Medical Care Plan Research Articles

The American Approach to Health Insurance

Dans cet article, publie pour la premiere fois dans le Quarterly Vol. 12, No 2, 1934, l'A. presente l'approche americaine de l'assurance sante, qu'il compare a l'approche europeenne, dont une premiere partie retrace les grandes etapes historiques (au Royaume-Uni et en Allemagne). L'arriere-plan historique de l'assurance maladie, telle qu'elle s'est developpee en Europe, est economique, son premier objectif ayant ete la protection du revenu, le remboursement des soins medicaux y etant un objectif second. Si l'experience europeenne est pleine d'enseignements, le cas des Etats-Unis necessite une approche differente, du fait que les couts des soins medicaux mettent desormais en jeu des sommes plus importantes et affectent bien plus de gens que ne le fait la perte de salaire due a la maladie, et aussi du fait que la provision d'un soin medical adequat, curatif et preventif, implique des possibilites plus importantes que dans l'ancien temps, pour soulager la souffrance, promouvoir la sante, augmenter l'efficacite economique. L'A. conclut ainsi son article par une serie de recommandations pour un systeme de sante plus stable, dans lequel les soins medicaux seraient pris en charge par l'assurance maladie, soutenue par l'impot.

Longitudinal analyses of four years of experience of a prepaid comprehensive medical care plan. 1958.

The spectacular contributions of science to medicine and the popularization of the results have greatly stimulated the demand on the part of the public for making modern medical benefits more readily accessible to a larger portion of the population. But the very advances which have stimulated this demand and which have focused attention on the preventive aspects of disease have also contributed greatly to the cost of medical care. On the one hand, this increased cost has led to an enormous growth in the application of the insurance principle to prepayment for medical and hospital care; on the other, it has led to new approaches in the organization of medical practice to provide this care. These changes in the methods of paying for and of providing medical care are comparative newcomers among American social institutions. Provision for prepayment of hospitalization began in 1933 with the establishment of Blue Cross plans. Prepayment of medical care is an even more recent phenomenon. Fewer than six persons per 1,000 held surgical and medical insurance in 1939. Today, according to the Health Information Foundation,2 almost 70 per cent of the population is protected or “covered” by some combination of hospital, surgical, or medical insurance. On the organizational side change has been less rapid, but there has been a steady growth in the number of group practice organizations. It has been estimated3 that while in 1932 there were 239 medical groups with 1,466 physicians in the United States, by 1951 there were 600 such groups with over 5,000 physicians. Growth in voluntary health insurance both in terms of people covered and in benefits offered will undoubtedly continue. New organizational patterns will continue to emerge. Unlike their predecessors, however, these new developments will be able to call upon a body of experience to guide them which was not available to most of the present voluntary prepayment plans for medical care at the time they were founded. The experience of one such plan—the Health Insurance Plan of Greater New York (HIP)—has been analyzed in the belief that it will be of value not only to HIP but also to administrators of other medical care plans, to welfare fund administrators, to public health officials, to community planners, to sociologists, and to the public in general, all of whom are interested in facts that bear on the problem of making the benefits of modern medical care available to the population. The HIP experience will be presented in three parts: Part I, the present paper, deals with enrollment experience and sets forth data on the extent to which enrollees of different classes remain in the Plan and factors influencing continuance of their enrollment; Part II will present information on the number and kinds of physicians’ services utilized by enrollees and how this utilization varies with length of coverage in the Plan; Part III will contain data on morbidity among enrollees of the Plan and will seek to develop measures of prevalence and incidence of various diagnoses as reflected in the operating records of HIP. These data represent the results of a “longitudinal” analysis of the first four years of operation in HIP—that is, they show the experience of the same group of individuals followed through four years of calendar time. They supplement material contained in a published report on the findings of a field survey inquiring into the health and medical care of HIP and New York City households4 which was essentially a cross-sectional study depicting the situation at a particular point in time.

