Only solicitors with proved expertise in medical negligence cases will get legal aid funding for such claims in the future, under plans unveiled by Britain’s lord chancellor last week.

The UK government believes it is wasting millions of pounds a year on non-specialist lawyers who fail to deliver an optimum service in this complex area of practice. From August 1999, only law firms with a clinical negligence franchise from the Legal Aid Board will be funded by taxpayers for malpractice claims. Solicitors who are members of specialist panels run by the Law Society and Action for Victims of Medical Accidents and who prove specialist competence, will be eligible for a franchise.

Only 185 solicitors in a total of 131 firms in the United Kingdom belong to the specialist panels, raising fears that some parts of the country will have insufficient expertise. But the lord chancellor, Lord Irvine, said that specialist solicitors would be expected to travel to see clients if necessary, as many already do.

Medical negligence cases have a notoriously low success rate compared with other types of case. Nearly half of the cases in 1996-7 ended inconclusively, with no trial or settlement, but costing the taxpayer 14m [pounds sterling] ($22.4m) in legal aid fees, more than half the total 27m [pounds sterling] net cost of clinical negligence cases to the board. Only two of every five cases that went to trial or were settled out of court resulted in compensation for claimants.

The board believes that one reason for the high failure rate is lawyers’ lack of expertise. The move to specialisation is likely to mean more successful claims, bigger awards, and higher legal costs for the NHS. But this could be offset to some extent by plans to limit aid to applicants whose cases have a 75% predicted chance of success.

Bent over and barely able to walk, Dale Gowan turned to Deaconess Medical Center’s emergency room for relief from the pain shooting down from his lower back and into his legs.

“We’re not in the pain management business,” Dale said the ER doctor told him before writing a prescription.

With his long hair and thin frame, Dale’s appearance apparently fit the profile of a drug user looking for a fix. At least, that’s the way Dale believes the doctor treated him - not as a man with a chronic back injury in need of attention.

A spokeswoman for Deaconess denies this was the case, which makes it the word of a health care professional against that of someone on Medicaid. But it would not be the first time Dale, 38, who came to Spokane in search of work with his wife, Rebecca, and their three children, has suffered the indignity of poverty. The family lived in an old school bus before entering a homeless shelter in January.

In March, soon after moving into the Salvation Army’s reduced- rent transitional housing apartments, Dale lost his job as a drywall hanger. His employer had read about Dale’s back problems in The Spokesman-Review.

More than 20 years of drywalling have damaged the vertebrae in Dale’s back, making it dangerous for him to continue the only work he knows.

In health care matters, the United States is still pretty much a country where you get what you pay for. By that standard, the Gowans are fortunate to have the care they are receiving at the Community Health Association of Spokane’s Maple Clinic.

CHAS, a nonprofit system of federally qualified community clinics, provides medical and dental care to patients regardless of insurance status. In 2003, the clinics treated more than 24,000 people, 18 percent of whom were homeless.

Nearly five months after his first visit to the Maple Clinic, Dale, who was diagnosed a year ago in Boise with a bulging vertebra, has yet to see a neurosurgeon or even get an MRI. Though primary care is available to the poor at clinics such as those run by CHAS, specialized care is still hard to come by for an estimated 45 million uninsured and an untold number of underinsured Americans.

Spokane is no exception.

“We haven’t as a community gone to the next step of getting people who have extreme needs that special attention,” said Becky Swanson, vice president for marketing and communications at Empire Health Services, which runs Deaconess.

Lernout & Hauspie Speech Products NV is paying up to 5.8m pounds ($9.3m) to acquire a company that established the coding standard for medical records in the UK. Its purchase of Computer Aided Medical Systems Ltd (CAMS) gives L&H a pivotal position in the medical market in the UK with the potential for growth in Europe.

CAMS is responsible for Read Codes, a standard method of classifying clinical terms in the UK that can be shared between medical professionals and enable medical records to be more easily analyzed. While L&H has seen the medical sector as one of the key vertical markets, particularly for its dictation products, the CAMS acquisition takes it into the coding market and an opportunity to create a comprehensive medical reporting package.

The development of IT systems in the UK’s state-run National Health Service has never been short of controversy and Read Codes, named after developer Dr James Read, have been criticized as being less comprehensive than international standards in certain specialist areas. However, supporters of the system have hopes that they could eventually be adopted as the standard for the European Community which would dramatically widen the market.

