New incentives regarding delivery of inpatient care by physicians and administrators have resulted from Medicare's DRG-based prospective reimbursement system. As these payment systems become widely adopted by other third-party payors, implications for adequate hospital reimbursement and quality inpatient care will intensify. This study of inflammatory bowel disease inpatients examines discharge data for 300 patients comprising 507 admissions from 1983 to 1987 at a large tertiary center hospital. While only 10.8% of these discharges were Medicare patients, all discharges were assigned a diagnosis-related-group reimbursement to derive a theoretical monetary loss or gain for the hospital. Overall hospital losses averaged $127.24 per case for this patient population, in which the medical and pediatric cases were adequately reimbursed, and the surgical admissions represented greater losses. The average length of stay for all patients decreased from 11.9 to 7.4 days over the study period, mostly a result of reductions in surgical hospital stays. We conclude that reimbursement for medical and pediatric discharges under DRG 179 appear adequate for this hospital, while surgical inflammatory bowel disease reimbursement is not. These data will be useful for comparison of future trends of inpatient utilization for inflammatory bowel disease patients as prospective reimbursement practices become more widespread.

A method was devised to offer a group of internists a system by which to analyze their practices, allowing them to identify areas where a change in practice habits might be beneficial. More than 3000 encounters between patients and internists in an eight-man group were analyzed for a number of variables. Significant differences existed between physicians as to the percentage of encounters that were physician-initiated rather than patient-initiated. Disposition of the encounters also varied significantly. The effect that the recycling of patients has on productivity, cost, and use of hospital facilities is discussed. In addition to geographic and specialty maldistribution, the maldistribution of physician time is a significant barrier to meeting the demands for medical care.

SUMMARY Thirty‐four cases of tuberous sclerosis are discussed and the pertinent literature is reviewed. As noted in previously reported cases the disease often afflicts the heart, kidneys, retina and bones in addition to the brain. The incidence and pattern of inheritance in tuberous sclerosis has not been completely elucidated. As many as one‐third of the cases have relatives with the disorder. The prevalence may be as great as I in 20,000 persons. The high frequency of benign, but slowly expansive, brain tumors in tuberous sclerosis is well known. The brain tumors which tend to block the foramina of Monro and produce hydrocephalus are often amenable to surgery. Smaller visceral growths, as well as those located in the brain, should usually be managed conservatively. The seizures in tuberous sclerosis are often grand mal, but may be focal or appear similar to infantile spasms. Usually the frequency of seizures decreases as the patient ages. There have been no metabolic or endocrinologic abnormalities reported to be typical of tuberous sclerosis, except for mild hypercalcemia. The hypercalcemia may relate to the degree of bone involvement. Tuberous sclerosis is one of the few diseases in which multiple tumors are part of the syndrome. The exact causation of the disorder is obscure. RÉSUMÉ Trente‐quatre cas de sclérose tubéreuse sont discutés et la littérature s'y rapportant est analysée. Comme on Ľa noté dans des cas rapportés précédemment, cette maladie affeete souvent le coeur, la rétine et les os en plus du cerveau. Ľincidence et le type d'hérédité dans la sclérose tubéreuse n'ont pas été complétemcnl élucidés. Le nombre des cas qui ont un parent atteint de ce désordre atteint un tiers. Son domaine s'étend sans doute jusqu'à une personne sur 20.000. On connait bien la haute fréquence dans la sclérose tubéreuse de tumeurs du cerveau bénignes mais s'étendant lentement. Les tumeurs cérébrales qui tendent à bloquer le trou de Monro sont souvent sensibles au traitment chirurgical. Les croissances viscérales plus petites, ainsi que celles localisées dans le cerveau, sont habituellement à traiter sans ablation. Les crises dans la sclérose tubéreuse sont souvent du grand mal, mais el les peuvent être focales ou apparaitre comme des spasmes infantiles. d'habitude la fréquence des crises décroît lorsque le patient avance en âge. On n'a rapporté aucune anomalie métabolique ou endocrinologique comme étant typique de la sclérose tubéreuse, à part une légère hypercalcémie. Ľhypercalcémie peut être en relation avec le degré d'atteinte osseuse. La sclérose tubéreuse est une des quelques maladies où les tumeurs multiples constituent une partie du syndrome. La cause exacte de ce désordre reste obscure. ZUSAMMENFASSUNG Vierunddreissig Fälle tuberöser Sklerosis werden erörtert, und die dazugehörende Literatur wird besprochen. Wie bei früher beschriebenen Fällen bereits festgestellt, greift diese Krankheit oft Herz, Nieren, Retina und Knochen an, im Zusatz zum Gehirn. Das Auftreten und Erscheinungsmuster der Erblichkeit bei tuberö...

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