Carrying out the Medicine/Public Health Initiative: the roles of preventive medicine and community-responsive care.

Leaders in medicine and public health, recognizing the inherent interdependency of these fields, established the Medicine/Public Health Initiative in the mid-1990s as "an evolving forum in which representatives of both sectors can explore their mutual interests in improving health and [can] define collaborative mechanisms to achieve that goal." The Initiative's participants developed six goals that they and others in medicine and public health across the nation should implement: engage the community; change the education process; create joint research efforts by clinical, public health, and preventive medicine investigators; develop a shared view of illness between medicine and public health; work together to provide health care; and work jointly to develop health care assessment measures. The authors describe the six goals in depth and explain the important combined roles of clinically-oriented preventive medicine and community-oriented preventive medicine--as practiced in a model of health care delivery called community-oriented primary care (COPC)--in implementing the Initiative's goals. They then report recent efforts, including two in Boston and Dallas, to merge medicine and public health, and state that academic health centers, which are in the process of reshaping themselves, can help themselves as well as the public by embracing their key role in the effort to integrate medicine and public health. In particular, they can expand and strengthen existing training programs in preventive medicine and COPC or add these programs to their curricula.

Without the denominator where is the quality improvement paradigm in the nation's health care reform?

This paper will argue that there is room for improvement in the quality of health care delivered in the United States. A quality improvement paradigm requires an assessment, inventory and prioritization of areas for improvement. It further nurtures the imperative of process improvement for the achievement of a targeted outcome. The dual obligations of reduction in outcome variability, and resource management, provide an exciting milieu for the integration of clinical practice, the numerator, with population based medicine, the denominator.

The prevention of injury from motorcycle use: epidemiologic success, legislative failure.

Following the repeal of the North Dakota mandatory motorcycle helmet law in 1977, the State Highway and Health Departments initiated a study to examine the impact of the change on driver safety. Motorcycle crash data gathered by the State Highway Patrol and other law enforcement agencies was augmented by death and injury reports submitted to the State Health Department by medical care providers. The combined data set produced 2934 crashes, 2162 traumatized victims, 3718 injuries and 53 deaths between January 1977 and December 1980. Reporting from medical providers increased the volume of crash reports, improved the reliability of the highway data and added an unrecognized population of victims to the data base. In spite of the clear indication that injuries and deaths had increased among motorcycle users who rode without helmet protection, legislative passage of a mandatory helmet law in either the 1979 or the 1981 North Dakota legislative session failed. The reasons behind the legislative rejection of efforts to improve highway safety are examined. The forces that affect politics are reviewed.

Motorcycle-related trauma and helmet usage in North Dakota.

A descriptive epidemiologic study utilizing a multi-disciplinary reporting format was undertaken to assess the impact of helmet usage on motorcycle trauma in North Dakota from 1977 through 1980. This approach yielded an 82.6% reporting increase compared to previous data collection techniques. More than 60% of the 2,934 crashes involved unhelmeted cyclists. Two-thirds of all crashes resulted in injury, with head, neck, and face (HNF) trauma accounting for 21.4% of all lesions. Compared to their helmeted counterparts, helmetless riders suffered HNF trauma 2.30 times as often, and were 3.19 times as susceptible to fatal injuries. the number of injuries and the severity of trauma were significantly higher (P = .01) for those individuals not wearing helmets. A substantial decline in usage occurred in those under 18 years of age, despite the legal requirement that this group wear protective headgear.

Drug compliance--a study of patient behavior based on medical records.

Studies concerned with medication compliance after initial prescription dispensing have been frequently cited in the literature; however, little research has been done on the initial filling of the prescription order. In order to ascertain the degree of compliance at the initial filling level, a study was carried out on a population associated with a neighborhood health center. Overall, the study indicated an initial filling compliance of 94 percent, which was affected by the site of patient encounter, the chronicity of the disease, and the specificity of the medication in relationship to the disease state. It was concluded that: prescriptions for chronic medications are filled at a higher rate than those for acute illnesses; specific medication for a specific illness has a much higher compliance rate than nondisease specific medications; ease of access to a pharmacy is related to a higher compliance level; and frequent patient contact for a specific disease tends to increase compliance.