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The article discusses the relevance of a cost-effective analysis to help medical personnel and policy makers plan their health care policy, which should provide optimal assistance to patients and their families.

It may be possible to grade health care recommendations based on the type of studies they are based on and other considerations. Health care recommendations are usually made when researchers review all the studies that have been done on a specific topic. The strongest evidence for a recommendation comes from randomized clinical trials (RCTs). Heterogeneity occurs when the studies show different outcomes from the same treatment. RCTs with no heterogeneity would rank higher than those with heterogeneity. Doctors would also have to decide how many patients they would need to treat to prevent the condition and whether patients at low risk even needed treatment. All of this information can be quantified to produce a grade for the recommendation.

Very few comprehensive trauma systems appear to exist in the United States. Trauma systems are programs designed to coordinate and facilitate care of critically injured patients. Trauma systems typically include designated trauma centers, protocols for assessing patient injuries before admission, and ongoing evaluation of trauma centers. Thirty-seven trauma system directors or administrators completed questionnaires about their trauma systems. Administering organizations have legal authority to designate trauma centers in Washington, DC, and 20 states. Seventeen of the respondents from state and regional authorities indicated that the number of trauma centers is limited based on community need. Evaluation of the transfer arrangements between hospitals indicated that four of five Florida regional authorities, and nine of 12 California regional authorities had written transfer policies. Regional authorities were responsible for interhospital transfers in Massachusetts. In order to function more efficiently trauma systems should limit the number of trauma centers based on community need, implement clear policies for interhospital transfers and develop centralized trauma-patient registries., Objective. - To examine the status of trauma system development and key structural and operational characteristics of these systems. Design and Setting. - National survey of trauma systems with enabling state statute, regulation, or executive orders and for which designated trauma centers were present. Participants. - Trauma system administrators and directors of 37 state and regional organizations that had legal authority to administer trauma systems, which represented a response rate of 90.2%. Main Outcome Measures. - Trauma system components that had been implemented or were under development. Results. - From 1988 to 1993, the number of states meeting one set of criteria for a complete trauma system criteria increased from two to five. The most common deficiency in establishing trauma systems was failure to limit the number of designated trauma centers based on community need. Although most existing trauma systems have developed formal processes for designating trauma centers, prehospital triage protocols to allow hospital bypass, and centralized trauma registries, several systems lack standardized policies for interhospital transfer and systemwide evaluation. Conclusion. - State and regional organizations have accomplished a great deal but still have substantial work ahead in developing comprehensive trauma systems. Research is needed to better understand the relationship between trauma volume and outcomes of care as well as the impact of trauma system structure and operational characteristics on care delivery. Improved measures of patient outcome are also needed so that effective system evaluation can take place. (JAMA. 1995;273:395-401)

The health care crisis in the US is both financial and philosophical. The US is the only developed country without a comprehensive health care system. US policymakers need to restructure their thinking and develop a new approach to the provision of health care. Health care policy should be restructured to approximate that on which the Social Security system is based. Development of a health care policy has been dominated by classical economists. These individuals support free competitive markets as the solution to the health care crisis. The Clinton administration promotes this viewpoint with its plan for managed competition. An alternative solution may be to develop a national health care insurance based on the example of the health care systems in other developed countries. This type of insurance would increase health care coverage, create a stable source of funding and contain costs., Every developed country except the United States has a comprehensive health system for coverage, service provision, and finance. Social policy in the United States once was guided by thinkers who realized this, and the Social Security system--complete except for health insurance--resulted. The climate of thinking changed, and health policy for some time has been dominated by classical economists who argue that free competitive markets will solve all problems. They justify their arguments by claiming that the only alternative is full government takeovers of service and financing, as in Canada. While this debate has dragged along, problems in the United States have become grave. Instead of reviving the institutional economics and social policies that once served the United States well, the Clinton administration has turned policy over to devotees of managed competition. But the problem is how to organize the country, and national health insurance--easily observed in other countries--is superior to the current chaos and free-market utopias in the United States. Important aims would be achieved, such as expanding coverage, obtaining stable revenue, and containing costs. Important political barriers can be overcome, such as resistance by small business. Such a health system includes machinery for setting goals and implementing results, involving collaboration among providers, payers and government. (JAMA. 1993;270:980-984)

