Aborto séptico: un problema actual / Septic abortion: a current problem

De 316 casos de aborto estudiados consecutivamente durante un año en el departamento de ginecología y obtetricia del Hospital Centrl Militar hubo 38 (12.0 por ciento) que fueron diagnosticados como aborto séptico. Escos casos se compararon con los de las 278 mujeres restantes del grupo cuyo aborto no fue séptico. No se encontraron diferencias en la edad y la paridad de las pacientes de ambos grupos, ni en el tiempo del embarazo en el momento del ingreso. Fue notable que en el grupo de pacientes con aborto séptico hubo más mujeres no unidas (solteras y divorciadas) que en el grupo control (39.4 vs 6.8 por ciento, p;0.01). También fue diferente la forma clínica del aborto, sobre todo porque en el grupo de aborto séptico no hubo casos de amenaza de aborto. Las pacientes con aborto sético se trataron con impregnación de antibióticos por 24 horas, previo al legrado uterino, excepto en los casos de hemorragia o instalación de choque séptico; 50 por ciento de las pacientes de aborto séptico necesitaron transfusión sanguínea. Una mujer con perforacion uterina e infección pélvica evidente requirió de histerectomía con salpingo-ooferectomía bilateral. La conclusión de este trabajo es que en la población que se atiende en el Hospital Central Militar en el aborto séptico no constituye un problema importante de salud, pero a pesar de los pocos casos que se atienden, es evidente la necesidad de buscar soluciones que los lleven a su total desaparición, y que son la intensificación de las campañas de planificación familiar y de despenalización del aborto.

Obesity in minority populations: policy implications of research.

Obesity is a major health problem for many Americans, with an overall prevalence for adults of approximately 25% and a range for specific subgroups of 24-75%. This range is striking and reflects many factors shown to influence the development and maintenance of obesity, including physical activity, diet, ethnicity, income, education, and genetic susceptibility. Many minority populations have higher prevalences of obesity and, thus, experience its adverse health consequences disproportionately. Research in diverse populations indicates that the relative importance of risk factors for cardiovascular disease varies in many populations. Data characterizing the profile of risk factors, including obesity and physical activity, for various special populations are limited and some, such as obesity, are based on standards developed in the general population. For public health policy and interventions to succeed, they must address the needs of special populations and of the overall population. This paper discusses some of the relevant broader social and research issues.

The uninsured. From dilemma to crisis.

KIE: An estimated 31 to 36 million Americans currently lack any form of health insurance, and underinsurance is also a chronic problem. In 1989, only 40% of the poverty population was covered by Medicaid. Employer-subsidized insurance has also seen gradual erosion over the years. Friedman warns that the issue of health care coverage, if not yet at a critical level, soon will be, for five reasons: coverage is a key factor in health improvement; health care institutions suffer increasingly from patients' uninsured care; fewer employers are offering coverage, due to the increasing costs of insurance; primary care in the emergency setting is inefficient, forcing society to pay dearly for care for the uninsured; and an industrialized democracy cannot justify such an overly selective and self-destructive health care system.^ieng

Health insurance values and implementation in The Netherlands and the Federal Republic of Germany. An alternative path to universal coverage.

The health care systems in the Netherlands and the Federal Republic of Germany are based on a set of values that involve mutual obligations between private parties. These obligations are realized through systems incorporating private practice physicians, community and church- and municipality-affiliated hospitals, and nonprofit and for-profit insurers. The underlying values and implementation approaches in these systems provide an alternative to the adoption of a Canadian-style health insurance system. A discussion that focuses on "obligations" rather than "rights" may be a more useful approach for the design of reforms of the American health system in the 1990s. Such a discussion would focus on the mutual responsibility of all parties to create and maintain a universal private health care system.

A call for action. The Pepper Commission's blueprint for health care reform.

