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Biomedical subjects

A M Bernard

Publications and source records attributed to A M Bernard.

At least 19 recordsLinked to original sources
PubMed1996

Comparing the hospitalizations of transfer and non-transfer patients in an academic medical center.

BACKGROUND: By accepting and caring for patients transferred from other institutions, academic medical centers have been able to develop comprehensive training and research programs. Whether academic institutions can continue to do this in the future is questionable. To the extent that transfer patients are more complex and severely ill than non-transfer patients, they are likely to consume more resources, and in managed care payment systems, they could place accepting hospitals in financial jeopardy. METHOD: Between July 1989 and December 1993, the internal medicine, surgery, and pediatrics services of the 880-bed University Hospital of the University of Michigan accepted 8,740 patients from other hospitals. The hospitalizations of these patients were compared with those of the 76,047 non-transfer patients on these services. The statistical methods used were Student's t-test, chi-square, Cochran-Mantel-Haenszel chi-square, and analysis of variance. RESULTS: The hospitalizations of the transfer patients were more complex and resource-use intensive. The transfer patients were more likely (p<.0000) to be length-of-stay outliers as defined by Medicare standards (28% vs 10%) and to suffer in-hospital death (9.4% vs 2.5%). After case-mix adjustment and exclusion of length-of-stay outliers, transfer patients on the three services (surgery, medicine, and pediatrics) remained in the hospital 1.62, 1.15, and 0.84 days longer (p<.0001) than non-transfer patients. Ancillary-service resource use was assessed using a relative-value-unit (RVU) scale based on direct-cost dollars. The transfer patients' case-mix-adjusted resource use exceeded that of the non-transfer patients by 1,155,850 and 957 RVUs for surgery, pediatrics, and medicine (p<.0001). Although the transfer patients were more likely to have Medicaid insurance, the differences in lengths of stay and use of ancillary services persisted throughout all insurance groups. Indeed, transfer status, compared with age, sex, and insurance status, was the best predictor of high resource use. CONCLUSION: The transfer patients stayed longer and consumed more hospital resources than did the non-transfer patients. Age, sex, case-mix, and insurance status did not account for these differences. To limit the financial liability that transfer patients pose, academic medical centers could be forced to abandon their traditional role of caring for such patients. The consequences of this possibility should be explored.

Academic Medical Centers↗
PubMed1996

Clara cell protein (CC-16) and surfactant-associated protein A (SP-A) in asbestos-exposed workers.

Asbestos-exposed workers (Asb) can sometimes develop lung impairments resembling idiopathic pulmonary fibrosis (IPF). Smoking is often a troubling confounder in the natural history of these lung diseases. Distal airspace epithelial cells, which are also altered in asbestosis, secrete Clara cell protein (CC-16, also designated CC-10) and surfactant-associated protein A (SP-A). By inhibiting phospholipase A2 (PLA2), CC-16 and SP-A are putative candidates for controlling lung inflammatory events. Both were measured with PLA2 activity in alveolar fluids (and sera for CC-16) of smoker and nonsmoker Asb and compared with smoking-matched normal subjects (N). CC-16 (in mg/L) was slightly increased in Asb and affected by smoking: nonsmoker Asb: 3.1 +/- 0.5 vs nonsmoker N: 1.9 +/- 0.2 (p < 0.05), smoker Asb: 1.7 +/- 0.3 vs smoker N: 0.6 +/- 0.1 (p < 0.05). SP-A (in microgram/mL) was enhanced in Asb but not affected by smoking: 5.4 +/- 1.5 in Asb vs 1.6 +/- 0.4 in N (p < 0.05), whereas SP-A to phosphorus ratio was increased in Asb but affected by smoking. CC-16 to albumin and CC-16 in serum to alveolar fluid ratios were altered by cigarette consumption in Asb (p < 0.05 vs N). Secretory PLA2 activity was slightly enhanced in Asb (p < 0.05 vs N). All data were similar between stages of disease. In summary, alveolar CC-16, SP-A, and secretory PLA2 activity were increased in Asb. Smoking affected several parameters. By this habit, Asb might reinforce lung profibrotic factors and increase their risk in developing lung alterations resembling IPF.

Adult↗
PubMed1996

[Pulmonary metastases with a prolonged development. Two cases of thyroid cancers].

