WORKMEN'S COMPENSATION—Emphasis on Rehabilitation

Since the first law was enacted in 1911 major emphasis has been placed on monetary satisfaction of liability with insufficient attention to rehabilitation of the occupationally disabled.An effective workmen''s compensation program must have three basic goals: (1) Rehabilitation of the occupationally disabled; (2) assured, prompt, and adequate indemnity for the occupationally disabled or their survivors; and (3) minimal costs to employers and society commensurate with the first two goals. It is suggested that the medical societies of each state provide a broadly representative committee to advise the administrative agency on medical policies and practices. This committee would prepare registers of all physicians in each locality who are willing and qualified to accept calls for service to injured employees, would mediate complaints originating with the employee, the employer, the insurance carrier or the administrative agency, and would cooperate with the administrative agency in educational programs for all concerned.It is the physician''s responsibility to help the administrative agency in shifting the emphasis from indemnity to rehabilitation. The disabled employee is entitled to all services available to restore him to an earning capacity.     

医疗保险专业委员会的工作实践与思考

如何保证医、保、患三方和谐发展，建立良好沟通平台，这是我国医疗保险制度建立实施过程中面临的主要问题。天津市医保专业委员会在3年工作中进行了探索和尝试，取得较好业绩。从医疗保险专业委员会成立的背景、工作职责、工作内容、存在的问题4个方面作了介绍，并提出了改进建议。     

A poliomyelitis survey the simple way: the Tanzanian experience.

A simple cost effective survey to assess the need for a rehabilitation service for individuals disabled by poliomyelitis was carried out making the maximum use of the existing government administration. The field team consisted solely of a medical officer and a health officer. The prevalence rate for paralytic poliomyelitis in the Mbeya region of Tanzania was 2.95/1000 persons. The rate for children under 10 years was 1.15/1000, suggesting that the expanded immunisation programme started in 1977 was being successful. With approximately 4000 cases of paralytic poliomyelitis in the Mbeya region a rehabilitation service would seem to be justified. If poliomyelitis surveys are required for rehabilitation purposes they must include all age groups. In this survey, had only school children been considered, as recommended by the World Health Organisation, two thirds of the cases would have been excluded, thereby hardly justifying a rehabilitation service.     

Disability under social security; medical evaluation and decision as to rehabilitation

Recent amendments to the Social Security Act give privileges to persons who are found to be disabled. In California, the State Bureau of Vocational Rehabilitation has responsibility for determining whether or not an applicant is disabled within the meaning of the Act. Each applicant must submit medical evidence provided by his own physician or by a hospital. The evidence is reviewed by both a physician and a counselor, who determine not only whether disability exists but also whether rehabilitation services might be helpful. In the first 9,000 cases in which determinations were made, 49 per cent of applicants were found to be disabled and 51 per cent not; but in recent months the proportion found disabled has increased. Diseases of the circulatory system and nervous system, including late effects of cerebrovascular accidents, were the largest groups of conditions causing disability. Psychoneurotic conditions and orthopedic and respiratory disorders were next in order. Some 10 to 15 per cent of applicants were referred for rehabilitation services, but of these only about one in six is accepted for rehabilitation, and only half of those accepted actually receive the services. Thus, it appears that only one per cent of workers applying for disability benefits are getting the services made available through state and federal sources to restore them to productive employment. Physicians need to be alert to opportunities provided in programs such as these to utilize all facilities to round out the full cycle of medical care.     

DISABILITY UNDER SOCIAL SECURITY—Medical Evaluation and Decision as to Rehabilitation

Recent amendments to the Social Security Act give privileges to persons who are found to be disabled. In California, the State Bureau of Vocational Rehabilitation has responsibility for determining whether or not an applicant is disabled within the meaning of the Act. Each applicant must submit medical evidence provided by his own physician or by a hospital. The evidence is reviewed by both a physician and a counselor, who determine not only whether disability exists but also whether rehabilitation services might be helpful.In the first 9,000 cases in which determinations were made, 49 per cent of applicants were found to be disabled and 51 per cent not; but in recent months the proportion found disabled has increased. Diseases of the circulatory system and nervous system, including late effects of cerebrovascular accidents, were the largest groups of conditions causing disability. Psychoneurotic conditions and orthopedic and respiratory disorders were next in order.Some 10 to 15 per cent of applicants were referred for rehabilitation services, but of these only about one in six is accepted for rehabilitation, and only half of those accepted actually receive the services. Thus, it appears that only one per cent of workers applying for disability benefits are getting the services made available through state and federal sources to restore them to productive employment. Physicians need to be alert to opportunities provided in programs such as these to utilize all facilities to round out the full cycle of medical care.     