Analysis of Battlefield Head and Neck Injuries in Iraq and Afghanistan

At the time of this study, the 1st place that an injured or ill American soldier in Iraq or Afghanistan would have been evaluated by an ENT-head and neck surgeon was at a tertiary care medical center as a result of air evacuation out of theater: Landstuhl Regional Medical Center (LRMC), Ramstein, Germany. By examining the ENT-related diagnoses of all air evacuations from downrange, we were able to match the patients classified as having battle injuries to determine the percentage with head and neck trauma. A prospective review of 11,287 soldiers air-evacuated from Afghanistan and Iraq, representing the 1st year of combat operations. A new, computerized patient-tracking system was created by our team to merge several disparate databases to generate and compile our data. The ENT-head and neck surgery department evaluated and primarily managed 8.7% of all patients evacuated out of theater by air to Germany. Other medical and surgical services managed 7.3% of all patients evacuated out of theater with overlapping ENT diagnoses. The number of potential ENT patients increased to 16% when one looked at all head and neck pathology instances seen by all medical and surgical departments hospitalwide. Of all patients air-evacuated and classified as having battle injuries, 21% presented with at least 1 head and neck trauma code. This is the 1st paper focusing on the role of the ENT-head and neck surgeon in treating a combat population and also the patterns of illness and head and neck injuries in a deployed force in our modern military. Improved soldier body armor has resulted in distinctly new patterns of combat injuries. Unprotected areas of the body account for the majority of injuries. These findings should be used to improve the planning and delivery of combat medical care.

Applying a quality use of medicines framework to using essential oils in nursing practice

Nurses are increasingly incorporating complementary therapies into their practices. Aromatherapy is one of the most popular therapies. The basis of aromatherapy is essential oils, which are chemically active substances with a long history of safe traditional use and a growing evidence base to support their use in nursing care. In Australia, essential oils are classified and regulated under the same policies as conventional medicines such as the National Medicines Policy and the Quality Use of Medicines (QUM) framework applies. QUM is a framework for selecting and using medicines safely and effectively if medicines are indicated. The key elements of QUM are a systems-based approach to using medicines based on relevant evidence, partnerships, and informed client consent. Clients are placed at the centre of a QUM medication management process, which is consistent with holistic care. Applying a QUM approach to essential oil use, Quality Use of Essential Oils (QUEO), involves developing effective systems for managing essential oils from an holistic perspective that includes structured assessment and diagnostic processes to enable effective essential oil prescribing and outcome monitoring. In a QUEO approach, essential oils are integrated into the client's overall medication regimen and care plan rather than being used as 'add-ons'. Adopting QUEO is consistent with the current national focus on the quality use of therapeutic substances, increases the profile of aromatherapy in nursing care and provides important information to guide future aromatherapy practices.

Maternal collapse

This review will summarize the latest publications on the causes, prevention and treatment of maternal collapse during pregnancy and the postpartum period. It will also explore some future trends particularly in the area of education and team working. Active management of the third stage of labour has been shown to decrease the incidence of postpartum haemorrhage. Inadequate or prolonged resuscitation following major postpartum haemorrhage can lead to myocardial damage. Guidelines that are followed and the use of drills and simulators may increase effective team working and lead to earlier recognition and treatment of maternal collapse. Some cases of amniotic fluid embolism resemble anaphylaxis and should be treated as such. Important evidence-based guidelines on the management of antithrombolytic prophylaxis and the management of pulmonary embolism have recently been published, which should help clinicians clarify their medical care plans. New resuscitation guidelines in the UK will probably mean that all healthcare workers (including obstetricians and midwives) will need appropriate training every year. Understanding the causes of maternal collapse, its early recognition and prompt resuscitation should decrease both maternal and fetal morbidity and mortality. There is increasing evidence that effective preventative measures and improved multidisciplinary team working may have an important impact on maternal and fetal well-being.

The goals of comprehensive and integrated disease state management for diabetic kidney-disease patients

Diabetes, cardiovascular disease, and chronic kidney disease present many challenges to clinicians as separate disease entities. Management and optimization of care of diabetic kidney-disease patients requires a proactive and integrated approach for all 3 disease states. To optimize the assessment, monitoring, and intervention in this population, comprehensive and integrated disease state management medical care plans must be established. Medical nutrition therapy is another key component that must be coordinated with these disease-state management medical care plans. Coordination of integrated disease-state management and medical nutrition therapy for diabetes, cardiovascular disease, and chronic kidney disease will help to improve patient outcomes and allow for a proactive approach to the identification, prevention, and management of potential disease-state complications. Several programs and guidelines have been established to accomplish these goals: the K/DOQI Clinical Practice Guidelines, the American Diabetes Association Standards of Medical Care for Diabetes (developed by the American Diabetes Association, the National Institute of Diabetes and Digestive Kidney Diseases, and the Centers for Disease Control-Diabetes Foundation), the National Diabetes Education Program, and the National Cholesterol Education Program. The multidisciplinary medical care team assumes an integral role in the success and implementation of this integrated approach as well as the empowerment of the patient in their own care.