After a year of deliberation and investigation, the Pepper Commission recommended action to ensure that all Americans would have health insurance protection in an efficient, effective health care system. Because it believes that action is urgent, the commission would build universal coverage by securing, improving, and extending the combination of job-based and public coverage we now have. Reform would entail the following elements: a combination of incentives and requirements that would guarantee all workers (with their nonworking dependents) insurance coverage through their jobs; replacement of Medicaid with a new federal program that would cover all those not covered through the workplace and workers whose employers find public coverage more affordable; guaranteed affordable coverage for employers--through reform of private insurance, tax credits for small employers, and the opportunity to purchase public coverage; a minimum benefit standard for private and public plans that would cover preventive and primary services as well as catastrophic care and would include cost sharing, subject to ability to pay; and a combination of public and private sector initiatives to promote quality and contain costs.

Restructuring health care in the United States. A proposal for the 1990s.

KIE: Nutter, et al. present proposals, developed by the Medical Schools Section of the A.M.A., for reform of the U.S. health care system. The goals of this plan include the definition of appropriate roles for business, government, and the individual; responsible cost containment; simplified administration; quality assurance linked to effective methods of technology assessment; continued public and private support for biomedical research; greater responsiveness by academic medicine to national health care needs in the areas of primary care and geographic distribution; health care payers' shared responsibility for the support of graduate medical education; and the measurement of the restructured system's effectiveness against changes in citizens' health status. Supportive of the Pepper Commission's proposed replacement of Medicaid with a public health plan, the authors also urge the continuation of Medicare, the provision of health benefits by all employers, and subsidized, regional insurance pools for those not covered by other means.^ieng

Universal health insurance through incentives reform.

Roughly 35 million Americans have no health care coverage. Health care expenditures are out of control. The problems of access and cost are inextricably related. Important correctable causes include cost-unconscious demand, a system not organized for quality and economy, market failure, and public funds not distributed equitably or effectively to motivate widespread coverage. We propose Public Sponsor agencies to offer subsidized coverage to those otherwise uninsured, mandated employer-provided health insurance, premium contributions from all employers and employees, a limit on tax-free employer contributions to employee health insurance, and "managed competition". Our proposed new government revenues equal proposed new outlays. We believe our proposal will work because efficient managed care does exist and can provide satisfactory care for a cost far below that of the traditional fee-for-service third-party payment system. Presented with an opportunity to make an economically responsible choice, people choose value for money; the dynamic created by these individual choices will give providers strong incentives to render high-quality, economical care. We believe that providers will respond to these incentives.

A framework for reform of the US Health Care Financing and Provision System. The Kansas Employer Coalition on Health, Task Force on long-term solutions.

KIE: Thirty million Americans lack health insurance, and despite soaring costs and a leading U.S. role in world health spending, American health statistics remain below the standards of industrialized democracies. Based on principles of universal coverage and responsibility, the Kansas Employer coalition proposes a restructuring of the American health insurance system with minimal reliance on regulation and maximum utilization of current structures. The proposed system would require coverage of every citizen by either an employer's plan or, by default, a tax-supported public plan. The long-term proposal also urges a community, not experience, rating basis for determining insurance premiums; health care cost containment through government dictation of maximum plan increases; government monitoring of health care quality; and individual responsibility for paying some fraction of the cost of each episode of care.^ieng

An American approach to health system reform.

In terms of the major objectives one would have for health system reform, this plan makes the following choices: 1. It would cover everyone, through Medicare (the elderly), employer-based coverage (some workers and dependents) or a state-level public program that would replace Medicaid (the poor, unemployed, and other workers and dependents). 2. There would be a standard minimum package of required benefits for employer-based and public programs, with legislative requirements on maximum cost-sharing. Choice of provider might be restricted in some states. 3. Administration of the private programs would be the responsibility, as now, of the employers and/or insurance companies. Administration of the public program would be the responsibility of the states, with the objective of maximizing responsiveness to local needs and conditions. 4. It would control costs through giving the states a substantial financial stake in ensuring that the public program costs did not grow faster than nominal GNP. State control would also allow the testing of different mechanisms for cost control, with the ultimate objective of identifying the most effective cost-containment strategies. 5. The cost would be borne by employers, employees, and taxpayers. Employers would be protected from exorbitant costs by being allowed the option of paying into a public plan rather than providing health insurance themselves. The poor and unemployed would be protected by having their coverage under the public program subsidized on a sliding scale. 6. The political feasibility test would be met by retaining a major role for insurance companies and by retaining the role of employer-based coverage--thus reducing the tax increase needed to ensure universal coverage. By allowing flexibility in design of cost-containment strategy, some of the controversy over this issue would also be deflected. Our proposal is also not without problems. First, our approach would still have adverse effects on the profitability of small businesses and on the employment prospects for low-wage workers--although these effects would be less than under conventional mandates and less than under proposals with higher tax rates. Second, some states may not want the responsibility we envision or have the capacity to carry it out. But several Canadian provinces are relatively small and are able to perform the same administrative functions within the Canadian national health system. In addition, since the federal government would continue to administer the Medicare program, states would have the option of tying their policies for hospital and physician payment and utilization control to those of Medicare.(ABSTRACT TRUNCATED AT 400 WORDS)