L&H plans to voice-enable the ReadEngine software and develop a version that would automatically identify and code medical terminology in text, eliminating a task now done by coding specialists. L&H is paying 3.8m pounds ($6.1m) for CAMS with an earn-out of 2m pounds ($3.2m) and says the acquisition will be accretive in 2000.

Dr. Alex Valadka has taken emergency room call in the nation’s fourth largest city, Houston, for 12 years. But only since last July did the 43 year-old neurosurgeon get paid for it.

One of two institutions where he practices. The Methodist Hospital, doles out $500 for each day he agrees to come in to treat emergency patients for cervical spine fractures, cerebral hemorrhages and more.

“Doctors brought it up. The hospital administration said, ‘no,’” Valadka, says. “Eventually they realized it was a trend.”

All Methodist community physicians are compensated now for covering the ER, whether or not they are called. Samplings of daily rates include $100 for pediatricians, $250 for general surgeons, topping off at $500 for cardiologists. “The stipend does not cover losses from being in your office and seeing patients, but it’s better than nothing,” Valadka says.

About 30 percent of the nation’s hospitals report they pay some specialists for ER call, according to a 2004 American Hospital Association survey of hospital leaders. About 2 percent of that number pays all specialists.

Most began the practice within the last two years. “It is becoming more common to pay physicians for on call ER coverage,” says Caroline Steinberg, vice president, trends analysis, AHA, Washington, D.C. Medical defense coverage and reimbursements for the poor are sometimes additional.

Stipends were little known only a decade ago. A confluence of changes in medicine altered what doctors provided voluntarily as a social imperative, as a means to build young practices and as a way to sustain old ones. A tide of uninsured patients, rising medical liability insurance rates and physician lifestyle issues converged to make ER call exceedingly undesirable. Doctors are demanding compensation.

“Historically, hospitals provided work shops for physicians in exchange for physicians having a responsibility to the community at large,” AHA’s Steinberg says. That workshop environment changed considerably when hospitalists started relieving primary care doctors of admissions in the 1990s.

At the same time, the growth of alternative practice venues, combined with technological and scientific advances that made outpatient surgeries possible, encouraged some surgical specialists, once dependent on hospitals, to reduce or drop their privileges.

My grandfather was a damage-control chief in the Navy. My dad never really joined the military, but he kind of stuck around in a military town [Norfolk]. My uncle on my mom’s side owns a marina, so I knew that I definitely wanted to do something on the water. I guess it flows in my veins. I bought my first boat when I was 18, a 26-foot little sailboat.

I had it narrowed down at one time to Marines, Navy and Coast Guard, but I ended up picking the Coast Guard mostly to try to do search-and-rescue type stuff. That was what I did in Key West. Coming here has been something completely different.

We were sent over to Africa basically to fulfill a mission that the Navy could not: teach these foreign navies the mission that we do in the Coast Guard of lifesaving, search and rescue, and guarding the coast against pirates and drug runners.

Basically, Fm in charge with making sure that onboard [the Bear], we receive message traffic and can communicate properly with the guys on land. We have lots of different equipment and lots of different ways to contact people, but just to try to find a method that gets through reliably on a consistent basis is probably one of the most difficult things.

This is definitely one of the more tight-knit, team-playing units that I’ve ever worked at. Our captain wanted to make sure, for example, that we came home a day early. And as petty as that sounds, we were just ready to come home. And when the command tries to take care of us, then we try and do our job a little better. And that, in turn, makes him look better.

I hope to be the kind of leader who can sit back and have guys who are well-trained and well-equipped enough that they can do their jobs well and come to me if they have problems, but let them get their own recognition for it.

I’ve got at least another three years to go. I really am kind of in limbo. I’m definitely making a headlong run at getting myself trained and prepped and ready for making it a career.

I’m currently going to an EMT (Emergency Medical Technician) school. I also go to school to learn how to use our ion scan machine, which is the machine that we use to scan for drugs, because that’s the mission on our next ship.

I don’t know about going to the top. I had actually hoped to achieve chief. I’ve already made E-5 in three years. It’s definitely achievable, maybe not within six years, but definitely within 10.

Background: The goal of asthma treatment is control of asthma and good quality of life for asthmatic patients; however, many asthmatic patients experience symptoms and limitations.

