Identifying Risks for Persistent Postconcussive Symptoms in a Pediatric Emergency Department: An Examination of a Clinical Risk Score.

OBJECTIVE: External examination of a clinical risk score to predict persistent postconcussive symptoms (PPCS) in a pediatric emergency department (ED). METHODS: Prospective cohort study of 5- to 18-year-old patients diagnosed with an acute concussion. Risk factors were collected at diagnosis and participants (n = 85) were followed to determine PPCS 30 days postinjury. Univariate logistic regression analyses were completed to examine associations of risk factors with PPCS. RESULTS: Headache and total clinical risk score were associated with increased odds of PPCS in the univariate analyses, OR 3.37 (95% CI 1.02, 11.10) and OR 1.25 (95% CI 1.02, 1.52), respectively. Additionally, teenage age group, history of prolonged concussions, and risk group trended toward association with PPCS, OR 4.79 (95% CI 0.93, 24.7), OR 3.41 (95% CI 0.88, 13.20), and OR 2.23 (95% CI 0.88, 5.66), respectively. CONCLUSION: Our study supports the use of multiple variables of a clinical risk score to assist with ED risk stratification for pediatric patients at risk for PPCS.

Modelling the process of encounter between general practitioner and patient as a method for the detection of psychosocial problems.

In the Netherlands all patient on the list of a GP can present with all health problems in all their stages of development at any time, and more than 80% of all complaints presented to a GP are resolved by him or her. Many of these problems have psychosocial aspects. GPs need a structured consultation model for the doctor-patient encounter and, at the same time, need an open consultation style. The model must be seen as an aid in the doctor-patient communication and in medical education. In this article such a model, based on the SOAP system, a system for medical recording is described. Furthermore, a broader protocol of the SOAP, called the BATHE, is introduced. In addition, a description is given of how students at the medical school of Maastricht University are trained to use this model, especially in the clerkship in general practice.

Educational objectives and requirements of an undergraduate clerkship in general practice. The outcome of a consensus procedure.

OBJECTIVES: The main aim of this study was to reach consensus between students, faculty and general practice teachers on the educational objectives and requirements of the clerkship in general practice. METHOD: The consensus procedure consisted of four steps and all active general practice teachers (n = 116) were asked to participate in the study. RESULTS: We identified 189 educational objectives: 127 complaints (problems, symptoms, syndromes), 29 clinical skills and 37 objectives concerning the theoretical dimensions of general practice. Educational requirements crystallized to 16 essential preconditions of a teaching practice and 35 didactic activities to be performed by the general practice teachers. CONCLUSIONS: These consensus results will be used to structure the medical curriculum and as guidelines for the educational process during the clerkship.

The transformation of hospital laboratories: why regionalization, consolidation, and reengineering will lead laboratories into the 21st century.

In 1990 we predicted that the growth of prospective payment and fixed reimbursement plans would force hospitals to transform the hospital laboratory into a cost center. The need to create alternative modes of care would further lead hospitals to create regional laboratory consortia. This would include the "commercialization" of the laboratory so that it could become a regional resource and expand outreach activities. This report updates events since 1990. Indeed, the arrival of prospective payment and fixed reimbursement has caused a radical upheaval among health care providers in every part of the country. The transformation was more rapid than we expected, particularly in two areas. First, the commercial laboratory industry devoured itself. By 1995 the consolidation movement ended and three huge national laboratory chains now provide laboratory services throughout the United States. Second, not only did prospective payment arrive in the form of capitated contracts for laboratory services, but it arrived with remarkable speed. It was coupled with the absolute decline for three years in Medicare reimbursement for lab services. Such changes to reimbursement levels have seriously undercut the financial viability of the laboratory industry. Hospital-based laboratories are responding to these pressures with three strategies: reengineering, consolidation, and networking. Six identifiable trends will drive the transformation of laboratories into regional provider consortia between now and the year 2000. We predict that the speed of this transformation will be even faster than that experienced by the consolidation of commercial laboratories. This will occur because hospital labs are already a component within integrated delivery systems. As these systems transform and evolve, the laboratories must transform in concert. Our experience indicates that laboratory consolidation delivers economic benefits that are considerably greater than either networking or reengineering. Consolidation, accompanied by new testing technologies and tighter data links, will lead the transformation of today's hospital laboratory into a "virtual" laboratory. Such laboratories will be self-sufficient, capable of performing all but esoteric tests in-house. It will be a "laboratory without walls," emphasizing testing performed at the point of care, be it bedside, physician's office, clinic, nursing home, ambulance, workplace, or patients' homes. A combination of economic and organizational pressures will cause hospital-based laboratories to adopt some form of regionalization within the next two to three years.

[Transmural teaching program from the family practice viewpoint]. / Een transmuraal onderwijsprogramma vanuit de huisartspraktijk.

OBJECTIVE: Evaluation of an experimental transmural teaching programme for postgraduate students following a general practitioners' course. DESIGN: Descriptive. SETTING: Institute for General Practice, University of Limburg, the Netherlands. METHOD: Experiences of 100 students who followed a patient from referral in general practice to the hospital (and back) were evaluated by means of a questionnaire. Questions concerned to what extent learning goals (insight into transferral from general practice to the hospital and the consequences for the patient) had been reached. RESULTS: The satisfaction of the students was moderately positive, but dependent on the briefing of the tutors and the exchange of experiences in the tutorial group. The information given by the general practitioner about the referral, the quality of the organisation in the hospital and the medical treatment received a positive judgment. The attention for the patient's views, and the quality of advice and information in the hospital were unsatisfactory in half of the referred cases, according to the student. Three quarters of the patients had a positive opinion regarding the referral in contrast to only half of the relatives. The pattern of the referred morbidity was comparable to the main health problems in general practice. CONCLUSION: The patient's view of his illness plays a central part in this transmural teaching programme. The results justify similar programmes in other disciplines.

