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Background: Many alcohol treatment outcome studies exclude some patients with particular problems, such as psychiatric disorders, noncompliance, and homelessness. Such criteria may increase the likelihood of a study being successfully conducted, but may also have the unintended consequence of reducing a study's ability to comply with National Institutes of Health guidelines for inclusion of racial minorities, women, and children in treatment research., Methods and Results: This paper examined this issue empirically using 5 prior studies of treatment systems enrolling over 100,000 alcohol patients. Widely used eligibility criteria in the alcohol treatment field typically exclude between one-fifth to one-third of patients from enrolling in research. Under several eligibility criteria, most notably those for drug use and social/residential instability, women and African-American patients are substantially more likely to be excluded than are men and non-African-American patients, respectively., Conclusions: In designing treatment studies with many eligibility criteria, researchers may therefore inadvertently be thwarting their own good faith efforts to ensure that a range of vulnerable populations are able to participate in research. We analyze the implications of this dilemma for the generalizability of treatment results and for research design, and provide data that may help researchers working in different treatment systems estimate the impact of various eligibility criteria.

Presented is the work of the Quality Assurance in Sociomedical Evaluation Project Group and its findings so far. The Project Group has developed a quality assurance concept for the outcome quality of sociomedical evaluations with personal examination and for evaluations on the basis of medical records. The quality criteria proposed by the Project Group are divided into primary as well as particular criteria. The primary criteria are: plausibility and conclusiveness, reproducibility, neutrality; the particular criteria are: formal and content programming, medical-scientific foundations, understandability, completeness, transparency, and efficiency. Both, the primary and the particular criteria are operationalized through examination questions. To fulfill a primary quality criterion, all related examination questions have to be answered in the affirmative. The particular criteria are related using a scoring system. The quality assurance programme also provides for a peer-review procedure; however, the manual for this procedure has yet to be developed. Research projects will be needed to determine the methodological requirements that have to be fulfilled for the proposed peer review procedure. Prior to implementation of the programme with the financially responsible pension insurance agencies it will be necessary to estimate the amount of time and manpower involved.

Cranio-cerebral injuries pose a significant problem not only for clinicians, but also for forensic medicine specialists. Due to the specific character of such injuries, they are a relatively frequent cause of diagnostic errors. The most common type of diagnostic errors involves failure to diagnose cranio-cerebral injuries, especially in emergency cases. The authors present cases, in which imaging diagnostic studies, implemented therapeutic procedures and numerous consultations have not prevented misdiagnosing the patients and their resultant death.

The report presents the problem of a diagnostic error consisting in abusing the diagnosis of cerebro-cranial injuries, and especially cerebral concussion. Diagnoses of cerebro-cranial injuries, including brain concussion established by physicians, including specialists, are often inappropriate in view of the medical history, clinical manifestations and laboratory findings. There are several reasons for the misdiagnoses (diagnostic abuse), but most commonly they result from an inappropriately taken medical history, excessive trust in the patient, and willingness to help the patient in receiving higher compensation. Overdiagnosing is also caused by the conviction shared by physicians that a diagnostic error lies in non-detection of a disease or injury rather than in overdiagnosing the patient in order to avoid subsequent charges. This is why proceedings at law against physicians who have overdiagnosed injuries occur only sporadically.

The paper presents and analyses problems which are encountered by an insurance company in connection with the opinions issued by experts appointed by a court in civil cases and concerning the evaluation of the results of accidents or damages in civil liability insurance. Every year, the group of physicians employed by the Office of Medical Services of Insurance at the PZU Zycie SA and PZU SA, issues opinions for about 3000 appeal and complicated cases from all over Poland. In some of the cases, an individual holding an accident insurance policy or an injured person in the case of civil liability insurance disagrees with the findings of the insurance company and brings the case to a civil court. About 7% of the opinions issued by the Office in 2005 were polemics with court experts, concerning their manner of classifying the results of an accident or an event which resulted in damage to an individual. Among the 200 opinions, there are several important and recurring problems, which are presented in the paper. The main doubts concern: 1. insufficient analysis of the circumstances of an event and drawing hasty conclusions about the cause-and-effect relationship, 2. claiming the certain occurrence of a cause-and-effect relationship, despite substantial doubts, 3. absence of analysis of general conditions of insurance, which in voluntary insurance may contain various exemptions and restrictions, 4. insufficient analysis of medical documentation containing information about some deviations before the event, 5. determining by the experts the degree of permanent loss of health despite the absence of functional impairment revealed in an examination, 6. determining permanent results of an accident based solely on unverifiable subjective complaints, 7. deciding about the percentage of permanent detriment to health in most cases on a slightly higher level than was decided by a physician who took such a decision for the insurance agency.