Study objectives: To examine treatment outcome in asthmatic patients under specialist care.

Design: Multicenter, cross-sectional study.

Setting: Four large outpatient asthma clinics in teaching hospitals in three Greek cities.

Patients: Three hundred seventy-eight randomly selected patients with mild or moderate asthma (265 female patients; mean age, 42.3 years).

Interventions: None.

Measurements and results: Patients completed a questionnaire structured with eight domains covering patient characteristics, drug use at baseline and during exacerbations, regular follow-up, emergency visits, asthma control, symptoms, and limitations. Results show that the majority of patients have symptoms and limitations in their physical and social activities and have frequent exacerbations, while > 40% of patients think that their asthma is not well controlled. Most of our patients receive preventive medication (primarily inhaled corticosteroids, but less so long-acting [beta]2-agonists [LABAs] and leukotriene antagonists), increase their use of medication in case of exacerbations and have regular follow-up. However, the report shows that 48% of patients tried to reduce their medication dose, a fact implying that compliance is not always good.

Conclusions: These data indicate that the goals of asthma treatment are not achieved, even under specialist care. Perhaps more effort should be invested in patient education while an increase in the use of LABAs and leukotriene antagonists, medications that have been shown to prevent exercise-induced bronchoconstriction and improve quality of life, may help better asthma outcomes.

Introduction

Inpatients with diabetes account for a substantial fraction of hospital bed occupancy and some report a poor experience of care (Audit Commission, 2000). In this article, Julia Pledger details the evidence for having a diabetes specialist nurse (DSN) with dedicated time to advise on the care and management of inpatients with diabetes. She then goes on to describe an intiative to employ a DSN with this role in the Bedford Hospital NHS Trust and reports on the evaluation of the first 6 months of the project, in terms of mean length of stay in hospital, bed occupancy figures and cost implications.

The CODE-2 study (Baxter et al, 2000) showed that the annual cost of care in the UK for people with type 2 diabetes makes up at least 4.1% of the entire National Health Service (NHS) spending, which amounts to approximately [pounds sterling]1.8 billion. Moreover, patients with diabetes as a co-existing condition occupy one in ten acute hospital beds (Audit Commission, 2000) and account for at least 8.1% of the NHS acute sector costs (King’s Fund Policy Insitute, 1996). This is a result, in part, of both the increased likelihood of admission and the greater mean length of stay (LOS), irrespective of the primary diagnosis.

Currie et al (1997) suggested that some of the excess LOS may not be due to the greater case complexity seen in diabetes, but instead may be a consequence of unfamiliarity of the non-specialist medical and nursing teams with diabetes management. In such cases, it could be uncertainty regarding the effects or timing of treatment that causes unnecessary delay in discharge.

In addition, the Audit Commission (2000) reported that patients frequently describe poor experiences of inpatient care, particularly in relation to:

* a lack of diabetes knowledge among hospital staff

* inappropriate timings of medication and food

* inadequate information

* delays in discharge resulting from diabetes, particularly when diabetes was not the original reason for admission.

Additional problems were identified by the Audit Commission, and two examples are as follows.

* Nurses were apt to take over the patients diabetes care entirely: patients were not allowed to self-inject, to undertake their own blood glucose monitoring or to make appropriate adjustments to their treatments.

* Patients’ wishes were frequently not explored; nor were they given information about the plan of management.

A Brave New World

To the Editors of American Demographics:

I work for a company that sells umbilical cord blood and stem cell collection services. From the information we gathered, we believe there are approximately 4 million births a year. It would be very helpful in our marketing efforts to expectant mothers if we knew what percentage of these births were to women over the age of 30, and even more helpful if we could further break down this group by household income levels. Thank you for your consideration.

Dan Boerger

President

Advantage Direct Marketing

Berwyn, Pa.

Dear Dan:

Your inquiry could not have come at a more newsworthy time. In fact, it arrived just as President Bush was calling for more funding of scientific research using stem cells from sources other than human embryos, such as umbilical cord blood.

