Generalist vs specialist medical care.
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Family Practice↗
Biomedical subjects
D K Greineder
Publications and source records attributed to D K Greineder.
Penicillin skin testing: a way to optimize antibiotic utilization.
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Adult↗
A randomized controlled trial of a pediatric asthma outreach program.
BACKGROUND: Previous studies have shown that asthma education and case management may reduce asthma emergency care, hospitalizations, and expenditures. OBJECTIVE: We sought to study the effect of an asthma outreach program (AOP), a team-based, case-management intervention, on emergency ward (EW) and hospital use. METHODS: Fifty-seven patients aged 1 to 15 years with the diagnosis of asthma based on the usual clinical practice criteria who were continuously enrolled in a staff-model health maintenance organization for a period of at least 2 consecutive years were randomized into 2 intervention groups. The control group received a single intensive asthma education intervention, and the AOP group received the same initial education but then was followed-up by an asthma case management nurse throughout the intervention period. RESULTS: EW visits, hospitalizations, and total outside-of-health-plan expenditures (consisting of EW and hospital expenses, as well as miscellaneous costs, such as ambulance, durable medical equipment, tertiary referrals, and home care) were assessed from claims filed for a year before and after enrollment. Control group patients experienced significant reductions in EW visits (39%), hospitalizations (43%), and outside-of-health-plan costs (28%), possibly as a result of the baseline educational intervention received by all enrolled patients, in conjunction with regression to the mean. AOP group patients experienced significant reductions in EW visits, (73%, P =.0002), hospitalizations (84%, P =.0012), and outside-of-health-plan use (82%, P <.0001). When compared with the control group, AOP group patients demonstrated additional significant reductions in EW visits (57%, P <.05), hospitalizations (75%, P <.05), and outside-of-health-plan use (71%, P <.001). Estimates of direct savings to the health plan ranged from $7.69 to $11.67 for every dollar spent on the AOP nurse's salary, depending on assumptions. CONCLUSIONS: Asthma patients in a staff-model health maintenance organization decreased their resource use between 57% to 75% by participation in an AOP as compared with a randomized control group receiving only an educational intervention. Substantial savings were achieved compared with the cost of the AOP nurse.
Adolescent↗
Utilization and cost of immunotherapy for allergic asthma and rhinitis.
BACKGROUND: Allergic rhinitis and asthma are important sources of morbidity among adults and children. Although immunotherapy is sometimes used to treat these conditions, there is little information on its use, adherence, or cost in the general population. OBJECTIVE: We sought to characterize the recipients of immunotherapy for allergic rhinitis and/or asthma with respect to their immunotherapy and utilization of health care services. METHODS: A combination of automated and manually extracted data was used to identify HMO members with diagnoses of allergic rhinitis or asthma who were treated with immunotherapy. Costs associated with immunotherapy and related care were examined by linear regression. Proportional hazards and Kaplan-Meier plots were used to evaluate duration of therapy. RESULTS: Of the 122,196 persons with a diagnosis of asthma or rhinitis, 2,667 were also treated with immunotherapy. Eligibility criteria were satisfied by 603 individuals who had 28,266 encounters for immunotherapy (median 48). Most patients (>80) were treated with multiple allergens; ragweed was the most common single allergen administered. Thirty-three percent of patients with sufficient observation time completed the intended course of 61 immunotherapy treatments. Females and younger patients had shorter durations of immunotherapy. The most common reason for discontinuation of therapy was patient's decision (54%). Immunotherapy costs were related most strongly to costs for care of rhinitis and asthma. Prescription drugs accounted for more than 50% of the non-immunotherapy costs; hospitalizations accounted for less than 20%. CONCLUSIONS: Approximately 2% of HMO members with an asthma or rhinitis diagnosis received immunotherapy. Although screened to optimize compliance, most patients did not complete immunotherapy. Costs of non-immunotherapy care were higher for individuals who completed immunotherapy which is consistent with more severe disease in this group.
Adolescent↗
Outcomes for control patients referred to a pediatric asthma outreach program: an example of the Hawthorne effect.
A study was designed to determine whether identification of high risk for exacerbations of asthma based on pediatrician concern, emergency department visits, or hospital stays results in a decrease of resource utilization because of referral to an asthma outreach program even if the intervention does not take place. The findings for such a group were compared with those for a group who did undergo intervention with an asthma outreach program. Fifty-six patients 1 to 14 years of age were assigned to one of two groups. The control group (those who did not undergo intervention) had consistent but not statistically significant reductions in utilization of emergency visits, hospitalizations, and dollars spent (21%, 24%, and 32%, respectively). The group who underwent intervention with the asthma outreach program had large and statistically significant decreases in the same parameters (emergency visits, 60%, P = 0.001; hospital stays, 74%, P = 0.008; dollars spent, 72%, P = 0.004). However, the apparently insignificant effect of the reductions in utilization by the control group substantially altered interpretation of the outcomes of the study. Cost savings were reduced from $11.69 per dollar spent on intervention to $6.49 per dollar spent. In before-and-after studies such as those typically conducted during continuous quality improvement projects, which typically do not have control groups, investigators need to consider control group effects when they assess the results of intervention.
