Perinatal regionalization versus hospital competition: the Hartford example.

OBJECTIVES: The increasingly competitive health care environment may undermine effective traditional regional organizations. It is urgent to document the benefits of perinatal regionalization for the emerging health care system. We present a case study that illustrates many of the challenges to and benefits of perinatal regionalization in the 1990s. BACKGROUND: The controversy in Hartford was sparked by a proposed merger of two major pediatric services into a full-service children's hospital. Community hospitals reacted with plans to upgrade their obstetrics/neonatal facilities toward level II (intermediate) or II+ (intensive) neonatal intensive care units (NICUs). The fear that unrestricted competition would drive up overall health care costs prompted the hospital association and Chamber of Commerce to retain consultants to evaluate the number and location of regional NICU beds. METHODS: The consultant team interviewed stake-holders in area hospitals, health maintenance organizations, insurance companies, businesses, state agencies, and community groups, and analyzed quantitative data on newborn discharges. RESULTS: The existing system worked remarkably well for clinical care, training, referrals, and provider and patient satisfaction. There was a high level of inter-hospital collaboration and regional leadership in obstetrics and pediatrics, but strong and growing competition between their hospitals. Hospital administrators enumerated the competitive threats that obligated them to compete and the financial disincentives to support the regional structures. Business leaders and insurance executives emphasized the need to control costs. Analysis of discharge data showed marginal adequacy of NICU beds but maldistribution between NICUs, particularly between level III and level II units. The consultants recommended no new beds based on population projections, declining lengths of stay nationally, and substantial gains available from aggressive back-transport of convalescing infants. The consultants emphasized the need for all stakeholders to support the regional infrastructure (referral, transport, education, evaluation, quality assurance) and to modify competition when it impaired effective regionalization. CONCLUSIONS: Regionalization permits better care at lower cost, yet competition may disrupt this effective system. Active cooperation by stakeholders is vital. Substantial new research is required to define optimal regional organization.

Stemming the AIDS epidemic. Drawing on past experience with VD control.

In view of the increasing concerns about AIDS, confidentiality, and reactions to risk factors such as homosexuality and drug abuse, our patients and communities should be familiarized with medicine's past successes in control of sexually transmitted diseases. The system of contact tracing and patient notification has been highly productive and can be done in a caring and effective manner to minimize emotional trauma and maximize protection of sexual partners, family, and the community. By building on the experiences of past programs, we can do much to slow the spread of human immunodeficiency virus infection and to counter the panic and irrational fears that are so prevalent. All this can be accomplished simply by utilizing the therapeutic and public health resources that are currently available.

Venereal disease control by health departments in the past: lessons for the present.

KIE: Programs of venereal disease (VD) control developed from the outset of World War I, through the 1930s and then World War II and its aftermath, are examined for their relevance to the problems posed today by AIDS. In light of past experience, "control" of AIDS, not eradication, is the most that can be expected from the public and health community reaction of increased federal funding in support of research and treatment, promotion of self-protective sexual behavior, and the attempt by public health professionals to approach the problem as one of health and related economic costs, rather than to assume a judgmental attitude. The involvement of all levels of government; the community at large; and the medical, educational, industrial, and social work sectors is essential for the success of a public health program which not only integrates new medical discoveries but also responds to the panicky reactions of the public and some health professionals to the AIDS patient.^ieng

Demonstration of a spirocheticidal effect by chemical contraceptives on Treponema pallidum.

PIP: The worldwide resurgence of venereal diseases has prompted new investigations in methods of topical prophylaxis for the prevention of sexually transmissible diseases. This article reports on the results of experiments conducted with 5 over-the-counter chemical contraceptives for intravaginal use, which were tested to determine their spermicidal effect on Treponema pallidum. Samples of Treponema pallidum containing more than 10 million spirochetes/ml were exposed to the diluted contraceptives in vitro, and also used in rabbits by inoculation via the intratesticular route. Of the 5 contraceptives tested both Delfen cream and Ortho cream completely inhibited spirochete mobility within 2 minutes of exposure in all dilutions; Koromex jelly was completely effective at 50% and 20% dilutions; Emko foam, Because foam, and Betadine vaginal gel were effective at 50%, 20% and 10% dilutions. The physiologic saline solution used for control purposes did not decrease the mobility of the spirochetes even at 5 or more minutes exposure. The 12 rabbits inoculated with spirochetes after the spirochetes had been exposed to 1 of the diluted products did not develop infection. These experiments confirm the spirocheticidal effect of the 5 chemical contraceptives, and suggest the potential usefulness of such intravaginal contraceptives in preventing person-to-person transmission of syphilis.^ieng

Venereal disease prevention.

