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Performance-based bundled payments have emerged as the most recent iteration of pay for performance. These are programs in which providers are paid a single fee for a set of evidenced-based services related to a diagnosis. The payments are typically linked to outcomes as well as other quality measures. This paper reviews two prominent bundled payment programs--PROMETHEUS and ProvenCare--and discusses the potential pitfalls of these approaches.

This paper is the first to describe the incidence of hospital-treated dog bites in Minnesota using hospital discharge data supplemented with medical record review. The rate of hospital-treated dog bites rose 40% during the 8-year period studied, with the largest growth being seen in the number of emergency department (ED) visits. The highest rates of both hospitalization and ED treatment occurred among children ages 1 to 4 years. In most instances (75%), the victim was familiar with the dog(s) involved. The dog bites most often occurred in the home (48%) and yard (18%). Our findings emphasize the importance of physicians, especially pediatricians and family physicians, counseling parents about the importance of supervising their children when they are around dogs and teaching them safe behaviors around animals. Finally, this study validates the value of hospital discharge data for surveillance of hospital-treated dog bites.

The estimated increase in life expectancy of the U.S. population will result in a greater incidence of age-related macular degeneration (AMD) in the next few decades. Exudative AMD, which is characterized by choroidal neovascularization, carries a high risk of severe central vision loss and can compromise an individual's independence and quality of life. The increasing burden of AMD has created an acute need for more effective treatments. Results from a recent large-scale study have shown that supplementation with antioxidants and zinc reduces the risk of progression of dry to exudative AMD. Standard thermal laser photocoagulation can reduce the risk of central vision loss in exudative AMD in a limited number of patients. The recent advent of photodynamic laser therapy has increased the number of patients with exudative AMD who can benefit from treatment. This paper summarizes the clinical presentation of AMD and reviews treatments that are currently available, as well as treatments in development.

In the United States, approximately 600,000 patients per year undergo surgical removal of the uterus at considerable cost to payers, patients, and society at large. Currently, most hysterectomies are performed via abdominal or vaginal surgery, but laparoscopic-assisted procedures are becoming more popular. Many studies have shown that laparoscopic surgery is a safe, effective, and less-intrusive alternative to open surgery. Laparoscopic surgery can be far less costly and painful, and it results in shorter hospital stays and recovery times. This paper compares laparoscopic supracervical hysterectomy with laparoscopic-assisted and standard hysterectomy and reviews 83 laparoscopic supracervical hysterectomies performed at a rural Minnesota hospital. Techniques, equipment, patient mix, indications, and complications are discussed. Most patients encountered few complications and were discharged from the hospital within 48 hours. The report demonstrates that laparoscopic supracervical hysterectomy is a beneficial alternative to standard and laparoscopic-assisted hysterectomy that can be performed in local hospitals.

Antimicrobial resistance is an important issue when treating patients with various bacterial, fungal, protozoal, and viral infections. Until recently, the focus of concern was on nosocomially acquired infections. However, organisms causing common community-acquired infections have now developed antimicrobial resistance. This paper provides a brief overview of this emerging global threat and discusses resistance in gram-positive organisms, outpatient and antibiotic use, and strategies to reduce antibiotic overuse. Curbing the overuse of antibiotics is crucial to reversing the increase in drug-resistant bacteria. We need to develop guidelines and educate physicians and the public on the use of antibiotics for respiratory syndromes with predominantly viral etiologies.

A growing number of rural cancer patients are receiving chemotherapy in hometown clinics and hospitals. Local access to cancer care offers many advantages to patients and providers, but is it safe to give intravenous chemotherapy? What precautions should be taken? Most physicians are well aware of the regulations pertaining to the use of universal precautions to prevent the spread of infectious diseases. A similar approach should be used for hazardous substances. As health care leaders and employers, physicians need to known the risk of exposing employees and themselves to potentially hazardous substances like chemotherapeutic agents. This paper offers current information for physicians to consider when providing cancer care in local health care facilities.

The demand for physicians in rural Minnesota is likely to increase significantly over the next few years. Nearly 20% of all rural physicians in Minnesota are older than age 65. This paper reports the results of a survey of rural Minnesota physicians over age 60 on their current practices and their plans for retirement. Of the 33 physicians questioned, 25 (75%) currently had plans to retire and more than half of the 25 planned to retire in the next two years. Factors that these physicians perceived as important in determining their decisions to retire or continue practice are described, and implications for the delivery of health care in rural communities are discussed.

Hysterectomy remains a commonly performed gynecologic surgery. An estimated 650,000 women in the United States undergo surgical removal of the uterus annually at a considerable cost to patients, payers, and society at large. Currently, two-thirds of hysterectomies are performed by abdominal surgery and approximately one-third by vaginal surgery. Most research supports laparoscopic-assisted hysterectomy as a safe, effective, and less intrusive alternative to open surgery. Laparoscopy is far less costly, results in less pain, and has a much shorter recovery period. This paper discusses such advantages of the laparoscopic approach over the standard abdominal hysterectomy and reviews 158 laparoscopic-assisted hysterectomies performed at a 100-bed rural Minnesota hospital. Techniques, equipment, patient mix, and complications are discussed. Patients experienced few complications, and most left the hospital in 48 hours.

Creating workable policies for allocating or rationing finite health care resources to meet the needs of individuals as well as the broader society vexes policymakers, providers, and consumers. This paper presents results of a March 1994 Lou Harris survey of 1,006 Minnesotans about health care allocation. Minnesotans believe that allocative or rationing decisions are inevitable and can be discussed. Individualized bedside allocative decisions are preferable to categorical or universal exclusions of some health care benefits. People want comprehensive health care and are willing to let sound clinical judgment, perhaps informed by practice guidelines, selectively withhold some services. The integrity of plan-based allocation or rationing may be best secured and safeguarded by standards that ensure that the decisions are based on patients' best interests, involve trusted clinical decision makers, and include lay participation in the decision making.