Adolescent↗
Inhaled steroids and the risk of hospitalization for asthma.
OBJECTIVE: To determine if anti-inflammatory treatment for asthma reduces the risk of asthma hospitalization. DESIGN: Retrospective cohort study. SETTING: A health maintenance organization (HMO) in eastern Massachusetts. PARTICIPANTS: Members of the HMO who were identified during the period October 1991 through September 1994 as having a diagnosis of asthma using a computerized medical record system. MAIN OUTCOME: Hospitalization for asthma. RESULTS: Of the 16941 eligible persons, 742 (4.4%) were hospitalized for asthma. The overall relative risk (RR) of hospitalization among those who received inhaled steroids was 0.5 (95% confidence interval [CI], 0.4-0.6) after adjustment for beta-agonist dispensing. Additional adjustment for age, race, other asthma medications, and amount and type of ambulatory care for asthma did not substantially affect the inverse relationship between use of inhaled steroids and hospitalization. Cromolyn was similarly associated with reduced risk, especially among children (RR,0.8; 95% CI, 0.7-0.9). In contrast, increasing beta-agonist use was associated with increasing hospitalization risk even after adjustment for other factors and medications. The steroid-associated protection was most marked among individuals who received the largest amount of beta-agonist. CONCLUSIONS: Inhaled steroids and, to a lesser extent, cromolyn confer significant protection against exacerbations of asthma leading to hospitalization. These results support the use of inhaled steroids by individuals who require more than occasional beta-agonist use to control asthma symptoms.
Administration, Inhalation↗
Assessment of asthma using automated and full-text medical records.
Automated medical records systems are used to study clinical outcomes and quality of care, but this requires accurate disease identification and assessment of severity. We sought to determine the reliability of identifying asthmatics through automated medical and pharmacy records, and the adequacy of such data for severity assessment. All adult health maintenance organization (HMO) members who received at least one asthma drug and an asthma diagnosis between April 1988 and September 1991 were identified. Records of a random sample were reviewed to validate the diagnosis and extract clinical information. Asthma drugs were dispensed to 15,491 individuals; 7583 (49%) also received an asthma diagnosis. Asthma drug use was three times greater for persons with diagnosed asthma compared to those with no diagnosis. Record review revealed that a coded asthma diagnosis had a positive predictive value of 86%. Nearly 4000 ambulatory encounters were reviewed, 10% of which were for asthma; the median number of encounters was two. Asthma symptoms were mentioned in 9% of all encounters; wheezing was most common. Peak flow and spirometry were measured in 4% and 1% of encounters, respectively. Records from recipients of asthma drugs who lacked an asthma diagnosis showed that 79% did not have asthma. Automated medical and pharmacy records from an HMO were relatively accurate when used to identify individuals with asthma. Similarly, most asthma drug recipients who lacked a coded diagnosis of asthma did not have asthma. However, conventional full-text records usually do not contain sufficient information to assess asthma severity, limiting the utility of such records for research and quality improvement.
Adult↗
Risk management in allergen immunotherapy.
The major risk of allergen immunotherapy is the development of systemic anaphylactic reactions. The reported frequency of systemic reactions after allergen immunotherapy varies from < 1% in patients receiving conventional immunotherapy to > 36% in patients receiving rush immunotherapy. Fatal and systemic reactions to allergen immunotherapy have similar characteristics. The onset of both types of reaction occurs < 30 minutes after injection in approximately 70% of patients. The most common risk factors for fatal and systemic reactions to allergen immunotherapy include a history of asthma, increasing allergen dose, high allergen sensitivity, previous systemic reaction, and injection during an active allergen season. On the basis of findings from several studies, precautions during allergen immunotherapy have been recommended. In addition, several interventions, including premedication with antihistamines or corticosteroids, measurement of peak flow before injection, and access to an antihistamine or injectable epinephrine after an allergen injection, have been suggested as measures to prevent reactions to and improve the safety of allergen immunotherapy. However, additional studies are necessary before these regimens are implemented routinely in allergen immunotherapy protocols.
Allergens↗
Reduction in resource utilization by an asthma outreach program.