Practical medical education in general practice.

The Medical Faculty of the University of Limburg in Maastricht, The Netherlands pays special attention to extramural care. The extramural profile of the Medical Faculty also manifests itself in the curriculum. Since 1978, a 12-week clerkship in practical medical training in general practice (PMT-GP) has been offered to fifth-year students. The general aim is to acquaint students with general medical aspects as well as specific primary care aspects of health care. The programme started in the autumn of 1978 with 24 students and 24 GP teachers. At present more than 100 GP teachers, working in about 70 practices, train 120-130 students a year. The model of the PMT-GP system is characterized by six features: a ratio of one GP teacher to one student; autonomous examination by the student of at least 15 patients a week; daily follow-up discussion on the basis of patient records prepared by the student; opportunities for self-study by the student; one tutorial day a week at the Medical Faculty; intensive contacts between the Faculty and GP teachers. Key activities of the PMT-GP include autonomous contacts with patients, written records and daily follow-up discussions with the GP teacher.

Laboratory cost and utilization containment.

The authors analyzed laboratory costs and utilization in 3,771 cases of Medicare inpatients admitted to a New England academic medical center ("the Hospital") from October 1, 1989 to September 30, 1990. The data were derived from the Hospital's Decision Resource System comprehensive data base. The authors established a historical reference point for laboratory costs as a percentage of total inpatient costs using 1981-82 Medicare claims data and cost report information. Inpatient laboratory costs were estimated at 9.5% of total inpatient costs for pre-Diagnostic Related Groups (DRGs) Medicare discharges. Using this reference point and adjusting for the Hospital's 1990 case mix, the "expected" laboratory cost was 9.3% of total cost. In fact, the cost averaged 11.5% (i.e., 24% above the expected cost level), and costs represented an even greater percentage of DRG reimbursement at 12.9%. If we regard the reimbursement as a total cost target (to eliminate losses from Medicare), then that 12.9% is 39% above the "expected" laboratory proportion of 9.3%. The Hospital lost an average of $1,091 on each DRG inpatient. The laboratory contributed 29% to this loss per case. Compared to other large hospitals, the Hospital was slightly (3%) above the mean direct cost per on-site test and significantly (58%) above the mean number of inpatient tests per inpatient day compared to large teaching hospitals. The findings suggest that careful laboratory cost analyses will become increasingly important as the proportion of patients reimbursed in a fixed manner grows. The future may hold a prospective zero-based laboratory budgeting process based on predictable patterns of DRG admissions or other fixed-reimbursement admission and laboratory utilization patterns.

Regionalization of laboratory care: a viable option for the 21st century.

The conversion of the hospital laboratory to a cost center under pressure of prospective payment and fixed reimbursement is increasingly forcing hospitals to consider alternative modes for delivery of laboratory care. Changes in the health care environment, amended statutes and regulations, and, particularly, dramatic developments in laboratory equipment, methodologies, and data processing technology make it advisable and feasible to contemplate the creation of regional laboratory consortia. A fundamental step in this direction is the "commercialization" of the hospital laboratory through a change in focus from being an in-house support program to becoming a regional resource. By the same token, the hospital laboratory can become an effective competitor of independent laboratories and be reconverted to a profit center. Creation of hospital laboratory consortia in a splintered, competitive environment requires a committed entrepreneurial effort and convincing evidence of potential benefits. The sequence of steps needed to achieve regional laboratory integration include concerting the goals and objectives of the interested parties, creating an appropriate committee structure, conducting a feasibility assessment, identifying alternative organizational and operational options, selecting a favorite option viewed by all parties as a win/win proposition, developing a business plan, and determining an implementation action plan. The major disadvantages of regionalization of laboratories are employee displacement, potential leveling of quality standards, and reduced hospital control. The major advantages include elimination of duplicate capital, personnel, and service costs, improved efficiency through test batching, reduced unit costs, increased technical capability through staff, instrument, and systems sharing, disengagement from hospital-imposed limitations, strengthened ability to penetrate the marketplace, freeing of hospital space for more direct patient care activities, and achieving a means for bonding physicians to the institutions.

Pseudomonas aeruginosa isolates: comparisons of isolates from campers and from sibling pairs with cystic fibrosis.

Sputum or deep throat specimen cultures were obtained from 47 cystic fibrosis (CF) patients residing together at an eight-day summer camp. Pre-camp, initial day, final day and post-camp cultures were obtained and Pseudomonas aeruginosa isolates were characterized by morphology, serotype, pigment production, serum sensitivity, antibiotic susceptibility patterns, hemolysis on blood agar, and CO2 growth requirement. Of the 47 patients, four were not chronically colonized with Pseudomonas and did not become colonized at camp. Analysis of the isolates from the other 43 revealed no significant alteration in the Pseudomonas colonization pattern. Cultures obtained from four sibling pairs among the campers and from 20 additional pairs of siblings revealed that siblings in 20/24 pairs had at least one identical serotype in common. Of the criteria used for characterization, serotyping was the most definitive method for strain identification. Serotyping by both the Homma system and the International system did not detect any serotype at a frequency of more than 31%. In this study, the predominant P. aeruginosa strain of the colonized patients did not change, and non-colonized individuals did not become colonized with P. aeruginosa.