KIE: To meet the need for expanded health care coverage in America, Holahan, et al. of the Urban Institute, incorporate aspects of the Canadian health care system and the Pepper Commission's proposals in the design of what they propose as a cost effective and politically acceptable health care reform package. Medicare would be unchanged. Employers would provide basic coverage for their workers, or pay a tax in support of state-administrated public health insurance programs. This public program would replace Medicaid, and would be utilized by three groups: those whose employers opted to pay a tax, the poor, and citizens who buy into the program. Strong incentives for states to control health care costs would be provided by requiring states to bear the burden of cost increases exceeding the rate of growth in GNP.

A tax reform strategy to deal with the uninsured.

The high level of ininsurance in the United States is due in large measure to the tax treatment of health care, which is based on the tax exclusion for company-provided plans. Correcting the perverse incentives for providers and patients resulting from this tax treatment is the crucial step to creating a national health care system that is affordable and efficient. The Heritage Foundation proposal calls for the elimination of the current tax exclusion and its replacement with a system of refundable tax credits for the purchase of health insurance and medical services.

The Health Security Partnership. A federal-state universal insurance and cost-containment program.

The Health Security Partnership attempts to assure (1) that all Americans have insurance coverage for a set of comprehensive health care benefits, (2) that cost-containment issues are addressed in a manner that does not impinge negatively on the quality of care, and (3) that provider freedom to deliver appropriate clinical care is strengthened. It assigns important responsibilities to the federal government (eg, specification of benefits, review of proposed state health care budgets), while permitting states to select, develop, and administer specific program design features they deem appropriate (eg, states could build on and expand the existing health system infrastructure, including private insurance, and/or extend the role of tax-supported programs). It is estimated that in its first year the program would add about 5% to America's health expenditures, but within a few years, cost-containment efforts and administrative efficiencies would reduce overall expenditures below what they otherwise would be.

Health access America--strengthening the US health care system.

Although Americans remain generally satisfied with the health care provided to them, sufficient access to high-quality, affordable health care for citizens without health care insurance has become an increasing problem in the last decade. Using the policy development process of the American Medical Association, Health Access America was conceived by the Association to improve access to affordable, high-quality health care. The proposal consists of six fundamental principles and 16 key points. This article specifically focuses on the five points that, if enacted into law, would improve access to health care for Americans who are, for various reasons, without health insurance.

Screening for HBsAg in pregnant women: a cost analysis of the universal screening policy in the province of Quebec.

We carried out a cost analysis of a universal prenatal screening policy for hepatitis B virus infection in pregnant women. A universal screening policy in the province of Quebec (87,000 births per year) would cost about $473,000 per year and the prevention of one chronic carrier, $8,915. The cost varied greatly according to the ethnic origin of the mother and the cost of the serologic test. Strategies to reduce the cost of the serologic test could greatly reduce the cost of this screening policy.

Looking abroad for changes to the U.S. health care system.

With the U.S. health care system in crisis, policy-makers and analysts in this country are looking seriously at foreign systems for clues to how to restructure our own. And those experts are turning away from the centrally controlled Canadian and British health care systems as models for our own, and looking toward systems such as Germany's and Australia's, which offer greater choice and more diverse health care markets.