Indicators of physician timeliness in the process of care.

Physician timeliness at the junctures that define an episode of inpatient care is an extremely important clinical process variable. Medical staff policies that describe acceptable performance with respect to timeliness could be used in peer review and continuous quality improvement activities. The authors' external peer review experiences suggest that physician timeliness may be of concern during the admission and discharge processes, the monitoring and follow-up of patient progress, the provision of verbal orders, the transfer of responsibility between physicians, and the use of consultants. A full discussion of the implications of physician timeliness could provide the vehicle for greater understanding of the value of continuous quality improvement in the hospital setting and lead to more complete participation in developing strategies to improve the processes of care.

The utility of PRO data on surgical volume: the example of carotid endarterectomy.

As part of a small-area analysis of carotid endarterectomy (CE) surgery, this review of Medicare claims data for a 26-month period addresses variations in surgical volume, mortality, readmissions, and charges. A surprisingly high percentage of surgeons performing CE did few procedures, and surgical volume appeared to be associated with higher mortality and charges. The implications of these data for both hospital credentialing committees and management and for purchasers and consumers of care, as well as the ways in which the Health Care Financing Organization's (HCFA) Health Care Quality Improvement Initiative (HCQII) will reorder their relationships with peer review organizations (PROs), are discussed. This study is useful in addressing the potential of efforts by PROs to increase the quality of care under the HCQII.

Responding to the workers' compensation crisis. A proposal on the structure and management of workers' compensation programs.

In 1990 job-related injuries are estimated to have cost American employers over $60 billion in direct workers' compensation expenses, a figure which has doubled in the past four years and which may do so again by 1995. The medical costs of treating work-related injuries and illnesses are estimated to have consumed 41 percent of workers' compensation payouts for 1990, the remainder by indemnity claims costs. Taken together with a 17.1 percent increase in group health care costs in 1990, there is concern for the maintenance of a reasonable business atmosphere under which businesses may remain competitive and prosperous, and employment will be available.

Hepatitis B antigen and antibody in the U.S. Army: prevalence in health care personnel.

The prevalence of Hepatitis B surface antigen (HB(S)Ag) and antibody (anti-HB(S)) seropositivity and the association of seropositivity with demographic, personal health, and professional experiences were studied in a cohort of Army Medical Department officer personnel. Serologic evidence of Hepatitis B infection was found in 5.0 per cent of personnel and was associated with age, sex, place of birth, history of hepatitis, history of blood transfusion, and previous overseas assignments. Seropositivity rates were higher for patient care oriented officer personnel, especially for those in surgical specialties, and rose with increasing professional experience. These data present a composite of risk factors operative in the acquisition of Hepatitis B seropositivity and identify a cohort for prospective study.

Persistence of antibody to hepatitis B surface antigen.

Sera from military personnel found to have antibodies to hepatitis B surface antigen (anti-HBS) in an epidemiological study of a hepatitis B outbreak were tested for persistence of that antibody 1 year later. Initially, 64% of the anti-HBS-positive sera reacted in passive hemagglutination tests with erythrocytes coated with hepatitis B surface antigen of both ayw and adw subtypes; the remaining sera reacted only with adw-coated erythrocytes (19%) or ayw-coated erythrocytes (17%). After 1 year, anti-HBS was detectable by passive hemagglutination tests in 87% of individuals with initial antibody to both subtypes but in only 41% and 16% (P less than 0.001) of those initially reacting only to adw- or ayw-coated erythrocytes, respectively. Seropositivity for anti-HBS correlated best with history of contact with jaundiced people (20.3%) and duty in Asia.

Amodiaquine resistant falciparum malaria in Thailand.

Amodiaquine cured 38% (13/34) of patients with falciparum malaria in Southeast Thailand. Chloroquine cured 0% (0/13). The cure rates with amodiaquine were the same whether a 1.5 g or 2.0 g course was used. Most patients were resistant to amodiaquine at the RI level and to chloroquine at the RII level. In hospital, amodiaquine cleared parasitemia more frequently than did chloroquine. With the 2.0 g course of amodiaquine, the parasite clearance time was 77 hours; the fever clearance time of 36 hours was low and suggests that amodiaquine does not cause a drug fever. Because of resistance, chloroquine should not be used for falciparum malaria in Thailand. Routine use of amodiaquine is not indicated because more effective drugs are available.

Longitudinal malaria studies in rural Northeast Thailand. Chloroquine treatment of falciparum malaria infections.

The efficacy of chloroquine in the treatment of falciparum malaria was studied in two villages in Northeast Thailand, an area endemic for chloroquine-resistant falciparum infections. Chloroquine did not appear to reduce the duration or density of parasitemias experienced by asymptomatic villagers, but did benefit, usually temporarily, many subjects with symptomatic or high-density infections. These observations suggest that the high prevalence of chloroquine-resistant infections in the villages is similar to data from the hospital and clinics serving the area. The question whether chloroquine should remain available to this population should be evaluated.

Comparison of a 9-phenanthrene methanol (WR33063), a 4-quinoline methanol (WR30090), and quinine for falciparum malaria in Thailand.

Quinine was compared with a 9-phenanthrene methanol (WR33063) and a 4-quinoline methanol (WR30090) for the treatment of 207 patients with falciparum malaria in Southeast Thailand. Quinine eradicated parasitaemia (average 70 hours) more rapidly than either WR30090 (72 hours) or WR33063 (77 hours). But WR33063 had a higher cure rate (92%) than WR30090 (86%) or quinine (85%). The mean duration of fever and of parasitaemia were combined with the failure rate to form an arbitrary efficacy index. Using this concept WR33063 was the most effective drug. The recrudescence rate correlated with the degree and duration of parasitaemia and with the duration of fever. WR33063 was the least toxic drug. Side effects associated with WR30090 appeared to be headache, backache and urticaria. Quinine was the most toxic drug. All 3 drugs were inconvenient in having to be administered every 8 hours for 6 days. One patient did not respond to oral quinine but did respond to an intravenous quinine infusion (IVQ). A "Medication Ward Round" was perfected during the study and comprised sequential history, drug administration, physical examination, dose notation and patient observation. Falciparum nephrosis was diagnosed in one patient.