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Biomedical subjects

H D Allen

Publications and source records attributed to H D Allen.

At least 37 records · Page 2Linked to original sources
PubMed1995

Clinical pathways can be based on acuity, not diagnosis.

The standardization of medical practice is gaining acceptance as a technique for controlling length of stay and hospital charges, while maintaining quality. Most clinical pathways address specific diagnoses or procedures, but we have developed a new approach in which pathways for cardiac care are based on acuity. All congenital cardiac surgical care rendered at Columbus Children's Hospital now falls within one of four such clinical pathways. This simplified approach is easy to use and has been well accepted. Our experience in a group of 107 consecutive patients treated in this fashion is described. The results of variance analyses, along with length of stay and charge data, are presented to demonstrate the degree to which resource utilization can be standardized in this widely variable group of patients whose problems were made cohesive by classification according to acuity level. We conclude that the resultant standardization offers considerable advantages for the managed care environment.

Cardiac Surgical Procedures↗
PubMed1995

Standardizing care delivery for infants and children with common congenital cardiac lesions.

The emergence of managed care is influencing the practices of pediatric cardiology and cardiac surgery. The need for efficiencies brought about by standardizing care whenever possible has led to the development of care guidelines and clinical pathways. Care guidelines are general algorithms mapping the care of a specific problem. They are patient oriented and cover all aspects of care from diagnosis onward. National task forces have recently published guidelines for the care of children with specific congenital cardiac defects, and some of these are reviewed. Clinical pathways are more specific to an episode of inpatient or outpatient care. They consist of expected defined outcomes of care, including all tests, monitoring, and intervention. In other fields, clinical pathways have been developed for specific diagnoses or procedures. However, in pediatric cardiac surgery, the variety of conditions and operations is so great that two different methods of acuity-based, rather than disease-based, clinical pathway methodologies were developed that have been shown to decrease lengths of stay and hospital charges. Refinement of the system will require more sophisticated data, including the delineation of actual costs rather than charges, along with refinement and standardization of outcomes measurements. With fundamental changes in the delivery system, the roles of the specialist and the primary care physician have undergone changes that will continue to evolve. Vigilance on the part of all providers will be necessary to assure quality of care in this new milieu.

Cardiac Surgical Procedures↗
PubMed1994

Pulmonary valve eccentricity in d-transposition of the great arteries and implications for the arterial switch operation.

Neoaortic valve regurgitation is a known complication of the arterial switch operation for d-transposition. Its etiology and long-term effects are undetermined. Observations of pathologic specimens from 67 patients with d-transposition of the great arteries with or without ventricular septal defects demonstrated that the pulmonary valve leaflets had unequal cusp sizes leading to eccentric closure. The posterior cusp was usually the largest and was anatomically related to the membranous ventricular septum and the anterior leaflet of the mitral valve. The right cusp was usually the smallest. Differences in cusp sizes were unrelated to age at death, sex or presence of a ventricular septal defect. To determine if eccentricity could be clinically detected, the pulmonary valves in 24 sequential patients with d-transposition were studied echocardiographically and angiographically. Aortic valves were studied for comparison. All pulmonary valves demonstrated eccentric closure in the long-axis echo plane, posterior in 15 patients and anterior in 9. Only 1 aortic valve showed eccentricity. Angiographic findings correlated with echo findings. Sixteen patients underwent arterial switch operations; 3 died. Twelve had angiography at 1 year. Eleven had neoaortic valve regurgitation: 5 grade I, 4 grade II and 2 grade III.

Adolescent↗
PubMed1994

Intraosseous adenosine. As effective as peripheral or central venous administration?

OBJECTIVE: The purpose of this study was to determine if intraosseous administration of adenosine is effective and, if so, to establish therapeutic dosage criteria for the intraosseous route compared with peripheral or central intraosseous route compared with peripheral or central venous routes. RESEARCH DESIGN: Randomized, unblinded, cross-over, within-animal control study. SETTING: University hospital in Ohio. SUBJECTS: Thirty newly weaned piglets. SELECTION PROCEDURE: Consecutive sample. INTERVENTIONS: Thirty newly weaned pigs were transesophageally (n = 26) or transvenously (n = 4) paced at a cycle length that was 10% longer than the Wenckebach threshold. The minimum effective dose of adenosine necessary to induce atrioventricular block during pacing was recorded for peripheral venous, central venous, and intraosseous routes. MEASUREMENTS AND RESULTS: The baseline resting heart rate and Wenckebach thresholds were not statistically different between subjects or between different routes of administration. The intraosseous route required a minimum effective dose of 127 micrograms/kg. Using a log transformation, the difference between central venous and peripheral venous doses was found to be statistically significant. The intraosseous dose was not statistically different from the central venous or peripheral venous doses. CONCLUSION: The intraosseous route is an effective way of administering adenosine. The peripheral venous dose required to achieve atrioventricular block is higher than the central venous dose and the intraosseous dose is intermediary to the central venous and peripheral venous doses.

Adenosine↗
PubMed1994

The cost of congenital heart disease in children and adults. A model for multicenter assessment of price and practice variation.

