- Email: [email protected]
High-Technology Home Care
changes in acute infarction also bear only a modest correlation with extent of myocardium at risk of infarction. 11 These studies have used the standard ECG, and it is unclear whether different lead systems or more extensive ECG mapping can better predict infarct size or area at risk of infarction. The ST changes observed on standard ECGs proved unsatisfactory in some studies 12 for the prediction of infarct-related artery patency after thrombolysis, yet prompt resolution of ST elevation associated with an intervention often predicts a patent infarct-related artery. This discrepancy points out the value of continuous ECG observation for the detection of patency of the infarct-related artery. 13 Continuous observation of the ST segment on the standard ECG or of the QRS and ST vector magnitude of vectorcardiograms has been suggested to be very valuable in prediction of infarct-related artery patency. 13· 14 The observations of Birnbaum et a! are valuable for two reasons. First, they may identify a high-risk population of patients with acute myocardial infarction who warrant aggressive management. Second, their observations indicate that the ECG may contain more information than meets the eye and that the ECG should be reassessed in light of the information obtained during the thrombolytic era. Ian P. Clements, M.D. Rochester, Minnesota Division of Cardiovascular Diseases, Mayo Clinic. Reprint requests: Dr. Clements, Mayo Clinic, Rochester, MN 55905 REFERENCES
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Blanke H, Von Hardenberg D, Cohen M, Kaiser H, Karsch KR, Holt J, et al. Patterns of creatine kinase release during acute myocardial infarction after non-surgical reperfusion: comparison with conventional treatment and correlation with infarct size. J Am Coli Cardiol 1984; 3:675-80 Miller TD, Gersh BJ, Christian TF, Bailey KR, Gibbons RF. Limited value of post-infarction thallium treadmill testing in the thrombolytic era [abstract]. Circulation 1992; 86(suppl I):l137 Braunwald E. Maroko PR. ST-segment mapping: realistic and unrealistic expectations [editorial] . Circulation 1976; 54:529-32 Holland RP, Arnsdorf MF. Solid angle theory and the electrocardiogram: physiologic and quantitative interpretations. Prog Cardiovasc Dis 1977; 19:431-57 Gibbons RJ, Verani MS, Behrenbeck T. Feasibility of tomographic Tc-99m-hexakis-2 methoxy-2 methylpropyl-isonitrile imaging for the assessment of myocardial area at risk and the effect of acute treatment in myocardial infarction. Circulation 1989; 80:1277-86 TIMI Study Group. Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction: results of the Thrombolysis in Myocardial Infarction (TIMI) phase II trial. N Eng! J Med 1989; 320:618-27 Christian TF, Clements IP, Gibbons RJ. Non-invasive identification of myocardium at risk in patients with acute myocardial infarction and non-diagnostic electrocardiograms with technetium-99m sestamibi. Circulation 1991; 83:1615-20
8 Schamroth L. The electrocardiography of coronary artery disease. Oxford, England: Blackwell Scientific Publications, 1975 9 Erhardt LR, Sjogren A, Wah berg I. Singleright-sided precordial lead in the diagnosis of right ventricular involvement in inferior myocardial infarction. Am Heart J 1976; 91:571-76 10 Hindman N, Grande P, Harrell FE, Anderson CE, Harrison D, Ideker RE, et al. Relation between electrocardiographic and enzymatic methods of estimating acute myocardial infarct size. Am J Cardiol 1986; 58:31-5 11 Clements IP, Kaufmann UP, Bailey KR, Pellikka PA, Behrenbeck T, Gibbons RJ. Electrocardiographic prediction of myocardial area at risk. Mayo Clin Proc 1991; 66:985-90 12 Califf RM, O'Neill W, Stack RS, Aronson L, Mark DB, Mantell S, et al. Failure of simple clinical measurements to predict perfusion status after intravenous thrombolysis. Ann Intern Med 1988; 108:658-62 13 Krucoff MW, Green CE, Sather LF, Miller FC, Pallas RS, Kent KM, et al. Noninvasive detection of coronary artery patency using continuous ST-segment monitoring. Am J Cardiol 1986; 57:916-22 14 Dellborg M, Topol EJ, Swedberg K. Dynamic QRS complex and ST segment vectorcardiographic monitoring can identify vessel patency in patients with acute myocardial infarction treated with reperfusion therapy. Am Heart J 1991; 122:943-48
High-Technology Home Care The Need for a Creative Management Approach care units with finite capacity have been C ritical constrained by excessive length of stay of patients
