Redefining the unacceptable.
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Adolescent↗
Biomedical subjects
A Dobson
Publications and source records attributed to A Dobson.
An examination of winners and losers under Medicare's prospective payment system.
Through case studies of 10 matched pairs of winner and loser hospitals under the Medicare prospective payment system (PPS), specific characteristics and management actions were identified that are related to strong financial performance. Because other payers are increasingly adopting PPS-like cost control incentives and because managed care is fundamental to the national health care reform debate, the successful strategies identified in this article may be of increasing importance to hospital managers.
Cost Control↗
Variability in the risk of major gastrointestinal complications from nonaspirin nonsteroidal anti-inflammatory drugs.
BACKGROUND: We have assessed the extent to which the risk of serious gastrointestinal complications from nonaspirin nonsteroidal anti-inflammatory drugs (NANSAIDs) varies with the age and sex of recipients, use of aspirin or alcohol, administration by the oral or rectal route, and dose and choice of drug. METHODS: A case-control study was performed with prospective recruitment of cases of gastrointestinal bleeding or ulcer perforation and age- and sex-matched controls. Information on preadmission drug use obtained by structured interview. RESULTS: Six hundred forty-four patients and 1268 controls were recruited. The odds ratio for upper gastrointestinal complications in users compared with nonusers of NANSAIDs increased with age: < or = 59 years, odds ratio 2.0; 60-79 years, odds ratio 3.0; > or = 80 years, odds ratio 4.2; and was higher in women (5.4) than in men (1.9). There was a linear dose-response curve that was steeper in women than in men. Combined exposure suggested additive risks: NANSAIDs and aspirin, odds ratio 6.7; NANSAIDs and alcohol, odds ratio 6.0 NANSAIDs by the oral route were associated with an odds ratio of 2.3, compared with 11.4 with rectal administration. Piroxicam was associated with the highest risk, odds ratio 4.8; and ibuprofen the lowest risk, odds ratio 0.7. CONCLUSIONS: A number of factors can alter the risk of major gastrointestinal complications with NANSAIDs and need to be considered when individual prescribing decisions are made.
Administration, Oral↗
Coronary heart disease case fatality in four countries. A community study. The Acute Myocardial Infarction Register Teams of Auckland, Augsburg, Bremen, FINMONICA, Newcastle, and Perth.
BACKGROUND: Community-based registers participating in the MONICA Project of the World Health Organization show markedly different attack and death rates of coronary heart disease. This variation is a function of both the incidence and case fatality occurring within countries. The contribution of case fatality to the international variation in coronary heart disease mortality rates is not well understood. METHODS AND RESULTS: The register data from eight study populations--Augsburg and Bremen in Germany, Auckland in New Zealand, Perth and Newcastle in Australia, and North Karelia, Kuopio, and Turku/Loimaa in Finland--were compared. All patients with definite myocardial infarction or coronary death aged 35 to 64 years occurring in the study populations in 1985 through 1989 are the basis for the case fatality calculations by different definitions: 28-day case fatality for all cases, for hospitalized cases, and for hospitalized 24-hour survivors; out-of-hospital case fatality; and 24-hour case fatality for hospitalized cases. Differences in case fatality were much smaller than differences in attack and mortality rates in these populations. About two thirds of deaths occurred before the patients reached a hospital. The 28-day case fatality ranged from 37% for men in Perth to 58% for women in Augsburg. Among those who reached the hospital alive, 28-day case fatality was 13% to 27% for men and 20% to 35% for women. In those who survived 24 hours from the onset of symptoms, 28-day case fatality was 8% to 17% for men and 12% to 26% for women. CONCLUSIONS: Differences in case fatality were not associated with differences in coronary mortality rates between these populations. As most deaths occurred before reaching a hospital, opportunities for reducing case fatality through improved hospital care are limited. This emphasizes the primary role of prevention in reducing coronary death rates.
Adult↗
Articulating the need for innovation and accountability.
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Health Policy↗
Effects of prior use of non-steroidal anti-inflammatory drugs on renal function and transfusion requirements after upper gastrointestinal haemorrhage.
