Radiation therapy after breast-conserving surgery; first results of a randomised clinical trial in patients with low risk of recurrence.

To study the role of radiotherapy and tamoxifen after breast-conserving surgery (BCS) in patients with a favourable prognosis, a clinical trial was initiated by the German Breast Cancer Study Group. Between 1991 and 1998, 361 patients (pT1pN0M0, aged 45-75 years, receptor positive, grade I-II) were randomised to radiotherapy (yes/no) and tamoxifen for 2 years (yes/no) in a 2x2 factorial design; the exclusion of seven centres (14 patients) left 347 patients in the analysis. After a median follow-up of 5.9 years, 77 events concerning event-free survival have been observed. Since a strong interactive effect between radiotherapy and tamoxifen has been established, the results are presented in terms of the treatment effects for all four treatment groups separately. Mainly due to the presence of local recurrences, the event rate was about three times higher in the group with BCS only than in the other three groups. No difference could be established between the four treatment groups for distant disease-free survival rates. It is concluded that even in patients with a favourable prognosis, the avoidance of radiotherapy and tamoxifen after BCS increases the rate of local recurrences substantially.

The physician executive: role in the adaptation of American medicine.

In the arena of managed care and large delivery systems, professional associations find it increasingly difficult to influence the environments in which their members practice. Physician executives appear likely to play key roles in the response of medicine to change. This article discusses how an analysis of the work of physicians involved in management fails to yield a clear analytic distinction between physicians engaged in management and the behavior of others who have managerial responsibility.

Accountability for health care: a white paper on leadership and management for the U.S. health care system.

Advancing and managing individual organizational priorities and favorably positioning the organization within the wider system, while remaining within the system's vision, values, mission and strategic plan, constitutes the great the paradox of modern health care management. A new cohort of managers, skilled as change agents for linking-pin organizations, will be necessary to assure accountable management in an environment where no one unit, department, organization, and perhaps no system possesses all of the competencies necessary for provision of care.

Contemporary models of change in the health professions.

This article reviews the special position that health professionals have occupied and the ways in which changes threaten the foundations of professional work. The application of modern management principles to health care runs the risk of overriding the "action orientation" that is a defining component of professional work. One goal of health workforce design should be the engineering of opportunities for the preservation of "professional voice" as a countervailing force to ensure high quality health care. Contemporary models of change applied to health care workforce include: (1) the system of professions models in which securing and maintaining jurisdiction are the mechanisms that professions employ to sustain their position, (2) a strategic adaptation model by which professions attempt to adjust to changing environments, (3) a model of redesigning patient care which applies Total Quality Management (TQM) and other "industrial techniques" to the health care workplace, and, (4) model of "consumer sovereignty" in which groups of citizens come together to determine the nature of care services and professional work, with the participation of the organizations and providers.

The Resource Management Initiative in the English National Health Service.

The Resource Management Initiative (RMI) is a policy thrust designed to more effectively utilize current expenditures in the United Kingdom's National Health Service by (1) integrating clinicians into management through a "clinical directorate," (2) establishing a closer external audit of the medical profession, and (3) implementing information systems. This article reviews the results from the first RMI sites and suggests a fit between the RMI effort and current programs in total quality management and continuous quality improvement.

The leadership and executive potential of physicians in an era of managed care systems.

The emergence of managed care signals a need for an expanded role for physicians. Physician executives, trained in management, have the potential to become champions of clinical integrity, negotiators with patient agent organizations, public interpreters of hospital performance data, consultants to the profession, and designers of health care systems. Nonclinically trained administrators have been slow to recognize the unique skills and perspective that physicians bring to the managerial suite. The clash of professional and managerial cultures has often been perceived as precluding a strong working alliance between physician and nonphysician executives. As hospital margins are threatened, decision protocols must not be designed to incorporate teams of leaders who are able to overcome the managerial/clinical divide. The management of this interface will demand the attention of both administration and boards and may require the establishment of new structures in health care organizations.

Hostility to people with AIDS: risk perception and demographic factors.

The objectives of this investigation were to determine the associations between perception of AIDS risk, demographic and socio-economic variables and hostility to PWA's. Factor analysis and multiple regression models were used to examine telephone survey data. The principal results show a strong positive association between hostility to PWA's and perception of high AIDS risk from low-risk activities, and between hostility and: non-Hispanic respondents, low-income respondents, respondents with less than a high school education, male respondents and respondents living in rural areas. Conclusions speak for a need for understanding of the multiple outcomes of educational campaigns, pretesting of educational campaigns across multiple populations, and continued study of risk perception, hostility and the effects of stigmatization.

Contract management requires strategic planning.

Contract management is more than just an alternative form of financing. Contract management enables hospitals to avoid costly investments in time, personnel, and capital by using outside sources to provide clinical and support services. However, healthcare organizations that contract for a large number of services run the risk of becoming "hollow hospitals"--institutions where patient care is no longer the hospital's core activity. Hospitals can avoid this situation by carefully reviewing the advantages and risks of contract management in terms of their mission, quality, and organizational objectives.

The graduate technical assistance program: an alternative to traditional training for health administration students.

This paper presents a discussion of current modes of field training for graduate students in health services administration and details the educational goals and structural elements of the Graduate Technical Assistance Program (GTAP) at Arizona State University. The program's unique features include an emphasis on provider defined problems and projects, timely response to these problems by students, and the involvement of students, throughout their training, in consultant relationships with providers. The program also places the student in a new set of collaborative relationships with program faculty. The profiles of the 21 organizations requesting technical assistance, the skills required for project completion, and the range of projects are detailed.

Inverse ratio of hCG in peritoneal fluid to that in serum in normal and tubal pregnancies.

The ratio of hCG in peritoneal fluid (PF) to that in serum (S) was studied in 60 patients with normal pregnancies (5th-15th wk of gestation = control group) and in 12 tubal pregnancies, 7 tubal abortions (5th-10th wk of amenorrhea) and one case of an early interstitial pregnancy (8th wk). The PF level in the control group was in every patient lower than in S independent of the gestational age. The ratio PF to S ranged from 0.24 to 0.87 (mean +/- S.E.: 0.51 +/- 0.02). In contrast to this, the patients with tubal pregnancy and tubal abortion showed in each case higher PF levels than in S. The ratio in the group with tubal pregnancy ranged from 1.1 to 374 (54 +/- 30) and in the group with tubal abortion from 1.2 to 162 (33 +/- 23). The difference in the ratio between the control group and both tubal pregnancy and tubal abortion was highly significant (P less than 0.001). The ratio of PF to S in the patient with interstitial pregnancy (0.73) did not differ from the control group. At the time of investigation, the S levels in all but 2 patients with ectopic pregnancy were below the range for normal pregnancy of the same gestational age. These findings indicate that the hCG ratio of PF to S may be dependent on the location of the gestational product.