who failed withdrawal from life-sustaining technology and achieved medical stability on prolonged support. Centers experienced with long-term mechanical ventilation have developed programs to select home-care candidates according to stricr criteria, to prepare them and their families with essential education and training, and to discharge them home safely from expensive acute-care settings. 1·8 As DeWitt eta! outline in their article in the May, 1993 issue of Chest (103:1560), despite years of experience, current resource management results in enormous waste due to misapplication, creating obstacles to discharge from hospital to home. High-technology home care (HTHC) has been the subject of much study and public debate. 9· 12 Public policy in the United States has struggled with financial concerns since President Reagan highlighted the plight of Katie Beckett, a ventilator-assisted child denied home care by bureaucratic red tape (New York Times, Nov 11, 1981). For the past decade, public funders have preferred to limit financial risk for HTHC by strict waivers from Medicaid regulations. Sources of private funding have limited reimbursement for HTHC by applying rigid cost-control strategies or by denying approval of needed benefits. Public regulatory policies and private reimbursement have limited access according to entry criteria and reduced flexibility, which individual complex home-care cases require. Editorials
Current management approaches to HTHC are not working; it is time for a change! All nations are facing escalating health-care expenditures, competing with other priorities for restricted resources. One prominent reason for uncontainable costs is the development and application of advanced life-sustaining technologies.13·14 All nations must meet challenges to adapt existing health systems to new, evolving needs. Growing numbers of the elderly, persons with chronic disabilities, and others with new concerns (such as AIDS patients and babies of addicted mothers) require health care from systems established from industrial-era models focused on acute care, which may not be appropriate for these new demands. Nations are searching for new nontraditional approaches to health-care delivery systems; such issues were highlighted at a recent international summit held for German health-system planning.15 Home care must compete for restricted financial resources in global health-care reform. Although most growth is being driven by the increasing proportion of elderly persons as a percentage of the total population, care for homebound elderly persons is only one component of home care, as shown by a recent survey of home-care physicians 16 Home-care applications of high technology for persons with long-term conditions requiring supplemental care givers will be at greatest risk in future health-care reform unless more creative management approaches are designed. In the United States today, HTHC is provided without an integrated management system. Sources of payment and services are fragmented and uncoordinated. Consequently, as DeWitt et al point out, operational inefficiencies result in cost inefficiencies, such as unacceptable delay in hospital discharge due to the mandatory prior approval funding process. In the past delivered at dramatic cost savings,17 HTHC may now cost more than long-term care alternatives, resulting in denial of the home care option-this despite the knowledge of quality, cost-effective HTHC models abroad and other creative management solutions.18'22 High-technology home care must and can be developed by creative management approaches that can deliver services within defined financial limits. It is vital that HTHC be given the opportunity to develop such model approaches, or it will not survive global reform. Cost overruns will lead some to question the ethical application of life-sustaining technology and utilization of resources for patients who could benefit when others are denied access to more basic care. Allen I. Goldberg, M.D. , F.C.C.P. Maywood, Illinois Professor of Pediatrics, Loyola University Stritch School of Medicine, and Director. Peaiatric Home Health, Loyola University Medical Center. Reprint requests: Dr. Goldberg, Director, Pediatric Home Health, Loyola University Medical Center, Maywood, IL 60153
REFERENCES
