James R. Webster

Reducing Delirium After Hip Fracture

To the Editor: I read with interest the two recent papers relating to strategies for reducing delirium after hip fracture 1,2 and the accompanying editorial. 3 Clearly these offer recommendations that should be heeded by all physicians involved in the care of such patients. It is encouraging to see that the topic of delirium is also receiving more general exposure and is now being appreciated as a major problem for patients towards the end of life. 4 With respect to other approaches for diagnosis and management of delirium and the cost-effective aspects of such interventions, I would cite a brief study we performed 5 that demonstrated that a physician/nurse dementia team, although very labor intensive, is medically and financially a winner. We demonstrated that, for 12 control and 29 delirious patients, a cooperative effort between a geriatric physician and an advanced practice geriatric nurse working with geographically assigned house staff and primary nurse care teams resulted in improved recognition of delirium and achieved a shorter length of stay. Significant cost savings occurred over the 6-week period of the intervention (approximately

Pulmonary alveolar proteinosis in two siblings with decreased immunoglobulin A

57,000). Because of the small sample size and short period of our intervention, we found no significant differences in deaths, restraint or neuroleptic use, or nursing home placement, which were all low in both groups. As was pointed out in the papers in the Journal , collaborative efforts in this area are fruitful, and, although much remains to be done, there is good reason to expect that major improvements can be made in outcomes for such patients, all we need to do is maintain our energy and focus.

Maffucci's syndrome (dyschondroplasia with hemangiomas).

A brother and sister with classic, biopsy proved pulmonary alveolar proteinosis are described. Both had low serum and low normal secretory immunoglobulin A (IgA) levels. A tendency for familial occurrence is possible and it is recommended that patients with pulmonary alveolar proteinosis, and their families, be evaluated for immunologic deficiencies.

Lactic Acidosis from Carboxyhemoglobinemia After Smoke Inhalation

Abstract A case of Maffuccis syndrome (dyschondroplasia with hemangiomas) is presented. The patients history revealed that two sarcomas had been successfully removed. However, the autopsy findings showed that carcinoma of the pancreas with widespread metastasis was the cause of death.

Positive Pressure as a Cause of Respirator-Induced Lung Disease.

Tissue hypoxia as a result of a wide variety of clinical situations had frequently been implicated as a cause of systemic acidosis due to the accumulation of lactic acid. Four patients suffering from smoke inhalation had lactic acidosis in association with carboxyhemoglobinemia. There was no evidence of decreased tissue perfusion, hypotension, arterial hypoxemia, or anemia. The following were tested in all patients: arterial pH (7.25 to 7.40), Pco-2 (19 to 27 mm Hg), Po (63 to 116 mm Hg), HCO-2- (11 to 19 meq/litre), carboxyhemoglobin (13% to 37%), and lactic acid (5.1 to 9.3 meq/litre). After therapy with oxygen and intravenous corticosteroids, there was prompt return of lactic acid levels, carboxyhemoglobin values, and arterial pH to normal. It is concluded that the cause of lactic acidosis in the presence of carboxyhemoglobinemia during smoke inhalation is tissue hypoxia. This tissue hypoxia is due to the reduction of the oxygen-carrying capacity of the blood and the concomitant shift of the oxyhemoglobin dissociation curve to the left, both known to result from carboxyhemoglobinemia.

Obtaining permission for an autopsy: Its importance for patients and physicians

Excerpt Prolonged artificial ventilation with high oxygen concentration is known on occasion to cause lethal lung damage. The lungs show vascular injury, hyaline membranes, atelectasis, interstitia...

Prevalence of cognitive impairment in an urban Hispanic community population.

This paper reviews the importance, benefits, and methods of increasing autopsy percentages. Its focus is on specific procedures for obtaining autopsy consent, particularly in terms of addressing the problems that most often interfere with obtaining permission for postmortem examination. Techniques for handling various misconceptions about autopsies are discussed. These guides for postmortem-related discussions with families will lead to improvement in overall physician performance and satisfaction.