OBJECTIVE: To study the effect of an asthma outreach program on emergency ward and hospital utilization. DESIGN: Before and after trial. SETTING: Ambulatory patients in a staff-model health maintenance organization with a 70% black inner-city population. PATIENTS: Fifty-three patients aged 1 to 17 years with the diagnosis of asthma based on usual clinical practice criteria. INTERVENTION: Asthma emergency ward visits and hospitalizations were monitored over a 6-month to 2-year period after enrollment in the program. Patients were scheduled for one-on-one orientation visits with the asthma outreach nurse and instructed in asthma management, medications, triggers, and use of inhalers and peak flowmeters. An individualized step-care treatment program was outlined for each patient by the nurse, primary care pediatrician, and, when appropriate, an allergist. The outreach nurse maintained personal or telephone contact with the families on a regular basis to assure understanding of and compliance with the treatment plan. OUTCOME MEASURES: Outcome was assessed by measuring annualized emergency ward and hospital admissions for each patient for an equal period before and after entry into the program. RESULTS: Emergency ward admissions were reduced 79% (from a rate of 72 visits per year to 15 visits per year, P < .0001) and hospital admissions were reduced 86% (from 35 per year to five per year, P < .001). These reductions were achieved by a single outreach nurse working an average of 8 hours per week at an annualized cost of $11,115; this saved approximately $87,000 in costs. CONCLUSIONS: Patients enrolled in a pediatric asthma outreach program experienced a significant reduction in utilization of emergency ward and hospital admissions, resulting in reduced cost of care.
Adolescent↗
Studies on human migration inhibitory factor: characterization of three molecular species.
Human migration inhibitory factor (MIF), obtained from supernatants of peripheral blood mononuclear cells stimulated with concanavalin A, was analyzed by gel filtration, isoelectrofocusing, and CsCl density gradient centrifugation. A distinct pattern of heterogeneity was determined on the basis of its harvesting time and biochemical criteria. Supernatants from cells cultured for 1 day contained a single peak of MIF activity with an isoelectric point of 4.3 to 5.2, an apparent m.w. of 23,000, and a density of 1.314 g/ml, the same as the density of the marker protein, 125I-HSA (1st day pH 5-MIF). Furthermore, this species of human MIF was sensitive to treatment with trypsin, strongly suggesting its being a protein, but not to treatment with neuraminidase and corresponds therefore to guinea pig pH 5-MIF. However, when 2nd day supernatants were analyzed under the same conditions, 2 MIF species were found. One species with an isoelectric point of 2.4 to 3.3 had an apparent m.w. of 65,000 (2nd day 3-MIF). The other species with an isoelectric point of 4.3 to 5.6 had an apparent m.w. of 23-43,000 (2nd day pH 5-MIF). Upon centrifugation in CsCl density gradients, the density (rho 25 of 1.314 to 1.414 g/ml) of both species was found to be greater than that of the pure protein, 125I-HSA. In addition, both species were chymotrypsin and neuraminidase sensitive but not trypsin sensitive, further suggesting their glycoprotein nature.
Animals↗
Generation of antigen-specific suppressor cells during allergy desensitization.
We used a suppressor-cell assay to study a possible mechanism of allergy desensitization. Before specific immunotherapy, blood mononuclear cells from 20 patients with ragweed hayfever failed to exhibit suppressor activity in vitro after stimulation by ragweed antigen E. However, when the 10 patients with allergic rhinitis had been desensitized by injections of ragweed extract, their mononuclear cells specifically suppressed a ragweed proliferative response six and 12 months after desensitization was begun (31 per cent and 48 per cent suppression, respectively). Suppressor mononuclear cells were not detected in 10 control subjects of in 10 patients with ragweed hayfever who were not desensitized. When mononuclear cells taken from treated patients were passed over columns containing insolubilized histamine, antigen-specific suppressor cells that could be activated by ragweed antigen were depleted. These results indicate that antigen-specific suppressor cells, probably bearing histamine receptors, are generated during desensitization to allergy and may be partly responsible for the efficacy of this therapy.
Adult↗
The immunopathology of Mooren's ulcer.
In a 42-year-old man with bilateral severe Mooren's ulcers, results of immunologic studies were normal, with the exception of an in vitro blastogenic response of the patient's lymphocytes to corneal stroma. The histologic studies revealed vast numbers of vacuolated neutrophils with intracytoplasmic phagosomes in and about the ulcerating cornea. Although the progression of ulceration was initially unaltered by surgical and pharmacologic trials, systemic immunosuppression with methotrexate may have prevented ulceration of the lamellar tectonic graft.
Adult↗
Histamine-induced suppressor factor (HSF): further studies on the nature of the stimulus and the cell which produces it.
