limilli *111@100618* 0 0 0 Justification Regional Medical Programs Increase or 1971 Estimate 1972 Estimate Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits . . . . 275 $4,@@36,000 275 $4,756,000 +$ 320,000 Other expenses . . . -- 77,970,000 -- 82P,515,000 +$4,545,000 Total . . . . . .275 $ 82, 406,000 275 $ 8 7, 271, 000 +$4, 865,000 General Statement The Regional Medical Programs Service provides a major mechanism and supports activities required to enhance the capacity of the health care system to furnish services of satisfactory quality to all Americans. Regional Medical Programs Service: (1) supports grants and contracts which on a regional basis bring toaether in a common effort the local medical centers, hospitals, and other health care facilities, health care provid(@rs and other resources to systematically identify health problems, commitments, and undertake the solutions; (2) furnishes professional and technical assistance and advice to the Regional Medical Programs, States, local communities and other relevant health agencies; (3) conducts programs through voluntary commitment of regional resources to bring about an increased, effective use of medical knowledge, -make more efficient use of physician and human medical care resources and. help remove barriers which impede entry of patients into the health care system, maintaining major focus on those diseases which are the greatest causes of morbidity, disability, and death in the United States; (4) facilitates and provides professional guidance at the regional level to other governmental and private efforts aimed at improving the organization and delivery of health care; (5) administers specialized pilot or educational or monitoring programs in the field of kidney disease and smoking and health, which have significant importance in improving personal health care and in contributing toward the accomplishments of Regional Medical Program goals. Regional Medical Programs: Increase or 1971. Estimate 1972 Estimate Decrease (a) Grants . . . . $70,@298,000 $75,000,000 +$4,702,000 Grants are awarded to assist in the planning, establishment and operation of Regional Medical Programs for research, training and demonstrations of patient care. It is the objective of the Regional Medical Programs to improve availa- bility of and access to high quality health care to all Americans through improvements in the development and more efficient utilization of health manpower and other resources. Approximately 2,700 institutions including all medical schools, 1,900 hospitals and a variety of State and voluntary health organizations are now participating in this effort to improve the quality of care and the adoption of the latest techniques in the delivery of health services. The Regional Medical Programs Service seeks to assist the established Regional Medical Programs to develop a framework of cooperative relationships for improving the organization and delivery of services to people. This framework is structured by developing the voluntary cooperation of the various providers of service, both public and private, in identifying the patients' needs. 1,11-ien these have been determined, the local groups and institutions develop projects and programs to meet these needs. The activities of Regional Medical Programs include the full spectrum of health care: prevention, primary care, specialized care using the latest scientific techniques, and rehabilitation. Regional Medical Programs provide funds for organizing a system of health care locally acceptable and responsive, but linked to regional resources not available locally. Program for 1971 and 1972 Fifty-five Regional Medical Programs are now conductingoperational activities. During the past year, events in the various regions have provided significant directions for the future. The newly emerging cooperative arrangements within the regions have demonstrated the role the Regional Medical Programs can play as a recognizable and locally acceptable force not only for health planning but for improving the organization and delivery of health care as well. These changing patterns in the health care system brought about through operational activities are affording the consumer immediate and direct benefits. The movement toward operational status is reflected by the fact that currently more than 50 percent of funds are now awarded for projects which demonstrate improved patient care methods, a significant increase from previous years when planning was the predominant activity. The fields of disease pre- veiition and screening for early detection of disease are receiving increasing emphasis. The special. problems of the poor in both rural and urban populations are being studied intensively. The effort of Regional Medical Programs to promote the regionalization of health resources and enhance the capabilities of providers of care at the com- munity level involves a number-of different approaches. One important approach involves all of the regions in developing a base for regional planning and decision-making through broad representation and partici- pation of health institutions, organizations and individuals on the planning committees and the Regional Advisory Group of each Region. The legislative extension of 1970 emphasized the development of such local planning capability, especially in relationships with Comprehensive Health Planning agencies. To promote such cooperation, the new law requires reciprocal membership on Regional Medical Program and Comprehensive Health Planning advisory groups. It also provides the Areawide Comprehensive Health Planning Agencies with the opportunity to review Regional Medical Program grant proposals to ensure conformance to cormnunity-established priorities. Recognizing that the programs need to complement and support one another as they work with the health institutions in their area, close cooperation will be encouraged in the form of joint planning and data collection efforts and common definition of subregional areas. Community planning assistance is being promoted in California where, for example, the California Regional. Medical Pro-ram recently provided both financial and staff assistance to the Welfare Planning Council of the Los Angeles Region for a community report on health problems and priorities in East Los Angeles. This community approach is a recognition of the fact that health needs originate in people. This recognition is especially important when looking at a "barrio" such as East Los Angeles. Regionalization and new organizational arrangements are major themes of Regional Medical Programs. Working relationships and linkages among community hospitals and between such hospitals and medical centers are among the primary concerns of the