The possibility has been investigated that, after admission to hospital with acute upper gastrointestinal bleeding, patients who have been users of aspirin and non-aspirin non-steroidal anti-inflammatory drugs have poorer baseline renal function, a greater improvement in renal function during their hospital stay, and a larger transfusion requirement than non-users. Patients over 50 years of age admitted to public hospitals with acute upper gastrointestinal bleeding were studied. Creatinine clearance was estimated from serum creatinine and the transfusion requirement was recorded as the number of units of blood transfused on Day 1 and throughout the entire hospital stay. Data were obtained prospectively from case notes and by structured interview. Users of non-steroidal anti-inflammatory drugs were significantly older than non-users. The estimated creatinine clearance on admission to hospital declined with age. Creatinine clearance was 13.2 (95% CI 6.0 to 20.4) ml.min-1 lower in users than non-users of non-aspirin non-steroidal anti-inflammatory drugs. However, the difference was attributable to the older age of the drug users rather than to the drugs themselves. On average, the increase in creatinine clearance during hospital stay was the same in users and non-users of non-aspirin non-steroidal anti-inflammatory drugs. Prior use of aspirin had no effect on any measure of renal function. The incidence of blood transfusion was higher in older than in younger patients but neither the incidence of transfusion, nor the transfusion requirement, was different between users and non-users of non-aspirin non-steroidal anti-inflammatory drugs and aspirin.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
The role of federal waivers in the health policy process.
Federal waiver programs enable states to bypass the requirements of federal programs such as Medicare and Medicaid to experiment with different ways of financing, organizing, and delivering health care. In tracking waiver activity from 1980 to 1990, the authors found that federal involvement with waivers lost momentum during the latter part of the 1980s, while state involvement increased. Three key issues dominate the discussion of waivers: administrative control, the role of the states, and the ability to evaluate demonstration waivers. Examination of the chronology of waiver activity suggests the emergence of a new era, wherein federal control reemerges as a way to counter the increased fragmentation of health policies among states. If this is the case, four areas need to be addressed: (1) balance of political and research objectives; (2) administrative flexibility for states; (3) careful scrutiny of rules; and (4) increased accountability. These recommendations can guide the federal government, with the states as partners, in its attempt to regain momentum in the use of waivers to expand the knowledge base.
Health Policy↗
Shifting no solution to problem of increasing costs.
Rising healthcare costs are being allocated unevenly because some stakeholders are better than others at insulating themselves from paying their share of the burden. Those with significant or group purchasing power are paying less than actual cost, forcing providers to shift a disproportionate share of the costs to small businesses and non-group purchasers. The magnitude of this cost shifting is large and growing. Its primary impact is a destabilization of insurance markets. Stability can only be restored with well thought-out proposals that deal with causes of the cost increases.
Cost Allocation↗
NSAIDs and risk of upper gastrointestinal bleeding.
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Anti-Inflammatory Agents, Non-Steroidal↗
Sequences downstream from the transcriptional start site are essential for microaerobic, but not symbiotic, expression of the Rhizobium meliloti nifHDK promoter.
Deletion analysis studies have been carried out on the nifHDK promoter (P1) of R. meliloti in an attempt to determine sequences involved in the expression of this promoter under both free-living microaerobic and symbiotic conditions. Deletion of a region downstream (+17 to +61) from the promoter element resulted in low levels of expression under free-living microaerobic conditions. However, wild-type levels of expression were obtained during symbiosis with Alfalfa plants. The sequences in this region were designated the "downstream sequences'. The pattern of expression observed when the downstream sequences were deleted was similar to that observed when a previously identified upstream activator sequence (UAS) was deleted. Only when both the downstream sequences and the UAS were deleted, did activity from the P1 promoter become significantly decreased during symbiosis. Expression studies of the P1 promoter in a nifA mutant background indicate that nifA is required for symbiotic expression of P1 which is enhanced by the presence of the downstream sequences.
Aerobiosis↗
Does the occupational structure of the Hunter Region explain the high rates of ischaemic heart disease among its men?
To compare rates of ischaemic heart disease (IHD) among men in occupation groups defined by the new Australian Standard Classification of Occupations (ASCO) and to investigate whether their high mortality rates from IHD in the Hunter Region of New South Wales (NSW) could be explained by its occupational structure, we used official death records and data from the World Health Organization MONICA Project conducted in Newcastle. The study population consisted of men aged 25 to 64 years in NSW and in the Hunter Region for whom occupational information was available. For deaths from IHD between 1984 and 1988 in NSW, indirectly standardised mortality and morbidity ratios (SMRs) were: significantly low for professionals, 66 (95% confidence interval (CI) 60-71) and managers and administrators, 79 (95% CI 74-83); intermediate for paraprofessionals (92), clerks (94) and salesmen and personal service workers (97); and significantly high for tradesmen, 113 (95% CI 107-118), labourers and related workers, 118 (95% CI 113-124) and plant and machine operators and drivers, 125 (95% CI 118-133). Broadly similar patterns were found for IHD deaths and for fatal and nonfatal myocardial infarction in the Hunter Region. When occupation- and age-specific mortality rates from IHD were used to calculate SMRs for the Hunter Region, SMRs for all ASCO groups except paraprofessionals were over 100. Mortality rates for occupational groups classified by ASCO were consistent with well-established differences associated with socioeconomic status.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Who eats what? A comparison of dietary patterns among men and women in different occupational groups.