Insurance Reform in a Voluntary System: Implications for the Sick, the Well, and Universal Health Care

level of social activity, and the presence of comorbid medical conditions. 4 Tinetti had postulated, in accordance with her findings, that self-efficacy or confidence in the ability to perform specific activities in specific situations shows a stronger association with ADL functioning and higher levels of physical and social activities than does self-reported falling. 5 The concept of self-efficacy has also been applied to fear of falls and their sequelae, which accounted for 18% of restricted activity days in older persons. 6 Our conclusion is that older women with both hip and Colle’s fractures have better rehabilitation potential despite their more-severe trauma experience and older age. The findings in this study suggest that the presence of concomitant fractures from the same trauma is a manifestation of better self-efficacy, which is a prominent positive prognostic factor.

Upper extremity blood flow in patients with chronic obstructuve airways disease.

There is a broad social consensus that private health insurance needs reform, especially in the individual and small-group markets. These markets are unstable, and coverage in them is unreliable. Competition among carriers is based on risk selection rather than on price and quality. For persons who become bad risks, coverage becomes unaffordable or unavailable. Between 1989 and 1991, the percentage of firms that offered health benefits to employees decreased for all firms, especially the smallest (Table 1) [1]. The goal of insurance reform, then, is to make insurance affordable and available to those who need it mostthe sick. The need for reform is agreed on, but the size and shape of that reform is not. Table 1. Percentage of Firms Offering Health Benefits, by Size, 1989-1991 Although insurance reform in a voluntary system will not necessarily expand overall coverage or contain health care costs, strong reforms can set the stage for the broader, system-wide change that is necessary for the achievement of universal coverage and cost containment. State governments have been enacting and implementing varying degrees of insurance reforms for several years, and some limited reform may be enacted at the federal level in the 104th U.S. Congress. In the wake of a failed comprehensive reform effort, the strength of incremental insurance reforms will serve as a barometer of the national commitment to the eventual achievement of universal coverage. National reforms that call on the broader community to reasonably share the risks and costs of both healthy and sick persons can provide a cornerstone for the building blocks of universal coverage. Although important, reforms that solve job lock (the inhibition of employment mobility due to preexisting conditions) stop short of defining the broader communitys responsibility for the sick cannot. Insurance reform as a bridge to universal coverage requires some resolution of the dichotomous roles of private health insurance in the U.S. political economy. In this paper, the roles of private health insurance as both an economic commodity and a social welfare tool are considered. Next, the roots of the markets problems are examined, and the reforms and rules that have been proposed or undertaken to resolve the conflicting roles of private insurance are analyzed. Finally, the need for federal involvement in setting industry standards is considered. Health Insurance as an Economic Commodity As an economic good, all insurance is a vehicle for reducing risk and increasing peace of mind. As such, it carries a price. The development of an insurance product for any particular risk is subject to the same rules of supply and demand as any other commodity. On the demand side, the size and predictability of the risk affect whether consumers will pay to insure against it. The risk must be large enough to exceed the ability of most persons to finance it through personal savings, and it must be common enough to worry about. Supply-side factors that affect the availability of insurance include the insurers ability to control adverse risk selection and moral hazard [2]. Adverse risk selection occurs when sick subscribers congregate in certain plans, making them more costly. Insurers rely on waiting periods, exclusions made on the basis of preexisting conditions (uncovered through medical underwriting), and the formation of random groups (for purposes other than insurance, such as business and professional associations) to control adverse risk selection. Moral hazard is the industrys term for the tendency of insurance to increase the risk for loss. For example, homeowners insurance increases the risk for fire, and health insurance increases both utilization of health care and medical costs. Health insurers respond to moral hazard by providing disincentives to use health coverage, including co-payments, deductibles, and premiums adjusted for health status (as determined by medical underwriting or past claims experience). The significance of health status goes beyond its role as a supply-side factor in an economic equation. Health status is integral to the principle of actuarial fairness [3]according to which policy holders should pay according to their risksthat is deeply ingrained in the insurance industry. Stone [3] ascribes a Calvinist flavor to the principle of actuarial fairness. She suggests that the founders of the insurance industry, reflecting social norms, drew inferences about an individual persons insurability from that persons station in life and perceived moral character. Over time, these inferences influenced statistical measures of risk in determining insurability. Something specific about individual persons, usually their trade or profession, determined the insurability