Objective: To evaluate the preliminary development and implementation plans for medication therapy management (MTM) services across plan sponsors for the Medicare Part D Prescription Drug Plans (PDPs) and provide pharmacists with insights for MTM development., Design: Cross-sectional survey., Setting: United States., Participants: 307 individual contacts from Medicare Advantage or stand-alone PDPs., Intervention: A survey comprising questions about the PDP demographics, plans and implementation, beneficiary eligibility criteria, scope of services, providers of services, and payment structure for MTM services was e-mailed and mailed in November 2005., Main Outcome Measures: Descriptive and bivariate analysis of survey items., Results: A total of 97 usable surveys were completed, a 31.5% response rate. Almost all respondents had a plan in place for MTM services. The majority of PDPs perceived that MTM would have a moderate benefit to their organization. Most PDPs planned to focus efforts on diabetes, heart failure, and other forms of cardiovascular disease. Overwhelmingly, PDPs planned to follow the Centers for Medicare & Medicaid Services (CMS) mandate for criteria regarding beneficiary eligibility. Only 8.2% of respondents planned to use a "traditional" pharmacist, such as a community, long-term care, hospital, or clinic pharmacist. The majority of PDPs (53.6%) planned to employ managed care pharmacists to administer MTM services., Conclusion: Pharmacists are eager to implement MTM services and are looking for PDPs to provide a path of implementation and reimbursement. Many PDPs were planning to deliver MTM services internally using health professional staff, thereby limiting the extent of participation of community, long-term care, hospital and health-system, and clinic-based pharmacists. Further research and advocacy are required to ensure that MTM services accomplish the true intent of the congressional and CMS mandates.

Objective: To analyze inpatient rehabilitation outcomes in total-knee arthroplasty (TKA) and total-hip arthroplasty (THA) patients using the 2004 Medicare 75% rule criteria., Design: This retrospective study compared outcomes in unilateral TKA (UTKA), bilateral TKA (BTKA), and THA after interdisciplinary inpatient rehabilitation (n = 867). Patients were separated into three comparison pairs: 1) UTKA or BTKA, 2) age <85 yrs or > or =85 yrs, and 3) body mass index (BMI) <50 or > or =50 kg/m. Length of stay (LOS), functional independence measure (FIM) scores (total, motor, and cognitive), hospital charges, FIM efficiency, and discharge disposition were analyzed., Results: BTKA improved total FIM score more than UTKA (43 vs. 38%; P = 0.039). TKA with BMI > or =50 kg/m had similar admission and discharge FIM motor scores compared with BMI <50 kg/m (P > 0.05). TKA patients > or =85 yrs had lower admission FIM scores, longer LOS (11.3 vs. 9.4 days), and 22% higher total charges than TKA patients younger than 85 yrs (P = 0.042). THA patients > or =85 yrs had 6-10% lower total FIM, FIM motor, and FIM cognition scores and were discharged to home less frequently than younger patients (P < 0.05). Total and daily charges were 21-162% higher in THA patients with BMIs > or =50 kg/m than in THA patients with BMIs <50 kg/m (P < 0.045)., Conclusion: All patients made functional gains during rehabilitation. However, the most costly and lengthy rehabilitation occurred in TKA patients > or =85 yrs and THA patients with BMI > or =50 kg/m.

This review was intended to familiarize psychiatrists with the implications of the Health Insurance Portability and Accountability Act of 1996 on the provision of third-party employment evaluations. Understanding the provisions of the act relative to third-party evaluations can assist psychiatrists in avoiding some of the conflicts that arise in performing such evaluations.

