Coordination, Switching Costs and the Division of Labor in General Medicine: An Economic Explanation for the Emergence of Hospitalists in the United States

General medical care in the United States has historically been provided by physicians who care for their patients in both ambulatory and hospital settings. Care is now increasingly divided between physicians specializing in hospital care (hospitalists) and ambulatory-based care primary care physicians. We develop and find strong empirical support for a theoretical model of the division of labor in general medicine that views the use of hospitalists as balancing the costs of coordinating care across physicians in the hospitalist model against physicians’ costs switching between ambulatory and hospital settings in the traditional model. Our findings suggest opportunities to improve care.

Should cost effectiveness analyses for NICE always consider future unrelated medical costs?

When developing guidance on the use of new technologies within the NHS, NICE recommends the use of cost effectiveness. Specifically, an intervention is deemed cost effective by NICE if ‘its health benefits are greater than the opportunity costs of programmes displaced to fund the new technology, in the context of a fixed NHS budget. In other words, the general consequences for the wider group of patients in the NHS are considered alongside the effects for those patients who may directly benefit from the technology.’ We argue that the technical guidelines for health technology assessment used by NICE should change given this definition of cost effectiveness. The point at issue is the handling of “unrelated future medical costs”

Modeling potential responses to smallpox as a bioterrorist weapon.

We constructed a mathematical model to describe the spread of smallpox after a deliberate release of the virus. Assuming 100 persons initially infected and 3 persons infected per infectious person, quarantine alone could stop disease transmission but would require a minimum daily removal rate of 50% of those with overt symptoms. Vaccination would stop the outbreak within 365 days after release only if disease transmission were reduced to <0.85 persons infected per infectious person. A combined vaccination and quarantine campaign could stop an outbreak if a daily quarantine rate of 25% were achieved and vaccination reduced smallpox transmission by > or = 33%. In such a scenario, approximately 4,200 cases would occur and 365 days would be needed to stop the outbreak. Historical data indicate that a median of 2,155 smallpox vaccine doses per case were given to stop outbreaks, implying that a stockpile of 40 million doses should be adequate

Association between cognitive performance and cortical glucose metabolism in patients with mild Alzheimer's disease

Background: Neuronal and synaptic function in Alzheimer's disease (AD) is measured in vivo by glucose metabolism using positron emission tomography (PET). Objective: We hypothesized that neuronal activation as measured by PET is a more sensitive index of neuronal dysfunction than activity during rest. We investigated if the correlations between dementia severity as measured with the Mini Mental State Examination (MMSE) and glucose metabolism are an artifact of brain atrophy. Method: Glucose metabolism was measured using {[}F-18]fluorodeoxyglucose PET during rest and activation due to audiovisual stimulation in 13 mild to moderate AD patients (MMSE score >= 17). PET data were corrected for brain atrophy. Results: In the rest condition, glucose metabolism was correlated with the MMSE score primarily within the posterior cingulate and parietal lobes. For the activation condition, additional correlations were within the primary and association audiovisual areas. Most local maxima remained significant after correcting for brain atrophy. Conclusion: PET activity measured during audiovisual stimulation was more sensitive to functional alterations in glucose metabolism in AD patients compared to the resting PET. The association between glucose metabolism and MMSE score was not dependent on brain atrophy. Copyright (C) 2005 S. Karger AG, Basel

The hidden burden of adult allergic rhinitis : UK healthcare resource utilisation survey

Funding Funding for this survey was provided by Meda Pharma.Peer reviewedPublisher PD

Striatal dopamine D2 receptor binding of risperidone in schizophrenic patients as assessed by 123I-iodobenzamide SPECT: a comparative study with olanzapine

The aim of this investigation was to compare the degree of striatal dopamine-(D2) receptor blockade by two atypical antipsychotic drugs, risperidone and olanzapine. The percentage of D2 receptor occupancy during treatment was calculated by comparing the results of 123I-iodobenzamide SPECT with those from healthy control subjects. Twenty inpatients suffering from schizophrenia or schizoaffective psychosis according to DSM IV/ICD-10 criteria were treated with clinically recommended doses of risperidone and compared with 13 inpatients treated with up to 20 mg olanzapine. Neuroleptic dose and D2 receptor blockade correlated strongly for both risperidone (Pearson r = –0.86, p = 0.0001) and olanzapine (Pearson r = –0.77, p = 0.002). There was no significant difference between the D2 receptor occupancy of the two substances when given in the clinically recommended dose range (unpaired t-test, t= –0.112, p=0.911)

Tidal Stabilization of Rigidly Rotating, Fully Relativistic Neutron Stars

It is shown analytically that an external tidal gravitational field increases the secular stability of a fully general relativistic, rigidly rotating neutron star that is near marginal stability, protecting it against gravitational collapse. This stabilization is shown to result from the simple fact that the energy $\delta M(Q,R)$ required to raise a tide on such a star, divided by the square of the tide's quadrupole moment $Q$, is a decreasing function of the star's radius $R$, $(d/dR)[\delta M(Q,R)/Q^2]<0$ (where, as $R$ changes, the star's structure is changed in accord with the star's fundamental mode of radial oscillation). If $(d/dR)[\delta M(Q,R)/Q^2]$ were positive, the tidal coupling would destabilize the star. As an application, a rigidly rotating, marginally secularly stable neutron star in an inspiraling binary system will be protected against secular collapse, and against dynamical collapse, by tidal interaction with its companion. The ``local-asymptotic-rest-frame'' tools used in the analysis are somewhat unusual and may be powerful in other studies of neutron stars and black holes interacting with an external environment. As a byproduct of the analysis, in an appendix the influence of tidal interactions on mass-energy conservation is elucidated.Comment: Revtex, 10 pages, 2 figures; accepted for publication in Physical Review D. Revisions: Appendix rewritten to clarify how, in Newtonian gravitation theory, ambiguity in localization of energy makes interaction energy ambiguous but leaves work done on star by tidal gravity unambiguous. New footnote 1 and Refs. [11] and [19

The construction of social housing pathways across Australia

This report examines the formal social housing pathways set out in policy and how these differ across jurisdictions. It uses a systems thinking approach to examine how actors, levers, feedback loops, incentives and disincentives influence formal social housing pathways. The discussion presents evidence from a comprehensive policy review, as well as data from interviews and a workshop with key stakeholders, including government representatives and community housing managers