Outlining his interest and work in the prevention of VD, especially gonorrhea and syphilis, the author addresses the questions of prophylaxis and contraceptives, together with their technological advances, and ties these two concepts into the complex fabric of human behavior, history of available therapy in both world wars as well as the economic, social, moral and national concepts of what constitutes proper emphasis: prevention or cure. Thus, the absence of therapeutic modalities spurred the United States Armed Services to utilize Credé's solution for urethral irrigation and locally applied calomel ointment for prophylactic purposes in World War I but abandoned this mode when cheap penicillin therapy became available after World War II. Similarly, the utilization of combined prophylactic and contraceptive methods for women has to await the overcoming of societal and parental resistance. Particularly where teenagers are concerned the importance of combined modalities is stressed.

PIP: During World Wars 1 and 2, the leading single cause of absence from duty in the armed services was VD (venereal diseases). The discovery of penicillin however, made it possible to cure VD in a short time, and many in the medical community believed that it was much cheaper to treat the disease than to prevent it. There was little interest then in the prevention of VD, including prophylaxis, even though the effectiveness of prophylaxis in managing VD was demonstrated during the 2 world wars when major reductions in risk of VD infections through the use of prophylaxis were achieved. As rates of penicillin-resistant gonorrhea, and other problems such as infection and infertility increase, however, the medical community will certainly be concerned with promoting types of self-protection behavior, such as the use of condom and vaginal contraceptives, and changed patterns of sexual behavior. Various clinical trials show that vaginal contraceptives have varying degrees of spermicidal and bactericidal effectiveness against the spectrum of organisms causing STD (sexually transmissible diseases). VD control programs experience various problems with respect to contraception, prophylaxis, and other elements of behavior required to maintain health. Patient motivation is critical because without it, effective methods are essentially worthless. Motivating youths to have responsible self-protective prophylactic behavior such as use of condom/vaginal contraceptives would reduce risk of unplanned pregnancy and STD transmission. The use of the contraceptive-prophylactic approach in a VD control and family planning program appears to offer great potential for the patient.

Virucidal effect of certain chemical contraceptives on Type 2 herpesvirus.

The virucidal effect of several chemical contraceptives was investigated and the findings are rrported. The supension of Type 2 herpes simplex virus, containing 10(6) to 10(7) tissue culture infectious doses per 0.1 ml., was inactivated on exposure to five different chemical contraceptives. For quantitative estimates of virucidal effect, 10 per cent solutions of these chemical contraceptives were tested with an exposure time of 10 minutes at room temperature. The methods for determination of residual infectivity included both virus assays in cultures of Vero cells and human embryo fibroblasts, as well as the intracranial inoculation of mice. Virus infectivity decreased 1,000- to 10,000-fold after contact with chemical contraceptives, indicating a substantial virucidal effect.

PIP: The frequent asymptomatic carriage of the Type 2 herpes virus by members of both sexes contributes to spread of the disease. This virus infection has been associated with the later development of cervical cancer. The virucidal effect of selected contraceptives, marketed for intravaginal use, was studied on Type 2 herpes virus. Preparations tested were Conceptrol, Cooper Creme, Preciptin gel, Lorophyn jelly, and Milex Cresent Jelly. Type 2 herpes virus (196-P10 of October 8, 1970) was used. An additional passage was made in human embryonic fibroblast cell culture. After 48 hours of incubation, ampules containing the infectious suspension were stored at -65 degrees C. This stock (TCID50), of virus was assayed in human embryonic fibroblastis and Vero cells (African green monkey kidney cell line). For use, the stock high titer (10 6 to 10 7 tissue culture infectious dose per .1 ml) virus suspension was serially diluted 10-fold. Initial 10% working dilutions of contraceptives and subsequent 10% dilutions of these were prepared in saline. Inoculated tissue culture tubes were incubated at 23 degrees C for 10 minutes. End points of infectivity were determined by reading the cytopathogenic effect. The intracerebral 50% lethal dose (LD50) of virus for mice was determined by injecting .03 ml/weaning mouse in each of 12 mice for each serial virus dilution. Injected mice were observed for 21 days to determine infectivity and lethal virus dose. To assure optimal conditions for the measurement of infectivity, the dilutions of virus before and after treatment with contraceptives were prepared in diluent containing 5% inactivated calf serum. No cytopathic effect was observed in the inoculated cell culture tubes beyond that attributed to the toxicity of contraceptives up to a dilution of 10 +-2% and 10 +-3%. A 1000-10,000 decrease in infectivity occurring after contact with the chemical contraceptives indicated a marked virucidal effect.