The following guidelines were developed for the medical assessment services of the German Pension Insurance Federal Institution. Starting from day-to-day practice, criteria and attributes to guide decisions for a systemisation of the sociomedical assessment of performance in breast cancer were compiled. The guidelines aim at standardising the sociomedical assessment of performance and help to make the decision-making process more transparent, e. g., for the assessment of applications for decreased earning capacity benefits. The guidelines summarise typical manifestations of breast cancer and describe the necessary medical information for the sociomedical assessment of performance. Relevant assessment criteria for the medical history, clinical examination, and for diagnostic tests are illustrated. The assessment of the individual's capacity is outlined, taking occupational factors into account. Following the determination of dysfunctions, the remaining abilities and disabilities, respectively, are deduced and compared with occupational demands. Finally, inferences are drawn regarding the occupational capacity of the individual.

Background: Requiring written informed consent for a minimal-risk survey may result in limited participation rates., Methods: Data from a cross-sectional survey of 177 older patients (87 blacks and 90 whites) with hypertension enrolled in the managed care Medicare risk product were used to assess participation rates pre- and postwaiver of written informed consent and Health Insurance Portability and Accountability Act (HIPAA) authorization. Prior to the waivers being granted, patients were contacted two times via mail with an introductory letter and an informed consent document. Those who completed and returned the informed consent document were administered the questionnaire. After 6 weeks, a waiver of written informed consent and HIPAA authorization was obtained from the Institutional Review Board. Nonparticipants were reapproached and asked to complete the questionnaire. Participation rates were recorded before and after receiving the waivers., Results: Participation rates increased from 21.5% in the prewaiver period to 57.4% in the postwaiver period (p < .001). Prewaiver participation differed by demographic subgroup and was higher among whites (26.7%) versus blacks (16.1%; p = .087), men (31.6%) versus women (16.7%; p = .024), and participants > or = 75 years old (28.4%) versus < 75 years old (14.6%; p = .025). In contrast, the postwaiver participation rate did not differ significantly across race, gender, or age subgroupings. Significant increases in participation rates from the pre- to the postwaiver time period were noted within each demographic subgroup (all p < .01)., Conclusions: We identified a substantial increase in participation rates postwaiver of written informed consent and HIPAA authorization in a minimal-risk survey. The need for written documentation for minimal-risk surveys may negatively impact recruitment of blacks, women, and patients < 75 years old.

The development of referral criteria has been seen as one of the keys to the proactive enhancement of the district nursing service to ensure equity and efficiency of service provision (Audit Commission, 1999). Referral criteria specify what constitutes an appropriate district nursing referral and who is the best person or service to undertake the care if it is not. With the continued focus of shifting the balance of care away from the hospital and into the community and a historically reactive rather than proactive work force, district nurses in Lothian, Scotland developed referral criteria for the service. This article discusses the drivers for the development of these criteria, how they were developed, and the anticipated difference implementation of the criteria would make to district nursing.

Background: The eligibility for recombinant tissue plasminogen activator (rtPA) is rare. We analyze the reasons for exclusion from rtPA among patients who were admitted to our hospital within 3 h., Methods: A strict protocol for hyperacute stroke was set in a university teaching hospital. Consecutive patients activating the protocol from June 2004 to October 2005 were prospectively registered and entered into a computerized database. The patients were excluded from rtPA according to the modified exclusion criteria from the National Institute of Neurological Disorders and Stroke rtPA trial., Results: Of the 182 patients activating the protocol, only 11 (6.04%) received intravenous rtPA and 4 (2.2%) IA thrombolysis. Patients were excluded for multiple reasons, and the main reasons for exclusion were minor or improving stroke (46.15%), hypertension (35.16%), insufficient time to complete studies or onset beyond 3 h after reconfirmation (24.17%) and intracranial hemorrhage (15.93%). Of 167 excluded patients, 72 (43.11%) were excluded by a single criterion, 53 (31.73%) by 2 criteria and 29 (17.36%) by 3 criteria. The mean time from hospital arrival to presentation to a neurologist was 9.24 +/- 15.11 min (n = 164, median = 8.00, mode = 10, range = 0-65). The mean time from hospital arrival to computed tomography (CT) was 21.67 +/- 23.95 min (n = 167, median = 20.00, mode = 10, range = 4-68)., Conclusion: An intrahospital stroke code was implemented to minimize intrahospital delay. However, only 11 patients received intravenous rtPA and 4 IA thrombolysis at our hospital from June 2004 to October 2005. The result brings into question the neurologist's conservative interpretation of the criteria and the necessity to clearly define some criteria. Furthermore an intrahospital stroke code should also be implemented for inpatients to maximize the eligibility for rtPA., (Copyright (c) 2006 S. Karger AG, Basel.)