Direct cost associated with acquired brain injury in Ontario

ABSTRACT: BACKGROUND: Acquired Brain Injury (ABI) from traumatic and non traumatic causes is a leading cause of disability worldwide yet there is limited research summarizing the health system economic burden associated with ABI. The objective of this study was to determine the direct cost of publicly funded health care services from the initial hospitalization to three years post-injury for individuals with traumatic (TBI) and non-traumatic brain injury (nTBI) in Ontario Canada. METHODS: A population-based cohort of patients discharged from acute hospital with an ABI code in any diagnosis position in 2004 through 2007 in Ontario was identified from administrative data. Publicly funded health care utilization was obtained from several Ontario administrative healthcare databases. Patients were stratified according to traumatic and non-traumatic causes of brain injury and whether or not they were discharged to an inpatient rehabilitation center. Health system costs were calculated across a continuum of institutional and community settings for up to three years after initial discharge. The continuum of settings included acute care emergency departments inpatient rehabilitation (IR) complex continuing care home care services and physician visits. All costs were calculated retrospectively assuming the government payer's perspective. RESULTS: Direct medical costs in an ABI population are substantial with mean cost in the first year post-injury per TBI and nTBI patient being $32132 and $38018 respectively. Among both TBI and nTBI patients those discharged to IR had significantly higher treatment costs than those not discharged to IR across all institutional and community settings. This tendency remained during the entire three-year follow-up period. Annual medical costs of patients hospitalized with a brain injury in Ontario in the first follow-up year were approximately $120.7 million for TBI and $368.7 million for nTBI. Acute care cost accounted for 46-65 % of the total treatment cost in the first year overwhelming all other cost components. CONCLUSIONS: The main finding of this study is that direct medical costs in ABI population are substantial and vary considerably by the injury cause. Although most expenses occur in the first follow-up year ABI patients continue to use variety of medical services in the second and third year with emphasis shifting over time from acute care and inpatient rehabilitation towards homecare physician services and long-term institutional care. More research is needed to capture economic costs for ABI patients not admitted to acute care.     

Rehabilitation of the Aged

The rehabilitation needs and goals of older people differ in many respects from those of the young. In younger individuals a crippling condition may affect an otherwise healthy body, while in an older person it may be superimposed on other pre-existing degenerative diseases. Thus, in older patients the restorative or rehabilitative phase rarely can be separated from the phase of definitive medical treatment.The primary goal of rehabilitation of younger individuals is usually vocational. In the older group this goal or objective is, by and large, secondary. This does not minimize, however, the value of medical and social services in the rehabilitation of older persons. The simple ability to care for his own personal needs can do much to help the elderly disabled patient regain his dignity and self-respect and remove his fears of becoming a burden on his family or society.     

Current capabilities of rehabilitation robots

Predictions are often made of intelligent and independently mobile robots for the disabled, and researchers are continually improving laboratory systems. Reductions in the cost of the technology involved may lead to affordable devices by the end of the decade. Less ambitious goals must be adopted by those projects wishing to distribute robotic aids to the disabled in the next few years. A modest selling price dictates the use of existing components. Even with the advent of more advanced robots, cost considerations may still make simpler devices an attractive alternative. Excessive optimism of future capabilities should be avoided, lest unrealistic expectations of current robotic aids hamper their development. Progress at all levels of rehabilitation robotics is complementary.     

THE NEUROLOGICAL PROGRAM OF THE VETERANS ADMINISTRATION

The reorganization of the medical department of the Veterans Administration has given considerable impetus to neurology, a part of the division of psychiatry and neurology. The neurologic service of the V. A. is the largest in the world today, and is constantly increasing. This service is made available to veterans through hospitals and regional offices within the designated area, which are branch administrative offices under the central office.A residency training program for specialization is under the direction of a deans'' committee in every large medical center. This committee, which is formed from the faculties of medical schools, also approves the visiting medical staffs of hospitals. The neurologic program consists of a number of special activities, which include residency training for certification, neurologic diagnosis, rehabilitation of patients with chronic illness, electroencephalography, epilepsy, aphasia and research. The paraplegia program is now a separate service, but is also participated in by the neurologist. Both the neurologist and the psychiatrist are interested in the patient with organic psychosis, and the neurologist also works in close relationship with the neurosurgeon.There is need for neurologists in the V. A., which offers attractive opportunities in clinical practice and in research, as well as inducements of advancement and adequate financial returns.     