Analysis of Patient Load Data From the 2002 FIFA World Cup Korea/Japan

Past history of mass casualties related to international football games brought the importance of practical planning, preparedness, simulation training, and analysis of potential patient presentations to the forefront of emergency research. The Japanese Ministry of Health, Labor, and Welfare established the Health Research Team (HRT-MHLW) for the 2002 FIFA World Cup game (FIFAWC). The HRT-MHLW collected patient data related to the games and analyzed the related factors regarding patient presentations. A total of 1661 patients presented for evaluation and care from all 32 games in Japan. The patient presentation rate per 1000 spectators per game was 1.21 and the transport-to-hospital rate was 0.05. The step-wise regression analysis identified that the patient presentations rate increased where access was difficult. As the number of total spectators increased, the patient presentation rate decreased. (p < 0.0001, r = 0.823, r2 = 0.677). In order to develop mass-gathering medical-care plans in accordance with the types and sizes of mass gatherings, it is necessary to collect data and examine risk factors for patient presentations for a variety of events.

Analysis of battlefield head and neck injuries in iraq and afghanistan

Objectives: Patterns of current combat injury are examined using data collected from the U.S. Army Combat Trauma Registry (CTR) and records from 2 major military hospitals. Prevalence of sites of injury are reported and compared to historical norms to identify significant changes in anatomic distribution. Methods: A retrospective review of patients treated for injuries sustained in combat operations in Afghanistan and Iraq from September 11 2001 to January 1 2004 was conducted. Over 28,000 patients were identified by the CTR and reviewed for abstraction and ICD-9 coding. At Landstuhl Hospital(Ramstein, Germany), 10,912 patients were evaluated and managed (2759 inpatient/8153 outpatient). At Walter Reed Medical Center (Washington, DC), 2150 patients were evaluated and managed. Combat mortality data from the Armed Forces Institute of Pathology (AFIP) were also analyzed. Results: Extremity injuries were most common (52%), followed by head and neck injuries (26%). Torso injuries accounted for only 7% of combat injuries. Analysis of combat fatalities revealed that head and neck wounds accounted for 64% of deaths. The mechanism of injury was explosive in 65.6%, gunshot wounds in 13.5%, blunt trauma in 11.5%, and unknown in 9.4%. Conclusions: Improved body armor and emerging enemy tactics have resulted in a distinctly new pattern of combat injury. Unprotected areas (ie, extremities and head and neck) account for the majority of injuries. Extremity injuries are generally not fatal. Unfortunately, wounds to unprotected regions of the head and neck account for the majority of combat deaths. These findings should be used to improve the planning and delivery of combat medical care.

Pour ou contre le déclenchement systématique du travail à 41Bsemaines d'aménorrhéeB?

We tested the hypothesis that perinatal oxytocin, given to pregnant women to induce labor, is related to offspring bipolar disorder (BP) and worse childhood cognitive performance among offspring. We also tested the association between childhood cognition and later BP.A population-based birth cohort derived from the Child Health and Development Study (CHDS) which included nearly all pregnant women receiving obstetric care from the Kaiser Permanente Medical Care Plan, Northern California Region (KPNC) between 1959 and 1966. Prospectively obtained medical and offspring cognitive performance were used. Potential cases with BP from the cohort were identified by database linkages. This protocol identified 94 cases who were matched 1:8 to controls.Perinatal oxytocin was associated with a 2.4 times increased odds of later BP. Oxytocin was also associated with decreased performance on the Raven Matrices, but not on the Peabody Picture Vocabulary Test (PPVT). Childhood cognition was not associated with later BP.Loss to follow-up must be considered in all birth cohort studies. In addition, the childhood cognitive battery did not include tests related to multiple domains of cognition which have been associated with later BP. A third limitation is the modest sample size of those exposed to oxytocin.This study provides evidence for a potentially important perinatal risk factor for BP and cognitive impairment in childhood. While the association between perinatal oxytocin and offspring BP must be viewed cautiously until further studies can attempt to replicate the result, it lends support to the broader view that neurodevelopmental factors contribute to BP.

Government and private insurance medical programs as well as MDVIP, an update.

