Primary care is essential to the effective and efficient functioning of health care delivery systems, yet there is an impending crisis in the field due in part to a dysfunctional payment system. We present a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care. Unlike former iterations of primary care capitation (which simply bundled inadequate fee-for-service payments), our comprehensive payment model represents new investment in adult primary care, with substantial increases in payment over current levels. The comprehensive payment is directed to practices to include support for the modern systems and teams essential to the delivery of comprehensive, coordinated care. Income to primary physicians is increased commensurate with the high level of responsibility expected. To ensure optimal allocation of resources and the rewarding of desired outcomes, the comprehensive payment is needs/risk-adjusted and performance-based. Our model establishes a new social contract with the primary care community, substantially increasing payment in return for achieving important societal health system goals, including improved accessibility, quality, safety, and efficiency. Attainment of these goals should help offset and justify the costs of the investment. Field tests of this and other new models of payment for primary care are urgently needed.
In an attempt to define guidelines for the assessment of acute asthma, we evaluated 205 patients who presented to the emergency room for treatment of asthma. Of the 205, 120 were successfully treated and discharged from the emergency room, 45 were hospitalized, and 40 were treated and discharged from the emergency room but had relapses within 10 days. A predictive index using a combination of presenting factors was developed: pulse rate greater than or equal to 120 per minute, respiratory rate greater than or equal to 30 per minute, pulsus paradoxus greater than or equal to 18 mm Hg, peak expiratory flow rate less than or equal to 120 liters per minute, moderate to severe dyspnea, accessory-muscle use, and wheezing. The index ranged from 0 to 7, increasing with the severity of symptoms. The index scores of the relapse group (4.9 +/- 1.0) and the admitted group (5.1 +/- 1.0) were both significantly different (p less than 0.001) from that of the successfully treated group (1.6 +/- 1.2). An index of 4 or higher was 95 per cent accurate in predicting the risk of relapse and 96 per cent accurate in predicting the need for hospitalization.
To define the time course of the metabolic acidosis that follows a single grand-mal seizure, we obtained serial blood samples from eight consecutive patients. Immediately after a seizure, the mean (+/- S.E.M.) venous lactate concentration was 12.7 +/- 1.0 meq per liter, the mean carbon dioxide content 17.1 +/- 1.1 mmol per liter, and the mean arterial pH 7.14 +/- 0.06. Sixty minutes later their values were 6.6 +/- 0.7 meq per liter (P less than 0.005), 23.6 +/- 1.1 mmol per liter (P less than 0.005) and 7.38 +/- 0.04 (P less than 0.005) respectively. The spontaneous resolution of the acidosis was due, in large part, to the metabolism of lactate and to the concomitant removal of hydrogen ion. There was no change in the serum potassium concentration, despite the development of a severe systemic acidemia and the subsequent return to normal of the pH. We suggest that the patient with seizures may serve as a unique model of lactic acidosis.
The creatinine clearance was calculated in standard fashion from a timed urine specimen (measured creatinine clearance [MCC]) and from a previously published formula (estimated creatinine clearance [ECC]), in 55 instances, in 19 consecutive patients who were admitted to the hospital for treatment with cisplatin. Using creatinine excretion as an index of completeness of urine collection, there were 19 (35%) inaccurate collections. The correlation between creatinine clearances calculated by both methods was excellent (r = 0.684, P less than .001) and improved when inaccurate collections were excluded (r = 0.922, P less than 0.001). A discrepancy between the two methods of 25% or more was found in 19 collections. Using data from patients with two or more collections to test whether or not the two methods produced equally variable results, indicated that the MCC is a more variable, less reliable method than the ECC. In eight of 55 urine collections, the results of MCC were not used as a guide to chemotherapy and, in an additional 16 should have not been used because of inaccuracy in the urine collection. These results suggest that the creatinine clearance as calculated by an alternative method (ECC) should replace the use of MCC when assessment of the renal function is needed before the administration of nephrotoxic agents.
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