOF d 1+8 und C 75mg/m2 KOF d 1–14, q28d) profitieren. Mit insgesamt 198 aktiv rekrutierenden Zentren und einem medianen Patientinneneinschluss von 33,0 Patientinnen/Monat war die ADEBAR Studie die bis zum Studienende am besten rekrutierende Studie Deutschlands in ihrem Indikationsbereich.

Should spontaneous and medically indicated preterm births be separated for studying aetiology?

An increasing proportion of preterm births result from medical interventions, and the practice of aggregating all preterm births vs. splitting into spontaneous and medically indicated preterm births is inconsistent. While mechanistic and clinical arguments can be offered for either approach, we empirically evaluated the predictiveness of a range of risk factors for preterm birth in the Pregnancy, Infection, and Nutrition Study. Most influences were shared across the two subsets - African-American ethnicity, advancing age, delivery at a university medical centre, prior preterm birth and smoking. Medically indicated preterm births appeared to be associated with intensity of medical care, higher in the university medical centre and lower for the poorest women. Body mass index was positively associated with medically indicated preterm birth and inversely with spontaneous preterm birth. Given the complexity of the aetiological pathways, both aggregation and disaggregation are well justified and should be included in studies of the causes of preterm birth.

Medication-Prescribing Errors in a Teaching Hospital

Improved understanding of medication prescribing errors should be useful in the design of error prevention strategies. To report analysis of a 9-year experience with a systematic program of detecting, recording, and evaluating medication-prescribing errors in a teaching hospital. All medication-prescribing errors with potential for adverse patient outcome detected and averted by staff pharmacists from January 1, 1987, through December 31, 1995, were systematically recorded and analyzed. Errors were evaluated by type of error, medication class involved, prescribing service, potential severity, time of day, and month. Data were analyzed to determine changes in medication-prescribing error frequency and characteristics occurring during the 9-year study period. A total of 11,186 confirmed medication-prescribing errors with potential for adverse patient consequences were detected and averted during the study period. The annual number of errors detected increased from 522 in the index year 1987 to 2115 in 1995. The rate of errors occurring per order written, per admission, and per patient-day, all increased significantly during the study duration (P < .001). Increased error rates were correlated with the number of admissions (P < .001). Antimicrobials, cardiovascular agents, gastrointestinal agents, and narcotics were the most common medication classes involved in errors. The most common type of errors were dosing errors, prescribing medications to which the patient was allergic, and prescribing inappropriate dosage forms. The results of this study suggest there may exist a progressively increasing risk of adverse drug events for hospitalized patients. The increased rate of errors is possibly associated with increases in the intensity of medical care and use of drug therapy. Limited changes in the characteristics of prescribing errors occurred, as similar type errors were found to be repeated with increasing frequency. New errors were encountered as new drug therapies were introduced. Health care practitioners and health care systems must incorporate adequate error reduction, prevention, and detection mechanisms into the routine provision of care.

Intensity of In-Hospital Care for Persons with AIDS

We evaluated the intensity of medical care for 30 consecutive AIDS patients at one hospital, using methodology based on the Delay Tool of Selker et al. Of 25 AIDS patients who survived hospitalization, 15 had at least one delay day in the hospital. Major factors associated with care that could have been provided at an alternative site included difficulty with skilled nursing facility placement in 20% of the patients, difficulty coordinating out-of-hospital care in 28%, and scheduling of outpatient surgical procedures in 12%. For the 15 patients who could have received some of their care at a lower intensity setting, a median of 7 hospital days could have been potentially saved with better coordination of outpatient care and increased availability of skilled nursing facilities. The five patients who died in hospital also used large amounts of resources and had long lengths of stay. Prior studies of non-AIDS patients revealed similar results, suggesting that, for reasons of quality of care, quality of life, and economics, policy-makers must develop managed care programs, skilled nursing facilities that accept AIDS patients, inpatient psychiatry facilities, and increased hospice availability.

Curing, caring, and economics: dilemmas of progress.

CURING, CARING, AND ECONOMICS: DILEMMAS OF PROGRESS DAVID MECHANIC* In the past 25 years, advances in science and technology have fundamentally altered the approach to medical care, the mix of health personnel , and the degree of public and private investment. In 1955, national health expenditures totaled $17.7 billion, 4.4 percent of the gross national product and slightly over $100 per capita. Twenty-five years later we are spending approximately $250 billion, approximately a tenth of our gross national product, and almost $1,000 per capita [I]. The increase in intensity of medical care is reflected in the fact that in 1960 community hospitals had 2.3 employees for every patient, but the ratio increased to 3.7 by 1977 [2, p. 226]. While the enormous growth of the health industries is apparent, their contribution to life and health and to the welfare of the nation, relative to magnitude of investment, is more commonly disputed [3]. With the impressive growth of medical research in the post-World War II period, and advances in biomedical knowledge, medical care became both more scientific and more capable of making a difference in particular instances. But with the exception of the control of mortality from infectious disease, which had a large impact, most of medical discovery affected outcomes at the margin and had only a modest impact on longevity. Whatever its self-conceptions, medicine was still as concerned with caring as with curing, and the chronic conditions that produce a heavy burden of illness and mortality still largely remain outside its control. It is now generally accepted that the health of populations depends more on their demography, their social structure, and how they choose to live than on medical care. Since 1955, economic advances, improved education, better access to medical care, and increased sophistication of care all contributed to significant reductions in infant mortality, and some advances in longevity as *University Professor and Dean, Faculty of Arts and Sciences, Rutgers University, New Brunswick, New Jersey 08903.© 1982 by The University of Chicago. AU rights reserved. 003 1-5982/82/2504-0305$01 .00 722 I David Mechanic · Curing, Caring, and Economics well [2, pp. 1 14-1 19]. The gap in length of life between men and women increased, however, reflecting the effects of differential life-styles and behavior. Much of the differential can be explained by greater exposure to violent death among men, or by differences in smoking, drinking, and other behaviors. The effects of behavior on health and longevity in turn affect demography, creating new social problems. The female advantage in longevity of almost 8 years results in a large imbalance by sex among the aged and in part explains the predominance of women in nursing homes. New technologies and changing attitudes similarly affect demographic trends. The introduction of a sophisticated technology that could be conveniently used—the birth control pill—allowed families and individuals substantially to achieve desired fertility, and resulted in a dramatic drop in the birth rate. The liberalization of attitudes toward abortion, and its legalization, allowed further "fine tuning" of individuals ' objectives. Demography, technology, and values all help determine the social policy agenda. Federal Programs in Health The past 25 years have also witnessed a massive involvement of government in medical care financing and regulation, and one dramatically altering organizational relationships in health care. The introduction of Medicare and Medicaid in 1966, and its impact on professionals, medical care institutions, and medical care costs, fundamentally changed the relationships between public authorities and private providers. While physicians and institutions benefited immeasurably from the increased financing made available by these programs, they also became quasipublic providers, ceding some of their operating flexibility to external authority. While massive federal programs spurred inflation, the use of sophisticated but not always necessary technology, and a strong profit orientation in the response of the private sector, they touched the lives of many people in need by providing sophisticated medical care not previously available. Medicare and Medicaid significantly improved access to medical care for elderly persons and for the medically indigent [4]. The traditionally observed relationship between low socioeconomic status and little use of physician services was reversed, and rates of admission to hospitals...