L. Gregory Pawlson

Chronic Illness: Implications of a New Paradigm for Health Care

A major factor in determining and maintaining the form of our health care system is our underlying assumptions about the origins of problems related to health. The author explores the implications of the change from an acute simple disease model to a chronic complex illness model for the evaluation of quality in health care.

The cost-effectiveness of three thyroid function testing strategies for suspicion of hypothyroidism in a primary care setting

Objective:To determine the sensitivity and specificity of thyroxine (T4)and the cost-effectiveness of three testing strategies in the diagnosis of hypothyroidism in a primary care setting.Design:1 A retrospective chart review to determine sensitivity and specificity of T4 in diagnosing hypothyroidism; a cost-effectiveness analysis comparing ordering an initial T4 test alone, an initial thyroid-stimulating hormone (TSH) test alone, and T4 and TSH tests together in diagnosing hypothyroidism; a sensitivity analysis was performed on critical assumptions.Setting:Primary care adult practice of a health maintenance organization.Patients:Eight hundred sixteen consecutive patients suspected of having hypothyroidism who had both T4and TSH tests performed.Interventions:None.Results:The sensitivity of a T4cut-off of 7 µg/dl (90.3 nmol/L) in diagnosing primary hypothyroidism was 93% (95% confidence interval =85–100%) and the specificity was 68% (95% confidence interval =65–71%). The cost-effectiveness ratios of using an initial T4or TSH test were about the same across a wide range of test characteristics and disease prevalence estimates. As the ratio of T4to TSH test charges declines from 0.6 to 0.2, the marginal cost of the TSH-first method increases from

Magnetic resonance imaging. Diffusion of technology in an ambulatory setting.

3,500 to

Financing Long-Term Care The Growing Dilemma

18,000 for each additional hypothyroid patient identified. Ordering both tests together was very costly compared with the single test methods (

Physician Payment Reform: Implications for Geriatrics

125,000 for each additional case diagnosed) and remained so under a wide range of assumptions.Conclusions:When hypothyroidism is suspected, a TSH-first testing approach is generally preferable due to its greater sensitivity and, under most assumptions, only small increment in average or marginal cost per case compared with a T4-first method.Objective:To determine the sensitivity and specificity of thyroxine (T 4)and the cost-effectiveness of three testing strategies in the diagnosis of hypothyroidism in a primary care setting. Design:1 A retrospective chart review to determine sensitivity and specificity of T4 in diagnosing hypothyroidism; a cost-effectiveness analysis comparing ordering an initial T4 test alone, an initial thyroid-stimulating hormone (TSH) test alone, and T4 and TSH tests together in diagnosing hypothyroidism; a sensitivity analysis was performed on critical assumptions. Setting:Primary care adult practice of a health maintenance organization. Patients:Eight hundred sixteen consecutive patients suspected of having hypothyroidism who had both T 4 and TSH tests performed. Interventions:None. Results:The sensitivity of a T 4 cut-off of 7 µg/dl (90.3 nmol/L) in diagnosing primary hypothyroidism was 93% (95% confidence interval =85–100%) and the specificity was 68% (95% confidence interval =65–71%). The cost-effectiveness ratios of using an initial T 4 or TSH test were about the same across a wide range of test characteristics and disease prevalence estimates. As the ratio of T 4 to TSH test charges declines from 0.6 to 0.2, the marginal cost of the TSH-first method increases from

Self-Reported Versus Actual Test Ordering Behavior Among Primary Care Clinicians

3,500 to

Screening for Thyroid Disease

18,000 for each additional hypothyroid patient identified. Ordering both tests together was very costly compared with the single test methods (

Effect of education and feedback on thyroid function testing strategies of primary care clinicians

125,000 for each additional case diagnosed) and remained so under a wide range of assumptions. Conclusions:When hypothyroidism is suspected, a TSH-first testing approach is generally preferable due to its greater sensitivity and, under most assumptions, only small increment in average or marginal cost per case compared with a T 4-first method.

Funding for geriatric medicine fellowships.

To better understand technology diffusion in an ambulatory care setting, we analyzed adult outpatients use of magnetic resonance (MR) and computed tomography (CT) imaging in a group-model HMO between 1986 and 1989. The use of MR, but not CT, increased at a rapid pace with only a small proportion of the scans being accounted for by primary care physicians.

Atrial fibrillation, stroke and anticoagulation

The financing of long‐term care is one of the largest and most vexing health care problems facing our society. The problem will be further exacerbated when the rate of growth in the number of persons needing long‐term care is further accelerated by the graying of those in the “baby boom” generation. The current financing mechanism, which relies almost entirely on concurrent funding through either a means tested welfare program (Medicaid) or self‐pay, is inequitable and inadequate even for our present needs. Despite the magnitude of the problem, only recently has sufficient attention been focused on finding alternatives to the current means of financing long‐term care. The search for a solution has been hampered by multiple, and sometimes conflicting, policy and political considerations. After reviewing the demographic and social roots of our current dilemma and listing the major alternatives for financing long‐term care, a series of basic principles and definitions are reviewed. These elements are meant to serve as guidelines to compare and evaluate the growing number of proposals which seek to create a more effective and equitable system for financing long‐term care. Future articles in this section will detail some of the more promising approaches to the dilemma of financing long‐term care.