OBJECTIVE: To assess the cost of congenital heart disease (CHD) and to assess whether practice pattern or price was more responsible for variation. RESEARCH DESIGN AND SETTING: Data were collected from Charleston, NC; Columbus, Ohio; Detroit, Mich; Houston, Tex; Los Angeles, Calif; and New York, NY. The CHD was first classified as to physiologic characteristics and severity. For each type of CHD, the number of clinic visits, hospitalizations, and years of medication use were estimated. RESULTS: On the basis of actual charges, the "prices" were calculated as follows, in 1992 dollars: for patients from birth to 21 years: benign disease (19% of patients), $3940; acyanotic disease (45%), $49,730; cyanotic disease (36%), $102,084; and average for all CHD categories, $59,877; for patients 22 to 40 years of age (of whom 24% had resolved defects or were dead): benign disease (19%), $3470; acyanotic disease (52%), $12,981; cyanotic disease (29%), $39,187; and average for all CHD, $18,773. The cost for the group from birth to 21 years varied from $47,500 to $73,600, accounting for 55% by practice (number of echocardiograms and cardiac catheterizations) and 45% by price, although mortality was similar. CONCLUSIONS: The treatment of CHD is comparatively inexpensive, especially in adult survivors. The variation in both practice and price bears further study, with comparison to determine the most cost-effective strategies for treating these patients.

Adolescent↗
PubMed1994

Cavopulmonary anastomotic aneurysm: a complication in pulsatile pulmonary arteries.

An aneurysm of a left superior vena cava developed after anastomosis to the left pulmonary artery during repair of an atrioventricular septal defect with a persistent left superior vena cava entering directly into the left atrium. We believe this implies caution should be used in accepting the recent suggestion of using a bidirectional cavopulmonary connection to a pulsatile pulmonary arterial circuit as a way of allowing anatomic correction of atrioventricular septal defect with a small right ventricle.

Aneurysm↗
PubMed1994

Coronary artery fistula in the pediatric age group: a 19-year institutional experience.

Ten patients with coronary artery fistulae were identified from records at Columbus Children's Hospital between 1974 and 1993. Clinical presentations of patients were quite variable, from 1 day to 20 years of age. Symptoms ranged from none to severe cardiorespiratory failure requiring extracorporeal membrane oxygenation. Long term follow-up revealed one sudden death and one spontaneous closure of the fistula. This lesion should be ruled out in patients who present as extracorporeal membrane oxygenation candidates. Patients with mild forms of this lesion may be followed up medically if the left to right shunt is inconsequential, because spontaneous closure is a possibility. Because of the risk of sudden death, close long-term follow-up is mandatory even for operated patients, and antiplatelet therapy should be considered for these patients.

Adult↗
PubMed1994

Use of cardiac catheterization in pediatric cardiac surgical decisions.

Current practice patterns relating to pediatric cardiac catheterization (Cath) have considerable economic implications. The decreased cost and risk of noninvasive methods such as echocardiography (ECHO) and magnetic resonance imaging (MRI) make them attractive alternative diagnostic methods if they can sufficiently define cardiac anatomy and the need for surgical intervention. We reviewed a recent cardiac surgical series of 465 cases in 1.5 years to determine how often a Cath was performed prior to surgery. Overall, 59.4% of the procedures were preceded by a Cath (76% of open heart operations, and 26.7% of closed heart operations). We specify the situations where we feel enough information is available for preoperative decision making from non-invasive testing, and we present some diagnostic pitfalls that have been encountered.

Cardiac Catheterization↗
PubMed1994

Cardiovascular health and disease in children: current status. A Special Writing Group from the Task Force on Children and Youth, American Heart Association.

More than 600,000 children in the United States have a congenital or acquired cardiac abnormality, and millions more are at risk of developing atherosclerotic disease in adulthood, a risk made particularly evident by the prevalence of cardiovascular risk factors in the young. There are barriers to optimum prevention and treatment of these conditions in children and youth. The AHA's Task Force on Children and Youth has described these barriers and outlined a series of recommendations and strategies to meet the challenges they impose. More research is needed, and research initiatives will be developed at scientific conferences designed to review critical areas of cardiac development and etiology of disease in children. Financial support for such research initiatives must be increased. Educational programs on cardiovascular risk factors will be extended to children and their families. When these programs are coordinated with efforts in the community and in schools, they will reduce the prevalence of cardiovascular risk factors. The task force recommends that various departments and committees of the AHA use their resources for the benefit of children: for example, by developing more research initiatives for funding by the AHA or NHLBI and increasing legislative and regulatory efforts in the areas such as mandatory school health programs and tobacco advertising. It is hoped that in the next decade, through research and educational efforts, many advances in the prevention and treatment of cardiovascular diseases in the young will be realized.

Cardiovascular Diseases↗
PubMed1992

Insurability of the adolescent and young adult with heart disease. Report from the Fifth Conference on Insurability, October 3-4, 1991, Columbus, Ohio.

By the mid-1990s there will be more than 500,000 young adults in the United States over the age of 21 with a cardiac malformation. Presently more than half of this population is denied insurance coverage entirely or in part because of their preexisting condition. Because some did not have coverage and because of uncertainty about whom to see for their cardiology care, patients assessed in NHS-II who were evaluated by their physician on an annual basis before the age of 21 were seen by a cardiologist only every 10 years after the age of 21. However, they have been shown by NHS-II to be well-educated, productive in the workplace, and to share an equal place in society with the general population. Their health-care costs are decidedly lower after the age of 21 than before. This group represents a microcosm of a general society of more than 37 million Americans who, for various reasons, are not insured. Dr. Wiener described an American health-care system in crisis. Smaller companies are no longer able to afford health insurance for all their employees, especially for those with preexisting conditions, because of an industry pricing concept based on a claims-experience standard rather than a community standard. The insurance industry, the government, and patients are demanding medical cost-containment. Health-care costs, 12.2% of the gross national product in 1990, are climbing, and no end to this increase is presently in sight.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