The Selection of Medical Students in Western Canada

The methods employed in the selection of medical students for the 1964-65 class of freshmen at the four Western medical schools are described and recommendations are made for improving the procedure. The structure and functions of the various selection committees varied from school to school but their prime purpose was the same—the selection of “good students” who would later become “good physicians”. Not surprisingly, academic achievement and confidence in estimating this ranked highest in importance, and while non-intellectual characteristics ranked almost as high, committee members had no confidence that they could evaluate these qualities.It is suggested that the ideal selection committee would be a “high-priority” committee consisting of six to eight members who would meet at least twice a year, have tenure of at least four years, be trained in interviewing applicants, consider Medical College Admission Test scores, review applications before each meeting, and establish research committees to investigate the students they choose.     

Part-time hospitalization programs: the neglected field of community psychiatry.

Part-time hospitalization for persons with psychiatric disorders is underdeveloped, underutilized and often poorly understood, but should be encouraged in view of the unsatisfactory living conditions of patients discharged from hospital who still require care, the reductions in psychiatric impatient populations and numbers of beds, the increasing costs of health services and the current fiscal restraints. Day and night hospitals can provide an alternative to inpatient or outpatient treatment, rehabilitation for the long-term patient or treatment for the patient in transition from inpatient to outpatient status. The day hospital can also provide a diagnostic setting. Such programs help preserve the patient''s position in the family and the community, minimize the ill effects of hospitalization, and lower capital and operating costs of the psychiatric services. Awareness by medical and paramedical services of the value of these programs would increase their utilization. Shifting the emphasis of administrative and fiscal policies from inpatient to part-time hospitalization programs is also required.     

Application of EMG signals for controlling exoskeleton robots.

Exoskeleton robots are mechanical constructions attached to human body parts, containing actuators for influencing human motion. One important application area for exoskeletons is human motion support, for example, for disabled people, including rehabilitation training, and for force enhancement in healthy subjects. This paper surveys two exoskeleton systems developed in our laboratory. The first system is a lower-extremity exoskeleton with one actuated degree of freedom in the knee joint. This system was designed for motion support in disabled people. The second system is an exoskeleton for a human hand with 16 actuated joints, four for each finger. This hand exoskeleton will be used in rehabilitation training after hand surgeries. The application of EMG signals for motion control is presented. An overview of the design and control methods, and first experimental results for the leg exoskeleton are reported.     

A rehabilitation ward in a district general hospital: first three years' experience.

The experience of the first three years'' work on a ward for the rehabilitation of patients was reviewed. Adults with physical disabilities or mixed physical and psychological disabilities, including unstable or deteriorating conditions, were accepted for intensive rehabilitation. Most patients had neurological disorders. The ward policy was that each patient had considerable time with the therapist, maximum personal independence was encouraged, and multidisciplinary staff meetings were held to agree the goals of treatment. Much effort was spent helping patients and relatives to adapt to conditions of progressive disability, but the response to questionnaires suggested that these patients as well as those who did improve received some benefit from being on the ward. Overall the benefits of the intensive rehabilitation that was offered on this ward outweighed those from short stays on medical wards.     

Cogwheel: A physician's view of a local version

A preliminary experiment in the divisional system of medical administration has been started in a large regional hospital in the Metropolitan area. This has involved considerable local interpretation of the original proposals in the Joint Working Party''s report. The chief benefits of this version as tried so far have been a more effective use of doctors'' time at all levels, a more rapid carrying out of practical suggestions, and closer co-operation between different departments. Those who give first administrative place to streamlined efficiency have seen the absence of an authoritative executive committee as the chief defect to date. The main fault in the eyes of those who emphasize the fundamental importance of participation has been the delay in the involvement of the junior medical staff.     