program. The linking of less specialized health resources and facilities such as small community hospitals with more specialized ones is an important way of overcoming the maidistribution of certain resources, and thereby increasing their availability and enhancing their accessibility. The development of regionalized professional and institutional linkages aids in linking patient care with health research and education within an entire region to provide a mutually beneficial interaction. It also helps to emphasize the delivery of primary care at the local or community level, while promoting specialty care as the province of the medical center and larger community hospitals. In North Carolina, community development of comprehensive stroke programs has been initiated, with a central coordinating unit-at the Bo@@7Man Gray School of Medicine. A broad range of activities is being undertaken, including publi- tation of guidelines for community stroke programs, educational activities such as training ProRrams for nurses, annual stroke workshops, stroke consultation service for physicians through the cooperation of the neurological, staffs of the. three medical centers, and a fainily-p@itient education unit, designed to help patients and their families learn to cope with the loiig-t(-,rm effects of stroke disability. A broad array of manpower activities is being developed to impact on the health care delivery system. Estimated numbers of health professionals who will be trained in 1971 as a result of Regional Medical Program activities are as follows: Doctors 31,628 Nurses 55,295 Allie,d/Other -Heiltli 3@9 000 Total 125,923 In addition, over 25,000 emergency health personnel (firemen, ambulance drivers, policemen, etc.) will receive training. These programs will include both the teaching of new skills and also the upgrading of existing skills as well as training new people in the allied and other health areas. Many Regional Medical Programs have conducted studies to determine the need for, willingness to accept and feasibility of training categories of manpower to extend the services of physicians. Most of these are related to the physicians' assistant concept. Some Regional Medical Programs are designing such projects and several have funded operational projects in t is area. In Alabama, the Regional Medical Program is sponsoring a program to formulate and implement training programs for allied health technicians through the coopera- tive use of funds, manpower, and facilities already in existence at the junior college and vocational technical training schools level. By linking the resources. of the University of Alabama, Regional Technical Institute, the Appalachian Development Coimnission, and 17 state supported junior colleges, Alabama is taking a giant step toward solution of its health manpower shortage. A Guest Residency Program, started two years ago with Regional Medical Program funds, has helped pave the way for what is a significant innovation in medical education (14AMI) by demonstrating the practicality of its decentraliza- tion. The new medical education plan, taking its name from the four States involved (Washington, Alaska, Montana, Idaho), r'ecently received a $1 million grant from the Commonwealth Fund. Alaska was selected as the first State to implement the new plan because of the close ties already created by the Wash- ington/Alaska Regional Medical Program between the University of Washington Medical School and Alaska academic and medical communities. Virtually all Regional Medical Programs have projects designed to augment the knowledge and level of performance of health professionals and parapro- fessionals. Many of these projects lead to the utilization of personnel in new ways. Perhaps the greatest Regional Medical Program thrust in this area is the training of coronary care unit nurses; over 7,000 registered nurses 8nd licensed practical nurses have been trained to date. Although Regional Medical Programs does not provide for patient services directly, it often gets involved in planning for and helping to establish those health care components which will deliver service. This includes a broad range Currently demonstrations arc,, being funded for ictivities such as: o@r o@r and -o Lli (-, r-in tens i-ve $13,800,000 care - Tl,-@ coronary care units and 8 mobile units rnbulator,7 care - 24 neighbor- 3,900,000 @hood health centers, clinics and outpatient departments Extended and home care 2,200,000 Other - such as emergency and l@300@000 transportation services Total $21,200,000 As a result of these demonstrations, communities and hospitals not directly involved in these projects have been spurred to make much needed improvements. For example, in 1966 there were only 375-425 coronary care units and 1,100 other intensive care units in the United States. B3, 1.969 these had increased to 2,101 coronary care units and 2,556 other intensive care units, corresponding to 500 percent and 150 percent increases, respectively. This range of activity and the types of operational components being carried on varies from region to region. In providing a mechanism for planning, decision-making, and sharing limited health manpower and facilities, the stress has been on local initiative and control to match local needs, problems, and available resources. It is expected that an increasing portion of available funds during 1972 will be directed toward the following general areas: * Activities which lead to more effective and efficient utilization of health manpower, especially in patient care settings. Training for new types of health manpower (e.g., physician assistants) will be emphasized, as will new organizational patterns which make greater use of paramedical personnel. * operational activities with increased emphasis on regionalization of health resources and services, with the focus on strengthening linkages between those institutions providing specialized care, such as the medical centers and affiliated hospitals, and primary care, being provided by smaller community hospitals, neighborhood health centers, and other community health facilities. * Conjoint and collaborative efforts with Areawide Comprehensive Health Planning agencies and similar agencies which foster community-based planning and programs that can begin to materially effect resource allo- cations/distribution for health at the local level. * Projects which emphasize disease prevention and early detection, including early and easy access to care. * Activities which encourage and support the development, operation and success of the emerging Health Maintenance Organizations. The increase in total funds available for obligation of $4,702,000 would provide $75,000,0(30 in 1972. Of this amount, $5,000,000 is earmarked for con- struction of a regional cancer center in the Northwestern part of the United States. The balance will be used to meet the continuation costs of grants for selected programs based on relative merit. In exercising the current--autliority to use funds for the purpose of program planning and evaluation, in addition to exercising this authority through grants. and contracts, these funds will also be used to finance consultative and other services required to prepare, monitor, and review various forms of evaluation. Such consultative services would be performed under contract or through the use of part-time or intermittent consultants. SELECTED DATA REGIONAL MEDICAL PROGRAMS Overviei%T Rec,ional Advisory Groups . . . ;C;s . . . . . . . . . . . . . 