Objectives: To identify the core best practice standards in ill-health retirement (IHR) procedures. To investigate whether changing medical criteria and introducing medical severance payments affect the rate and cost of IHR., Methods: The core standards for best practice in IHR procedures were distilled from the published literature. On 1st April 2000 the study pension scheme altered the IHR medical criteria to define permanent incapacity and introduced medical severance payments for employees with temporary incapacity. Rates and costs of IHR were measured before and after these changes., Results: Following the changes, the annual rate of IHR fell from 8.89 to 2.90 per 1000 members (P < 0.001), the median age at IHR rose from 50 to 55 years (P = 0.01) and pension scheme costs fell by 25 million pounds sterlings per year., Conclusions: Changing medical criteria and introducing medical severance payments may reduce the rate and costs of ill-health retirement. Target rates of four cases of IHR per 1000 active members per year, and 15% of total retirements, are proposed for schemes serving industries with average health risks.

We estimate that only one-third of patients coinfected with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are eligible for therapy for HCV with interferon (IFN) and ribavirin, and, of those who are eligible, two-thirds decline treatment. To date we have initiated treatment with IFN and ribavirin for 8% of coinfected patients evaluated, and <1% of patients have had a sustained virological response. During this process, we have identified many problems that significantly limit our ability to initiate and complete treatment with IFN in this population and have categorized these difficulties into 4 main challenges. They include access to care, contraindications or barriers to treatment, patients' reluctance to start treatment with IFN, and the low tolerability of treatment. If patients coinfected with HCV and HIV are to be treated for hepatitis C in greater numbers, these issues will need to be addressed.

Injection drug use has fueled the epidemic of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection in the United States. Nevertheless, drug dependence is among the main reasons that coinfected persons are not being treated for HCV infection. This report describes the development and progress of an HIV clinic program (funded by the Ryan White Comprehensive AIDS Resources Emergency Act) to deliver care for HCV infection to HIV-seropositive injection drug users. To optimize safety and adherence, pegylated interferon is directly administered to patients in the context of integrated addiction, psychiatric, and HIV and HCV therapy. Ribavirin is packed weekly in pill boxes for patients to take at home. Thus far, adherence to weekly visits for treatment with interferon has been 99%. No one has had to stop treatment for HCV infection because of ongoing drug use, addiction relapse or exacerbation, or psychiatric complications. Presented here is a work in progress, rather than a finished research project or definitive model of care.

Despite the high prevalence of hepatitis C virus (HCV) infection among drug users enrolled in methadone maintenance treatment programs, few drug users are being treated with combination therapy. The most significant barrier to treatment is lack of access to comprehensive HCV-related care. We describe a pilot program to integrate care for HCV infection with substance abuse treatment in a setting of maintenance treatment with methadone. This on-site, multidisciplinary model of care includes comprehensive screening and treatment for HCV infection, assessment of eligibility, counseling with regard to substance abuse, psychiatric services, HCV support groups, directly observed therapy, and enhanced linkages to a tertiary care system for diagnostic procedures. Our approach has led to high levels of adherence, with liver biopsy and substantial rates of initiation of antiviral therapy. Two cases illustrate the successful application of this model to patients with HCV infection complicated by active substance abuse and psychiatric comorbidity.

Heard of Section 731 of the Medicare Modernization Act? The provision, meant to clear up the generally murky and unwieldy Medicare reimbursement approval process, could quicken the national approval process for medical procedures and devices. The changes will create a more definable approach to OK'ing new technologies. "I like the idea of bringing more science to bear," says Richard Pico, left.

