[How to interpret and pursue a prolonged quick time or APTT]. / Orientation diagnostique devant une anomalie du TP ou du TCA.

The standard hemostasis workup [quick time (QT), and activated partial thrombin time (APTT)] is very commonly prescribed but its interpretation is often difficult for practitioners who are not specialized in hemostasis. Here, we review the principles of the diagnostic approach to these tests. Only a very basic knowledge of the coagulation cascade is necessary to identify which clotting factor tests to prescribe and to interpret the results. Deficiency in several clotting factors suggests liver dysfunction, disseminated intravascular coagulation (DIC) or vitamin K deficiency. If a single factor is deficient, we review the different causes of acquired deficiencies and briefly discuss the characteristics of the different congenital defects, which generally require specialized management. Lupus anticoagulant is a common and generally benign cause of prolonged APTT to be aware of, which is not related to a hemorrhagic risk. A good knowledge of the diagnostic approach to abnormal QT or APTT generally allows the resolution of the most common situations.

[Von Willebrand disease]. / La maladie de Willebrand.

Von Willebrand factor is involved in primary hemostasis (adhesion of platelets to subendothelium and platelet aggregation) and acts as the carrier of coagulation factor VIII. Von Willebrand disease, resulting from a quantitative or qualitative defect of this factor, is the most frequent inherited bleeding disorder. It is mainly responsible for symptoms such as mucocutaneous bleeding and excessive bleeding after trauma or invasive procedures, but can also cause gastro-intestinal bleeding or hemarthrosis in the most severe forms of the disease. There are numerous causes of physiological variation of von Willebrand factor plasma levels which can be responsible for diagnostic difficulty or changes in symptoms over time. Diagnosis relies primarily on clinical symptoms but requires the use of several laboratory analyses: von Willebrand factor activity and antigen testing and factor VIII activity. More specialized assays allow classification of the disease in various types and subtypes which imply different management strategies (types 1, 2A, 2B, 2M, 2N, and 3). Treatment is based on desmopressin, responsible for an increase in plasma concentration of von Willebrand factor, and plasma-derived von Willebrand factor concentrates which can be combined with factor VIII.

Transforming the long-term care system: policy and managerial challenges.

As the need for long-term care of people with disabilities increases, the model of care faces crucial changes, including a shift from institutional to independent living, significant changeover in organizational auspices, and policies created by the Americans with Disabilities Act. Such systemic changes pose fiscal, technological, and social challenges to policymakers and managers of care delivery.

The changing face of long-term care.

In this article, we present population estimates of individuals with disabilities and discuss the manner in which the composition of this population is changing. We then highlight aspects of service delivery systems that are evolving in response to the changing long-term care (LTC) population. Following a summary of financing issues, we discuss several cross-cutting issues related to the organization of service delivery, quality assurance (QA), and financing. Current and future Health Care Financing Administration (HCFA) research and demonstrations emerging from these issues are then described.

Nursing home resident assessment and case-mix classification: cross-national perspectives.

Two broadly applied systems in the United States, the National Resident Assessment Instrument/Minimum Data Set and the Resource Utilization Groups, have provided new insight into the quality, delivery, and financing of nursing home care. In this article, the authors describe research efforts in eight other nations to translate, validate, and use one or both systems to understand their own long-term care systems. This consortium of studies, using common instruments, provides potential cross-national analyses that capitalize on differences in practice patterns and system designs to address critical policy issues.

Trends in Medicaid payments and utilization, 1975-89.

Trends in Medicaid payments and utilization from 1975 through 1989 are examined in this article. Medicaid payments grew significantly over the period 1975-89, but the rate of growth was uneven. Total payments grew rapidly from 1975 through 1981, but the rate of growth slowed considerably from 1982 through 1988. Recent data suggests that there may be a new discontinuity in the series; payments increased sharply in 1989. Sectors that account for growth in the costs of the program are identified by examining who are served and what types of services they receive. The dynamics of change in Medicaid payments within sectors also are explored by examining changes in the number of people receiving services and the average payment per recipient.

Medicaid recipients in intermediate care facilities for the mentally retarded.

In this study, we examined Medicaid utilization and expenditure patterns of Medicaid recipients in intermediate care facilities for the mentally retarded (ICF's/MR) in three States: California, Georgia, and Michigan. Data were obtained from uniform Medicaid data files (Tape-to-Tape project). Most recipients in ICF's/MR were nonelderly adults with severe or profound mental retardation who were in an ICF/MR for the entire year. The average annual cost of care ranged from $26,617 per recipient in Georgia to $36,128 per recipient in Michigan. The vast majority of recipients were low utilizers of other Medicaid services. Approximately one-third of the recipients were also covered by Medicare.

Nursing home pre- admission screening: a review of state programs.

From January through March of 1981, the Health Care Financing Administration (HCFA) surveyed the agencies of 49 States and the District of Columbia responsible for the administration of the Medicaid program. The purpose of the survey was to determine if the agencies had a nursing home pre-admission screening program for Medicaid patients. Twenty-eight States and the District of Columbia responded that there was a state-wide, pre-admission screening program for Medicaid patients prior to their entry into a nursing home, or that there was a program operating in a portion of the State. HCFA collected information on the scope of the programs, the agencies responsible for conducting pre-admission screening, the composition of the screening teams, and the characteristics of the client assessment instruments. Two States, Virginia and Massachusetts, provided information on program impact. This article presents the findings of the survey and explores several aspects of the Medicaid program influencing the effectiveness of pre-admission screening. It begins with an overview of the policy issues which have influenced the development of pre-admission screening and defines the core components of these programs.

Trends in nursing home expenditures: implications for aging policy.

Nursing home care has become a major governmental responsibility. Public expenditures for nursing home care amounted to $7.3 billion in 1977. They represented 57.2 percent of the $12.8 billion nursing home bill nationally and 12 percent of public spending on all personal health care. Nursing home care absorbs more than one-third of all Medicaid expenditures. This paper explores expenditure patterns in recent years and discusses some of the factors that will influence these patterns in the future. First we analyze recent trends over the five-year period ending 1977. Then we project future utilization based on current age-specific use rates. Finally, we review recent studies on the potential cost of savings of noninstitutional alternatives to nursing home care.