The Tufts partnership for managed care education.

The authors describe the formation and the academic activities of the Tufts Managed Care Institute, a collaborative venture of Tufts University School of Medicine and Tufts Health Plan, an independent-practice-association (IPA)-model health maintenance organization (HMO). In 1994, the dean of the medical school and the CEO of the HMO recognized the need for collaboration to prepare students and practitioners for high-quality, cost-effective practice in a managed care environment. They established an advisory committee to oversee a six-month feasibility study to interview experts and opinion leaders and identify critical characteristics of the ideally prepared managed care practitioner. In 1995, with start-up funding from the HMO, the institute began its operations as a freestanding enterprise with board representation from the two sponsoring institutions. While many of the institute's programs have been developed for practicing physicians and other health care professionals, this article focuses on the academic activities. For medical students, the approach has been to blend managed care principles and practices into existing courses, problem-based learning cases, and clerkships, rather than creating separate managed care courses. For primary care residents, the institute has a grant to develop managed care curricula in conjunction with Tufts-affiliated residency training programs. Faculty development is accomplished through dedicated workshops and seminars, and through increased dialogue between traditional faculty and managed care professionals. In all of its programs and activities the institute has fostered greater contact and collaboration between colleagues from both sides of the health plan-academia "divide." Operationally, the institute structure, with dedicated full-time administrative staff, provides the singular focus necessary to establish managed care education as a top priority for the partnership. At the same time, sustaining this freestanding organization and infrastructure requires increased resources. Initial responses to the institute's programs and activities have been positive, both from the local Tufts community and from external parties. Yet the partnership must establish methods to evaluate the institute's long-term impact in its efforts to help practitioners succeed in a transforming landscape.

Undergraduate medical education in prepaid health care plan settings.

The authors in this article focus on prepaid health care plan (PHCP) involvement in undergraduate medical education and report the results of two surveys undertaken to determine the extent of such involvement. Additionally, the authors provide a review of published studies that have examined the costs of such training. The survey findings show that current use of PHCPs for educational purposes is distributed throughout all four years of undergraduate medical education and is apparently on the rise. In addition to 26 medical schools reporting formal educational arrangements with health maintenance organizations, 35 other schools indicated that they either planned or were seriously considering such arrangements with PHCPs had ongoing ad hoc arrangements with PHCPs, or attributed their lack of an arrangement to an absence of appropriate opportunities rather than to any conceptual reservations. Three studies represented the extent of the published research that could be identified on the costs of formal undergraduate clinical training in PHCPs. Serious inconsistencies in the methodologies employed in those studies resulted in widely varying and even contradictory findings.

Screening for congenital hypothyroidism. Results in the newborn population of New England.

During the first year of operation, the New England Regional Hypothyroidism Screening Program determined the concentration of thyroxine (T4) levels in dried blood on filter paper from 129,028 infants born in Connecticut, Maine, Massachusetts, New Hampshire, and Rhode Island. Specimens from approximately 3,800 neonates were found to have levels of T4 below the lower limit of normal (less than 6.0 microgram/dl) and were assayed for thyroid-stimulating hormone (TSH) content. Levels of TSH were elevated (greater than 20 muU/ml) in 31 infants, 23 of whom eventually proved to have unequivocal hypothyroidism. Based on these figures and including two hypothyroid infants who were not tested, the incidence of congenital hypothyroidism in the New England region is approximately 1:5,200 births. The estimation of T4 values supplemented by measurement of TSH values on specimens with low T4 values has proved to be a satisfactory approach to large-scale screening for congenital hypothyroidism.

Eastern equine encephalitis in Massachusetts, 1957-1976. A prospective study centered upon analyses of mosquitoes.

Reappearance of eastern equine encephalitis (EEE) in Massachusetts residents in the 1970's provided an opportunity to assess the predictive value of data on rainfall, EEE in horses, and carriage of EEE virus (EEEV) by mosquitoes, factors which had been studied annually since the last EEE outbreak in 1955-1956. The cycle of multiple cases during 1973-1975 started in a second consecutive year of rainfall that exceeded the annual mean by more than 20 cm, conditions recapitulating the 1955-1956 experience. In 1973, widespread EEE fatalities in horses presaged human cases, another recapitulation of the 1955-1956 experience. However, in 1974, when horses were immunized extensively, no equine cases were seen even though three human fatalities occurred. An unseasonably early appearance of EEEV in mosquitoes was the only basis upon which the threat to humans could have been recognized. These changes in the recognition and distribution of EEEV activity from season to season illustrate the difficulty in making rational decisions regarding widespread aerial insecticide applications for mosquito control.

The state and territorial public health laboratory: program activities, organization and prospects for the future.

During the past two years we have studied the characteristics of state and territorial public health laboratories in an attempt to develop guidelines for considering reorganization of laboratory services in Massachusetts. Only a few recent monographs have dealt with this topic and, to our knowledge, the functional and organizational characteristics of these laboratories have not been reviewed. The state public health laboratory system affords an excellent example of applied laboratory science or technology organized to provide basic public health services. In this paper the programs and organization of the state public health laboratory are reviewed, and a functional basis more responsive to society's current needs is suggested.

Effect of dosage and route of inoculation upon antigenicity of inactivated influenza virus vaccine (Hong Kong strain) in man.

Earlier studies on the antibody response to inactivated influenza vaccines injected by different routes have given contradictory results, some suggesting that 0.1 ml intradermally is superior to 1.0 ml subcutaneously, others suggesting the opposite. With the advent of the 1968-69 Hong Kong influenza epidemic it seemed worth while to re-evaluate whether a smaller intradermal dose would elicit antibody responses comparable to those following a larger subcutaneous dose.A study was performed evaluating 3 doses: 0.1 ml (65 CCA), 0.25 ml (160 CCA), and 0.5 ml (320 CCA) of zonal-purified vaccine. The 0.1-ml dose was administered by both routes, and the other doses subcutaneously only. The effect of "booster" inoculation by the same route 2 and 4 weeks later was also studied. Sera were examined for haemagglutination-inhibiting antibody, and antibody response was determined by the percentage showing 4-fold or greater titre rises and by increase in geometric mean titre.The antibody response to the first inoculation was highest in the 0.1-ml intradermal groups and the lowest in the 0.1-ml subcutaneous groups. All groups receiving a second inoculation 2 weeks after the first experienced an increase in antibody response; responses to the second inoculation given 4 weeks after the first were variable. Considering the over-all effect of all combinations of doses and routes, the intradermal groups appeared to achieve the best antibody response and the 0.1-ml subcutaneous groups the least.There appeared to be an inverse relationship between antibody response and pre-immunization antibody titre.The data show that, with vaccine of similar CCA content, 0.1 ml intradermally would be a reasonable alternative to, and perhaps better than, the usual 0.5-ml subcutaneous dose. The limitations of this approach are discussed.