The authors report two cases of differentiated carcinoma of the thyroid with pulmonary involvement showing as miliary shadowing radiologically which preceded the diagnosis of the thyroid neoplasm by 35 and 6 years respectively. The two patients had undergone cervical radiotherapy in infancy for lymphadenopathy whose aetiology had not been determined. The scintigraph with iodine 131 showed tht in two cases there was a bilateral and diffuse pulmonary uptake in keeping with pulmonary lesion of metastatic origin. Our observations recall the possibility of a slow evolution of pulmonary metastases and carcinoma of the thyroid and the role of cervical irradiation in the development of such cancers. With miliary shadowing a metastatic origin, in particular that of the thyroid, should be considered and in the majority of cases the proof could be supported using iodine 131 scintigraphy. The delay in appearance of pulmonary metastases during the course of cancer of the thyroid is variable. They occur most often after the initial diagnosis or more rarely preceding the discovery of a primary thyroid cancer. The pulmonary metastases may be asymptomatic. This neoplasm may benefit from a specific effective therapy and prolonged remissions have been described even with metastases.

Adult↗
PubMed1995

Biokinetics and stability aspects of biomarkers: recommendations for application in population studies.

The knowledge of the toxicokinetics of chemicals is an important prerequisite of biological monitoring of exposure. Kinetic data allow to determine whether the test is likely to reflect the recent exposure or to integrate the exposure over a certain period of time. They are necessary to select the appropriate parameter, biological specimen and sampling time by taking into account the type of exposure and the sensitivity of the analytical method. Various mathematical models have been developed to provide a global and quantitative description of the behavior of the chemical in the organism. In practice, however, the parameter to which one usually refers is the elimination half-life of the biomarker which reflects both the affinity of the chemical for the biological matrix and the efficiency of excretory or metabolic processes. Since chemically-induced diseases usually develop following repeated exposures over many years, markers which are the most useful for population studies are those integrating the dose received by the organism or by the target organ(s) over a toxicologically relevant period of time exposure. For a reliable application of biological monitoring in population studies, information must be collected on the stability of the biomarker and the precautions to be taken during transportation and storage of samples. The factors most likely to affect the stability of the parameter are evaporation, chemical deterioration, precipitation, adsorption on vessel surfaces and contamination. This paper formulates a series of practical recommendations to prevent or minimize variations in the pre-analytical phase which might be caused by these factors.

Biomarkers↗
PubMed1995

Renal effects in children living in the vicinity of a lead smelter.

A cross-sectional study was carried out to determine whether environmental exposure of children to lead may cause renal effects. The study involved a total of 195 children aged 12 to 15 years. One hundred forty-four children (63 boys and 81 girls) were recruited from two schools in the vicinity of a lead smelter and 51 (25 boys and 26 girls) from a school in a rural area. Compared to their referents, boys and girls from the two schools in the polluted area had significantly higher levels of lead in blood (PbB) but similar levels of cadmium (CdB) and zinc protoporphyrins (ZPP). The functional integrity of the kidney was assessed by measuring the urinary excretion of beta 2-microglobulin, Clara cell protein, retinol-binding protein (RBP), albumin and beta-N-acetyl-D-glucosaminidase. The most significant and consistent finding of the study was that children from the two schools in the polluted area showed a significant elevation of the urinary excretion of RBP that paralleled the level of lead in blood or in the dust collected on the school playgrounds. A similar pattern was observed for the prevalence of elevated values of urinary RBP which increased from 3.9% in the control area up to 17% in the most polluted school. Urinary RBP was found to be associated with PbB (partial r2 = 0.046, P = 0.005) in a stepwise regression analysis testing also the influence of age, sex, CdB, and ZPP. In conclusion, the present study suggests that lead contaminating the environment may cause slight effects on the proximal tubule function in children at exposure levels close to those associated with CNS deficit.

Adolescent↗
PubMed1995

The integrated inpatient management model. Lessons for managed care.

The Integrated Inpatient Management Model was a 2.5-year controlled prospective trial of using a clinical information system to direct and monitor physician and hospital practice on general medicine services of an 880-bed university hospital. For the over 2,000 admissions on both a control service and the intervention service, the mean length of stay (LOS) decreased when compared with historic norms (0.68 and 0.95 days respectively; P < 0.01 for both). This difference in mean LOS represents a savings of 580 hospital days for the intervention over the control service; (95% confidence interval, 300 to 1420 days). There also was a trend for the intervention service to have fewer LOS outliers than expected (P = 0.14). Ancillary service use decreased by 17% on both control and intervention services (a trend that disappeared after the study was terminated), while other internal medicine services experienced a 29% increase in this measure of resource use. The intervention service experienced fewer preventable deaths (P = 0.04), but there were no differences in global quality of care measures, readmission and mortality rates, and patient satisfaction. This use of a clinical information system is a prototype for the systems that will be needed for all forms of managed care.