On November 19,1945, President Truman outlined a Prepaid Medical Insurance Plan for all people through the Social Security System. Because of its comprehensive nature, it was coined "National Health Insurance." On July 30,1965, President Johnson signed the Medicare and Medicaid bill (Title XVII and Title XIX of the Social Security Act). Today, many groups of people are covered by Medicaid. However, there are strict requirements that may vary from state to state. Medicare offers the following types of medical heath care plans to include the original Medicare plan that is a "fee for service" plan. The individual may stay in the original plan unless he/she chooses to join a Medicare+ Choice Plan or a Medigap Plan. Most individuals will receive Medicare Part A when they are 65 without paying a premium because it has been deducted annually through their tax payments before the age of 65. Medicare Part A helps pay for the following: inpatient hospital care, skilled nursing facility, hospice care, and some home health care. Medicare Part B, however, must be paid by the individual through premiums to the Federal government. Medicare Part B medical insurance pays for doctors' services, outpatient services, and some other services that Medicare Part A doesn't cover. In an effort to supplement one's health care coverage, the individual may select either a Medicare+ Choice Plan or a Medigap Policy. The Medicare+ Choice Plan has four different types: Medicare Managed Care Plans, Medicare Private Fee for Service Plan, Medicare Preferred Provider Plans, and Medicare Specialty Plans. If one selects a Medigap policy, one may choose either a Medigap SELECT Policy or the standard Medigap policy. The front of a Medigap Policy must clearly identify it as a "Medicare Supplement Insurance." One must be carefully advised of the selection of the Medigap Policy. The Medicare Part B has a wide range of preventative services, including tests for breast cancer, cervical cancer, vaginal cancer, and colorectal cancer; bone mass measurements; diabetes monitoring and diabetes self-management; flu, pneumonia, Hepatitis B shots, and prostate cancer screening tests. It is important to emphasize that Medicare and Medicare supplemental insurance policies do not pay for home health care, such as durable medical equipment. Because of the enormous complexity of the wide variety of health insurance plans and their billing strategies, many physicians are electing to charge their patients an additional fee for being part of their practice. In return for their annual fee, their patients receive immediate cell phone access to their doctor 24 hours a day, 7 days a week. In addition, they receive same-day appointments and on-time appointments. They also spend as much time with their doctors as they wish. It is not surprising that there is growing evidence that the privately insured patient with a life-threatening illness will live longer than those individuals who have the same disease but have public insurance only. Legislatures are well aware of this crisis in medical care that must be corrected immediately.

Epidemiological and demographic HIV/AIDS projections: South Africa

The Epidemic Projection Package (EPP) recently developed by the UNAIDS Reference Group on Estimates, Models and Projections and the Spectrum model program developed by the Futures Group were used to model the South African HIV epidemic, project future trends in HIV/AIDS and estimate the demographic impact of AIDS. The national HIV prevalence surveys among pregnant women from 1990–2001 and the first national, population-based HIV survey in 2002 served as the data sets used to calibrate the input HIV prevalence values for the model. The scenario created by the model showed that a dramatic rise in HIV prevalence during the 1990s has peaked in 2002 with 4.69 million infected people and it is projected that the epidemic in South Africa has now begun to level off. Adult (15–49 years) incidence rates have decreased substantially in the past five years since 1997 (4.2%) and are expected to reach a level of 1.7% in 2003. The annual number of deaths due to AIDS is projected to peak with 487 320 AIDS deaths in the year 2008. By 2020, the total population of South Africa is expected to be 23% smaller than it would be without AIDS, however, a negative population growth rate is not expected during the projection period. Life expectancy at birth is expected to hit a low of 45.6 years in the time period 2005–2010, which is 22 years less than it would have been in the absence of AIDS. Ten years from now over 2.5 million AIDS orphans are projected for South Africa. Models play an important role in estimating HIV variables that are difficult to measure. Projections of the future HIV/AIDS burden in South Africa underscore the importance of acting now to reduce the number of new infections and plan for medical and social care needs.

Case Study: A Patient With Type 2 Diabetes Working With an Advanced Practice Pharmacist to Address Interacting Comorbidities

