From the Canadian Medical Association Journal:Critical Care Bypass
Emergency department overcrowding: ambulance diversion and the legal duty to care [Commentary]
The legal duty of physicians and hospitals to provide emergency care [Review]
In January 2000, 18-year-old Joshua Fleuelling suffered an
asthma attack and was transported by ambulance to hospital, but not
the one nearest his home because it was on "critical care bypass."
Anne Walker examines policies of critical care bypass in a legal
framework, reviewing the concept of duty to care as it relates to
emergency physicians, who do not necessarily have a pre-existing
relationship with their patients. She discusses the legal dilemmas
that arise when the physician's duty to care confronts real-world
problems of staff and equipment shortages and emergency department
overcrowding. In a related commentary, Jane Upfold provides an
emergency physician's perspective on the challenges of weighing the
potential harms of having patients diverted to another hospital
against those of accepting critically ill patients and possibly
jeopardizing the care of patients already in the overcrowded
From the Archives of Internal Medicine:Primary Care Quality in the Medicare Program
Comparing the Performance of Medicare Health Maintenance Organizations and Traditional Fee-for-Service Medicare
Dana Gelb Safran, ScD; Ira B. Wilson, MD, MSc; William H. Rogers, PhD; Jana E. Montgomery, ScM; Hong Chang, PhD
Background: Since 1972, Medicare beneficiaries have had the option of enrolling in a Medicare-qualified health maintenance organization (HMO). Little information exists to inform beneficiaries' choices between the traditional fee-for-service (FFS) Medicare program and an HMO.
Objectives: To compare the primary care received by seniors in Medicare HMOs with that of seniors in the traditional FFS Medicare program, and among HMOs, and to examine performance differences associated with HMO model-type and profit status.
Methods: Data were derived from a cross-sectional observational survey of Medicare beneficiaries 65 years or older in the 13 states with mature, substantial Medicare HMO markets. Only beneficiaries continuously enrolled for 12 months or more in traditional FFS Medicare or a qualified Medicare HMO were eligible. Data were obtained using a 5-stage protocol involving mail and telephone (64% response rate). Analyses included respondents who identified a primary physician and had all required data elements (N = 8828). We compared FFS and HMO performance on 11 summary scales measuring 7 defining characteristics of primary care: (1) access, (2) continuity, (3) integration, (4) comprehensiveness, (5) "whole-person" orientation, (6) clinical interaction, and (7) sustained clinician-patient partnership.
Results: For 9 of 11 indicators, performance favored traditional FFS Medicare over HMOs (P<.001). Financial access favored HMOs (P<.001). Preventive counseling did not differ by system. Network-model HMOs performed more favorably than staff/group-model HMOs on 9 of 11 indicators (P<.001). Few differences were associated with HMO profit status.
Conclusions: The findings are consistent with previous comparisons of indemnity insurance and network-model and staff/group-model HMOs in elderly and nonelderly populations. The stability of results across time, geography, and populations suggests that the relative strengths and weaknesses of each system are enduring attributes of their care. Medicare enrollees seem to face the perennial cost-quality trade-off: that is, deciding whether the advantages of primary care under traditional FFS Medicare are worth the higher out-of-pocket costs.
Arch Intern Med. 2002;162:757-765
From the British Medical Journal:Apparently Credible Websites May Not Be Accurate
(Accuracy of information on apparently credible websites: survey of five common health topics)
Apparently credible websites may not necessarily provide higher levels of accurate health information, finds a recent study in BMJ.
Researchers examined the relation between credibility features and accuracy of contents of 121 websites that provided information on five common health topics: chronic obstructive pulmonary disease, ankle sprain, emergency contraception, menorrhagia, and female sterilisation.
The entire contents of the selected websites were assessed for three credibility features (source, currency and evidence hierarchy) and accuracy of contents. They found 93% of websites described the source of medical information, 49% displayed the date that the information was posted, and 18% displayed evidence hierarchy (i.e., levels assigned to various pieces of information were related to their validity or methodological quality).