Ancillary Services, Hospital↗
PubMed1994

Structure of the mouse dipeptidyl peptidase IV (CD26) gene.

Dipeptidyl peptidase IV (DPP IV, EC 3.4.14.5) is an ectopeptidase whose expression is modulated during thymocyte differentiation and T cell activation. We describe here the organization of the mouse DPP IV gene. This gene, which encompasses more than 90 kb, is composed of 26 exons separated by introns, the lengths of which vary from 100 bp to more than 20 kb. Reverse PCR performed on RNA from different tissues indicated that DPP IV transcripts do not contain alternatively spliced CDS sequences and, therefore, are supposed to yield a single polypeptide. However, two types of specific mRNA have been detected that differ in their 3'UTR sequences. They derive from alternative polyadenylation of the DPP IV primary transcript, since the different 3'UTR sequences are contiguous in the mouse DPP IV gene. Sequence analysis of the gene 5'-flanking region revealed several structural features found in the TATAA-box-less promoters, including a G+C-rich segment, a high frequency of dinucleotide CpG, and an imperfect symmetrical dyad. The DPP IV gene was assigned by in situ hybridization to the mouse [2C2-2D] region, which is syntenic with human chromosome 2. These data indicate that the human Dpp4 locus is located within this synteny region (i.e., 2q14-q37). The genomic organization of the mouse DPP IV gene is compared to that of classical serine proteases and serine hydrolases. As structural and mechanistic conservation in the absence of sequence similarity is the most remarkable feature among alpha/beta hydrolases [Ollis, D. L., et al. (1992) Protein Eng. 5, 197-211], we report the possible evolutionary link between the DPP IV related family and alpha/beta hydrolases.

Alternative Splicing↗
PubMed1994

Serum Clara cell protein: an indicator of bronchial cell dysfunction caused by tobacco smoking.

Clara cell protein (CC16) is a 16-kDa protein secreted by Clara cells and other nonciliated cells of both the bronchiolar and bronchial epithelium. CC16 is present in high concentrations in the respiratory tract secretions but occurs also in other fluids such as serum. In this study, CC16 has been measured in the sera from 65 female and 69 male current smokers and in a sex- and age-matched control group of 135 neversmokers. Lifetime smoking averaged (geometric mean) 12.7 (range, 0.6 to 61.3) and 17.9 (range, 0.8 to 126) pack-years in female and male smokers, respectively. A significant reduction of Clara cell protein was found in the sera of smokers of both sexes. In neversmokers serum CC16 was independent of sex but significantly increased with age. In current smokers serum CC16 was also negatively correlated with both the current and lifetime cigarette consumption and with the 24-h urinary excretion of thiocyanate. After adjustment for age, a linear dose-response relation was apparent between smoking history and serum CC16, the latter decreasing on average by about 15% for each 10 pack-year smoking history. The present study supports the concept that CC16 in serum is a marker of bronchial dysfunction caused by tobacco smoke. As CC16 appears to be a natural immunosuppressor of the respiratory tract, its decreased production might explain some inflammatory changes associated with smoking.

Adult↗
PubMed1994

Do attending or resident physician practice styles account for variations in hospital resource use?

Prospective payment has created incentives for hospitals to identify physicians who are responsible for high or excessive rates of resource use. However, at teaching hospitals it is unclear whether individual attending or resident physicians account for a substantial portion of the observed variations in hospital resource use. To explore this issue, case-mix adjusted hospital length of stay and ancillary resource use at a university teaching hospital for 7,667 consecutive discharges on general medicine wards and 7,566 discharges on medical subspecialty wards were evaluated. After controlling for case mix and patient characteristics (patients' age, sex, marital status, insurance status, and ward service), only 2% of the length of stay variance (log transformed) was attributable to the attending physician on general medicine wards (P = 0.06) and 1% on subspecialty medicine wards (P < 0.01). For total ancillary resource use, about 2% of the variance was attributable to general medicine and subspecialty ward attendings. Similar associations were found for resident physicians, although the overlap of attending and resident physicians' month-long rotations prevented critical appraisal of their independent contributions to resource use. Furthermore, labeling attending physicians as high or low hospital resource utilizers based on data from one month of attending duty (mean admissions = 33 +/- 7) would be scarcely better than randomly classifying them (kappas ranged from -0.05 for length of stay on subspecialty services to 0.18 for pharmacy use on general medicine services). In conclusion, in this university teaching hospital, attendings and residents account or a small, although statistically significant, amount of the variation in hospital resource use. It would be impractical for the hospital to reliably profile the resource use intensity of individual physicians.