3 0 k F . . . . . . . . . . . . . 4 Planning, Comittees and Tas o 5 Local and Area Advisory Groups . . . . . . . . . . . PMP Staff . . . . . . . . . . . . . . . . . . . . . . . . . . 6 CHP - RINT Relationships . . . . . . . . . . . . . . . . . . . 6 Hospital Involvement . . . . . . . . . . . . . . . . . . . . 7 Operational Programs by: - Program Emphasis - Disease - Health Care Organization and Delivery . . . . . . . . . 8 Health Professionals Trained . . . . . . . . . . . . . . . 9 Office of Program Planning and Evaluation Regional Medical Programs Service February 15, 1971 2-16-71 OIIERVIFll REGIONS 'THERE ARE 56 REGIONAL NEDICAL PROGRME 54 are operational Of these: 5 are in their fourth operational program period TS are in their third @l are in their second 10- are in their first LARGEST REGION In population: California (20 million) In size: Ilashington-Alaska (638,000 square miles) S@LEST REGION In population: Northem Neiv England (44S,000) In size: Metropolitan 1,Vashington D.C. (1,500 square miles) BOMDARIES: NLMER OF REGIONS IIHICH . Encompass single states . . . . . . 32 . Encompass two or more states . . . . 4 . Are parts of single states . . . . . 12 . Are parts of two or more states 8 POPUIATIOIN: NUMBER OF REGIONS IVHICH HAVE Less than 1 million persons s 1 million to 2 million 11 2 million to 3 million 14 3 million to 4 million 8 4 million to 5 million 7 Over 5 million 11 D(2 @UARTEI\O. Grantees Coordin tin@ Head Universities 36 State (29) (26) Private 7) 5) Non-profit Agencies, 20 25 State Medical Societies 5) 4) Non-profit corporation (is) (21) 2 INVOLVEMENT PERSONNEL: PEOPLE IWOLVED IN THE RMPs TOTAL 16,500: 1550 FrE core staff members 2040 FFE project staff members 2700 on Regional Advisory Groups 10,200 on task forces and local advisory groups. HOSPITALS: A TOTAL OF OVER 2,200 OF @-IE NATION'S 7,000 IIOSPITALS ARE NOIV INVOLVED IN R'vlP PLANNING AND OPERATIONAL ACTIVITIES: Over 200 short-term, non-federal hospitals represented on Re atonal Advisory Groups Almost 700 STNF represented on other regional and subregional plannin-g bodies 2 000 STNF involved in operational activities. FLJNDING $223 MILLION I-IAD BEEN AWARDED TO THE PROGRAMS TFIROUGH FY70. NET GRANT AIVARDS IN FY70 TOTALLED 78,202 MILLION 3 REGIONAL ADVISORY GROUPS SIZE * 1967 1600 total membership 30 average group size * 1969 2500 total membership 45 average group size * 1970 2680 total membership 48 average group size * 10-19 members: 3 RAGs 20-29 members: 11 RAGs 30-S9 members: 34 RAGs 60-99 members: 5 RAGs 100-199 members: 2 RAGs over 200 members: 1 RAG * Largest: Ilestern New York (329) Smallest: Missouri.(12) COMPOSITION total 2680 members 728 (27%) practicing physicians 387 (14%) medical center officials 347 (13%) hospital administrators 231 9%) voluntary health organization representatives 204 8%) public health officials 25S (10%) other health workers 516 (19%) members of the public 12 RMP staff members 4 PLANNING CONIMITI'EES AND TASK FORCES NLMER AND SIZE: 500 COi@4ITTE@ES IN 56 REGIONS: 5300 TOTAL MEMBEP,,SHIP COiAPOSITIOiN: By Profession Number Percent TOTAL 320 100 Physicians 3273 62 Registered Nurses 486 9 Hospital &Nursing Home Administrators 326 7 Other Health 346 6 Business or Managerial 312 6 Other 577 10 By Affiliation Number Percent TOTAL 320 100 Medical School 872 16 Affiliated Hospitals 508 10 Other Hospital Interests 879 17 Medical Society 212 4 Public & Other.Health Agencies. 290 5 Voluntary Health Agencies .355 7 Health Practitioners 1180 22 Public or Consumers 198 4 Other 826 15 Almost half of these committees are organized according to categorical diseases; the remaining are in areas such as manpower, training, data collection, hospital planning, and evaluation. 5 LOCAL AREA AND ADVISORY GROUPS PURPOSE: TO STLJDY AND PROPOSE ACTIVITIES TO @ET CO@ITY NEEDS AND TO STRENGTHEN RELATIONSHIPS AMONG LOCAL INSTITURIONS AND WITH THE @DICAL CENTER. 27 Regions have 33S such groups (4800 ersons) p 129 of these are located in the Georgia Region Mbst include representatives of local hospitals, local health professionals and other community leaders. Many do cooperative planning with CHP (b) agencies Composition is primarily consumer and hospital oriented. COMPOSITION By Profession Number Percent TOTAL 4843 100 Physicians 2001 41 Registered Nurses 445 9 Hospital Administrators 672 14 Other Health 227 5 Business or Managerial S22 1 Other 996 20 By Affiliation Nwnber Percent TOTAL 4843 100 Medical Schools 75 2 Affiliated Hospitals 4S2 9 Other Hospital Interests 9S4 20 Medical Society 401 8 Public & Other Health Agencies Soo 10 Voluntary Health Agencies 349 7 Health Practitioners 904 19 Public or Consumer 723 is All Other 485 10 6 REGIONAL @IEDICAL PROG@ STAFF TOTAL: 3S90 FULL-TI@ EQUIVALENTS lS47 on CORE STAFFS 2043 staffing OPERATIONAL PROJECTS FTE-Is FrE's CORE OPERATIONAL A TIVITIES TOTAL lS46 2043 Physicians -226 293 Registered iNTurses 53 369 Allied Health. 45 262 Other Professional/Technical 708 703 r Secretarial Z)14 41-6 CHP PT\IP RELATIONSHIPS S3 regions have overlapping advisory group membership with state and areawide agencies: 18 CHP "A!' staff members are on Regional Advisory Groups (18 reuions) C, 25 CHP "B" staff members are on Regional Advisory Groups (16 regions) * 23 regions have common data collection activities with state agencies '@d 7 ateaivide agencies * 16 regions report that their local advisory aroups have defined relation- C> sTips (staff sharing, joint review, etc.) with GT areawide agencies. 7 HOSPITALS TOTAL NUMBER INVOLVED IN REGIONAL MEDICAL'PROGRAMS: 2210 Short-tem, non-federal 2080 (94%) Long-tem, non-federal 60 3%) Federal 70 3%) SHORT-TERM, NON-FEDERAL HOSPITALS INVOLVED: 2080 By bed Size Under 200 beds 1310 (63%) 200-399 beds 480 (23%) Over 400 beds 290 (14%) By Affiliation Medital school affiliated 1370 (66%) Non-affiliated. 