Concern about possible exposure of hospital staff to HIV-infected patients has recently increased, leading to a situation of potential conflict between staff members' need to know whether patients are infected, and patients' rights to confidentiality. To learn more regarding HIV-testing policies in acute-care hospitals, a random sample of 561 private and public hospitals was studied. The chief administrator of each facility received a letter explaining the study, followed some time later by a 15-minute telephone interview. The questions concerned the hospital's history with respect to the admission of AIDS patients, its HIV-testing policies, and the origin of those policies. Results showed that 83 percent of the institutions had admitted at least one patient with AIDS. Fewer than 10 percent had admitted more than 20 AIDS patients during 1988. Slightly more than 83 percent of the hospitals had a written HIV-testing policy, and the factor that had been most influential in developing such a policy was staff members' fear of being infected. A detailed presentation of the elements of the hospitals' testing policies appears. Many (78 percent) required that the patient's informed consent be obtained before testing for HIV; however, notification of the patient in the event of a positive result was required in only three out of four hospitals. Half the hospitals required that test results be placed in patients' charts, to "protect" insurers. Certain policies, such as review of treatment plans for HIV-positive patients, could result in substitution of a less dangerous for a more dangerous procedure; more administrators said such reviews were commonly made because of staff fears of infection (25 percent) than because of potential benefit to the patient (23 percent). Balancing patients' rights against the rights of health care providers is not an easy task for institutions in the face of the AIDS epidemic. (Consumer Summary produced by Reliance Medical Information, Inc.)

International Physicians for the Prevention of Nuclear War (IPPNW) originated in 1981 in the US and is now an international organization with a membership of 250,000 people from more than 70 nations. The group was awarded the 1985 Nobel Prize for Peace. Its focus has remained the prevention of nuclear war, by political advocacy and public education. However, current political and global trends have forced a re-evaluation of the role of international physician nongovernmental organizations (NGOs). One approach to counter the understandable opposition of government officials to IPPNW is to adopt their conceptual frameworks. These frameworks often establish 'fateful visions', ideas about how the world could be. Ten such visions are presented in tabular form. Three of these are shared by IPPNW, and that organization's goal of total disarmament should not be viewed apart from the political changes that will have to be effected before disarmament can even be realistically discussed. Physicians do not have an impact on these changes. Nor are nuclear weapons a major force in the violence that occurs in the world; rather, conventional weapons are what men, women, and children die from in modern times. Thus, the abolition of nuclear weapons as the main goal of IPPNW presents problems. What can physicians do to bring about 'desirable worlds'? As internationalism develops, leading to reduction of nationalistic fervor, offensive weapons will become less critical. IPPNW facilitates internationalism, and emerging needs for interdependence among countries will result in a broader focus for the physicians' movement. One such change is the growth of newly industrialized countries; another is the deterioration of the environment. Changing immigration patterns, the human immunodeficiency virus (associated with AIDS), and other disease outbreaks, also call for re-evaluation of the role of NGOs. Overall, physicians will be called upon to act as advocates because of their special knowledge and expertise. Much of their activity will be in the areas of public policy and should remain free of ideological constraints. In this capacity, physicians can act to promote the positive interdependence among nations essential for the survival of civilization. (Consumer Summary produced by Reliance Medical Information, Inc.)

The policy requiring HIV-infected health care workers to disclose this information to patients should be changed. Research has shown that the risk of transmission in the health care setting is extremely low, and forced disclosure violates the health care worker's privacy and civil rights. An updated policy is described.

Governmental policy and public money have a profound effect on the number of physicians being trained and on their ultimate choice of specialties and regions of the country in which to practice. In the 1960-70s Federal policy actively participated in increasing the number of physicians who entered primary-care practice. There is presently one physician for every 500 Americans, and the number of physicians is continuing to increase at a rate which is three times greater than the increase in the United States population. These statistics have encouraged changes in public policy and a general withdrawal of public funding from programs which influence geographic distribution of physicians. There is growing concern within the profession, however, that the number of primary-care physicians has been dramatically reduced. The 67,687 family- and general-practice physicians who were active in 1986 is less than half of the number who practiced in 1949. Coupled with this decline in manpower is a maldistribution of primary care physicians throughout the country. Historically rural areas have been especially dependent on the general practice physician, and although many family practice specialists have moved into more rural environments, the absolute number is less than the requirement of these communities. Increasingly, medical training has become economically dependent on income for the provision of service, and this fact ties the flow of money to more specialized tertiary-care facilities that are largely involved in training physicians to practice in medical and surgical specialties. The situation is only seen to be correctable by reform and adjustments of public policy, which will lead to the support of medical training for primary-care medical practice and in a correction of the current maldistribution of medical school graduates., ABSTRACT: The decline in general practice, the arrested growth of family medicine training programs, and the increased subspecialization of internal medicine and pediatrics are responsible for the continuing decrease in the proportion of physicians in the United States who practice a primary care specialty. Since 1963, the number of physicians has more than doubled, but the ratio of office-based primary care physicians to the national population has decreased. This trend has been especially pronounced in rural areas and impoverished urban communities. There is evidence that the proportion of young physicians entering primary care specialties is declining. Medical education has become increasingly reliant on service income, making it difficult to fund training in primary care specialties. Grants for graduate training in primary care specialties have not increased with inflation, and outright elimination of these programs is under consideration. Public programs that fund medical education must be reformed to improve the geographic and specialty distribution of physicians.