Comparative costs of urgent care services in university-based clinical sites.

OBJECTIVE: To identify the most cost-effective utilization of resources for urgent care for a managed care Medicaid population at a university medical center. The null hypothesis was that there are no significant differences between the costs and types of services for patients with comparable urgent care problems who are seen in outpatient clinical settings compared with those seen in the central emergency department of a university medical center. DESIGN: Retrospective case study comparing patient visits and charges for three clinical urgent care locales by diagnosis, severity of illness, age group, time period in which seen, and reason for referral. SETTING: Ambulatory care and hospital emergency department facilities at a university medical center. PATIENTS: 1096 Medicaid patients who were enrolled in the university physicians' managed care plan. MAIN OUTCOME MEASURES: Diagnosis-specific comparisons of types of services and charges for patient visits. RESULTS: There were significantly higher charges for all urgent care diagnoses of patients treated in the emergency department compared with urgent care facilities; these costs were higher in all categories of charges. CONCLUSIONS: A variety of alternatives to use of the full emergency department are more cost-effective in providing urgent care services for Medicaid clients in a managed care setting.

Cost containment and quality of life. An experiment in compassion for physicians.

A review of emergency department visits during a 2-year period and before and after the liberation of physicians from a requirement of gatekeeping for some patients during the night showed no significant increases in the use or costs of services to our Medicaid enrollees for all but children under 6 years of age between 10 PM and midnight. We recommend that a more humane and practical view be taken of middle-of-the-night gatekeeping requirements for physicians functioning in managed-care environments. We also suggest, as many hospitals have already learned, that the costs of emergency department services for Medicaid patients can be reduced and that care may be enhanced by the offering of 24-hour urgent care services at or near the emergency department.

The spectrum of pulmonary edema: differentiation of cardiogenic, intermediate, and noncardiogenic forms of pulmonary edema.

Pulmonary edema fluid and serum samples were obtained from 20 patients with cardiac and noncardiac pulmonary edema, and total protein, albumin, and globulin concentrations were measured. The mean edema fluid to serum protein ratio in patients with pure cardiogenic pulmonary edema was 0.37 +/- 0.09. In contrast, the patients with pure noncardiogenic pulmonary edema had protein ratios of 0.84 +/- 0.12 (p less than 0.001). Another group of patients with both cardiac and noncardiac causes for edema demonstrated edema fluid to serum protein ratios that were significantly higher than those found in the cardiogenic patients and lower than the protein ratios in the noncardiogenic patients (0.60 +/- 0.07) (p less than 0.01) A cardiac or noncardiac causes of pulmonary edema could be determined in all patients, using edema fluid to serum total protein ratios in conjunction with globulin ratios. Cardiogenic and noncardiogenic pulmonary edema represent the extremes in the spectrum of pulmonary edema. A combination of increased permeability and hydrostatic pressure may account for an intermediate form of pulmonary edema.

Comparison of measured and calculated colloid osmotic pressure of serum and pulmonary edema fluid in patients with pulmonary edema.

Serum and pulmonary edema fluid samples of 26 patients with pulmonary edema were examined. The correlation coefficient comparing measured colloid osmotic pressure (COPm) to calculated colloid osmotic pressure (COPc) (Landis and Pappenheimer equation) was 0.84. Significant differences between COPm and COPc were noted when total protein (TP) concentrations were less than or greater than 5 g/dl (p < 0.001 and p < 0.01, respectively). Twenty-one of 69 samples (30%) had a greater than 4 mm Hg difference between measured and calculated values. COP should be measured rather than calculated for accurate determinations.

Evaluation of a new pregnancy test claiming beta-subunit specificity.

A new hemagglutination-inhibition tube test for human chorionic gonadotropin said to be beta-subunit specific was compared with a widely used similar test that is not beta-specific. Also compared were the latex agglutination-inhibition slide test from the same manufacturer, along with a similar non-beta-subunit specific slide test. Although the new tube test showed good sensitivity, false-positives still occurred in the perimenopausal age group.

PIP: A comparison was made between a new hemagglutination-inhibition tube test for human chorionic gonadotropin said to be beta-subunit specific and a widely used similar test that is not beta specific. The latex agglutination-inhibition slide test from the same manufacturer and a similar non-beta-subunit specific slide test were also compared. The study group was made up of random urine specimens submitted for pregnancy tests for 251 patients at a large county hospital in Miami, Florida. The tests were conducted between April and August 1978 among a group of patients who had a large variety of problems, including menstrual and hormonal irregularities, acute vaginal bleeding, or abdominal emergencies. The directions of the manufacturers were followed for the 4 pregnancy kits evaluated. The test results were recorded as either positive or negative. Of the 251 patients tested, 48 were pregnant, 161 were not pregnant, and 43 had insufficient follow-up for diagnosis. For 37 of the 48 patients with clinical or tissue diagnoses of pregnancy, all 4 of the tests were performed and were positive. 135 nonpregnant patients had negative results for all 4 tests. 8 patients who were pregnant had negative results by either 1 or more of the 4 tests, and the majority of the false-negatives were for those who were in early pregnancy or for patients who were aborting. The new tube test showed good sensitivity, but false-positives still occurred in the perimenopausal age group.

Fatty tumors of the thorax demonstrated by CT.

The radiographic signs previously described for fatty tumors of the thorax although helpful are nonspecific. In the past, the diagnosis of benign fatty tumors of the chest in asymptomatic patients required surgical intervention. This report illustrates the gamut of fat-containing tumors of the thorax encountered over a recent 1 year period. CT proved to be helpful in the diagnosis and management on these cases. When the CT numbers of the fatty lesion was around -55 EMI units, intervention was felt to be unnecessary. However, when the CT number of the mass ranged from --10 to--20 EMI units, intervention was felt to be necessary since a malignancy could not be excluded on the basis of the CT findings alone.