710 (34%) TOTAL NUMBER INVOLVED IN RMP OPERATIONAL ACTIVITIES: 1600 TOTAL NLMER SPONSORING RMP OPERATIONAL ACTIVITIES: 190 8 OPERATIONAL PROGRAMS The CURRENT LMTE-L OF FUNDING is $9S million, which includes approxi- mately $39.8 (42%) for core and $5S.2 (58%) for projects. Operational activities reflect the following program emphases: Activity 100% Continuing Education 22% Manpower Development and Utilization 31% (General) Patient Care Demonstrations 31% Coordination for Health Services 8% Research and Development 8% Disease 100% Heart disease 26% Cancer 12% Stroke 13% Kidney disease 3% Related diseases 9% Multicategorical and/or nonspecific 38% Organization and Health Care Delivery 100% Ambulatory care services (e.g., 7% outpatient depts., neighborhood health centers Other out-of-hospital services-(e.g., 7% home health, extended care, patient education) Intensive care (e.g., coronary care units, 23% stroke units) Support services (e.g., laboratory 8% .services, registries, medical records) Electronic monitoring networks and other 16% consultation services Comunity faculty for subregional S% programs Integrating services c;f several hospitals 15% and other agencies Other 19% @TH PROFESSIONALS REACHED THROUGH EDUCATION AND TRAINING PROGRA-\4S Grand FY68 FY69 FY70 FY71 Totals 6/l/70--271/71 TOTAL 1935,708 l@139 100% 52,396 100% 63,973 100% 76,200 100% Physicians 46,352 319 28 15,719 30 14,714 23 15,600 20 RNI 68 440 729 64 24 102 46 19 832 31 23 777 31 s Allied Health *-56,438 80 7 61,288 12 2lp7SO 34 283,320 38 muitidis- 22.?478 11 1 61287 12 7,6Z7 12 8)1503 11 ciplinary Includes approximately 20,000 emergency health personnel such as ambulance drivers, firemen, etc. Tebrua,ry is, 1971 Distribution of Grants Aiiarded by Prim@ary ,@ctivity En,,I)hasis and Categorical Disease (Net to Date and i@i,@ailable Current Period) . Funds Available Current Program Period Net Operational Grants Aivarded to Date (Level as of 12/31/70 Total Not $254.2 Total Available $9s.o Program Direction - Project $ 91.5 Progr@in, Direction - Proiect $39.8 Developm,ent, Plarnina Develo-pinent, P-La@-min@ Operational Projects $162.7 @,erational Projects @55.2 Activity Emphasis - ,@rojects $162.7 Activity EEphLasils - Pro@ects total $55.2 Education & Training 88.1 Education & Training 29.1 De,monstration of Cate 'D-3.1 Domoiistratio3i of Care 21.7 Research & Developiient 21.5 Research & llevelopn@e-iit 4.4 Disease 162.7 Disease 55.2 Ijeart 4S.9 Ileart 14.1 Cancer 17.1 Ciiicer 6.s Stroke 17.4 Stroke 7.1 Related (Diabetes, 16.4 Related (Diabetes, 6.5 Kidney, Pulmonary) Kidney, Pulnion.-.ry) 1 65.9 i,,Iulticategorical 21.0 ,vtulticateaorical February 11, 1971 OPPE February 9, 1971 Status of OPERATIONAL GRANTS 1967 1968 1969 1970 1971 Awarded Awarded Awarded Awarded Awarded 28 AlabamA ................... ... 903,105 1,148,226 32,507 04 Albany .................... 914,627 1,1@0')'015 139,617 1,534,208 1,094,930 52 Arkansas .................. ... ... 579,924 983,127 ... 56 Bi-State .................. ... ... ... 1,012,307 19 California ................ ... 2@232,864 9,,602,090 2,376,152 9,256,963 50 Central N.y............... ... 460,314 1,237,940 45,039 618,002 40 Colorado-Wyoming .......... ... 1,146,824 1,336 738 08 Connecticut ............... ... 1,548,257 1,197,354 31 D.C. Metropolitan ......... ... 418,318 1,427,008 1,189,486 508,893 24 Florida ................... ... ... 779,085 1,757,031 68,933 46 Georgia ................... 1,416,777 2,635,789 68,660 2,167,534 26 Greater Delaware .......... ... ... 2,862,484 2,500$033 ... 58 Greater New York .......... 967,010 27,282 371,532 3,093,923 ... 01 Hawaii .................... ... 903,301 914,701 1,047,774 43 Indiana ................... ... ... 1,572,396 1,632,990 lil9l,212 15 Intemountain ............. 1,790,603 1,789,792 3,113,706 3,553,599 28,444 27 Iowa ...................... ... 412,841 73,979 1,208,683 02 Kansas .................... 1,076,600 1,576,304 1,727,063 58,516 ... 54 Maine ..................... ... 318,239 862,529 453,406 895,756 44 Maryland ................... ... 2,236,520 2,124,469 51 Memphis ................... 173,119 749,448 890,107 1,301,111 1,027,301 53 Michigan .................. 852,241 989,229 2,725,658 57 Mississippi ................ ... ... 731,406 1,754,474 ii5,,,834 09 Missouri .................. 2,887,903 4,490,607 5,227$008 4,996@201 129,985 32 Mountain States ........... ... 206,913 1,997,283 1,959,224 ... 47 Nebraska - South Dakota ... 350,339 214,987 501,206 1,162,224 395,441 42 New Jersey ................ ... ... 1,030,563 1,412,366 ... 34 New Mexico ................ ... 475,798 1,959,119 1,189,341 February 9, 1971 0 Status o OPERATIONAL GRANTS 1967 1968 1969 1970 1971 Awarded Awarded Awarded Awarded Awarded 03 Northern New England ...... ... 955,086 313,788 660,571 21 Northlands ............... ... ... 1,308,058 1,470,765 ... 06 North Carolina ............ ... 1,799,654 2,168,829 2,275,014 52,166 63 Northwestern Ohio ........ 1,545,276 26,651 22 Ohio State ............... ... 964,367 204,175 809,686 48 Ohio Valley .............. ... 855,317 1,269,711 23 Oklahoma ................. ... ... 1,121,457 1,408,097 ... 12 Oregon ................... ... 598,879 831,888 888,385 14,872 65 Puerto Rico .............. ... 238,027 -253,065 1,058,789 ... 25 Rochester ................ ... 724,664 1,018,675 939,674 35 South Carolina ........... ... 931,507 1,234,457 1,333,301 59 Susquehanna Valley ...... 546,067 719,427 18 Tennessee Mid. South ..... ... 2,088,598 2,712,154 2,668,969 (21,813) 07 Texas .................... ... 1,943,569 ... 2,764,538 1,821,674 62 Tri-Stat6 ................. ... ... 436,122 1,642,162 48,620 38 Wash. - Alaska ............ ... 1,086,764 1,090,197 2,035,610 13 Western N.y .............. ... 357,761 1,647,796 1,413,701 226,720 31 Western Pennsylvania ..... ... ... ... 2,359,490 ... 37 Wisconsin ................ 643,008 1,209,914 1,841,718 1,200,949 8,160,201@, 27,363,664 65,099,569 71,553,652 25,952,247 REGIONAL MEDICAL PROGRAMS SERVICE Applications Approved to Date by the National Advisory Council on Regional Medical Programs but Not Funded Alabama . . . . ... . . . . . . . . .$ 1,576,462 Albany . . . . . . . . . . . . . . . 92,920 Arizona . . . ... . . ... . . . . . . 177,501 Arkansas . . . . . . . . . . . . . . . 1,207,486 Bi-State . . . . . . . . . . . . . . . 141,800 California . . . . . . . . . . . . . . 2,359,803 Central New York . . . . . . . . . . . 280,558 Colorado/Wyoming . . . . . . . . . . . 62,482 Connecticut . . . . . . . . . . . . . 567,094 Florida . . . . . . . . . . .. . . . . 639,681 Georgia . . . . . . . . . . . . . . . 706,570 Greater Delaware Valley . . . . . . . 668,320 Hawaii . . . . . . . . . . . . . . . . 756,191 Illinois . . . . . . . . . . . . . . . 1,667,027 Indiana . . . . . . . . . . . . . . . 684,627 Intermountain . . . . . . . ... . . . 703,248 Iowa . . . . . . . . . . . . . . . . . 425,013 Kansas . . . . . . . . . . . . . . . . 716,622 Louisiana . . . . . . . . . . . . . . 