A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates.

UNLABELLED: Neonates who require a central venous catheter (CVC) for prolonged vascular access experience high rates of catheter-related bloodstream infection (CRBSI). PURPOSE: A multicenter randomized clinical trial was undertaken to ascertain the efficacy of a novel chlorhexidine-impregnated dressing (Biopatch Antimicrobial Dressing) on the CVC sites of neonates for the prevention of catheter tip colonization, CRBSI, and bloodstream infection (BSI) without a source. Setting. Six level III neonatal intensive care units. Patients Studied. Neonates admitted to study units who would require a CVC for at least 48 hours. METHODS: Eligible infants were randomized before catheter placement to 1 of the 2 catheter site antisepsis regimens: 1) 10% povidone-iodine (PI) skin scrub, or 2) a 70% alcohol scrub followed by placement of a chlorhexidine-impregnated disk over the catheter insertion site. A transparent polyurethane dressing (Bioclusive Transparent Dressing) was used to cover the insertion site in both study groups. Primary study outcomes evaluated were catheter tip colonization, CRBSI, and BSI without an identified source. RESULTS: Seven hundred five neonates were enrolled in the trial, 335 randomized to receive the chlorhexidine dressing and 370 to skin disinfection with PI (controls). Neonates randomized to the antimicrobial dressing group were less likely to have colonized CVC tips than control neonates (15.0% vs 24.0%, relative risk [RR]: 0.6 95% confidence interval [CI]: 0.5-0.9). Rates of CRBSI (3.8% vs 3.2%, RR: 1.2, CI: 0.5-2.7) and BSI without a source (15.2% vs 14.3%, RR: 1.1, CI: 0.8-1.5) did not differ between the 2 groups. Localized contact dermatitis from the antimicrobial dressing, requiring crossover into the PI treatment group, occurred in 15 (15.3%) of 98 exposed neonates weighing

Why primary care physicians join HMOs.

OBJECTIVE: To determine the reasons why primary care physicians affiliate with health maintenance organizations (HMOs) and assess how these reasons vary with personal and practice characteristics. STUDY DESIGN: A 1996 national telephone/mail survey of primary care physicians who were affiliated with at least 1 HMO plan for more than 9 months. METHODS: Survey responses were assessed according to geographic region, age, income, level of involvement in managed care, and HMO penetration rate. The sample consisted of 210 primary care physicians who played a role in the decision to affiliate. RESULTS: The overwhelming reason primary care physicians affiliated with an HMO was to retain patients. Eighty-three percent reported this as one of the reasons for affiliating and 59% reported it as the primary reason. Physicians with the greatest portion of income from managed care and physicians practicing in areas with high HMO penetration were most likely to report quality of life issues--such as more personal time, more predictable work hours, or reduced administrative burden--as the rationale for HMO plan affiliation. CONCLUSIONS: These findings support the view that the majority of HMO-affiliated physicians join HMOs to avoid a perceived penalty associated with lack of affiliation, rather than for positive reasons. The data also suggest that physicians with managed care experience affiliate more often for quality of life reasons.

Do hospital-based rural health clinics improve the performance of the parent hospital?

This study shows that establishing an RHC may lead to beneficial impacts for the parent hospital, and that these benefits have been experienced by categories of hospitals that are now subject to the new limit on RHC reimbursement legislated by the Balanced Budget Act.

Access to dental care in the United States.

The authors analyzed data from the 1994 National Access to Care Survey and estimated the extent of dental care wants in the U.S. population and in various population subgroups. The authors found that 8.5 percent of the population wanted, but did not readily obtain, dental care in 1994. The prevalence of unmet dental care wants varied by demographic and socioeconomic characteristics, and income and health insurance status. Findings suggest that financial barriers to access are significant in explaining the prevalence of wanted dental care.

Can survey data be used to estimate physician practice costs?

Health policy makers rely on survey estimates of physician practice costs to set reimbursement rates. The Health Care Financing Administration has just funded a multimillion dollar effort to collect survey data that will be used to revise payments under the Medicare Fee Schedule. However, the ability of large-scale physician surveys to obtain accurate information about practice costs is not apparent. This article examines several of the key obstacles encountered when trying to obtain accurate estimates. Rates of both unit and item nonresponse over time are described; in general, there is a trend toward lower unit response rates and higher item response rates. The article also examines logical inconsistencies in data. The results suggest that physician surveys may not be the most appropriate source of data about physician practice expenses. Health policy makers concerned about provider reimbursement issues should seriously scrutinize the accuracy of results from physician practice cost surveys. This article concludes by suggesting alternative methodologies for incorporating physician practice costs into reimbursement rates.

Individuals with mental retardation in residential facilities: findings from the 1987 National Medical Expenditure Survey.

Data from the 1987 National Medical Expenditure Survey, a large survey designed to yield national estimates pertaining to the use of medical care, were used to compare residents of state institutions with residents of other types of residential facilities. Findings concur with past studies: Residents of state institutions were more severely retarded and more likely to have other disabilities and functional impairments than were residents of other residential facilities. However, many residents of other facilities had severe impairments. Relatively more persons with severe impairments resided in these facilities in states where small facility beds were relatively plentiful.

Insurance coverage and the demand for dental care. Results for non-aged white adults.

The fraction of the U.S. population with private dental insurance coverage increased considerably during the past two decades. Experimental data from the Rand Health Insurance Study have revealed that dental insurance is an important determinant of demand. In this analysis, detailed health insurance data from the National Medical Care Expenditure Survey are used to study the effects of insurance on demand by a standard population of white adults aged 16 to 64. Results from this national probability sample are generally comparable to those from the Rand experimental data. Estimates indicate that the primary effects of dental insurance are to facilitate access to care and to increase dental expenditures. Results are consistent with the notion that first-dollar coverage exerts a greater effect on demand than insurance which requires payment of a deductible. Findings also suggest that insurance affects the mix of dental services received. Loss of dental benefits because of cost containment efforts will result in significant reductions in demand for dental services.