Advanced practice pharmacists in the field of diabetes work collaboratively with patients’ medical providers, often in primary care settings or in close proximity to the providers’ practices. They help to integrate the pharmaceutical, medical, education/ counseling, and direct patient care activities necessary to meet patients’ individual self-management and diabetes care needs. Patient education and self-management behavioral change are underpinnings of pharmaceutical care, and not only as they directly relate to the use of medications. Pharmacists, especially those who are certified diabetes educators (CDEs), frequently provide diabetes patients with education not only on medications, but also on the overall disease state, nutrition, physical activity, decision-making skills, psychosocial adaptation, complication prevention, goal setting, barrier resolution, and cost issues. In addition to these substantial education responsibilities, advanced practice pharmacists who are Board Certified–Advanced Diabetes Managers (BC-ADMs) play an expanded role that encompasses disease state management. This includes performing clinical assessments and limited physical examinations; recognizing the need for additional care; making referrals as needed; ordering and interpreting specific laboratory tests; integrating their pharmacy patient care plans into patients’ total medical care plans; and entering notes on patient charts or carrying out other forms of written communication with patients’ medical care providers. Depending on state regulations and physician-based protocols, some advanced practice pharmacists can prescribe and adjust medications independently or after consultation with prescribing clinicians. The clinical activities of BC-ADM pharmacists are not carried out independent of referring, collaborative practitioners. Rather, they are complementary to and serve to enhance the diagnostic, complex physical assessment, and management skills of medical providers. The following case study illustrates the pharmacotherapeutic challenges of diabetes with other comorbidities, which can lead to potential drug-drug and drug-disease interactions. Although it does not offer detailed solutions to such problems, this case does describe the process of patient care and problem resolution …

Caregiver assessment: pro.

As determined by the Consensus Guidelines for the Design and Implementation of Clinical Trials in ALS (1998), the primary and secondary endpoints in ALS trials should be crisply deŽned. A change in muscle strength or survival and death and/or permanent continuous ventilator dependence are important and, at the present, the most important, primary endpoints for therapeutic trials. When discussing the necessity for caregiver evaluations in ALS clinical trials, the purpose of doing so and its subsequent outcome must be considered. There are few references in the literature on the precise study of caregiver evaluations for a therapeutic trial of ALS or any other disease (except Alzheimer’s Disease, since the caregiver is eventually the surrogate for the patient and is therefore needed to obtain data on patient improvement; this is not the case in ALS). Data from studies of caregivers in ALS have been consistent in their reports of psychological and physical illhealth, burden, distress and goals of caregiving (Table 1). It is also documented that there exists a concordance between the caregiver’s and the patient’s level of distress but to what degree this truly affects a patient’s overall wellbeing is not clearly understood. The dependency of the ALS patient on a caregiver for the physical aspect of daily living and compliance with the medical plan of care is understood. All of this lends itself to support the perception of the patient–caregiver system as a unit that is not mutually exclusive. Thus, it may be hypothesized that ‘wellness’ in the caregiver equates with ‘wellness’ in the patient, not limited to the effect on the quality of life, physical well-being, and psychosocial aspect of the patient. It is essential to evaluate caregiver status at the same time as attempting to achieve the patient-oriented primary outcome(s) of the therapeutic trial. The primary endpoint of a trial may result in any one of the following outcomes: as such, each outcome will have a unique impact on the patient–caregiver system.

Dietitians place feeding tubes?

Dietitians place feeding tubes?

Self-care and the doctor-patient relationship.

An important factor contributing to the steep rise in health care costs in the late 1960s was a reversal from the predominance of acute illness to that of chronic disease. Beginning with the philosophy of Illich and Levin, and the practical instruments of Fries, Sehnert, Vickery, and Ferguson, a new movement in patient self-care emerged. However, such programs were not integrated into organized medical care plans and though theoretically attractive had not yet proven to improve health or decrease costs. The contributions to the self-care movement made under the intellectual guidance of Halsted Holman and the relevant literature produced are reviewed. While caring for chronic rheumatic diseases, Halsted Holman discovered that patient self-report was a more powerful predictor of outcome than were traditional biologic measures such as anti-DNA antibodies. Realizing the role that patient knowledge of their own disease course might play, he developed the Arthritis Self-Management course, a lay-led self-care program emphasizing patient participation. Holman and colleagues next elucidated the pivotal importance of Bandura's theory of self-efficacy in the improved patient outcomes initially observed. These self-care techniques were woven into the structure of the Midpeninsula Health Service, showing for the first time reductions in subsequent office visits and enhanced quality. In partnership with Kaiser Health Plan, these techniques showed improvements in self-efficacy health behaviors, status, and use in a randomized trial of more than 1,000 patients. Halsted Holman and colleagues have played a seminal role in the translation of academic self-care theory into community practice.