547,532 Maine i. . . . . . . . . . . . . . . 751,761 Maryland . . . . . . . . . . . . . . . 562,404 Memphis . . . . . . . . . . . . . . . 661,405 Metro. New York . . . . . . . ... . . 687,547 Metro. D.C . . . . . . . ; . . . . . . 1,949,005 Michigan . . . . . . . . . . . . . . . . 1,713,674 Missouri . . . . . . . . . . . . . . . 828,719 Mountain States . . . . . . . . . . . 565,748 Mississippi . . . . . . . . . . . . . 35,420 North Dakota . . . . . . . . . . . . . 145,383 Nebraska . . . . . . . . . . . . . . . 349,632 South Dakota . . . . . . . . . . . . . 379,000 New Jersey . . . . . . . . . . . . . .2,165,069 New Mexico . . . . . . . . . . . . . . 171,215 North Carolina . . . . . . . . . . . . 466,156 Northeastern Ohio . . . . . . . . . . 48,233 Northern New England . . . . . . . . . 58,050 Northlands . . . . . . . . . . . . . . 1,180,657 Northwestern Ohio . . . ... . . . . . 266,768 Page 2 Ohio State . . . . . . . . . . . . . 284,938 Ohio Valley . . . . . . . . ... . . .. 854,874 Oklahoma . . . . . . . . . . . . . . 205,978 Oregon . . . . . . . . . . . . . . . 901,738 Puerto Rico . . . . . . . . . . . . . 903,426 Rochester . . . . . . . . . . . . . . 437,891 South Carolina . . . . . . . . . . . 69,281 Susquehanna Valley .. . . . . . . . . . 223,273 Tennessee Mid-South . . . . . . . . . 405,290 Texas . . . . . . . . . . . . . . . . 830,230 Tri-State . . . . . . . . . . . . . . 996,530 -Virginia . . . . . . . . . . 705,724 Washington/Alaska . . . . . . . . . . 652,438 Wisconsin . . . . . . . . . . . . . . 1,156,355 Western New York . . . . . . . . . . 1)106)242 Western Pennsylvania . . . . e,. - - 43,911 West Virginia . . . . . . . . . . . . 483,047 Total Direct Costs . . . . . .$37,227,949 Estimated Indirect Costs . . . 8,004,009 Subtotal . . . . . . . . . . .$45,231,958 Reduction on Awards for Continuation and Renewal Activities Total Direct Costs . . . . . .$ 1,878,149 Estimated Indirect Costs . . . 412,732 $ 2,290,881 Total . . . . . . . . . . . . .$47,522,839 RMPS-GMB February 12, 1971 (2) (3) 14 (5) (6) PXi GION CUi@rLIITI,IEN'T Pr@ DU CT I O'N' NE@4 LE\TEL CARR)rOVI,'I@ TOTAL 1. @abaina $ 870,771 $104,493 $ 766,278 -0- $ 766,278 2.'Wibany 91.5,910 109,909 1806,001 30,000 836,001 3.- Arkansas 1,315,752 106,501 1,209,251 -0- 1,209,251 4.' Arizona 81@1,191 97,343 713,848 -0- 713,848 5. Bi-State 709 ' 587 85,150 624,437 235,646 860,083 6. California 7,068,289' 848,195 6,220,094 480,168 6,700,2()) 7. Central New York 700,091 84,011 616,080 29,000 645@080 8. Colorado/1-lyoming 1,094,572 131,348 963,224 34,774 997,998 9. Connecticut 1,370,565 164,468 1,206,097 -0- 1,206,09/-, 0. Florida 1,535,568 184,268 1,351,300 -0- 1,351,300 1. Georgia 2,022,571 242,709 i,779,862 -0- 1,779,862 2. Greater Del. V. 2,109,357 253,123 1,856,234 -0- 1,856,234 3. Hawaii 923,143 11-0,777 '812,366 23,396 835,76?- 4. Illinois 1,532,333 183,880 1,348,453 -0- 1,348,453 5. Indiana 1,121-,41@l 134,569 986,842 -0- 986,8,/,2 6. Intermountain 2,446,230 293,548 2)152,682 -0- 2,152,682 7. Iowa 651)417 78,170 5733247 -0- 573,247 8. Yansas 1,404,795 168,575 1,236,220 228,805 1,465,0215 9. Louisiana 628,369 75,404 552,965 -0- 552,965 0. Maine 893,780 107,254 786,526 10,693 797,210 1. Maryland 2,077,883 249,346 1,828,537 -0- 1,828,537 2. Itempliis 1,086,048 130,326 955,722 -0- 955,72-2 3. Metro. D.C. 1,008,728 121,047 887,681 -0- 887,681 4. Metro. New York 2,539,887 304,786 2,235,101 -0- 2,235,101 5. Michigan 1,601,367 192,164 1,409,203 -0- 1,409,203 6'*ssissippi 966,160 115,939 1850,221 -0- 850,221 7. ssouri 2,047,610* 222,193 1,825,417 -0- 1,825,417 8@ Mountain States 1,611,764 193,412 1,418,352 -0- 1,418,352 D. Nassau/Suffolk 838,061-i.- 43,567 794,494 -0- 794,494 ). Nebraska/IS. Dakota 500,250 60,030 440,220 -0- 440,220 1. New Jersey 1,236,255 148,351 1,087,904 -0- 1,087,904, 2. New Mexico 1,036,719 124,406 912,313 133,452 1,045,765 3. North Carolina 1,5@,5,105* 125,413 1,419,692 -0- 1,419,699 4. North Dakota 310,683 37,282 273,401 19,900 293,301 5. Northeastern Ohio 786,187 94,3li2 691,845 -O- 691,845 S. N. New England 670,677 80,481 590,@1.96 -0- 590,196 7. North.lands 1,315,368 157)844 1,157,524 -0- 1,157,524 B. Northwest Ohio 781,027 93,723 687,304 -0- 687,304 ). Ohio State 714,075 85,689 628,386 -0- 628,38-0 ). Ohio Valley 1,039,195 124,703 914)492 25,000 939,49"' L. Oklahoma 839,205 100,705 738,500 -0- 738,500 Oregon 761,268* 38,382 722,886 -0- 722,886 3. Puerto Rico 958,163 114,980 843 1-83 -0- 843,183 i. Rochester 508,667 61,040 447,627 -0- 447,627 i. South Carolina 1,089,023 130,683 958,340 203,768 1,1621108 Susquehanna V. 545,915 65,510 480,405 -0- 480,40:-) Tennessee Mid-S. 1,985)627 238,275. 1,74'7,352 -0- 1,747,352 3. Texas 1,316,700 158,o64 1,158,696 549,344 1,708,OZ4.' Tri-State 1,882,485 225,898 1,656,587 -0- 1,656,587 ginia 764,826 91,779 673,047 -0- 673,0/17 REGI@0,Nl -CO@,@,'! @i@ T REDOCTION NEt,,' 1,EVLL CART-',YOVLR TOTAL il. Wasliii-igton/Alaska $1,617,379 $18-1-,485 .$ 1,435,894 -0- $1,435,894-'l i2. West Virginia 516,567 61-,988 454,579 -0- 4541579 53.iW-stc-rn New York 1,029,459 123,535 905,924 -0- 905,924 54. cstern Penna. 944,257 113,311 830,946 -0- 830,946 ')5.- Wisconsin 1,081,569 129,788 951,781. 60,704 1,012,485 Total $69,679,861 $8,1-04,102 $61,575,759 $2,064,650 $63,640,409 L/ Level for 11 month budget period Level for 10 month budget T)eriod 6 month extension with funds Includes additional support over previous commitment. The source of these funds are from the balance created by the 12% reduction of the initial commitment of program support for FY 1971. The regions and amounts are as follows: 1. $ 105,000 l@lashi.ngton/Alaska 2. 428,246 Arkansas 3 196,000 'Lklissouri 4. 500,000 North Carolina 5. 441,414 Oregon 6. 475,000 Nassau/Suffolk $2,145,660 Total additional funds to be av,@arded in FY 1971 are: 1. $500,000 Nebraska 7/l/71-6/30/72 2. $379,500 South Dakota 7/l/71-6/30/72 'he #ant periods be-innin- 7/l/71 for Kansas and South Carolina will be funded from 0 0 Y 1972 appropriations. GMB/Pl@iPS 4/13/71 NEW PREVIOO CHANGE IN PREVIOUS ,@ION CO@L%IITMENT REDUCTION REDUCTION REDUCTION LEVEL NEW LEVEL CARRYOVER TOTAL Al--bama $ 870,771 $104,493 $ 74,016 -$ 30,477 $ 796,755 $ 766,278 @0- $ 766,2@ Alba-,iy 915,9-'@O 109,909 91,591 -18,318 824,319 806,001 30,000 8-IJ6,OC Arkansas 1,315,752 106,501 75,438 -31,063 812,068 1,209,251 -0- 1,209,2:-z Arizo-,ia 811,191 97,343 68,951 -28,392 742,240 713,843 -0- 713,Sz Bi-State 709,587 85,150 60,314 -24,836 649,273 624,646 235,646 860,0": 7,068,289 848,195 @c Cal@Lfornia 600,804 -240-,391 -6,467,485 6,220,094 480,168 6,700,"' Central New York 700,091 84,011 59,507 -24,504 640,584 -616,080 29,000 645,0@ Colorado/1,7yoming 1,094,572 131,348 93,0"j8 -38,310 1,001,534 963,224 347774 9 9 7 9@c, ,Conr.ecticut 1,370,565 164,468 116,498 -47,970 1,254,067 1,206,097 - 0- 1,206,OS -53,745 -0- Florida 184,268 130,523 1,405,045 1,351,300 1,3-Dl,@-C Georgia 2,022,571 242,709 171,918 -70,791 1,850,653 1,779,862 -0 1,779,8@ '@'-eat@-r Del. V. 2,109,357 2-@)3,123 700,000 +446,877 1,409,357 1,856,234 -0- 1,856,2@ -32,310 844,676 812,366 23,396 835,7c a@.7 a 923,143 110,777 78,467 -53,632 1,402,085 1,343,453 -0- Illinois 1,532,333 18',880 130,248 -39,250 1,026,092 986,842 -0- Indi--E,,a 1,121-,411 134,569 95,'JI9 - intermountain 2,446,2@O 293,548 207,929 -85,619 2,2387301 2,1-52,682 -0- 2,l-rj2,6(@ 5 7 3 2 z I ow a 651,417 78,1.70 55,370 -22,800 596,047 573,247 -0- K.a,isas LI 1,404,795 168,575 11-9,407 -49,1.68 1,285,388 1,236,220 228,805 1,465,0,', Loui-si-a-,ia 623,369 75,404 53,411 -21,993 574,958 552,965 -0- 552,,-;( -31,233 817,809 786,526 10,693 797,2' 893,780 107,254 75 , 9 7 1 +2501654 1,577,833 1,828,537 -0- ',',ir nd ,,, , y I @,.i 2,077,P,83 249,'@146 500,000 -21,721 -0- 955,7, 1,086,048 1'JO,326 108,605 977,443 955,722 -20,174 -0- 887,6,' D.C. 1,008,728 121,047 100,873 907,855 887,681 Metro. New York 2,5@39,887 304,786 500,000 +195,214 2,039,887 2,235,101 -0- 2,235,1( -56,048 1,465 251 1,409,203 -0- 1,409,2( @'@ch-1--an 1,601,367 192,164 136,116 I 966,160 115,9-9 82,123 -33,816 884,037 850,221 -0- 850,2, Mississippi -64,807 1,694,224 1,825,417 -0- 1,825,4- ,Yiissouri 2,047,610 * 222,193 157,386 @lountain States 12611,764 193,412 136,999 -5n@,413 1,474,765 1,418,352 -0- 1,418,3' -12,707 332,201 794,494 -0- 794, 4( Nassau/Suf.Lolk 838,061 * 43,567 30,860 -17,509 457,729 440,220 -0- 440,2: ,@ebraska/S. Dakota@ 500@250 60,030 42,521 -43,270 1,131,174 1,087,904 -0- 1,087,9'@ New Jersey .1,23-0,255 148,351 105,081 ,,@el.7 %,'exico 1,036,719 124,406 103,672 -20,734 933,047 919-,313 133,452 1,045,7@ -36,580 956,272 1,419,-092 -0- l@419,6( iNotth Carolina 1,545,105 125,413 88,833 -107874 284,275 273,401 19,900 293,3( North Dakota 310,683 .37,282 26,408 -15,723 707,568 691,845 -0- 691,8@ Northeastern Ohio 786,187 94,342 78,619 NEW PREVIOUS CHAI\TGE IN PREVIOUS T,GION COVII=NT REDUCTION REDUCTION REDUCTION LEVEL NEW LEVEL CAPRYOVER TOTAL iN. New En-land $ 670,677 $ 80,481 $ 57,007 23,474. $ 613,670 $ 590,196 -0- $ 590,14. Nortlillands 1,315,368 157,844 111,806 -46,038 1)203,562 1,157,524 -0- 1,157,5@ Northwest Ohio 781,027 93,723 78,103 -15,620 702,924 687,304 -0- 687,'Jl( Ohio State 714,075 85,689 71,408 -14,281. 642,667 628,386 "O- 628,-) Ohio Valley 1,039,195 124,703 88,331 -36,372 950,864 914,492 25,000 939,L,@ Okla7nona 839,205 100,705 71,332 -29,373 767,873 738,500 -0- 7')S,5@ Ore-o-@l 761,268 38,382 27,187 -11,195 292,667 722,886 -0- 72-@),S -33,537 'Pu@arto Rico 953,163 114,980 81,443 876,720 843,183 -0- 843,'- Rochesterlv 508,667 61,040 43,236 -17,804 465,431 447,627 -0- 447,61 South Carolina.J/ 1,OP,9,023 130,683 92,566 -38,111 996,457 953,31@O 203,768 1,162,11 Susquehanna Valley 545,915 65,510 46,402 -1g,lb8 499,513 480,405 -0- 480,4@ Tennessee viid-South-L/ 1,985,627 '233,275 168,778 -69,497 1,816,849 1,747,352 -0- 1,747,--). Texas 1,316,700 158,004 111,919 -'li6,0,@5 1,204,731 1,158,696 549,344 1,1-08,0 Tri-State 1,882,485 225,898 160,011 -65,887 1,722,474 1,656,587 -0- 1,656,5 764,826 91,779 65,010 -26,769 699,816 673,047 -0- 673,0 Washin@ton/Alaskal-/ 1,6'L7,379 181,485 128,552 -52,933 1,383,827 11%435,894 -0- 1,435,8' T -18,080 472,659 - 454,579 -0- 454,5 .,qest Virginia 516,567 61,988 43,903 Western New Yorl& 1,029,459 123,535 87,504 -36,031 941,955 905,9/--4 -0@ 905,9 Western Penna. 944,257 113,311 80,261 -33,050 863,996 830,946 -0- 830,9 Wisconsin 1,081,569 129,788 91,933 -37,855 989,636 951,781 60,704 1,012,4 Total $69,679,861 $8,104,102 $6,963,513 $1,143,589 $60,570,688 $61,575-1-759 $2,064,650$63,640,4i Level'for 11 month budget period Level for 10 month budget period 6 month extension with funds .ncludes additional support over previous commitment. The source of these funds are from the balance created by the L2% reduction of the initial commitment of program support for FY 1971. The regions and amounts are as follows: 1. $ 105,000 Washington/Alaska 2. 428,246 Arkansas 3. 196,000 Yiissouri G.MB/@S 4. 500,000 North Carolina 4/13/71 5. 441,414 Ore-on 6. -475,000 Nassau/Suffolk $2,145,660 Total Regional ',I(---di-cal Programs b@l @, ion,-, t@ States for Grants 1970 Actual. 1971,. E@tir@,iate 1.972 Estimate. Grants Grants Grants Alabama ....................... $1,148,266 $ 855,228 $ 855,228 Alaska (See Wash.) ............ --- --- --- Arkansas ...................... 983,127 986,663 986,663 Arizona ....................... 1,079,200 901,822 901,822 California .................... 1,742,652 7,857,994 7,857,994 Colorado ...................... 3,295,962 3,008,703 3,008,703 Mountain States IU@llT!-WICHE ... (1,959,224) (]-,791,839) (1,791,839) Colorado-Wyoming P,:,T (1,336,738) (1,216,864) (1,216,864) Connecticut .................... 1,197,354 1,523,691 1,523,691 Delaware (See Pa.) ............ --- --- --- District of ColtimDia ......... 4 1,431,784 I.,103,044 1,103,044 Florida ....................... 1,756,986 1,707,130 1,707,130 Georgia ....................... 87,270 2,248,543 2,248,543 Hawaii ........................ 914,701- 1,026,281 1,026,281 Idaho (See Colo.) ............. --- --- --- Illinois .................... .. 2,216,960, 1,703,533 1,703,533 Indiana ....................... 1,632,990 1,2@6,702 1,246,702 Iowa .......................... 1,144,663 724,197 724,1-97 Kansas ........................ 58,5.1-6 1,561,746 1,561,746 @@eiitucky (Ohio Valley) ........ 1,141,193 1,155,300 1,155,300 uislana ..................... I.,144,180 698,574 698,574 1WIaine .......................... 453,ziO6 993,516 993,516 Maryland ...................... 2,325)944 1,91.7,127 1,917,127 Massachusetts (Tri-State) ..... 1,587,046 2,092,806 2,092,80 Michigan ...................... 2,737,658 1,780,280 1,780,280 Minnesota (Northlands) ........ 1,492,265 1-,462,328 1,462,328 Mississippi ................... 1,811,387 1,074,105 1,074,105 Missouri ...................... 5,726,953 2,847,349 2,847,349 Missouri PMP (4,714,6lq6) (2,058,482) (2,058,482) Bi-State (1,012,307 (788,867) (788,867) Montana (See Colo.) ........... --- --- --- Nebraska ...................... 1,162,224 556,141 556,141 Nevada (See Colo.) ............ --- --- --- New Hampshire (See Mass.) ..... --- --- --- New Jersey ..................... 1,362,417 1,374,376 1,374,376 New Mexico .................... --- 1,133,652 1,133,652 New York ..................... 7,379,835 6,371,918 6,371,918 Albany .................. ... (1,534,208) (1,001,548) (i,001,548) Western N.Y4 (1,271,728) (1,144,475) (1,144,475) Rochester (939,674) (565,499) (565,499) Central N.Y. (45,039) (778,310) (778,310) Greater N.Y. (3,210,923) (2,478,462) (2,478,462) Nassau-Suffolk (378,263) (403,624) (403,624) orth Carolina ................ 