Accuracy of website contents was judged against recognised guidelines for each of the five health topics. Websites with a description of credibility features tended to have higher levels of accuracy, but this relationship was not strong, say the authors.
They conclude: "Our study shows that features of website credibility have only slight or at best moderate correlation with accuracy of information in five common health topics. Thus, apparently credible websites may not necessarily provide higher levels of accurate health information."
Quality of Health Information on the Internet Has
(Follow up of quality of public oriented health information on the world wide web: systematic re-evaluation)
The quality of health information on the internet has improved over the past few years despite concerns over poor quality and its possible consequences, concludes a study in this week's BMJ.
In 1997, the quality of web information on managing fever in children at home was assessed and was found to be poor. Four years later, researchers in Italy re-evaluated the quality of these web pages, plus a more recent sample of pages, using the same methods.
They found 19 of the 41 (46%) original pages still existed. Of these, two had additional information. Five pages had been replaced with new content and three were the same as the original pages.
Only two (5%) of the new pages adhered to the guidelines for quality of content compared with three (8%) of the original pages. However, 18 (45%) of the new pages compared with only three (8%) of the original pages adhered to most of the guidelines.
They conclude that, although the quality of health information on the Internet has improved over the past few years, monitoring health information on the Internet for accuracy, completeness, and consistency is still fundamental.
Most Popular Websites Not Necessarily of Highest
(Breast cancer on the world wide web: cross sectional survey of quality of information and popularity of websites)
The more popular websites providing information about breast cancer are not necessarily of higher quality, concludes a study in BMJ.
The search engine Google was used to generate a list of websites about breast cancer.
The top 200 sites returned by Google were divided into "more popular" and "less popular" based on the number of links to a site from other sites.
More popular sites were more likely to contain information on ongoing clinical trials and results of trials, than less popular ones. More popular sites were also more likely to provide updates on other breast cancer research, information on legislation and advocacy, and a message board service.
More popular and less popular websites did not differ in any of the quality measures studies. Furthermore, the presence of inaccurate information did not differ between more popular and less popular sites.
These results show that type rather than quality of content determines popularity of websites, say the authors. It remains the responsibility of the medical community to ensure adequate of online medical content, to educate the public regarding quality measures, and to direct patients to sites of known quality, they conclude.
From Health Affairs:Health Affairs periodically publishes peer-reviewed articles exclusively on its website. These articles are selected based on their timeliness and relevance to the contemporary policy debate. They are available in either HTML or PDF format and access is free to all site visitors.
Changes In Insurance Coverage: 1994-2000 And Beyond
Overall uninsured rate is stubborn even in economic upturn.
John H. Holahan and Mary Beth Pohl, April 3, 2002
Renewed Emphasis On Consumer Cost Sharing In Health Insurance
Higher deductibles and copayments are offsetting premium increases.
James C. Robinson, March 20, 2002
With Responses By:
Robert M. Crane and Laura A.Tollen, and Jay Gellert
Trends In Medicare Supplemental Insurance and Prescription
Drug Coverage, 1996-1999
A close look at relative changes in supplemental coverage.
Mary A. Laschober, Michelle Kitchman, Patricia Neuman, and Allison A. Strabic, February 27, 2002
Geography And The Debate Over Medicare Reform
A proposal that addresses causes of Medicare funding woes: geographic variation and lack of incentive for efficient medical practices.
John E. Wennberg, Elliott S. Fisher, and Jonathan S. Skinner, February 13, 2002
With Responses By:
Max Baucus & Elizabeth J.Fowler, Karen Wolk Feinstein, James Jeffords, Nancy Johnson, Robert E. Nesse
The Sad History Of Health Care Cost Containment As Told In
Managed care is not alone in its failure to solve the healthcare cost problem.
Drew E. Altman and Larry Levitt, January 23, 2002
With Responses By:
Henry J. Aaron, Thomas Bodenheimer, Helen Darling
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