Analysis of Variance↗
PubMed1994

Pretargetted imaging of colorectal cancer recurrences using an 111In-labelled bivalent hapten and a bispecific antibody conjugate.

In 11 patients recurrence of colorectal cancer was suspected by a rise in serum carcinoembryonic antigen (CEA) (nine cases), by a subocclusive clinical situation (one case) or by endoscopy (on an anastomosis, one case). Two-step tumour targetting was performed by a first injection of 0.1 mg kg-1 of unlabelled bispecific antibody conjugate (an anti-CEA Fab' fragment chemically coupled to an anti-diethylene triamine pentaacetate (DTPA)-indium fragment) followed 4 to 5 days later by injection of the bivalent DTPA hapten labelled with 5 to 8 mCi 111In. Planar scintigraphy, single photon emission computed tomographic (SPECT) 360 degrees acquisitions and whole-body scans were obtained 4.5 and 24 h after injection of the radiolabelled hapten. Biodistribution was determined for eight patients at 48 h. The final diagnosis was confirmed histologically in nine patients (eight by second-look surgery, one by laparotomy). Overall, results were one true negative (1-year follow-up) and 10 true positive; however, for the three large liver metastases (3 to 6 cm), only the periphery of the metastasis had high uptake compared to normal liver. For pelvic recurrences, immunoscintigraphic (IS) contrast was better for small tumours. The highest tumour uptake was found for a 1 cm diameter pelvic recurrence (7.2% i.d. kg-1). Mean tumour-to-blood ratios were 6.4. Thus, this two-step tumour targetting technique, which uses a bispecific antibody conjugate and an 111In-labelled bivalent hapten injected sequentially without chasing the excess bispecific antibody, provided satisfactory results in this preliminary clinical trial for detection of recurrent colorectal cancers.

Adenocarcinoma↗
PubMed1994

Factors involved in entry of the human immunodeficiency virus type 1 into permissive cells: lack of evidence of a role for CD26.

It has been proposed recently that the cell surface peptidase CD26 acts in concert with CD4, the human immunodeficiency virus (HIV) primary receptor molecule, to mediate HIV entry into permissive cells. We have failed to detect significant levels of CD26 cell surface expression and enzymatic activity in a number of commonly propagated human CD4+ cell lines, although CD26 mRNA was present at very low levels, as detected by reverse transcription PCR. No relationship existed between the expression of CD26 and the ability of these cells to be infected with HIV or to fuse to form syncytia. We have tested two inhibitors of CD26 enzymatic activity and several anti-CD26 monoclonal antibodies and found that they inhibit neither HIV infection nor HIV-induced syncytium formation. NIH 3T3 cells stably transfected with the cDNAs for human CD4 and CD26 expressed these molecules at the cell surface and had CD26 enzymatic activity. Inoculation of the double transfectants with HIV did not result in virus entry above the background level, as verified by PCR amplification of viral DNA. We were unable to recover infectious virus from the HIV-inoculated NIH 3T3 double transfectants either by transfer of supernatants or by cocultivation with human CD4+ indicator cells. Moreover, the transfectants did not fuse with HIV-infected cells to form syncytia, nor were syncytia observed in HIV-inoculated cultures. These results are inconsistent with the CD26 molecule being a cofactor for entry of HIV in CD4+ cells.

3T3 Cells↗
PubMed1994

Multiparametric classification of muscle T1 and T2 relaxation times determined by magnetic resonance imaging. The effects of dynamic exercise in trained and untrained subjects.

