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By H. Gunock. Spertus College.

The decades from World War II through the implementation of Medicare are gen- erally considered American medicine’s “golden age toprol xl 100mg generic. Dramatic increases in malprac- tice litigation toward the end of this period arguably sought to justify the public’s trust order toprol xl 25mg without a prescription. Lawsuits imposed real emotional and reputational costs on defendants but seldom constituted a severe financial burden toprol xl 100 mg amex. As studies from the 1980s demonstrated toprol xl 25 mg lowest price, even substantial increases in liability insurance premiums were quickly passed through to patients and payers as higher fees (6 order toprol xl 100mg online,7). By contrast, the current malpractice crisis follows nearly two decades of sustained effort to rein in health care spending. Cost-based reimbursement and “usual and customary” fees are, in most cases, distant memories. Medicare pays administrative prices that are not responsive to unexpected jumps in short-term input costs for providers. Private health insurers are equally reluctant to renegotiate provider contracts. Lack of these safety valves potentially impairs access to care for patients in already underserved communities if hospitals or physi- cians find liability insurance unaffordable. Even in areas where the supply of physicians and hospitals remains high, the health care system is less financially resilient and a malpractice crisis can seriously disrupt medical careers and therapeutic relationships. Cost containment has also had important direct effects on malprac- tice exposure and on physicians’ reactions to it. Higher throughput to maintain revenue, greater delegation of tasks to nonprofessional staff, and complex administrative systems of managed care oversight all increase risk of error, and the undercurrent of financial motivation makes patients less trusting and more litigious. Against this backdrop of cost-containment, a widening malpractice crisis epitomizes physi- cians’ growing sense that they have lost control over their professional lives. This strikes physicians as particularly unfair because tort law still attributes to them a much higher degree of clinical autonomy and authority than their day-to-day experiences suggest. The litigation process is too slow, too costly, too uncertain, and too unpleasant. Premiums for primary liability coverage are too volatile and, for some physicians, too expensive. Excess coverage and reinsurance are becoming unaffordable for hospitals and other medical institutions. EXPOSED WEAKNESSES IN THE MALPRACTICE SYSTEM The pressures described in the preceding section have exposed major weaknesses in the way that allegations of medical malpractice are handled. Much like the American health care system itself, the mal- practice system is a patchwork of historically derived institutions and practices rather than a product of careful deliberation or rational social choice. The malpractice system has three basic goals: (a) reducing rates of iatrogenic injury (“deterrence”), (b) relieving the burden on those who have suffered such injury (“compensation”), and (c) distinguish- ing blameless from blameworthy conduct (“justice”). In pursuit of these goals, liability is filtered through three functional components of the malpractice system: patient care, legal process, and liability insurance (8,9). Available evidence indicates that all three com- ponents fall well short of ideal performance (see Table 1). Optimal levels of patient safety are achievable only if the health care system has clear, consistent incentives to gather information about errors, process that information into prevention strategies, coordinate the actions of individual and institutional providers, and communicate effectively with patients. The legal system should provide these incentives by exposing instances of iatrogenic injury, demanding persuasive evidence of avoidability, and awarding damages consistent with loss. The insur- ance markets should support the legal system by offering peace of mind to careful physicians and making compensation available to victims. Insurers should dispose of meritless claims, help providers improve their safety records, and weed out the worst offenders. Chapter 17 / New Directions in Liability Reform 255 Patient Care AVOIDABLE INJURIES The tort reform movement of the 1970s and 1980s was based on two related beliefs: (a) few incidents of actual negligence occur in health care, and (b) most litigation reflects social and financial influences apart from medical quality (10). Subsequent research, much of which is a direct outgrowth of public interest in malpractice reform, largely confirmed the second perception but refuted the first. The Harvard Medical Practice Study (HMPS) reviewed medical records from hos- pitalizations in New York State during 1984 and looked for associated liability claims; it concluded that roughly six unfounded claims were filed for every meritorious one (11). In a follow-up study, the severity of the plaintiff’s condition, not negligence or even medical causation, was the strongest predictor of payment through the legal system for cases evaluated by the HMPS (12).

