Buprenorphine treatment of pregnant opioid--dependent women: maternal and neonatal outcomes.

This open-label prospective study examined maternal and neonatal safety and efficacy outcome measures during and following prenatal buprenorphine exposure. Three opioid-dependent pregnant women received 8 or 12 mg sublingual buprenorphine tablets daily for 15-16 weeks prior to delivery. Results showed that buprenorphine in combination with comprehensive prenatal care was safe and effective in these women. Prenatal exposure to buprenorphine resulted in normal birth outcomes, a mean of 4.33 days (minimum possible=4) hospitalization, and a 'relatively mild' neonatal abstinence syndrome comprised primarily of tremors (disturbed), hyperactive moro and shortened sleep after feeding. The infants required no pharmacological treatment. Onset of neonatal abstinence signs occurred within the first 12 h after birth, peaked by 72 h and returned to below pre-12 h levels by 120 h. It is concluded that buprenorphine has potential utility for the treatment of pregnant opioid-dependent women.

Cost-effectiveness of treatment for drug-abusing pregnant women.

Neonatal intensive care unit (NICU) and drug treatment costs were compared in two groups of pregnant drug abusing women: 100 admissions to a multidisciplinary treatment program and active in care at the time of delivery and 46 controls not entering drug treatment. Clinical measures included urine toxicology at delivery, infant birthweight. Apgar scores and need for and duration of NICU services. Cost measures included drug treatment and NICU costs. Treatment patients showed better clinical outcome at delivery, with less drug use and higher infant estimated gestational age, birthweight and Apgar scores. Infants of treatment patients were also less likely to require NICU services and, for those that did, had a shorter stay. When total cost was examined (including drug treatment), mean net savings for treatment subjects was $4644 per mother/infant pair. The study demonstrates the cost-effectiveness of treatment for pregnant drug abusing women, with savings in NICU costs exceeding costs of drug treatment.

Promoting parent-provider interaction during young children's health-supervision visits.

We prompted parents to increase their interactions with health-care providers during their children's health-supervision visits. Before scheduled appointments we asked parents of 32 infants and young children if they had specific child health questions or concerns. Sixteen parents randomly assigned to the prompted group were then prompted to initiate discussions of their concerns. Sixteen control parents discussed unrelated topics before their appoitments. Prompted parents initiated significantly more interactions with health-care providers and more health and behavioral topics were discussed during their appointments. Both parent groups reported satisfaction with health-care services. Further research is needed to determine the clinical significance of outcomes associated with enhanced parent-provider interaction during children's health-supervision visits. These visits are ideal settings for behavioral research on improving health care for children and their families.

Lecture skills in medical education.

The lecture is the most common method of transmitting information in medical schools and continuing medical education. In recent years this educational method has received considerable criticism because of poor lecturers and poor learning. The major advantage of the lecture is the ability to teach pertinent up-to-date information in an efficient manner. The major limitation is the passivity of the method with the teacher speaking and the listener passively receiving the material with considerable opportunity to be bored. The effective techniques of lecturing are: 1) environment aids learning: 2) an introduction perks interest; 3) stating objectives helps audience to respond analytically; 4) outlining a lecture helps clear thinking; 5) non-verbal behavior increases learning; 6) use of voice shows interest and clarity; 7) content is understood if it fits objectives; 8) organized lecture fits the time available; 9) visual aids used should be clear and understandable; 10) a summary helps to retain what is learned; 11) closure should be upbeat and should restate objectives; 12) questions should be answered succinctly. The medical lecturer can improve his skills by studying them, rehearsing while being observed by colleagues and by performing a self-analysis of video-taped lectures.

A national survey of performance objectives of physician's assistant training programs.

A nationwide survey of physician's assistant (PA) training programs was carried out to determine the performance expected of students upon graduation. A list of tasks reflecting primary medical care problems was sent to PA program directors asking whether they expected their graduates to be able to perform the task, only to know about the task, or neither to be able to perform nor to have knowledge of the task. The results indicated that all students were expected to perform a history and physical examination. Almost all of the program directors expected students to establish a working diagnosis for the most common problems and to formulate a management plan for many of them. Extensive skills in patient education and counseling were expected. There was considerable congruence among the directors in performance expectations of students. The expected performance of the PA student by graduation emerged as comprehensive and not merely technical.

Planning health services for a city jail: impact of contractual services on men's sick call.

A nonviolent protest by prisoners began a 2-year planning process leading to the implementation of contractual medical services at Baltimore City Jail. This study was conducted in order to assess the impact of contractual services on the process of men's sick call. The contractual program was associated with a decrease in utilization of men's sick call: 62.9 patient visits per day per 1,000 prisoners in 1975 versus 27.4 patient visits per day per 1,000 prisoners in 1978; an increased duration of encounter; 2.8 minutes in 1975 versus 10.9 minutes in 1978; and with changes in prescribing patterns and in categories of patients' complaints. Baltimore City Jail spent about $588 per prisoner-year during fiscal year 1977, and about $670 per prisoner-year during fiscal year 1978, the first year of contractual services. We conclude that a system of health services for a large, urban jail can allow time for humane and professional encounters between providers and patients.

Human ecology and the geographic distribution of physician assistants.

Ecological characteristics of states were correlated with measures of the geographic distribution of physician assistants, and, for comparative purposes, of new physician licenses. It was hypothesized that prior physician-to-population ratios, the distribution of physician assistant training opportunities, and the nature of state laws regulating physician assistants also would affect the geographic distribution of physician assistants. Population size, of course, is strongly correlated with the total number of both groups in the various states. When numbers relative to population are considered, physician assistants are concentrated in states with extensive training opportunities and, to a lesser extent, favorable laws. In contrast, new physician licenses tend to be concentrated in states that already have high physician-to-population ratios.

Staffing pattern of a health maintenance organization. A systems approach.

A systems analysis approach was applied to a study of health provider jobs in a health maintenance organization to develop a proposal for an improved staffing pattern and an appropriate training curriculum for the provider. Physicians reported performing 512 ambulatory care tasks; health associates, 372; and health assistants, 284. Overlap was found among each group, especially in data-gathering tasks. This led to reallocation of tasks, with the most complex but smallest number assigned to the physician, and the least complex but highest number assigned to the assistant. In turn, a staffing pattern was suggested whereby a team of two physicians, four associates, and eight assistants would be able to manage the visits of 10,000 patients.

Task analysis in health manpower development and utilization.

Job analysis and tast analysis are systems methods which examine the functions of individuals and allocate these functions into job descriptions which can make for a better utilization of health manpower by a restructuring of the jobs of health professionals and a restructuring of curricula as a reflection of the jobs to be performed. These analytic methods have had limited application to the health field. This methodology was applied to the education of a nonphysician family health team for an inner-city prepaid comprehensive health center and staff development at a health maintenance organization, and has served as the basis for the curriculum of an associate degree physician's assistant program and a baccalaureate degree health associate program. Among the advantages for the application of this method are the interrelationship of resulting jobs rather than isolation and career mobility in both the work situation and curricula. Constraints include the lack of entry level jobs, the prestige of the Bachelor's Degree, the need for proficiency tests for advanced standing, tuition costs, and the traditional attitudes of health agencies on release time and educational institutions on basic requirements.

Hiring a new health practitioner.

Individuals are now being trained to function at varying levels of expertise as primary care practitioners, and the selection of a new health practitioner appropriate to the physician's individual practice can prove to be an asset professionally, personally, and economically.