The Center for Medicaid and Medicare Services (CMS) has recently revised their end-stage renal disease (ESRD) Medical Evidence Report, Medicare Entitlement, and Patient Registration CMS 2728 Form. The modified algorithm calls for the use of formulae to estimate glomerular filtration rate (GFR). The new criterion is defined as estimated GFR of less than 20 ml/min per 1.73 m(2). GFR is either estimated by Schwartz formula (C(SCH)) in children or Modification of Diet in Renal Disease formula (C(MDRD)) in adults. The purpose of this communication is to test the validity of the new CMS GFR algorithm in detecting children who need renal replacement therapy. We evaluated two cohorts of children. Group I included single-center data from 626 (125)I-iothalamate clearance studies (C(IO)) that were compared with the simultaneous estimation of GFR by C(SCH). Group II included data on 659 children from the patient incidence registry obtained from the ESRD Network of Texas between February 1996 and October 2003. In group I there were 76 children (76 C(IO)) with C(SCH) less than 20 ml/min per 1.73 m(2) of whom 50 (67%) had C(IO) less than 15 ml/min per 1.73 m(2). Of children with C(IO) less than 15 ml/min per 1.73 m(2), 62% had a C(SCH) less than 20 ml/min per 1.73 m(2). The ability of C(SCH) greater than 20 ml/min per 1.73 m(2 ) to predict C(IO) greater than 15 ml/min per 1.73 m(2 )(negative predictive value) is 0.95. The number of children who were started on dialysis in Texas within the study period was 659 (group II). The mean C(SCH)+/-SD was 10.8+/-7.7 ml/min per 1.73 m(2). Of the patients who were initiated on dialysis, 94% had C(SCH) less than 20 ml/min per 1.73 m(2). The results were sustained when race, gender, age range, and type of diagnosis were considered. The new CMS algorithm provides a good negative predictive estimate of GFR less than 15 ml/min per 1.73 m(2).

The purpose of this descriptive study was to explore the concept of moral turpitude and related terms as they are used in the process of licensing professional nurses. The researchers reviewed applications for licensure and nurse practice acts or rules and regulations for nursing for the 50 states and Washington, DC. Terms such as moral turpitude, moral character, and morality are used by approximately half of the states and, when used, are not usually defined. Agreement among states on uniform definitions and standards of nursing practice can be a step toward aligning practice acts, bringing consistency to disciplinary actions, and informing the public about the profession's standards for practice.

This paper examines how rates of uninsurance for low-income parents have been changing over time and the extent to which expanding coverage to parents through Medicaid and the State Children's Health Insurance Program (SCHIP) could help them. We find that uninsurance rates have been rising for low-income parents, especially those living in poverty, and that Medicaid and SCHIP could greatly reduce uninsurance among parents and would likely increase their access to care. Such expansions would still leave many noncitizen parents uninsured and would require reaching and enrolling families whose children have remained uninsured despite being eligible for public coverage.

Aims and Objectives: To investigate the time required by family caregivers to carry out selected care activities. The project was initiated by the responsible ministry for German Long Term Care Insurance. The Long Term Care Insurance provides recommendations for specific time ranges for care activities as a basis for assessment., Methods: Cross-sectional descriptive study, convenience sample of 200 households. Time was measured during direct observation using a stopwatch (time-and-motion method)., Results: The time taken for care activities had large standard deviations. For many activities, <50% of the cases fell in the recommended time range. No significant influences on the different durations were found., Conclusions: The results give no support for the assumption that recommended time ranges can enhance assessment comparability and adequacy., Relevance to Clinical Practice: In order to predict the amount of work in nursing it is more important to assess the patient's situation and history, and the goal to be reached by nursing care than to know the title of the required nursing intervention.

Objective: Dietary assessment has been used for certification to receive food supplements or other nutrition services and to provide feedback for educational purposes. The proportion of individuals correctly certified as eligible is a function of the amount of error that exists in the dietary measures and the level of dietary intake used to establish eligibility. Whether individuals are correctly counselled to increase or decrease the consumption of selected foods or nutrients is a function of the same factors. It is not clear, however, what percentage of individuals would be correctly classified under what circumstances. The objective of this study is to demonstrate the extent to which measurement error and eligibility criteria affect the accuracy of classification., Design: Hypothetical distributions of dietary intake were generated with varying degrees of measurement error. Different eligibility criteria were applied and the expected classification rates were determined using numerical methods., Setting and Subjects: Simulation study., Results: Cut points of dietary intake at decreasing levels below the 50th percentile of true intake were associated with lower sensitivity and predictive value positive rates, but higher specificity and predictive value negative rates. The correct classification rates were lower when two cut points of dietary intake were used. Using a single cut point that was higher than the targeted true consumption resulted in higher sensitivity but lower predictive value positive, and lower specificity but higher predictive value negative., Conclusions: Current methods of dietary assessment may not be reliable enough to attain acceptable levels of correct classification. Policy-makers and educators must consider how much misclassification error they are willing to accept and determine whether more intensive methods are necessary.