A NALYSIS OF A M EDICAL T ENT AT THE T ORONTO C ARIBANA P ARADE

Objectives. To review the experience with an on-site medical tent for a mass gathering and to analyze patient records in a manner to more appropriately allocate resources and identify possible delays in definitive care. Methods. The logistics of providing an on-site medical tent is reviewed, followed by a retrospective chart review of 126 patients over a two-year period. Prior to the chart review, an injury classification was developed that categorized patients based on the necessity of transport to hospital. Data were also analyzed for times of peak patient flow, types of injuries, and needless delays in definitive care. Results. An average of 63 patients (95% CI 44–77) were seen in the tent and 1.3 patients sought care per 10,000 spectators. Peak times were between 1600 and 2000 hours. The average number of patients each hour was 6.5 (95% CI 0–13). Severe, intermediate, and minor injuries accounted for 16%, 38%, and 46% of total injuries, respectively. Nine cases were found where the patients arrived and left the medical tent by ambulance. Four of these instances may have represented a needless delay in definitive care. The details of each of these cases are reviewed. Conclusions. The results indicate that on-site medical coverage, with appropriate supports, is indeed safe. The framework provided with regard to setup and analysis of workload will help others in the planning of medical care for similar mass gatherings.

ETHICAL ISSUES CONFRONTING ONCOLOGY NURSES

The focus of this article is the ethical dilemmas challenging oncology nurses and their patients. The cancer diagnosis itself may present ethical issues related to genetic testing, prevention and early detection, and information sharing. Cancer treatment options may involve considerations related to level of appropriate care, informed consent, patient education, and unproven, but promising, therapies. Finally, the ethical issues related to outcomes of the disease and treatment, such as pain control, advanced directives, do not resuscitate order, discontinuation of medically inappropriate care, euthanasia, and physician assisted suicide are discussed.

Risk of invasive squamous carcinoma of the cervix associated with screening intervals of 1, 2, and 3 years: a case–control study

Objective: To compare the risks of developing invasive squamous carcinoma of the cervix (ISCC) associated with different lengths of time following a negative Pap test result. Methods: We conducted a matched case–control study using subjects who were members of Kaiser Permanente Medical Care Plan–Northern California Region. Women with an initial diagnosis of ISCC between 1983 and 1995 who had been members of the Health Plan at least 30/36 months before the date of histologic diagnosis comprised the cases (n = 482). Two controls per case (when available) were matched for age, length of membership, and race (n = 934). We defined the screening interval as the time between the last negative Pap test result and the histologic diagnosis of invasive malignancy. We defined a negative Pap test result as a result reported as normal or one with a reading not associated with squamous dysplasia or cancer (eg, benign cellular changes, metaplasia). Results: Invasive squamous carcinoma of the cervix was diagnosed in 103, 42, and 28 women at 0–18-, 19–30-, and 31–42-month intervals (respectively) following a negative test result. The odds ratio for 2- versus 1-year intervals was 1.72 (95% CI, 1.12–2.64; P = 0.013), and for 3- versus 1-year intervals was 2.06 (95% CI, 1.21 –3.50; P = 0.007). The odds ratio for 3- versus 2-year intervals was 1.20 (95% CI, 0.65–2.21; P = 0.561). These results were not substantially changed by controlling for the number of previous consecutive negative test results or for ever having had an abnormal test result while a plan member. Conclusions: In this large health plan, the odds ratios for the diagnosis of ISCC following a negative Pap test result were significantly greater for 2- and 3-year intervals than for a 1-year interval. We were unable to demonstrate a significant difference between 3- and 2-year intervals. The relevance of our findings needs to be placed in the context of the low absolute risks of developing ISCC during the first 3 years following a negative Pap test result before making policy recommendations.

Hospital-managed advanced care of children in their homes.

A hospital-managed project for the advanced care of children in their homes (SABH) has been established in Sweden. The aim was to provide an alternative to inpatient paediatric care by providing hospital-at-home care to stable infants and children using mobile units based on advanced information and communication technology. The Karolinska Hospital children's ward and emergency room referred children to SABH care. A medical care plan was drawn up by the physicians and nurses responsible for the patient while in hospital, in conjunction with the parents and the patient. In one year, 350 episodes of care requiring 3000 bed-days were managed by SABH in the children's homes rather than at hospital. Forty-two per cent of the patients were aged less than one year, 41% were between one and six years old, and 17% were older than six years. SABH care was at least 30% cheaper than conventional hospital care and patient satisfaction with the service was high. At the conclusion of the two-year project, the SABH became a permanent unit at the Karolinska Hospital.

Podiatry in the 1996 Summer Olympic Games.

The 1996 Summer Olympic Games in Atlanta, Georgia, were the largest in Olympic history, with 197 countries participating. These Centennial Games also represented podiatry's greatest involvement in the Olympics to date. The author describes the planning, organization, delivery, and outcome of podiatric medical care in an Olympic Games setting and presents data to assist in the future utilization of podiatry in other multiday, multievent sport competitions.