Managing and redesigning the continuum of care: the value chain model.

Systems of care have to be managed, measured, and continuously improved. In the current health care environment, the integration of clinical medicine, systems thinking, and quality management disciplines provides needed tools and skills and identifies key leverage points and learning opportunities to improve the quality of services delivered. This article presents the value chain model and plan, designed to assist managers, physicians, and organizations in managing and redesigning the continuum of care.

Description of case-mix adjusters by the Severity of Illness Working Group of the Society of Hospital Epidemiologists of America (SHEA).

Hospitals, insurance companies, and federal and state governments are increasingly concerned about reducing patient cost expenditures while maintaining high quality patient care. One method of reducing expenditures has been to tie hospital reimbursement with a prospective payment system based on diagnosis-related groups (DRGs). However, reimbursement under the DRG system is not acceptable for all patients in all hospitals because it is neither an accurate predictor of costs nor of clinical outcome.

Loiasis and renal failure.

A patient with a filarial infection due to Loa loa and renal failure was treated with a modified regimen of diethylcarbamazine while receiving hemodialysis. Infection with Loa loa may be associated with glomerulonephritis due to immunologically mediated injury. Serum immune complexes were elevated in our patient, and a kidney biopsy specimen revealed globally sclerosed glomeruli.

Cutaneous mycobacteriosis: analysis of 34 cases with a new classification of the disease.

Several points can be made from analysis of the published cases of cutaneous mycobacteriosis and those in our series: 1) mycobacterial cutaneous infections are probably more common than is reported-we collected 34 cases over a 10-year period; 2) most patients with cutaneous infections caused by nontuberculous mycobacteria have significant underlying disease; 3) there is a relative lack of classic histologic features in patients with cutaneous mycobacteriosis, and there appear to be diverse forms of clinical presentation; 4) a high index of suspicion is needed in evaluating patients with possible cutaneous mycobacteriosis, and appropriate cultures must be done to establish the diagnosis. In attempting to provide a practical classification of cutaneous mycobacteriosis which includes infection by nontuberculous mycobacteria, we propose the following grouping, which uses simple terms, avoids confusing nomenclature, and incorporates pathophysiologic descriptions and prognostic information: 1) Mycobacteriosis caused by inoculation from an exogenous source. 2) Cutaneous mycobacteriosis caused by spread from an endogenous source.

The accuracy of diagnosing pulmonary tuberculosis at a teaching hospital.

Accuracy of the clinical diagnosis of tuberculosis and of the mycobacteriology laboratory test results was assessed in a teaching hospital by reviewing clinical and microbiologic data on patients from whom Mycobacterium tuberculosis had been recovered. Mycobacteria were isolated in 230 of 6,550 specimens (3.5%).

Human pulmonary pasteurellosis.

Pasteurella multocida causes hemorrhagic septicemia in many domestic and wild animals. The most common human infection with P multocida is a local cellulitis following animal-inflicted wounds, preponderantly cat bites and scractches. The typical clinical manifestations and complications have been well described previously.

Successful treatment of invasive pulmonary aspergillosis in the immunocompromised host.

We have reported the successful treatment of a patient with acute leukemia complicated by pulmonary aspergillosis, a commonly fatal situation. Specific diagnosis was obtained easily by transbronchial lung biopsy. Our therapeutic approach included aggressive treatment of both the underlying malignant process and the aspergillosis with a combination of amphotericin B and rifampin.

Fatal pneumonitis and septicemia after fiberoptic bronchoscopy.

This report describes the development of fatal pneumococcal pneumonia and septicemia following fiberoptic bronchoscopic examination and endobronchial biopsy of a patient with severe chronic congestive heart failure. Although a causal relationship has not been proven, the temporal sequence seems to favor this over a coincidental nosocomial infection. This case emphasizes that significant and occasionally fatal infectious complications may occur following fiberoptic bronchoscopic examination.