Now, to answer your question: In July, the Centers for Disease Control (CDC) released preliminary birth data for 2000, which confirms your figure for the number of new births. Indeed, last year there were 4.1 million births, about 106,000 more births than in 1999. Women ages 30 and older gave birth to 36.3 percent of the babies born in 2000, up slightly from 35.7 percent in 1999. Moreover, the CDC reports that in 2000, birth rates (the number of births per 1,000 women) for women ages 30 and older rose to their highest levels in 30 years. Currently, there are 94.2 births per 1,000 women age 30 to 34; 40.3 for women 35 to 39; 7.9 for women age 40 to 44; and 0.5 for women age 45 to 54.

For the income breakdown, we turned to the 2000 Current Population Survey’s (CPS) Fertility of American Women study. Of course, the numbers you desire are not available in a nice, easy-to-read report, so we got crunching. According to American Demographics’ analysis of CPS data on women ages 30 to 44 who gave birth in the past year, 10 percent came from families with an annual income of less than $15,000; 14 percent had incomes between $15,000 and $29,999; 19 percent earned between $30,000 and $49,999; and 23 percent took home between $50,000 and $74,999. The largest share of this population (34 percent) had a combined annual household income of $75,000 or more. That’s what you would call a “sugar mommy.”

The Physical Medicine and Rehabilitation Service provides a critical role in the assessment, management, and disposition of the newly injured combatant. This role has been well demonstrated during Operation Enduring Freedom and Operation Iraqi Freedom. Military physiatrists are uniquely suited to support military service members as they maximize their function and either return to duty or transition to civilian life.

Introduction

The Physical Medicine and Rehabilitation (PMR) Service plays a critical role in the assessment, management, and disposition of the injured combatant. This role was well demonstrated during Operations Enduring and Iraqi Freedom. Having the PMR Service within the same department as orthopedics, physical therapy, and occupational therapy greatly enhances the communication and flexibility to provide optimal medical and rehabilitative care for those injured combatants with musculoskeletal injuries.

All combat casualties who are admitted to Walter Reed Army Medical Center (WRAMC) receive several automatic referrals, including an evaluation from the PMR Service. PMR consultation to the primary admitting service helps to focus each patient’s rehabilitation plan at the earliest possible moment. PMR consultations also help to identify other comorbidities such as peripheral neuropathies, fractures, and mild traumatic brain injuries that might not yet have been identified during the initial acute phase of inpatient treatment. In addition to providing comprehensive rehabilitative care plans, it is customary for PMR consultations to provide recommendations for pain management, bowel and bladder management, and strategies for avoiding complications of immobility such as deep venous thrombosis, skin breakdown, or contracture formation. These consultations also ensure coordination with social work services and allied health professionals for appropriate disposition, which can include transition to an inpatient rehabilitation service.

The primary goal of the PMR consultation is to ensure the holistic management of the patient and that all strategies for restoring optimal function are being considered.

Telehealth promises to transform the way healthcare is practiced and delivered. Nowhere is this more apparent than in northwest Alaska, where telehealth has bridged the gap between providers in remote villages and specialists who can provide expanded care to rural patients.

The Northwest Arctic Borough of Alaska includes 11 remote villages; healthcare facilities in each community have minimal capabilities. The district is roughly the size of Indiana and has a population of approximately 7,600. With no roads connecting it with the rest of Alaska–and no roadways connecting any of the villages with each other–travel is limited to boat or small plane, weather permitting. This region is located far above the Arctic Circle, where temperatures reach 50 degrees below zero and more than 40 inches of snow fall each year.

In the past, rural patients who needed immediate treatment had to travel to the nearest health center, about 200 miles away, via Medivac aircraft. Now, through telehealth technology and a network provided by GCI ConnectMD, patients in these rural communities have access to specialty care, greatly expanding treatment options and improving the quality of care.

The Maniilaq Association

Small, disparate communities in rural Alaska must pool resources and apply for federal funding to gain access to technology that can expand the boundaries of their isolated villages. As a result, people in northwest Alaska formed the Maniilaq Association, which provides health and social services to people within the borough. A nonprofit corporation, the Maniilaq Association represents 12 federally recognized tribes.

The town of Kotzebue, with a population of 3,082 people, serves as the regional center for 11 remote villages. These villages range in size from tiny Kobuk, with 109 people, to Point Hope, with a population of about 1,000. Maniilaq manages a health center in Kotzebue, which is the primary healthcare facility for the residents of the borough, as well the village clinics. The next nearest healthcare facility that offers comparable service is more than 600 miles away. The village clinics are staffed by two to five community health practitioners who have undergone training similar to EMTs.