Muscle relaxation times can now be measured accurately with magnetic resonance imaging (MRI), distinguishing working muscles from non-working muscles. A correlation between T2 increase and work intensity has been shown in healthy volunteers. The small amount of data on T1 relaxation times is contradictory. In addition, all the published studies have concerned short-duration exercise in subjects of unknown training level. The goals of this study were (i) to determine T1 and T2 variations in thigh muscles after long dynamic exercise, (ii) to analyse the effects of training and (iii) to determine the relationship between power output and relaxation times after exercise. Sedentary men, soccer players and tri-athletes performed submaximal dynamic exercise at a constant heart rate for 15 min. MRI was performed before and 5 min after the end of exercise. The results showed (i) that T1 increased in parallel to T2 in anterior thigh muscles and (ii) that multiple correspondence analysis and hierarchical ascending classification can discriminate three subjects classes according to power output, training level and relaxation times, which fitted well with our three groups of subjects.

Adolescent↗
PubMed1994

Urinary protein 1 or Clara cell protein: a new sensitive marker of proximal tubular dysfunction.

Protein 1 or Clara cell protein (CC16) is a 16 kD protein secreted predominantly by Clara cells in terminal bronchioles and from puberty on in the male urogenital tract. The sensitivity of CC16 in urine as an index of proximal tubule dysfunction was compared to that of retinol-binding protein, beta 2-microglobulin and alpha 1-microglobulin. These microproteins were measured by latex immunoassay in the urine from 114 pregnant women, 126 diabetics (65 men and 61 women), 80 workers exposed to cadmium (36 men and 44 women), and from healthy subjects matched for age and sex. In women, CC16 appeared consistently as a much more sensitive index of tubular dysfunction than other microproteins. In female diabetics, for instance, the prevalence of elevated values of CC16 in urine (53%) largely exceeded that of other microproteins (< 30%) and even of albumin (35%). In men, however, the existence of a post-renal secretion contaminating the urine limits the sensitivity of CC16 which was revealed to be higher than that of other microproteins, in diabetics only. The assay of urinary CC16 has the potential, especially in women, to detect very subtle defects of the proximal tubule which pass completely unseen with other microproteins. We postulate that this unique sensitivity of CC16 is due to its very low concentration in tubular fluid which, combined with its anionic character, strongly hinders its access to brush border binding sites.

Adolescent↗
PubMed1994

Early decrease of serum Clara cell protein in silica-exposed workers.

Clara cell protein (CC16) is a 16 kDa protein secreted by nonciliated cells of the tracheobronchial tree; it has recently been proposed as a peripheral marker of respiratory epithelial injury. The concentration of CC16 was measured in the serum and, when available, in the sputum of 86 miners exposed to silica and of 86 control subjects matched for age, body mass index and smoking status (26 lifelong nonsmokers and 60 current smokers in both groups). Workers were exposed to silica-rich dust in a quarry for 15.2 months on average. No difference between exposed and control workers could be detected with regard to respiratory symptoms, chest radiographs or lung function tests. By contrast, the concentration of CC16 in serum was decreased in silica-exposed workers (geometric mean 12.3 micrograms.l-1) compared to controls (16.3 micrograms.l-1). The decrease was found both in lifelong nonsmokers (14.7 vs 21.9) and current smokers (11.3 vs 14.5). In the latter, tobacco smoking caused a decrease of serum CC16 that was additional to that associated with silica exposure. The determination of CC16 in sputum samples, judged to be reliable on the basis of the CC16/alpha-amylase concentration ratio (mostly from smokers), also revealed a reduction of CC16 following silica exposure (46.2 vs 106 mg.l-1). We conclude that alterations in the serum concentrations of CC16 probably reflect very early toxic effects of silica particles on the respiratory epithelium. This reinforces the view that serum CC16 is a sensitive marker, which might improve our ability to detect exposure to chemicals potentially harmful to the respiratory tract.

Adult↗
PubMed1994

Cadmium: exposure markers as predictors of nephrotoxic effects.