Cost-benefit analysis in patients with sleep-related breathing disorders - diagnosis and ncpap therapy during medical rehabilitation]

In a multi-centre study, 745 patients undergoing internal medical rehabilitation (for hypertension, coronary heart disease, gastrointestinal and respiratory diseases) were investigated. The health economic benefit was evaluated during the 3 weeks of medical rehabilitation, during which a sleep-medical diagnostic work-up and treatment were applied. Ambulatory screening for sleep-related breathing disorders was carried out in all patients. In positive cases (Apnoea-Hypopnoea Index > or = 10) transfer to our sleep lab was recommended. 103 patients were found to be positive, of whom 47 attended the lab; 23 of these accepted nCPAP therapy, while 24 did not. The costs of the additional diagnosis and treatment were considered incremental costs--and the benefit identified as the decrease in days off work as revealed by a comparison of the year before with the year after rehabilitation. Days off work decreased by 38.4 days in the treated group, and increased by 25.4 days in the untreated group. The results were extrapolated to all patients in internal medical rehabilitation in Germany, and a cost-benefit analysis showed that the benefit of expanding the additional investigation to cover all patients would far exceed the incremental costs in the first year after rehabilitation by 58.26 Mio [symbol: see text] and in the second year by 81.15 Mio. [symbol: see text].     

Parents for children.

Parents for Children is a specialist adoption agency set up to find homes for children with special needs--that is, those with physical, mental, and emotional handicaps; older children; and sibling groups. Of the first 38 children placed, one child died and six placements broke down, although four children were later re-placed. Almost all the children referred to the agency had been in care for most of their lives. A full assessment of each child is necessary before placement, but in several cases the medical assessment in care had been inadequate. Many of the prospective parents themselves had serious medical conditions. The agency has proved that homes can be found for children in need, but there have been problems and parents require advice and support in the management of the children after placement.     

Legal Implications of Physical Examinations

With the new national emphasis on the prevention of occupationally incurred disease, legislative constraints have been placed in connection with the medical examination of employed persons at health risk. Concurrently, there is mandated a system of communication to the worker of the significant clinical findings encountered on his physical and laboratory inventories.     

Use of personal medical records for research purposes.

The established practice of doctors using medical records for research purposes is threatened by the recent proposed guidelines from the Department of Health, the BMA, and the European Commission. The European Commission has proposed that explicit consent should be obtained from each patient before his or her medical records can be used; the proposals from the Department of Health and the BMA would require all research that needs access to personal medical records to be submitted to an ethics committee. We believe that these proposals would seriously impair an entire category of research and suggest therefore that another set of guidelines, proposed by a Royal College of Physicians'' working group, should be used to modify the proposals. The guidelines of the working group encourage the use of medical records for research and ensure that such use can be made in a confidential manner without causing harm.     

The chief medical residency in Canada: comparison of opinions between physicians-in-chief and chief medical residents.

We conducted a survey of physicians-in-chief (PCs) and chief medical residents (CMRs) in training programs throughout Canada to determine their attitudes toward the need for and role of CMRs in Canada and to rate the importance of CMR duties and attributes. Forty-three hospitals with 5 to 126 house staff in all eight provinces with medical schools were surveyed; 36 PCs (84%) and 29 CMRs (67%) returned a completed questionnaire. Compared with the CMRs the PCs preferred more prior training (p less than 0.03), estimated as significantly less the time spent by CMRs in required duties (p less than 0.05) and rated as more important the responsibilities of faculty-house staff liaison, house staff leader, house staff role model and teaching house staff (p less than 0.05) and the attributes of clinical judgement, medical knowledge, clinician model and research interests (p less than 0.03). All of the PCs and 97% of the CMRs rated the position as somewhat to very necessary; 83% of the PCs and 66% of the CMRs would not alter the present CMR roles. A total of 92% of the PCs felt that the position was very or somewhat advantageous with respect to a future private practice, compared with 67% of the CMRs (p less than 0.02). Increased administrative and committee duties, decreased teaching and future reductions in house staff were identified as major but reversible threats to the unique quality of the CMR position. We conclude that the CMR has a necessary, important and highly regarded role in Canadian university hospitals that could possibly be improved by regular review by the PC and CMR at each hospital to avoid the identified problems.     

The Hospital Medical Advisory Committee—The Cabinet of the Medical Staff

Before a hospital medical staff can realistically accept responsibility for the professional practices of its members, a principle initially fostered by the American College of Surgeons and adopted by both the Canadian and American accreditation programs, it must have an effectively functioning medical staff organization. The medical advisory committee is the most important committee of the medical staff organization. A representative composition, adherence to sound administrative principles, and recognition of its prime functions of co-ordination, supervision and jurisdiction will permit this committee—and the total medical staff organization—to discharge adequately the very important responsibilities delegated to them by the governing board of the hospital. Properly structured medical staff bylaws with clearly defined terms of reference assist the smooth functioning of the “cabinet” of the medical staff and safeguard the prerogatives of the individual members of the staff.