2,275,014 2,430 000 2,430,000 North Dakota .................. 361,371 345,394 345,394 Regional. Medical Programs Obligations to States for Grants (Continued) 1970 Actual 1971 Estimate 1972 Estimate Grants Grants Grants Ohio ........................ $2,705,489 $2,zi94,588 $2,494,588 Ohio State (422,606) (780,840) (780,840) N.W. Ohio (1,545,276) (854,053) (854,053) N.E. Ohio (737,607) (859,695) (859,695) Oklahoma .................... 1,41-3,974 932,966 932,966 Oregon ...................... 888,385 355,590 355,590 Pennsylvania ................ 5,561,803 3,369,032 3,369,032 Delaware Valley (2,500,033) (1,712,369) (1,712,369) Western Pennsylvania (2,359,490) (1,049,755) (1,049,755) Susquehanna Valley (702,280) (606,908) (606,908) Puerto Pico ................. 1,070,577 1,065,215 1,065,215 Rhode Island (See Mass.) .... --- --- --- South Carolina ............... 1,234,457 1,210,695 1,210,695 South Dakota (See Nebraska). --- ---- --- nnessee ................... 3,970,080 3,395,065 3,395,065 Tennessee Mid-South (2,668,969) (2,207,472) (2,207,4"/2) Memphis (1,301,111 (1,187,593 (1,187,593), Texas ....................... 2,805,538 1,463,809 19463,809 Utah (Intermountain) ........ 3,562o599 2,719,536 2,719,536 Vermont (N. New England) .... 313,788 745,609 745,609 Virginia .................... 656,633 1,020,331 1,020,331 Washington .................. 2,035,610 1,681,350 1,681,350 West Virginia ............... 447,905 574,281 574,281 Wisconsin ................... 1,843,-868 1,202,@-08 1,202,408 Wyoming (See Colorado ...... --- $78,202,039 $74,91.8,618 $74,918,618 In-center Hosl)ital Heiinodialysis Chronic Hemodialys_is Cost figures range from $15,000 to $50,000 annually per person. Home Dial@i-s For dialysis in the home by the patient or a family member costs average $15,000 for the first year of dialysis which includes an average 10 weeks of in-center training, purchase of equipment, and home renovation. Ensuing years cost in the home range from $5,000 to $7,000 annually. Limited Care Dialysis Although complete cost data on dialysis provided in low overhead facilities is not available, indices-point to an annual cost data range from $7,500 to $15,000 per year per person. KIDNEY DISEASE (;ONTROI, PROGI@)'@M Cost Trends_Li@r - ii@s p liii I- a @.. i.o n it is very diffic6lt to discuss how advances in transplantation have led to cost reductions without first defininc, the components of transplant cost. The two biggest and most problematical components of transplant costs are the pre-transplant dialysis (if you want to consider this as a transplant cost) and the post-transplant complications. The cost of the actual transplant itself and the immediate postoperative hospital care for a normal surgical end result is somewhat fixed and standard and is comparable to other surgical costs. Any improvements in transplant costs, therefore, will have to come e ither in the reduction of pre-transplant dialysis time or in the reduction of post-transplant complications. Most medical research and advances have also been in.these two areas. As the result'of organ procurement projects supported by the Kidney Disease Control Program and various other organ procurementan.d sharing projects through the country, there is the feeling, although very subjective, that because of organ sharing and procurement programs, a patient's time awaiting cadaver transplantation has been reduced.' This, in turn, reduces the pre-operative dialysis which, therefore, represents a cost savings.- As far as advances directed toward the problem of rejection are concerned, advances have been -made in two basic areas: 1. Tissue typing - Within the last 5 years, considerable refinement in technique and knowledge of tissue typing has been made. Although there is a great deal of controversy at the moment, about the efficacy of tissue typing, mosttransplanters will agree that tissue typing has contributed significantly to the recent improvement in transplant survival data. This is even more evident in the living related donors, but is also true for cadaveric donors. As tissue typing has become more refined and transplants are done between more genetically com- patible donor and recipient, the complications of rejection have decreased, thus representing a significant cost reduction. 2. Immunosuppression Immunosuppression directed against the transplan- tation rejection phenomena has also improved over the past 5 years, with ALG probably being the most significant addition to the immuno- suppressive armamentarium ' This area, like that of tissue typing, is by no means adequate as yet, and continued research must be done. However, better immunosuppressive therapy has resulted in fewer complications as well as the ability to treat reject ion at an earlier stage and has resulted, ultimately, in less morbidity and less cost. Another very recent technical advancement, which has represented significant cost saving in a limited number of transplant centers, is the pulsatile pro- fusion apparatus developed by Dr. Belzer. In the centers most ex erienced p in using this apparatus, one is able to remove the donor kidneys, and evaluate them anatomically and physiologically,before embarking on the tissue typing, thus cutting down significantly on tissue typing expenses. However, this saving is significant only in a limited number of centers that ha@@e had a great deal of-' experience this apparatus. As more c@c-iltiers use it and gain.inore experience with it, one is hopeful that this will represent wide- spread savings. Another very significant factor affecting reduction of transplant costs is experience and number of transplants done by the center. Dr. KoLi.ntz's testimony at last year's Senate hearings stated that of the 200 transplants that were performed at their center, the first 50 cost about $20,000, the next 100, between $10,000 and $15,000, and the last 50, between $5,000 and $10,000. Unfortunately, progress in transplantation has been somewhat slow and steady, and there have been no major or drastic brealcthroLichs as yet. I CD have rendered transplantation just an ordinary surgical procedure. Therefore,-costs still tend to be very high and somewhat difficult to assess. KIDF,FY DISI@'.ASE COI@ROL PROG-@01 Cost Trends in Ileinodi@ii.ysis 41 Thc,:@Kidney Disease Control Program let 12 six-year home hemodi.,ilysis training program contracts in 1967. The purposes of these contracts are to test the feasibility of home dialysis as an effective and efficient method of treatment of end-stage kidney disease, to provide the Ki ney Disease Control Program with pertinent cost and medical- data, and to develop financial sources other than Federal to support such a training program. The cost data collected from these