The effect of vaginal lubricants on Neisseria gonorrhoeae.

The possible interference of vaginal lubricants in culture diagnosis of gonorrhea was investigated by studying in vitro effect of selected lubricants on Neisseria gonorrhoeae. Two lubricants widely used in family planning and other clinics were demonstrated to have a bactericidal effect on N. gonorrhoeae when tested with more than one method. Gonococci were killed on contact with Lubrifoam, even at a 10 per cent concentration, and an exposure time as short as one minute was sufficient to inhibit the growth on chocolate agar medium. The K-Y jelly showed less inhibitory effect than Lubrifoam. These findings suggest that certain vaginal lubricants have bactericidal effects and their presence can inhibit the growth of Neisseria gonorrhoeae.

Potential impact of chemical prophylaxis on the incidence of gonorrhoea.

PIP: This paper presents a stochastic statistical model to evaluate the potential impact on the incidence of gonorrhea of a prophylactic intravaginal compound. The model predicts the change in the national incidence of gonorrhea in the US at various hypothetical levels of effectiveness of the topical prophylactic and of population usage. Factors analyzed in calculating the expected number of cases of gonorrhea under different conditions included the average risk of an uninfected person acquiring gonorrhea during a generation (incubation + average time to next sex act), the overall rate of loss of infectiousness whether by treatment or spontaneous cure during a generation, the proportion of at risk individuals prevented from acquiring a gonococcal infection in a generation by a prophylactic compound, and the proportion of the population at risk using the compound before each act of coitus. This model indicates that, with no changes in venereal disease prevention and treatment programs, the number of cases of gonorrhea will increase by 17% from 577,486 in 1970 to 674,804 in 1971. However, if only 30% of the population at risk used a prophylactic product that is 70% effective, gonorrhea could be almost completely eliminated within 5 years. Even a 50% effective prohylactic used by only 25% of the at risk population could produce dramatic decreases in the incidence of gonorrhea in a short time. Prophylactic programs will be most effective if incorporated into existing treatment and education programs.^ieng

Studies on development of a vaginal preparation providing both prophylaxis against venereal disease, other genital infections and contraception. 3. In vitro effect of vaginal contraceptive and selected vaginal preparations of Candida albicans and Trichomonas vaginalis.

PIP: 41 preparations (jellies, creams, foams, etc.) were tested each in several dilutions with physiological saline for effect on inhibition of growth of C. albicans and T. vaginalis. 21 contraceptives and 20 noncontraceptives were employed. In both types of cultures, 1 method used to study growth involved mixing of preparation and organisms and intervals of 1, 5, or 10 minutes before inoculation of the medium, while the other method involved inoculation after the prepartion was added to the medium. These method types are referred to in the study as time exposure and dilution. Evaluation was 48 hours after start of incubation. The contraceptives effective (no growth) at some concentration from 10%-50% against C. albicans by the time-exposure method were the same contraceptives effective by the dilution method. They were Certane vaginal jelly, Lorophyn jelly, Contra foam, Lorophyn suppositories, Koromex A vaginal jelly, and Lanesta gel. Certane vaginal jelly was effective after exposure (interval after mixing and before inoculation) for 1 minute. Among the noncontraceptive preparations 10 were effective by the time-exposure method and an additional 4 were effective by the dilution method. In an associated test C. albicans was uninhibited by exposure up to 10 minutes in a pH of 2.2-10, thus casting out the possibility that the preparations are effective through pH. By the time exposure method all contraceptives were effective against T. vaginalis, most at a 1% concentration. All except 2 noncontraceptives were effective by both methods. The use of some of these preparations, contraceptive and noncontraceptive, might reduce the female's risk of contracting either infection during intercourse.^ieng

Studies on the development of a vaginal preparation providing both prophylaxis against venereal disease and other genital infections and contraception. II. Effect in vitro of vaginal contraceptive and non-contraceptive preparations on Treponema pallidum and Neisseria gonorrhoeae.

PIP: 20 vaginal contraceptive preparations and 17 other compounds, mostly vaginal antiseptics, were studied in vitro for their effect on the motility of virulent T. pallidum and were also studied for their bactericidal or bacteriostatic effects on N. gonorrhoeae. Concentrations of several contraceptives and other preparations as low as 10/0 were effective in immobilizing spirochaetes in suspension within 1-1.5 minutes. Similarly, several products inhibited gonococcal growth. These results in vitro are reported. Further studies in vitro and in vivo are in progress to find the preparations which show the greatest potential for topical use in venereal disease prophylaxis and contraception. Commercial sources for the contraceptive and noncontraceptive preparations are given.^ieng