A general guide for describing the depend on the degree and type of sen- degrees of hearing loss associated with sorineural damage cheap 25 mg toprol xl amex. Duration of Loss or Age of Onset Another classification of hearing loss is Table 5–1 Functional Implications of Degrees based on when the hearing loss occurred: of Decibel Loss • Prelingual hearing loss occurs before 26–40 Mild hearing loss order toprol xl 100mg free shipping. In ideal listening the individual acquires language buy 100 mg toprol xl amex, usu- conditions safe toprol xl 100mg, hearing is minimally ally before the age of 3 cheap toprol xl 25 mg fast delivery. Degree of Hearing Loss Hears loud conversational speech that is close by. Has difficulty Hearing loss can also be classified hearing in group situations. Conversational • Hard of hearing refers to individuals speech severely affected. May hear (or feel from usually have difficulty understanding than 90 vibrations) only very loud sounds. Hearing loss may be congenital or The type and degree of hearing loss ex- acquired. Congenital hearing loss is present perienced by individuals, regardless of the at birth. Hearing loss usually hearing loss are genetic transmission (inheri- involves more than a reduction in the ted hearing loss), caused by the mother’s loudness of sound. Some hearing losses prenatal ingestion of drugs that are harm- also result in a distortion of sound so that ful to the developing auditory system of words may be heard but are difficult to the fetus or prenatal exposure to in- understand or are garbled. The degree, pro- may develop recruitment, a symptom gression, and age of onset of inherited characterized by an abnormally rapid in- hearing loss vary widely, depending on crease in the perception of loudness with the specific condition or syndrome. Individuals some instances, genetics may not cause with recruitment have a narrow range deafness per se but rather predispose in- between a level of sound loud enough to dividuals to hearing loss induced by be understood and a level of sound that noise, drugs, or infection (Steel, 2000). Unexpected many instances hearing loss is multifacto- sounds may startle individuals with re- rial, caused by both genetic and environ- cruitment and distract them from inter- mental factors (Williams, 2000). There- Acquired hearing loss occurs after birth or fore, increasing the loudness of sound later in life. There are a number of causes does not correct the hearing problem and of acquired hearing loss. Noise-induced hearing loss is a com- Conditions of the Outer Ear mon but preventable type of acquired hearing loss. Avoiding loud noises or wear- Conditions of the outer ear can con- ing ear protectors when exposed to loud tribute to hearing loss when there is an noise could drastically reduce the inci- obstruction that disrupts the mechanical dence of noise-induced hearing loss. Although conditions of injury or disease, such as from traumatic the outer ear may not have a major impact brain injury or from multiple sclerosis on hearing or may be correctable, they affecting the auditory pathway. Presby- may also be disfiguring, causing cosmetic cusis (hearing loss associated with aging) concerns. The extent to the outer ear can result from congenital which degeneration of portions of the au- conditions or from trauma. Other condi- ditory system is due to the aging process tions of the outer ear that may impede Hearing Loss and Deafness 149 hearing are buildup of earwax (cerumen), Because of the proximity of the mastoid foreign bodies in the ears, or growths (e. Com- as it once was because of the earlier detec- plete occlusion, however, generally results tion of otitis media and treatment with in a low to moderate conductive loss. Con- antibiotics; however, chronic mastoiditis ditions of the outer ear that cause tempo- and associated complications can result if rary conductive hearing impairments can previous ear infections are left untreated. Otosclerosis Conditions of the Middle Ear Otosclerosis is a hardening of the ossi- cles (incus, stapes, and malleus of the mid- Conditions of the middle ear may cause dle ear), which transmit sound impulses temporary or permanent hearing loss. Early symptoms may in- clude trouble hearing on the telephone Perforated Tympanic Membrane but not in crowds. It causes conduc- A thickened or perforated tympanic mem- tive hearing loss because hardening of the brane (ruptured eardrum) may or may not ossicles reduces the efficiency of the trans- impair hearing. Some individuals may also have vestibular symptoms such as ver- Otitis Media tigo (dizziness) or impaired equilibrium. Individuals with otosclerosis often hear Otitis media (inflammation and fluid amplified speech well and without distor- buildup in the middle ear) can cause con- tions; consequently, they are usually good ductive hearing losses because of collec- candidates for hearing aids. Hearing can tion of fluid in the middle ear or because also often be restored or improved with of damage to the tympanic membrane (ear- surgical intervention; however, surgery drum) as a result of infection or rupture. When de- Usually, with appropriate treatment, per- termining if surgery is appropriate, indi- manent hearing loss will not result.