1 Burr BH, Guyer B, Todres ID, Abraham B. Chiode T . Home care for children on respirators. N Eng! J Med 1983; 309:131923 2 Goldberg A, Noah Z. Fleming M, Staniek L, Childs B, Frost L, et al. Quality of care for children who require prolonged ventilation. QRB 1987; 13:81-8 3 Frates RC, Splaingard ML, Harrison GM. Outcome of home mechanical ventilation for children. J Pediatr 1985; 106:850-56 4 Make B, Gilmartin M, Brody J, Snider GL. Rehabilitation of ventilator-dependent individuals with lung disease: the concept and initial experience. Chest 1984; 86:358-65 5 Schreiner MS, Donar ME, Kettrick RG. Pediatric home mechanical ventilation. Pediatr Clin North Am 1987; 34(1):47-60 6 Gilgoff I, Kahlstrom E, MacLaughlin E, Keens TG. Long-term ventilatory support in spinal muscular atrophy. J Pediatr 1989; 115:904-09 7 Bach J, Alba A, Pilkington LA, Lee M. Long-term rehabilitation in advanced stage of childhood onset, rapidly progressive muscular dystrophy. Arch Phys Med Rehabil 1981; 62:328-31 8 O'Donohue WJ, Giovannoni RM , Goldberg AI, Keens TG, Make BJ, Plummer AL, et al. Long-term mechanical ventilation: guidelines for management in the home and at alternative community sites. Chest 1986; 90(supp1):1S-37S 9 Report of the Surgeon General's Workshop: children with handicaps and their families-case-example: the ventilatordependent child. Washington DC: US Department of Health and Human Services, 1983; PHS-83-50194 10 US Congress, Office of Technology Assessment. Technology dependent children: hospital vs. home care=ma technical memorandum. Washington, DC: US Government Printing Office, 1987; OTA-TM-H-38 11 US Congress, Office of Technology Assessment. Life sustaining technologies and the elderly. Washington, DC: US Government Printing Office, 1987; OTA-BA-306 12 US Department of Health and Human Services. Report of the Task Force on Technology Dependent Children (vols 1 and 2). Washington DC: US Government Printing Office, 1988; HCFA 88-021271 13 Institute of Medicine. Assessing medical technology. Washington, DC: National Academy Press, 1985 14 Weisbrod BA. The health care quadrilemma: An essay on technology change, insurance, quality of care and cost containment. J Econ Lit 1991; 29:523-52 15 Cologne, Germany: Max-Pianck-Institut fiir Gesellschaftsforchung, November 1990 16 Goldberg AI. What is a home care physician? Am Acad Home Care Physicians Newsletter 1991; 3(3):1, 5-7 17 Goldberg A, Faure EAM , Vaughn CJ, Snarksi R, Seleny F. Home care for life-supported persons: an approach to program development. J Pediatr 1984; 104:785-95 18 Goldberg AI, Faure EAM . Home care for life-supported persons in England: the Responaut program. Chest 1984; 86:910-14 19 Goldberg AI, Faure EAM. Home care for life supported persons in France: the regional association. Rehabil Lit 1986; 47(3-4):6084, 103 20 Goldberg AI. Home care for life supported persons: the French system of quality control, technology assessment, and cost containment. Public Health Rep 1989; 104:329-36 21 Goldberg AI, Alba AA, Oppenheimer EA, Roberts E. Caring for mechanically ventilated patients at home [letter] . Chest 1990; 98:1543 22 Goldberg AI. Mechanical ventilation and respiratory care in the home in the 1990's. Respir Care 1990; 35:247-59 CHEST I 105 I 1 I JANUARY, 1994
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Blanke H, Von Hardenberg D, Cohen M, Kaiser H, Karsch KR, Holt J, et al. Patterns of creatine kinase release during acute myocardial infarction after non-surgical reperfusion: comparison with conventional treatment and correlation with infarct size. J Am Coli Cardiol 1984; 3:675-80 Miller TD, Gersh BJ, Christian TF, Bailey KR, Gibbons RF. Limited value of post-infarction thallium treadmill testing in the thrombolytic era [abstract]. Circulation 1992; 86(suppl I):l137 Braunwald E. Maroko PR. ST-segment mapping: realistic and unrealistic expectations [editorial] . Circulation 1976; 54:529-32 Holland RP, Arnsdorf MF. Solid angle theory and the electrocardiogram: physiologic and quantitative interpretations. Prog Cardiovasc Dis 1977; 19:431-57 Gibbons RJ, Verani MS, Behrenbeck T. Feasibility of tomographic Tc-99m-hexakis-2 methoxy-2 methylpropyl-isonitrile imaging for the assessment of myocardial area at risk and the effect of acute treatment in myocardial infarction. Circulation 1989; 80:1277-86 TIMI Study Group. Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction: results of the Thrombolysis in Myocardial Infarction (TIMI) phase II trial. N Eng! J Med 1989; 320:618-27 Christian TF, Clements IP, Gibbons RJ. Non-invasive identification of myocardium at risk in patients with acute myocardial infarction and non-diagnostic electrocardiograms with technetium-99m sestamibi. Circulation 1991; 83:1615-20