contracts has shown that the costs of home dialysis are considerably lower than center dialysis and the trends of these home costs indicate they will continue to drop. Contributing factors to these lower costs have been such things as: 1. lowerin- costs of equipment and supplies; 2. bulk buying and storage of supplies by the training center for the home patient; 3. development of techniques for resue of certain supplies, i.e., blood tubing, artificial kidney (coil, capillary, and Kiil); 4. lower personnel costs through the effective use.of paramedical personnel for patient training and supervision; and 5. effective utilization of already over-crowded hospital beds: if a hospital operates on a 6 day, 2 shift schedule, 4 center dialysis patients will continually occupy one bed; however, if that same bed is used to train a patient for home dialysis using the average training time of 6 to 8 weeks, six to eight patients will occupy that bed every year. A certain number of patients cannot be trained for home hemodialysis for a variety of reasons, some of which include intellectual inability to grasp the procedure, psychological problems in accepting the responsibility, and not having a reliable partner to assist in the procedure at home. Thus, in order to develop a relatively economical way to treat these patients, the concept of "limited care" dialysis came into being. The Kidney Disease Control Program began funding three limited care facilities in June 1970. The purpose of these units is to provide dialysis in a low overhead facility staffed with limited medical personnel and operated essentially by para- medical personnel. Complete cost data on the operation of this kind of unit is not available at this time but all indexes point to average costs per dialysis of between $50 to $100 as compared to the average of $200 to $300 per dialysis costs in a hospital setting. Th e Doi-t Do I 1. ow P ib e r A r I- f i c i 0, I Y, l@l-. This d4alyzer is ccyiposed some 10 cellulose acet,,.te hollow fibers, plasticized aLid ivibec!,ded a Eilic@one rubber at either end. The fibers are but 2.t5 r.-tcrorts iii Providing an effective dialyzing surface of apprw@.4.z-tutely I we-,,@er square, They are about 8 inches long and requ4-ze only abo,it Ilr@ to 135 its of pr;-nii-ng fluid (depending upon the georieti-y of the header used). "ic (3@ th@@.@, diL,,Iyzer, in general, is aq effective ,as e@ coil. %?ith rcig.,-,trd to dislyspnce and iiltrafiltri@-i-ion. Its cost. els@2 of u-@-e, and its reti@@pabil,ity make it r.;)re effici@,j@t tli-ati riost of thL, cqui@i--.i4teiit. llc)wever, all Ls not as rosy as appears. 'Iiie one major d@-ti@baclt to this piece of equipment is in its teric,t(,ncies, a fact that ir,,il@es its general appli- cability iLqpract:ical at the prese-ckt In rc-.,I.,,ard to performance, the dialy&@ai-ice, as measured by the creatiiiii).e, urpa and phosphate clearances, demonstrate that this i.init functions effecrivel)y as the Coil an considerably r@tore so th@sn the I<:til. In addit4L.o-l-, Dr. Cotch uas not able to dettonstrcte any tattgible in tl).e I)ei.ng of t e pat (--Gets dialy;,ed with ,4i-iy of these was quite easi.ly give effect,ed by vai.-y!L).,-,, the iie ircs pr,,)duced by a Vc@rLturi. 1,7,egative pressures could be easil.y frori a -250 to a -500 milli- meters of mercury with a more 25- to 30-pourid @,rat(,@rlieoJ pressure. @,io potential problems arise in this rea: 1. Attaining a 30-pound head of pressure from the water tap, and 2. Adjustments that would necessarily be made to adapt the dialyzet to these new pressures. Apparently, both can be handled quite easily mechanically. Ilowever, the latter of those points appears to be more troublesome because of the reluctance of some of the Manufacturing companies to make modifications on their machines (usually, this involves not much more than A change in dial settings and readout dials). In regard to its efficiency of use, this unit combines the best points of the Kiil and the Coil dialyzers. The unit at present costs about $18.95. Mass'production began in January and over 1,200 were sold. February sales figures will run over 2,000 and there is presently an adequate inventory on hand for purchase. It comes presterilized, requiring only a brief period of time to set it up,, yet it can easily be cleaned and resterilized with Formalin solution, to be used again (a process which only takes about 15 minutes). The HRAK can be used without a blood pump and can be used with either a fistula or an external cannula. The major problev, assoc;-ated with this ei@..a'4y@,er its thromliagenic tenden- c icis, to b,@i r!@@z o@,,Iy u-c,@Lt. but also to the individual patient. Si,icli ;@s fiber distortion, ki p@blem which probably will not be coir@pletely eradicated because of the difficulty in the r,ianufacturirig proce,-,@ll itself, and the rhipe of header, ati area where blood pools before it goes throu@d, the hollo-,q fib4@rs, Care the tt4o major at the presp-;iL Ofteii, oi@te i.@ill see significant stagnation of floi,- in the header I)ecau e of fluid dynan@ic changes occurring wi)c-.n frc;-@'" a large, I-,,ore tube to a very st@ll hoi.-e tube. I-,ideed9 both of theme -@rart(:)rs wall t,,4iid toward spontaneous tiironj>oE:is. In to - co-iisi era 0 patient variarce in regard to spontaneous clotting within the dialyzer itself. Dr. C,-,)tch has already undertaken sortie basic coagulation studies in small groups of patients, and these seem to sugrest t:hat there are certain characteristics fot;r,,d in pif:iei-its do not reEdily clot their units. These factors are threefold: 1. They seem to fire prolonged blc-e(lin- tizic., 2. They appc6r to have a decreased prothroribin. cop..sutnption time; and 3. They appear to have abnorirxil platelet cluLlipLrig with collogen One therapeutic maneuver that immediately suggests itself is to place patients on long-t6rm anticoagulatibri with Coumadin. Foviever, this only slightly prolonged the life of the dialyzer in those patients with a tendency to clot but, unfortunately, with a significant increase in morbidity. This finding hints that the clotting may be primarily related to factors other than those related to coagulation. Indeed, Dr. Gotch presently suspects that the clotting is secondary to Olatelet- fibrin clumping, which subsequently occludes the hollow fibers and secondarily results in clot formation. At present, he was working on more detailed coagulation experiments in an attempt to further elucidate the problem. The Cordis Dow Corporation is presently in the process of developing a more efficient capillary that will effectively reduce clot formation. It will be introduced by Dr. Gotch at the ASAIO this summer And subsequently be put on the market. It will sell for the same price as the present kidney.