Since PPS, the Intake Department focus includes evaluation of the level of home care services needed and payment coverage criteria. This article focuses on questions intake staff should ask to adequately screen for home care eligibility. Even though the OASIS assessment cannot be completed prior to the start of care visit, screening information can be collected that relate to the OASIS questions.

The goal of the present study was to assess the validity of the Medicare hospice eligibility guidelines for dementia patients, as well as identify predictors that could more accurately identify prognosis in dementia patients referred to hospice. A retrospective chart review was conducted, including initial assessment and longitudinal follow-up of patients until the time of death. In addition, a second validation cohort was also followed. Participants consisted of 245 patients admitted to a large community-based hospice with a diagnosis of dementia, including a validation sample of 80 patients. The Kaplan-Meier estimation of survival and a Cox regression analysis (p > 0. 05) revealed no significant relationship between the Medicare guidelines or any component of the guidelines and survival at six months for the initial and validation samples. Significant multivariate predictors of shorter survival in both the initial and validation sample include greater age (p = 0. 02) and anorexia (p < 0. 001), as well as a combination of anorexia and greater functional impairment (p = 0.005). Overall, the results indicated that the Medicare guidelines were not valid predictors of survival in hospice patients with dementia and should be altered to include empirically valid predictors. Advanced age, as well as impaired nutritional and functional status, was associated with shortened survival in these patients. The predictor variables identified are an initial step toward providing improved prognoses for advanced dementia patients, their families, and practitioners. Broader issues in improving access to hospice care for dementia patients are discussed.

In the early stages of welfare reform, a variety of studies found that many families that left welfare also left the Food Stamp Program (FSP), even though most were still eligible for it. This paper examines more recent data to determine whether this behavior has continued or whether at least some of it was due to initial misunderstandings about eligibility. Our results show that families leaving welfare continued leaving the FSP at about the same rate in 1999 as they had 2 years earlier. For example, only half of families who left welfare and had incomes below 50% of the federal poverty level continued participating in the FSP. We also show that more families reported leaving the FSP because of administrative issues in 1999 than did in 1997. Families that left the FSP were more likely to have moved recently and to have owned cars than families that remained. Our results raise concern that structural reforms are needed to make it easier for the working poor to receive these benefits. Recent federal changes in the FSP have allowed states to move in that direction.

Background: Beta-blockers reduce morbidity and mortality when administered to high-risk patients undergoing major noncardiac surgery, yet little is known about how often they are being prescribed. Clinical practice guidelines are tools that can be used to speed the translation of research into practice and may be one method to improve the use of beta-blockers. Before implementing any guideline, it is important to forecast its potential clinical and financial impact., Methods: We conducted a retrospective cohort study, using administrative and medical record review data, of all adult patients undergoing major noncardiac surgery at Baystate Medical Center, Springfield, Mass, during a 1-month period in 1999. Patients with 2 or more cardiac risk factors or with documented coronary artery disease were classified as high risk and were considered eligible for treatment with a beta-blocker if they had no obvious contraindications to its use. We estimated the potential clinical benefit of treating eligible patients with a beta-blocker by extrapolating the treatment effect observed in a previously reported randomized clinical trial., Results: Of 158 patients undergoing major noncardiac surgery, 67 (42.4%) seemed to be ideal candidates for treatment with perioperative beta-blockers. Of these 67 patients, 25 (37%) received a beta-blocker at some time perioperatively. During the course of a year, we estimate that between 560 and 801 patients who do not receive beta-blockers might benefit from treatment with these medications. Full use of beta-blockers among eligible patients at our institution could result in 62 to 89 fewer deaths each year at an overall cost of $33 661 to $40 210., Conclusions: There seems to be a large opportunity to improve the quality of care of patients undergoing major noncardiac surgery by increasing the use of beta-blockers in the perioperative period. A clinical practice guideline may be one method to achieve these goals at little cost.