8 Schamroth L. The electrocardiography of coronary artery disease. Oxford, England: Blackwell Scientific Publications, 1975 9 Erhardt LR, Sjogren A, Wah berg I. Singleright-sided precordial lead in the diagnosis of right ventricular involvement in inferior myocardial infarction. Am Heart J 1976; 91:571-76 10 Hindman N, Grande P, Harrell FE, Anderson CE, Harrison D, Ideker RE, et al. Relation between electrocardiographic and enzymatic methods of estimating acute myocardial infarct size. Am J Cardiol 1986; 58:31-5 11 Clements IP, Kaufmann UP, Bailey KR, Pellikka PA, Behrenbeck T, Gibbons RJ. Electrocardiographic prediction of myocardial area at risk. Mayo Clin Proc 1991; 66:985-90 12 Califf RM, O'Neill W, Stack RS, Aronson L, Mark DB, Mantell S, et al. Failure of simple clinical measurements to predict perfusion status after intravenous thrombolysis. Ann Intern Med 1988; 108:658-62 13 Krucoff MW, Green CE, Sather LF, Miller FC, Pallas RS, Kent KM, et al. Noninvasive detection of coronary artery patency using continuous ST-segment monitoring. Am J Cardiol 1986; 57:916-22 14 Dellborg M, Topol EJ, Swedberg K. Dynamic QRS complex and ST segment vectorcardiographic monitoring can identify vessel patency in patients with acute myocardial infarction treated with reperfusion therapy. Am Heart J 1991; 122:943-48
High-Technology Home Care The Need for a Creative Management Approach care units with finite capacity have been C ritical constrained by excessive length of stay of patients
who failed withdrawal from life-sustaining technology and achieved medical stability on prolonged support. Centers experienced with long-term mechanical ventilation have developed programs to select home-care candidates according to stricr criteria, to prepare them and their families with essential education and training, and to discharge them home safely from expensive acute-care settings. 1·8 As DeWitt eta! outline in their article in the May, 1993 issue of Chest (103:1560), despite years of experience, current resource management results in enormous waste due to misapplication, creating obstacles to discharge from hospital to home. High-technology home care (HTHC) has been the subject of much study and public debate. 9· 12 Public policy in the United States has struggled with financial concerns since President Reagan highlighted the plight of Katie Beckett, a ventilator-assisted child denied home care by bureaucratic red tape (New York Times, Nov 11, 1981). For the past decade, public funders have preferred to limit financial risk for HTHC by strict waivers from Medicaid regulations. Sources of private funding have limited reimbursement for HTHC by applying rigid cost-control strategies or by denying approval of needed benefits. Public regulatory policies and private reimbursement have limited access according to entry criteria and reduced flexibility, which individual complex home-care cases require. Editorials
Current management approaches to HTHC are not working; it is time for a change! All nations are facing escalating health-care expenditures, competing with other priorities for restricted resources. One prominent reason for uncontainable costs is the development and application of advanced life-sustaining technologies.13·14 All nations must meet challenges to adapt existing health systems to new, evolving needs. Growing numbers of the elderly, persons with chronic disabilities, and others with new concerns (such as AIDS patients and babies of addicted mothers) require health care from systems established from industrial-era models focused on acute care, which may not be appropriate for these new demands. Nations are searching for new nontraditional approaches to health-care delivery systems; such issues were highlighted at a recent international summit held for German health-system planning.15 Home care must compete for restricted financial resources in global health-care reform. Although most growth is being driven by the increasing proportion of elderly persons as a percentage of the total population, care for homebound elderly persons is only one component of home care, as shown by a recent survey of home-care physicians 16 Home-care applications of high technology for persons with long-term conditions requiring supplemental care givers will be at greatest risk in future health-care reform unless more creative management approaches are designed. In the United States today, HTHC is provided without an integrated management system. Sources of payment and services are fragmented and uncoordinated. Consequently, as DeWitt et al point out, operational