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Animals↗
Production of human lymphocyte mediators after activation with periodate or neuraminidase and galactose oxidase.
Treatment of human mononuclear cells with sodium metaperiodate (NaIO4) or neuraminidase and galactose oxidase (NGO) results in lymphocyte activation and subsequent generation of supernatants rich in migration inhibitory factor (MIF) and leukocyte inhibitory factor (LIF). Preliminary characterization of these mediators by Sephadex G-100 gel filtration suggests that they are similar to antigen- and concanavalin A-induced MIF and LIF, eluting in the 25000 m.w. and 68000 m.w. regions, respectively. The possibility of galactose oxidase carryover into the supernatants has been studied and conditions are described that minimize this eventuality. A method is presented for producing control and lymphokine-rich supernatants both of which have been exposed to identical concentrations of NGO although in the control activation is blocked by the addition of 0.1 M galactose to the incubation. These findings establish NaIO4 and NGO as useful mitogens for generating human lymphokine-rich supernatants that can be used without further purification.
Chromatography, Gel↗
Plasminogen activator production by human monocytes. I. Enhancement by activated lymphocytes and lymphocyte products.
Human monocytes, but not nylon wool column-nonadherent lymphocytes, produce plasminogen activator. The activity is found only in association with intact cells. Exposure of monocytes to activated lymphocytes or to lymphokine-rich supernatants enhances monocyte plasminogen activator production. The assay allows assessment of baseline and activated human monocyte function.
Antigens, Bacterial↗
Macrophage-lymphocyte interaction. III. Site of alloantiserum inhibition of T lymphocyte proliferation induced by allogeneic or aldehyde-bearing cells.
Inhibition by anti-Ia sera of guinea pig T lymphocyte proliferation induced by allogeneic macrophages (MLR) and NaIO4 or neuraminidase-galactose oxidase-treated macrophages has been investigated in order to identify the target cell upon which the antisera act. Anti-2 and anti-13 alloantisera were found to inhibit both MLR and aldehydeinduced T cell reactivity when directed against the specificity of the stimulatory macrophage. Little or no inhibition was observed when these antisera were directed against the T lymphocyte specificity when cultures were harvested at the time of peak proliferation. In addition, anti-2 serum was found to inhibit macrophage-lymphocyte rosett formation at 20 hr between neuraminidase-galactose oxidase-treated strain 2 macrophages and strain 13 lymphocytes. These findings demonstrate that inhibition of T cell proliferation can be produced by anti-Ia sera directed against the macrophage and raise the possibility that Ir gene products may function in part at the level of the macrophage.
Animals↗
Macrophage activation of allogeneic lymphocyte proliferation in the guinea pig mixed leukocyte culture.
The role of the macrophage in the guinea pig mixed leukocyte culture was investigated. Macrophages obtained from oil-induced peritoneal exudates, peritoneal wash-out cells, spleen, and alveolar washings were found to be effective stimulators of allogeneic lymph node and splenic lymphocyte DNA synthesis. The stimulatory properties of macrophages proved radioresistant but viability dependent. Unfractionated lymph node cells or adherence column purified lymph node lymphocytes and thymocytes were only minimally active as stimulators, even in the presence of macrophages syngeneic to the responder lymphocytes. Allogeneic fibroblasts, polymorphonuclear leukocytes, L2C leukemia cells, and xenogeneic (murine) macrophages failed to simulate. These data provide evidence that the macrophage is the predominant stimulator of the mixed leukocyte culture in the guinea pig.
Animals↗
The requirement for macrophage-lymphocyte interaction in T lymphocyte proliferation induced by generation of aldehydes on cell membranes.
Guinea pig T lymphocyte proliferation induced by sodium periodate (NaIO4) or neuraminidase-galactose oxidase (NG) occurs when lymphocytes and macrophages are cultured together after treatment of either purified T lymphocytes or macrophages with these agents. Regardless of which cell initially bears the modified surface carbohydrate, lymphocyte proliferation requires the presence of viable homologous macrophages and fails to occur when they are replaced with fibroblasts, erythrocytes, L2C leukemia cells, thymocytes, PMN, line I hepatoma cells, or murine macrophages. Lymphocyte proliferation resulting from NaIO4 or NG treatment of lymphocytes is diminished when these cells are treated with proteolytic enzymes or aged in in vitro culture for 48 hr. By contrast, proteolytic enzyme treatment or in vitro aging has no effect on the ability of NaIO4 or NG-treated macrophages to induce lymphocyte proliferation. The requirement for macrophage-lymphocyte interaction in NaIO4 or NG-induced lymphocyte proliferation is indicative of a central role for the macrophage in the initiation of T lymphocyte proliferation.
Aldehydes↗