Unlabelled: OBJECTIVES. This study modeled the health and federal fiscal effects of expanding Medicaid for HIV-infected people to improve access to highly active antiretroviral therapy., Methods: A disease state model of the US HIV epidemic, with and without Medicaid expansion, was used. Eligibility required a CD4 cell count less than 500/mm3 or viral load greater than 10,000, absent or inadequate medication insurance, and annual income less than $10,000. Two benefits were modeled, "full" and "limited" (medications, outpatient care). Federal spending for Medicaid, Medicare, AIDS Drug Assistance Program, Supplemental Security Income, and Social Security Disability Insurance were assessed., Results: An estimated 38,000 individuals would enroll in a Medicaid HIV expansion. Over 5 years, expansion would prevent an estimated 13,000 AIDS diagnoses and 2600 deaths and add 5,816 years of life. Net federal costs for all programs are $739 million (full benefits) and $480 million (limited benefits); for Medicaid alone, the costs are $1.43 and $1.17 billion, respectively. Results were sensitive to awareness of serostatus, highly active antiretroviral therapy cost, and participation rate. Strategies for federal cost neutrality include Medicaid HIV drug price reductions as low as 9% and private insurance buy-ins., Conclusions: Expansion of the Medicaid eligibility to increase access to antiretroviral therapy would have substantial health benefits at affordable costs.

The recently published final regulations for transactions and code sets under HIPAA are the light at the end of the tunnel in the quest for uniform healthcare standards--and the first step on a long road to HIPAA implementation. What are the standard transactions and code sets? This article takes an in-depth look.

Background and Purpose: Although the North American Symptomatic Carotid Endarterectomy Trial (NASCET) has shown carotid endarterectomy (CEA) to be protective compared with medical therapy alone, its stringent eligibility criteria excluded patients with severe medical, angiographic, and neurological risk factors. We sought to determine the safety and efficacy of stent angioplasty in this high-risk subset for whom the perioperative morbidity and mortality of surgery are elevated., Methods: Twenty-eight consecutive symptomatic NASCET-ineligible patients (10 female; median age, 72.2 years) underwent microcatheter-based carotid stent angioplasty. Half of the patients had sustained a previous stroke. Classification of surgical risk by Sundt criteria yielded no patients in grade 1, 3 patients in grade 2 (10.7%), 8 in grade 3 (28.6%), and 17 (60.7%) in grade 4. Stratification of stroke risk for medical therapy according to the European Carotid Surgery Trial (ECST) 5-point score showed 8 patients with a score of 3 (28.6%), 12 with 4 (42.8%), and 8 with 5 (28.6%). Follow-up was obtained in all patients at a median of 14 months., Results: The procedure was technically successful in all cases (100%), with immediate stenosis reduction from a mean of 80.3% to 2.7%. There were no periprocedural deaths, 1 major stroke (3.6%), no minor strokes, and 3 transient ischemic attacks (10.7%). In-hospital complications included 2 nonfatal myocardial infarctions, 1 case of acute renal failure, and 1 groin hematoma requiring transfusion. There were 5 deaths during the follow-up period, all beyond 30 days after the procedure: 3 from cardiac causes, 1 from lung cancer, and 1 following unrelated surgery. The patient with major stroke died at 7.8 months during rehabilitation. No surviving patients had further strokes, and all except 1 (95.5%) remained asymptomatic. Anatomic follow-up in 20 patients showed occlusion in 2 (10%) (1 symptomatic, 1 asymptomatic) and intimal hyperplasia in 3 asymptomatic patients (15%)., Conclusions: The clinical results and sustained freedom from symptoms and stroke during the short available follow-up period suggest that stent angioplasty may be useful in the treatment of symptomatic cervical carotid stenosis in high-risk patients despite a notable incidence of restenosis.

This study examined the prevalence of drug use in a nationally representative sample of 1989 recipients and 6840 nonrecipients of four welfare programs. Data from the 1995 National Household Survey on Drug Abuse (NHSDA) were analyzed using the conditional form of multiple logistic regression with matching of respondents on neighborhood of residence. Weighted proportions and variances accounting for the complex sample design of the NHSDA survey were estimated using the Taylor series linearization method. The results indicate that drug use is 50% more common in households with welfare recipients than in nonwelfare households. Programs making welfare eligibility contingent on the recipient working toward a drug-free lifestyle are worth examining, although a vigilant eye must be kept on the potential unintended consequences.