Cadmium (Cd) is a cumulative element with a biological half-life of > 10 years in humans. The total amount of Cd accumulated in the liver and in the kidney can be measured in vivo by neutron activation (or x-ray fluorescence), but this technique does not necessarily measure the fraction that is biologically active. At low exposure (i.e., general environmental exposure or moderate occupational exposure), blood Cd is mainly influenced by the last 2 to 3 months of exposure. Under such conditions, the Cd concentration in urine mainly reflects the amount of Cd stored in the body, particularly in the kidney. In Europe and the US, the Cd reference values are usually < 2 nmol/mmol creatinine. Because most of the Cd in urine is probably bound to metallothionein, the changes in the urinary metallothionein concentration parallel those of Cd. The determination of Cd concentration in hair is of limited value because in humans it is difficult to distinguish between externally deposited and endogenous Cd. Fecal Cd is a good indicator of the oral daily intake. The results of several cross-sectional epidemiologic studies of the relation between the prevalence of renal dysfunction and Cd concentration in urine led us to propose a biological limit value for Cd of 5 and 2 nmol/mmol creatine for adult male workers and the general population, respectively.

Adult↗
PubMed1993

Identification of serine 624, aspartic acid 702, and histidine 734 as the catalytic triad residues of mouse dipeptidyl-peptidase IV (CD26). A member of a novel family of nonclassical serine hydrolases.

Dipeptidyl-peptidase IV (DPP IV, CD26, EC 3.4.14.5), a multifunctional ectoenzyme, is involved not only in the proteolytic cleavage of X-Pro from the NH2 terminus of a variety of biologically active peptides, but also in activation signal transduction and cell matrix adherence processes. We recently characterized mouse DPP IV cDNA and identified the serine protease Gly-X-Ser-X-Gly consensus motif in its extracellular domain. Mouse DPP IV does not exhibit sequence similarity with any of the classical members of this enzyme family (e.g. chymotrypsin and subtilisin) but shares a conserved structural domain of approximately 200 amino acids with several nonclassical serine hydrolases. In this study, analysis of the similarity of secondary structures and amino acid sequences between these enzymes led us to identify several conserved residues likely to be involved in the catalytic site of these DPP IV-related enzymes. These amino acids (Ser624, Asp702, and His734) were found to be arranged in a novel sequential order as compared with that of archetypal serine proteases (e.g. nucleophile (Ser)-acid-His versus His-acid-nucleophile (Ser), respectively). To directly explore the involvement of these residues in the catalytic function of these enzymes, we performed in vitro site-directed mutagenesis on mouse DPP IV cDNA. Our results indicate that although conservative or non-conservative permutations at these positions do not significantly alter the surface expression and biochemical properties of the mutant molecules, they completely impair their DPP IV enzymatic function. In contrast, mutagenesis of two other aspartic residues (Asp599 and Asp657), also conserved between these DPP IV-related enzymes, did not affect the enzymatic properties of the mouse enzyme. These data provide evidence that DPP IV and its related enzymes belong to a novel family that displays a catalytic triad distinct from that of the classical serine proteases.

Amino Acid Sequence↗
PubMed1993

Evaluating the care of general medicine inpatients: how good is implicit review?

OBJECTIVE: Peer review often consists of implicit evaluations by physician reviewers of the quality and appropriateness of care. This study evaluated the ability of implicit review to measure reliably various aspects of care on a general medicine inpatient service. DESIGN: Retrospective review of patients' charts, using structured implicit review, of a stratified random sample of consecutive admissions to a general medicine ward. SETTING: A university teaching hospital. PATIENTS: Twelve internists were trained in structured implicit review and reviewed 675 patient admissions (with 20% duplicate reviews for a total of 846 reviews). RESULTS: Although inter-rater reliabilities for assessments of overall quality of care and preventable deaths (kappa = 0.5) were adequate for aggregate comparisons (for example, comparing mean ratings on two hospital wards), they were inadequate for reliable evaluations of single patients using one or two reviewers. Reviewers' agreement about most focused quality problems (for example, timeliness of diagnostic evaluation and clinical readiness at time of discharge) and about the appropriateness of hospital ancillary resource use was poor (kappa < or = 0.2). For most focused implicit measures, bias due to specific reviewers who were systematically more harsh or lenient (particularly for evaluation of resource-use appropriateness) accounted for much of the variation in reviewers' assessments, but this was not a substantial problem for the measure of overall quality. Reviewers rarely reported being unable to evaluate the quality of care because of deficiencies in documentation in the patient's chart. CONCLUSION: For assessment of overall quality and preventable deaths of general medicine inpatients, implicit review by peers had moderate degrees of reliability, but for most other specific aspects of care, physician reviewers could not agree. Implicit review was particularly unreliable at evaluating the appropriateness of hospital resource use and the patient's readiness for discharge, two areas where this type of review is often used.

Health Resources↗