Dietary data were obtained during a community-based study of risk factors for heart disease in 1983. Results were compared for men and women in broadly defined socioeconomic groups based on occupation and education. People in higher status occupation groups and with more education, and women more than men, had food consumption patterns more consistent with current health promotion messages. For example, they reported eating more wholemeal or brown bread and more fresh fruit and vegetables, drinking more skim or low-fat milk, eating fewer eggs and having less sugar in hot drinks or on cereals. There was some evidence, however, of an interplay of influences of cost and health awareness. For example, retired men were less likely than employed men to eat butter, cream, fresh fruit and vegetables, while men in the upper socioeconomic groups reported relatively higher consumption of butter and cream. The results emphasise the need for a range of strategies aimed at specific subgroups in order to improve national dietary patterns in Australia.
Adult↗
Action of sympathomimetic drugs on the bronchial circulation of the horse.
In the quietly standing horse I.V. administration of adrenaline decreased, and of dobutamine increased, bronchial artery flow. These changes paralleled changes in arterial pressure. With phenylephrine and noradrenaline bronchial artery flow decreased while arterial pressure increased, indicating active vasoconstriction in the bronchial circulation. With clenbuterol an increase in bronchial artery flow was accompanied by a decrease in systemic blood pressure, indicating bronchial arterial vasodilatation. We conclude that alpha-constrictor and beta 2-dilator receptors are present in the bronchial artery bed and that stimulation of these receptors could explain changes in flow seen in the horse during exercise and anaesthesia.
Animals↗
Dicarboxylic acid transport and regulation of nitrogen fixation in Rhizobium meliloti.
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Biological Transport, Active↗
Pulmonary shunting by the bronchial artery in the anaesthetized horse.
In the quietly standing horse the bronchial arterial blood flow is low, 0.1-0.2% of the pulmonary arterial flow. In horses anaesthetized with halothane, the bronchial arterial flow is reduced by a greater fraction than that in the pulmonary artery. Thus the shunting through the bronchial circulation is decreased about 3-fold by anaesthesia, and cannot, therefore, contribute significantly to the increased alveolar-arterial gradient seen in dorsal recumbency. The results indicate bronchial vasoconstriction under anaesthesia.
Anesthesia↗
Effect of clenbuterol on arterial oxygen tension in the anaesthetised horse.
In horses in dorsal recumbency, spontaneously breathing oxygen, with halothane at a constant end-tidal concentration, the arterial oxygen tension (PO2) increased from 9.9 +/- 0.3 SEM kPa to 21.7 +/- 4.0 kPa with 0.8 micrograms kg-1 clenbuterol and to 29.1 +/- 3.8 kPa with 2.4 micrograms kg-1 clenbuterol. In horses initially in dorsal recumbency then turned to sternal recumbency the PaO2 rose to 54.0 +/- 3.0 kPa, but this rise was unaffected by clenbuterol administration. The response in dorsal recumbency was consistent with clenbuterol counteracting the factor postulated to direct the pulmonary blood flow caudodorsally, but the response to clenbuterol in sternal recumbency was not. Although these results do not unequivocally characterise the postulated factor, the effect of the clenbuterol itself is of interest because of its potential as a treatment for the low PaO2 often observed in anaesthetised horses.
Anesthesia↗
The role of parasites in regulating host abundance.
It has been 11 years since Anderson and May demonstrated the theoretical ability of helminth parasites to regulate host population abundance. In this review we consider how their work has advanced our understanding of the role of parasites in host populations. In particular Marilyn Scott and Andy Dobson consider three questions. What is meant by regulation? Is there empirical evidence that parasites can regulate host population abundance? Is it possible to predict the sort of host parasite association where one is most likely to be able to detect parasites as a major regulatory force?
Journal Article↗