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Individ- help the individual improve or stabilize uals as well as family members may feel motor ability generic toprol xl 25 mg online, prevent contractures cheap toprol xl 50mg without prescription, or helpless and hopeless cheap toprol xl 25 mg free shipping. As a result buy toprol xl 25mg with amex, they adapt the environment to promote safe- may be reluctant to participate in activi- ty and maximum independence order toprol xl 50mg overnight delivery. Occupa- ties designed to maintain or improve their tional therapists may help individuals current level of function. Speech therapists ed to behavioral changes may result in may help individuals maximize their unsafe situations for the individual. Those speech capability as well as their ability to who are in denial about their condition swallow. In some instances cognitive and their limitations may also be exposed retraining and memory training may be to situations that could result in unsafe useful. Individuals are usually affected in cult, social interactions also become more middle or later life, with males affected difficult, resulting in increasing social iso- more frequently than women. Personality changes that may pro- duce violent or hostile behaviors further Manifestations of ALS stress support systems. Because Huntington’s disease has a Symptoms of ALS depend on the area of genetic component, family members may the nervous system affected; both upper be under the additional stress of knowing and lower extremities are affected. There that they may themselves be at risk for are two primary forms of ALS: developing Huntington’s disease. Coun- • Spinal form seling, education, and support can help to • Bulbar form reduce the stress that family members may be experiencing. The spinal form of ALS is characterized by muscular weakness, muscle atrophy Vocational Issues in Huntington’s Disease (decrease in size), spasticity, and hyperac- tive reflexes. Individuals may first com- Huntington’s disease is a progressive, plain of tripping, stumbling, or awk- degenerative disease; however, in the ear- wardness when walking or running. In the bulbar condition progresses and individuals have form individuals may first notice difficul- increasing difficulty with memory, com- ty in breathing, slurring of speech or low- munication skills, and physical ability, ered volume when speaking, or difficulty sheltered employment may be the most with swallowing. As the condition progresses, symptoms become worse, spreading to other parts of Amyotrophic Lateral Sclerosis the body so that eventually, whether the (ALS; Lou Gehrig’s Disease) individual first experienced the bulbar or spinal form of ALS, he or she eventually Amyotrophic lateral sclerosis (ALS), also experiences all the symptoms. Individuals sometimes referred to as Lou Gehrig’s dis- become increasingly weak and immobile. They may experience respiratory mus- current medical theory suggests a multi- cle weakness leading to breathing factorial etiology that may include genet- problems, and in later stages of the con- ic, viral, autoimmune, and neurotoxic fac- dition they may require ventilatory assis- Neuromuscular Conditions 101 tance in order to breathe. Cognitive func- Psychosocial Issues in ALS tion, sensation, vision, hearing, and bow- el and bladder function are usually not The social, economic, and psychologi- affected. It is common for individuals with ALS to Diagnosis of ALS experience fear, anxiety, and depression, especially as the condition progresses There is no reliable laboratory test to and the individual recognizes rapid pro- detect the presence of ALS. Diagnosis is gressive deterioration of physical func- usually based on the symptoms the indi- tion. Because of loss of mobility and in- vidual exhibits and their progression and creased dependency, feelings of helpless- the individual’s medical history, and by ness and powerlessness are also common. Some individuals may experience discour- agement and become angry as their phys- Treatment and Management of ALS ical limitations increase. They may ex- perience grief with each subsequent loss of There is no cure for ALS, and no effec- function. There may be loss in social rela- tive treatment is currently available. They may feel vidual with ALS to remain independent as guilty because of their increased depend- long as possible, be comfortable, and ence on others and may express concern avoid complications. Treatment of symp- and frustration over the burden they feel toms is used to maintain muscle function, is being placed on family members. Medications to reduce Since individuals with ALS need sub- spasticity may be used; however, these stantial help with most activities of daily can also increase muscle weakness and living, family members most often find cause sedation. Physical therapy may be themselves in a caregiving role even in helpful to maintain function and to the early stages of the individual’s condi- reduce the painful symptoms brought on tion. If the individ- Occupational therapists can provide sup- ual with ALS is also the major breadwin- port and help individuals to adapt their ner, financial issues may become a major environment in order to maximize func- concern.