of their lives. From an economic perspective, actuarial fairness is said to contribute to the efficient allocation of insurance resources. If persons pay according to their risks, they are paying the right price and can make accurate choices about the risk they seek to bear and the risk they seek to sharethe level of coverage they want. From the perspective of the classical economist, these kinds of individual preferences are essential to the efficient allocation of resources. If low-risk persons are forced to subsidize high-risk persons through artificially set higher prices, then they may purchase less insurance or no insurance, resulting in inefficiently low levels of coverage. Conversely, artificially low prices for high-risk persons will encourage them to purchase too much insurance, resulting in inefficiently high levels of coverage. This, in turn, contributes to higher health care costs [4]. Health Insurance as Social Welfare On the other hand, health care coverage is considered so vital that much of U.S. society believes that everyone must have at least partial access to this coverage. Unlike other forms of insurance, health coverage is directly related to survival, to life and death. The social belief that health insurance is different from other types of insurance and should be accessible to everyone is manifested in societys interventionthrough public hospitals, Medicaid, and other mechanismsinto the deterioration of health of persons who cannot or will not purchase health insurance. However late, inefficient, or ineffective, some degree of mutual aid is triggered by sickness [3]. The social welfare view of health insurance also derives from the fact that individual control over health status is much more limited than individual control over other risk factors, such as those for fire or automobile loss. Although lifestyle choices certainly contribute to health status, many other factorsincluding genetic, biological, and environmental influencesare beyond the control of the individual. Researchers are finding that even smoking and dietary habits are attributable in some measure to biological influences. From this perspective, actuarial fairness through risk rating is unfair. For other types of risks, society clearly supports actuarial fairness and risk rating; it is considered unfair to make everyone responsible for the practicessuch as bad driving, the purchase of expensive cars and homes, and activities such as skydiving and race car drivingof the few. Moreover, segmenting these risks invests individual persons with responsibility that can lead to safer driving, safer buildings, and safer hobbies. When risks can be substantially controlled, risk segmentation helps insurance to function well as an economic commodity and even contributes to public welfare by reducing risky behavior. Risk rating enables individual persons to choose any combination of risk shifting, risk reduction, or risk bearing for a corresponding price, and the segmented markets that are formed as a result reach stable equilibriums. The social welfare dimension of health insurance is perhaps most evident in the historical transformation of this insurance from a traditional risk protection product to a payment mechanism for routine health care. This is partly the result of tax incentives and historical influences that have encouraged employers to buy increasing amounts of health care, but the fact that health insurance was readily sold as a group product and that employees were eager to trade wages for health coverage reflects strong support for health insurance as a social welfare tool. As a financing mechanism, health insurance defies the logic of actuarial fairness. Unlike life, fire, and automobile insurance, health insurance is used over and over to pay for preventive and other minor services as well as critical care. To apply actuarial fairness through risk rating to this type of insurance is inherently contradictory and renders the insurance product ineffective. Taken to its logical extreme, actuarial fairness would separate risk by individual person, in which case the rational economic response would be to pay ones own health care bills. This, of course, would eliminate the market for health insurance altogether. To the rest of the industrialized world, the essential nature of health care and the inherent difference between health risks and other risks are self-evident. Except for the United States and South Africa, all industrialized nations finance health care on a community-wide basis, and almost all members of the community essentially have equal access to the health care system. The concept of private health insurancedriven perforce by economic principlesas the major financier of a nations health care is comparatively odd. The American College of Physicians reaffirms its commitment to universal health care coverage. To that end, the College recommends reforms of the private insurance market that 1) harness the benefits of economic principles, including competition based on price and quality but not risk selection and 2) spread risk, financing, and access broadly across communities. The Colleges insurance reform rec

Dismissing the Immortality Myth: Improving Care and Incidentally Reducing Costs

The peripheral circulator status of the upper extremity vascular bed has been described in patients with obstructive airways disease. An indicator-dilution method was used to estimate blood flow. Despite hypoxemia and hypercapnia with and without acidosis, the total upper extremity and forearm blood flow and vascular resistance were within the normal range in most patients studied. Correction of hypoxemia, despite enhanced hypercapnia, did not alter total or forearm blood flow. Some of the factors which might influence the measured blood flow values are discussed.