Improving Healthcare Quality in the United States: A New Approach.

Improving the quality of health care has been a focus of health reformers during the last 2 decades, yet meaningful and sustainable quality improvement has remained elusive in many ways. Although a number of individual institutions have made great strides toward more effective and efficient care, progress has not gone far enough on a national scale. Barriers to quality of care lie in fundamental, systemwide factors that impede large-scale change. Notable among these is the third-party financing arrangement that dominates the healthcare system. Long-term goals for healthcare reform should address this barrier to higher quality of care. A new model for healthcare financing that includes patient awareness of the cost of care will encourage better quality and reduced spending by engaging patients in the pursuit of value, aligning incentives for insurers to reduce costs with patients' desire to receive excellent care, and holding providers accountable for the quality and cost of the care they provide. Several new programs implemented under the Patient Protection and Affordable Care Act aim to catalyze improvement in the quality of care, but the law takes the wrong approach, directing incentives at providers only and maintaining a system that excludes patients from the search for high-value care.

Individual and social concerns in American surgical education: paying patients, prepaid health insurance, Medicare and Medicaid.

The education of the U.S. surgeon was traditionally based on a system in which surgeons-in-training cared for a population of largely indigent patients in a setting of graded responsibility. To ensure an ethically appropriate bargain, senior surgeons served as mentors, assumed ultimate responsibility for the patient, and supervised the surgical care of the ward patient by the surgical trainee. During the 20th century, changes in health care financing challenged this comfortable accommodation between charity care and medical education. As others have also written, the introduction of prepaid health insurance plans such as Blue Cross/Blue Shield in the early third of the century, the rapid expansion of employment-based health benefits during World War II, and the enactment of the Medicare and Medicaid legislation under Titles XVIII and XIX of the Social Security Act all contributed to a dramatic reduction in hospital ward (i.e., service) populations. The tension between education and patient care remains incompletely resolved; the proper balance between supervision and graded responsibility for the resident is ultimately worked out on an individual basis. Newer issues facing U.S. surgical education, including the justifiable demand for greater transparency, are likely to upset this suspended truce and lead to renewed discussions about such fundamental concepts as the definition of the resident and the role of the patient in the education of future surgeons.

Unpowered scooter injuries reported to the Consumer Product Safety Commission: 1995-2001.

There has been a marked increase in the use of unpowered scooters over the past few years. Along with this, there has been an increase in injuries related to their use. The objective of this study was to review the unpowered scooter-related injury reports compiled by the United States Consumer Product Safety Commission (CPSC) and to describe the scope and type of injuries sustained. A consecutive case series of injuries sustained by individuals using unpowered scooters between January 1995 and June 2001 was compiled by the CPSC and was made available for review. Data collected included general demographics, date and type of injury, a brief description of the event, treatment, and outcomes. Data are reported using descriptive statistics. During the study period, 469 unique cases of unpowered scooter-related injuries were compiled by the CPSC and reviewed for the present analysis. The median age of those injured was 10 years (range, 1-70 y) with 63% male. Of those injured, 24 (5.1 %) required hospitalization. The most frequent injuries were lacerations (26%), fractures (22%), and contusions (16%). Of interest; 15 deaths were reported. A broad spectrum of injuries was reported to the CPSC related to the use of unpowered scooters. Although most injuries were relatively minor, there were 15 deaths reported. Although most injuries occurred in older children and young adolescents, the very young and adults were not immune from injuries. The risk of injury from unpowered scooters and the need for safety awareness should be stressed to all individuals including the very young and adults.