inefficiencies result in cost inefficiencies, such as unacceptable delay in hospital discharge due to the mandatory prior approval funding process. In the past delivered at dramatic cost savings,17 HTHC may now cost more than long-term care alternatives, resulting in denial of the home care option-this despite the knowledge of quality, cost-effective HTHC models abroad and other creative management solutions.18'22 High-technology home care must and can be developed by creative management approaches that can deliver services within defined financial limits. It is vital that HTHC be given the opportunity to develop such model approaches, or it will not survive global reform. Cost overruns will lead some to question the ethical application of life-sustaining technology and utilization of resources for patients who could benefit when others are denied access to more basic care. Allen I. Goldberg, M.D. , F.C.C.P. Maywood, Illinois Professor of Pediatrics, Loyola University Stritch School of Medicine, and Director. Peaiatric Home Health, Loyola University Medical Center. Reprint requests: Dr. Goldberg, Director, Pediatric Home Health, Loyola University Medical Center, Maywood, IL 60153
REFERENCES
1 Burr BH, Guyer B, Todres ID, Abraham B. Chiode T . Home care for children on respirators. N Eng! J Med 1983; 309:131923 2 Goldberg A, Noah Z. Fleming M, Staniek L, Childs B, Frost L, et al. Quality of care for children who require prolonged ventilation. QRB 1987; 13:81-8 3 Frates RC, Splaingard ML, Harrison GM. Outcome of home mechanical ventilation for children. J Pediatr 1985; 106:850-56 4 Make B, Gilmartin M, Brody J, Snider GL. Rehabilitation of ventilator-dependent individuals with lung disease: the concept and initial experience. Chest 1984; 86:358-65 5 Schreiner MS, Donar ME, Kettrick RG. Pediatric home mechanical ventilation. Pediatr Clin North Am 1987; 34(1):47-60 6 Gilgoff I, Kahlstrom E, MacLaughlin E, Keens TG. Long-term ventilatory support in spinal muscular atrophy. J Pediatr 1989; 115:904-09 7 Bach J, Alba A, Pilkington LA, Lee M. Long-term rehabilitation in advanced stage of childhood onset, rapidly progressive muscular dystrophy. Arch Phys Med Rehabil 1981; 62:328-31 8 O'Donohue WJ, Giovannoni RM , Goldberg AI, Keens TG, Make BJ, Plummer AL, et al. Long-term mechanical ventilation: guidelines for management in the home and at alternative community sites. Chest 1986; 90(supp1):1S-37S 9 Report of the Surgeon General's Workshop: children with handicaps and their families-case-example: the ventilatordependent child. Washington DC: US Department of Health and Human Services, 1983; PHS-83-50194 10 US Congress, Office of Technology Assessment. Technology dependent children: hospital vs. home care=ma technical memorandum. Washington, DC: US Government Printing Office, 1987; OTA-TM-H-38 11 US Congress, Office of Technology Assessment. Life sustaining technologies and the elderly. Washington, DC: US Government Printing Office, 1987; OTA-BA-306 12 US Department of Health and Human Services. Report of the Task Force on Technology Dependent Children (vols 1 and 2). Washington DC: US Government Printing Office, 1988; HCFA 88-021271 13 Institute of Medicine. Assessing medical technology. Washington, DC: National Academy Press, 1985 14 Weisbrod BA. The health care quadrilemma: An essay on technology change, insurance, quality of care and cost containment. J Econ Lit 1991; 29:523-52 15 Cologne, Germany: Max-Pianck-Institut fiir Gesellschaftsforchung, November 1990 16 Goldberg AI. What is a home care physician? Am Acad Home Care Physicians Newsletter 1991; 3(3):1, 5-7 17 Goldberg A, Faure EAM , Vaughn CJ, Snarksi R, Seleny F. Home care for life-supported persons: an approach to program development. J Pediatr 1984; 104:785-95 18 Goldberg AI, Faure EAM . Home care for life-supported persons in England: the Responaut program. Chest 1984; 86:910-14 19 Goldberg AI, Faure EAM. Home care for life supported persons in France: the regional association. Rehabil Lit 1986; 47(3-4):6084, 103 20 Goldberg AI. Home care for life supported persons: the French system of quality control, technology assessment, and cost containment. Public Health Rep 1989; 104:329-36 21 Goldberg AI, Alba AA, Oppenheimer EA, Roberts E. Caring for mechanically ventilated patients at home [letter] . Chest 1990; 98:1543 22 Goldberg AI. Mechanical ventilation and respiratory care in the home in the 1990's. Respir Care 1990; 35:247-59 CHEST I 105 I 1 I JANUARY, 1994
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