A comparison of resource utilization in nurse practitioners and physicians.

CONTEXT: Nurse practitioners increasingly provide primary care in a variety of settings. Little is known about how resource utilization for patients assigned to nurse practitioners compares with that for patients assigned to physicians. OBJECTIVE: To compare health care resource utilization for adult patients assigned to a nurse practitioner with that for patients assigned to a resident or attending physician. DESIGN: Prospective, quasi-randomized study. SETTING: Primary care clinic at a Veterans Affairs medical center. PATIENTS: 450 new primary care patients: 150 were assigned to a nurse practitioner, 150 to a resident physician, and 150 to an attending physician. OUTCOME MEASURES: We collected data on laboratory and radiologic testing, specialty care, primary care, emergency or walk-in visits, and hospitalizations over a 1-year period. We also collected information on baseline chronic illnesses, blood pressure, and weight. RESULTS: Resource utilization for patients assigned to a nurse practitioner was higher than that for patients assigned to a resident in 14 of 17 utilization measures (3 were statistically significant) and higher in 10 of 17 measures when compared with patients assigned to an attending physician (3 were statistically significant). None of the utilization measures for patients in the nurse practitioner group was significantly lower than those for either physician group. CONCLUSIONS: In a primary care setting, nurse practitioners may utilize more health care resources than physicians.

Relationship of self-reported oral health and nutritional risk among hospitalized older adults.

Oral health and nutritional risk were assessed in 300 hospitalized older adults using self-reported instruments. Patients who self-reported poor oral health status were at greatest nutritional risk. Study results suggest that self reported oral health and nutritional risk are multidimensional and that screening instruments may help identify patients who could benefit from a dental referral. The combination of nutritional and oral health screening methods may be an efficient and cost-effective method for nondental health care providers to identify and refer older adults for oral health care.

War crimes during the Persian Gulf War.

Evidence of violations of the 1949 Geneva Conventions by Iraq's military personnel during Desert Shield and Desert Storm are described and adverse effects on the Kuwaiti health care delivery system are discussed. New diplomatic and military initiatives that include education and accountability are needed to ensure better compliance with international conventions designed to protect victims of war.

Epidemiology of falls among patients in a rehabilitation hospital.

Falls in institutional settings have been associated with considerable morbidity. Although risk factors for falls have been described for acute care and geriatric settings, data from the rehabilitation setting are sparse. To provide a descriptive epidemiology, incident reports of falls were reviewed at a 151-bed rehabilitation facility. Of 567 patients admitted between January 1 and December 31, 1984, 71 (12.5%) experienced at least one fall; most (75%) of the falls occurred in patients using wheelchairs. Risk for falls was associated with increasing age (p less than 0.05), a diagnosis of stroke, or lower extremity amputation (p less than 0.05). Of the 71 fallers, 31% experienced repeat falls which tended to occur more frequently with older age, disorientation, and nonambulatory status at first fall. Nearly 13% sustained injuries, which tended to occur more frequently among disoriented and wheelchair or bedfast patients. These data suggest that groups of patients who are at high risk for falls within the rehabilitation setting can be identified for the purposes of prevention, and targeted for preventive measures.

A program to teach house calls for the elderly to fourth-year medical students.

The authors report on the development, implementation, and evaluation of a curriculum to teach house calls for the elderly to fourth-year medical students. A faculty committee drew up a statement of philosophy: developed attitude, knowledge, and skill objectives: and specified required educational experiences for the curriculum. which was incorporated into a required eight-week rotation in ambulatory medicine. In 1985 and 1986, 18 students completed the new curriculum at three different clinic sites and made a total of 167 documented house calls. Prerotation and postrotation measurement of the students' attitudes documented a significantly (p less than .003) more favorable attitude toward house calls after completion of the curriculum. The students further indicated that they were more likely after the curriculum than before it to provide house calls as part of their future medical practice. The students' evaluation of the curriculum provided information on the relative effectiveness of teaching strategies used in the curriculum and documented the success of the curriculum in transmitting knowledge about the homebound elderly.

Planning health services for a city jail: impact of contractual services on men's sick call.

A nonviolent protest by prisoners began a 2-year planning process leading to the implementation of contractual medical services at Baltimore City Jail. This study was conducted in order to assess the impact of contractual services on the process of men's sick call. The contractual program was associated with a decrease in utilization of men's sick call: 62.9 patient visits per day per 1,000 prisoners in 1975 versus 27.4 patient visits per day per 1,000 prisoners in 1978; an increased duration of encounter; 2.8 minutes in 1975 versus 10.9 minutes in 1978; and with changes in prescribing patterns and in categories of patients' complaints. Baltimore City Jail spent about $588 per prisoner-year during fiscal year 1977, and about $670 per prisoner-year during fiscal year 1978, the first year of contractual services. We conclude that a system of health services for a large, urban jail can allow time for humane and professional encounters between providers and patients.

Immunological studies in acute pseudomembranous esophageal candidiasis.

Immunological studies in 3 patients with acute pseudomembranous esophageal candidiasis are presented. None of the patients had history or clinical signs of chronic mucocutaneous candidiasis. All 3 patients had an intact humoral response as measured by the presence of elevated candida agglutinating antibody titers. However, further investigations revealed a cell-mediated immune defect characterized by in vivo and in vitro anergy to candida antigen in these patients. Response to the other antigens was found to be intact in 2 of 3 patients. Successful medical therapy was associated with return of skin and lymphocyte reactivity to candida antigen in two cases.

Concentrations of levamisole required for enhanced proliferation of human lymphocytes and phagocytosis by macrophages.

We studied the in vitro effects of levamisole on phagocytosis by macrophages and on proliferation of lymphocytes obtained from human peripheral blood. It was observed that levamisole directly stimulated phagocytosis in a lymphocyte-free system. Enhancement was optimal at a concentration that inhibited antigen- or mitogen-induced stimulation of sensitive lymphocytes. Lower concentrations of levamisole enhanced the proliferative lymphocyte response.

Treatment of Bacteroides endocarditis with carbenicillin.

A heroin addict developed acute bacterial endocarditis with Streptococcus viridans and Bacteroides melaninogenicus. Although blood cultures became negative during penicillin G and clindamycin therapy there was little clinical response. Prompt clinical improvement was achieved with intravenous carbenicillin in a dose of 40 g daily. In vitro testing supported the superiority of carbenicillin therapy in this patient.

A micromethod for evaluating the phagocytic activity of human macrophages by ingestion of radio-labelled polystyrene particles.

Studies in vitro of human macrophage function in health and disease have been impeded by the difficulty of obtaining such cells in sufficient number. Unlike animal species, the only readily available source of human macrophages are circulating monocytes. Herein, a method is described whereby the phagocytic rate of small numbers of glass-adherent mononuclear cells can be accurately measured. The method utilizes the ingestion by macrophages of technetium labelled polystyrene particles; both the radiolabel and ingestible substrate are readily available and the labelling process simple and efficient. The phagocytic rate can be expressed as radioactive counts per microgram of cell protein; data is also presented showing that the number of particles ingested per cell can be accurately derived.