Prioritization of health care services: a progress report by the Oregon Health Services Commission

Article Abstract:

A progress report is presented concerning the activities of the Oregon Health Services Commission (HSC), a group of 11 people appointed by the governor in 1989 to develop a priority ranking system for health services in the state. Services were to be ranked according to their importance to the population served; the state legislature would then decide, based on available funds, to which rank to extend Medicaid coverage (for people at or below the federal poverty level). The plan represents a covert rationing approach to health care. The methods used by the HSC, which consists of five physicians, a public health nurse, a social worker, and four laypeople, are described. The benefit of a service was defined as the difference between the quality of well-being (QWB) score (based on the presence of symptoms in 24 categories) for the patient with a particular medical condition, and the QWB score after treatment. Cost-benefit formulas were calculated for the treatments, taking into account health outcomes; however, outcome data based on well-controlled trials were not available for most common treatments. Therefore, a consensus on outcomes was obtained from experienced medical practitioners. Twelve public hearings, 47 community meetings, and a telephone survey were also held to encourage public participation. The initial results of the HSC's efforts were flawed and caused considerable public outcry, but improvements in the methodology and available data led a new set of care categories. These were then ranked according to their importance to the individual, to society, and to whether the category was an essential part of a care plan. Medical condition/treatment pairs were then assigned to the appropriate categories and ranked according to their cost/benefit ratios. The HSC has tackled an enormous task, made more difficult by the lack of clear-cut information on treatment outcomes and costs. (Consumer Summary produced by Reliance Medical Information, Inc.)

Medical economics, Laws, regulations and rules, Reports, Political aspects, Medical care, Cost of, Health care costs, Oregon, Oregon. Commission on Health Services

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Conversion disorder: camouflage for brain lesions in two cases

Article Abstract:

Conversion disorders are among the more difficult diagnoses with which physicians have to contend. Conversion disorder is the modern diagnostic category for what has traditionally been called hysteria. Conversion disorder usually presents as a vague body complaint, and further workup reveals no physiologic cause or possible pathological mechanism. To complete the diagnosis of conversion disorder, a precipitating psychological event should be found. It is evident, however, that a number of various organic illnesses, especially multiple sclerosis, may appear at first presentation to be conversion disorder. Two cases are presented in which a neurologist was unable to find any physical basis for the patient's symptoms, and a diagnosis of conversion disorder was proffered. In one case, the Minnesota Multiphasic Personality Inventory was administered to the patient and revealed a hysteric personality profile, which hastened the diagnosis. It is interesting to observe that, in both cases, the diagnosis of conversion disorder was suspect to the psychiatrist to whom the patient was referred. Both patients, a 64-year-old man and a 49-year-old man, died from the medical causes of their symptoms. In one case, the cause of the disorder was a small metastatic tumor in the brain, which was confirmed on autopsy. In the other case, the cause of the ostensibly hysterical symptoms was actually found to be a ruptured cavernous hemangioma (tumor of the blood vessels) in the pons of the brain upon autopsy. (Consumer Summary produced by Reliance Medical Information, Inc.)

Case studies, Diagnosis, Brain tumors, Conversion (Psychoanalysis), Conversion disorder, Hysteria (Mental disorder)

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Thyrotoxic periodic paralysis; report of 10 cases and review of electromyographic findings

Article Abstract:

Episodic paralysis is an unusual complication of overactive toxic thyroid condition. The clinical findings in 10 patients with thyrotoxic periodic paralysis were reviewed. All 10 patients were young men with an average age of 28.4 years. The condition has been found in many racial and ethnic groups, but is believed to occur most frequently in Orientals. Eight of the patients were white, one Oriental and one Hispanic. The first attack of paralysis occurred within three months of symptoms of increased thyroid activity. Quadriplegia, paralysis of all extremities, developed in six patients and paraplegia, usually affecting the lower extremities, appeared in four. Measurements of thyroid hormone showed the thyroid hormone T3 to be elevated in all patients. Electrophysiologic studies of nerve conduction proved normal. Characteristic electric changes were found in muscles following prolonged exercise. Medical staff witnessed acute attacks in three different patients and were able to monitor blood levels of potassium during an acute episode in six patients. In all cases the value of potassium was abnormal. The cause of the condition remains unknown, but speculation involves changes in the ability of sodium to move across cell membranes. Sodium ions are extremely important in the maintenance of electrophysiologic conditions in the body and are related to the mechanism of impulse conduction and muscle contraction. The electrophysiologic evidence also points to the muscle cell as the location of the defect which results in the paralysis.

Causes of, Complications and side effects, Paralysis, Hyperthyroidism

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