The goal of the present paper is to compare the rules used in Germany and Poland to establish an individual's eligibility for a disability pension in cases of orthopedic disorders. Harmonizing these rules is one of the basic factors needed to create the proper platform for cooperation among health care systems in all the countries associated with the European Union. This second part of the work will discuss the Polish rules for eligibility proceedings in orthopedic cases. The example of spinal disorders is used to explain the format for the examination conducted by an orthopedic specialist in the course of the process of determining the disability group to which the person belongs.

Community-based services (CBS) have long used checklists to determine eligibility for contraceptive method use, in particular for combined oral contraceptives (COCs) and the 3-month injectable contraceptive depot-medroxyprogesterone acetate (DMPA). As safety information changes, however, checklists can quickly become outdated. Inconsistent checklists and eligibility criteria often cause uneven access to contraceptives. In 1996, WHO produced updated eligibility criteria for the use of all contraceptive methods. Based on these criteria, new checklists for COCs and DMPA were developed. This article describes the new checklists and their development. Several rounds of expert review produced checklists that were correct, comprehensible and consistent with the eligibility requirements. Nevertheless, field-testing of the checklists revealed that approximately half (48%) of the respondents felt that one or more questions still needed greater comprehensibility. These findings indicated the need for a checklist guide. In March 2000, WHO convened a meeting of experts to review the medical eligibility criteria for contraceptive use. The article reflects also the resulting updated checklist.

The aim of the present paper is to compare the rules used in Germany and Poland to establish an individual's eligibility for a disability pension in cases of orthopedic disorders. Harmonizing these rules is one of the basic factors needed to create the proper platform for cooperation among health care systems in all the countries associated with the European Union. This first part of the work discusses the German rules for eligibility proceedings in orthopedic cases. The example of spinal disorders is used to explain the scheme of the examination conducted by the specialist to determine the disability group to which the person should belong. Attention is drawn to the rules governing the use of additional tests and eligibility proceedings.

The incidence of malignant mesothelioma, the main consequence of exposure to asbestos, will increase considerably in the Netherlands in the coming decades. In the next 35 year, some 20,000 people will die from malignant mesothelioma. The diagnosis of malignant pleural mesothelioma in practice is based on histological examination in about 80%, on cytological examination in 15% and on other forms of examination, e.g., high resolution computer tomography (HRCT), in 6% of the cases. Using a combination of various noninvasive methods, such as anamnesis, physical and röntgenologic examination, HRCT and spirometry, the diagnosis of asbestosis is made erroneously in 5% of the patients examined. With regard to allowance of financial compensation to patients with pleural mesothelioma and asbestosis, a part is played by the fact that views differ internationally concerning the criteria on which the diagnosis should be based. For mesothelioma cytologic and histologic examination are the most important. For asbestosis, the Health Council considers HRCT as crucial, if necessary supplemented by histological examination, plus a history of exposure to asbestos and pulmonary dysfunction. In mesothelioma cytological and histological examination are the most important.

Long-term care (LTC) eligibility criteria are applied to a sample of 8,437 people with dementia enrolled in the Medicare Alzheimer's Disease Demonstration. The authors find that mental-status-test cutoff points substantially affect the pool of potential beneficiaries. Functional criteria alone leave out people with relatively severe dementia and with behavioral problems. It is therefore important to consider both behavioral and mental-status-test criteria in establishing eligibility for community-based services for people with dementia.

In summary, most low-income elderly and disabled persons lack coverage for important medications, resulting in avoidable deterioration of health among those with chronic illnesses and use of expensive institutional services. Rapidly escalating drug costs, more restrictive drug-coverage policies, and a dramatic increase in the population of elderly and disabled persons will exacerbate these problems. With the current budget surplus, as well as bipartisan concern about health care needs and public concern about drug costs and coverage, it is time to act responsibly and aggressively. We recommend a national replication of the best features of state pharmacy-assistance programs in a federal-state insurance program for low-income Medicare enrollees, either alone or in combination with expanded Medicare coverage. Such a program will reduce the current inequitable situation in which the most vulnerable patients have the least access to medications, with serious medical and economic consequences.