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Outcome of endoscopy and barium radiography for acute upper gastrointestinal bleeding: controlled trial in 1037 patients discount toprol xl 25mg without a prescription. The value of antenatal cardiotocography in the management of high risk pregnancy: a randomised controlled trial purchase 100mg toprol xl with visa. A randomised controlled trial of non-stress antepartum cardiotocography trusted 100mg toprol xl. Diagnostic efficacy of impedance phletysmography for clinically suspected deep-vein thrombosis discount toprol xl 50 mg with mastercard. Reduction in mortality from breast cancer after mass screening with mammography toprol xl 100mg low cost. Cardiovascular morbidity and mortality among hypertensive patients in general practice: the evaluation of long-term systematic management. Evaluation of screening for breast cancer in a non-randomised study (the DOM project) by means of a case control study. Reduction of breast cancer mortality through mass-screening with modern mammography. The role of before–after studies of therapeutic impact in the evaluation of diagnostic technologies. Computerized cranial tomography: effect on diagnostic and therapeutic planns. Diagnostic impact of the erythrocyte sedimentation rate in general practice: a before–after analysis. Relation between sampling device and detection of abnormality in cervical smears: a meta-analysis of randomised and quasi-randomised studies. Carotid endarterectomy for asymptomatic carotid stenosis: a meta-analysis. Although the “gaussian” definition is traditionally common, the “therapeutic definition” of normal is the most clinically relevant. The four most relevant types of question are: q Phase I questions: Do patients with the target disorder have different test results from normal individuals? The answer requires a comparison of the distribution of test results among patients known to have the disease and people known not to have the disease. This can be studied in the same dataset that generated the Phase I answer, but now test characteristics such as sensitivity and specificity are estimated. To get the appropriate answer, a consecutive series of such patients should be studied. These questions have to be answered by randomising patients to undergo the test of interest or some other (or no) test. Introduction When making a diagnosis, clinicians seldom have access to reference or “gold” standard tests for the target disorders they suspect, and often wish to avoid the risks or costs of these reference standards, especially when they are invasive, painful, or dangerous. No wonder, then, that clinical researchers examine relationships between a wide range of more easily measured phenomena and final diagnoses. These phenomena include elements of the patient’s history, physical examination, images from all sorts of penetrating waves, and the levels of myriad constituents of body fluids and tissues. Alas, even the most promising phenomena, when nominated as diagnostic tests, almost never exhibit a one-to-one relationship with their respective target disorders, and several different diagnostic tests may compete for primacy in diagnosing the same target disorder. As a result, considerable effort has been expended at the interface between clinical medicine and scientific methods in an effort to maximise the validity and usefulness of diagnostic tests. This book describes the result of those efforts, and this chapter focuses on the specific sorts of questions posed in diagnostic research and the study architectures used to answer them. At the time that this book was being written, considerable interest was being directed to questions about the usefulness of the plasma concentration of B-type natriuretic peptide in diagnosing left ventricular dysfunction. Because real examples are far better than hypothetical ones in illustrating not just the overall strategies but also the down-to-earth tactics of clinical research, we will employ this one in the following paragraphs. To save space and tongue twisting we will refer to the diagnostic test, B-type natriuretic peptide, as BNP and the target disorder it is intended to diagnose, left ventricular dysfunction, as LVD. The starting point in evaluating this or any other promising diagnostic test is to decide how we will define its normal range. This chapter deals with the strategies (a lot) and tactics (a little) of research that attempts to distinguish patients who are “normal” from those who have a specific target disorder.

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