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Biomedical subjects

H Johnson

Publications and source records attributed to H Johnson.

At least 127 records · Page 7Linked to original sources
PubMed1989

Pediatric patients, race, and DRG prospective hospital payment.

The diagnosis related group (DRG) prospective hospital payment system contains inequities in hospital payment for certain groups of patients. Patients of lower socioeconomic status may be underreimbursed by DRGs. We analyzed pediatric patients and hospital resource consumption by race (white, Hispanic, and black) using a DRG prospective payment "all payer" system. All hospitalized pediatric admissions over a 3-year period (N = 14,489) were analyzed by race at a large academic medical center. Mean hospital length of stay and cost per patient (adjusted for DRG weight index) was significantly greater for black and Hispanic pediatric patients compared with whites. Financial risk as measured by outliers and losses under DRGs was greater for blacks and Hispanics compared with whites. Black and Hispanic patients had a higher proportion of emergency admission to the hospital compared with whites, a greater severity of illness (as measured by total International Classification of Diseases, ninth revision, Clinical Modification codes), and (on average) higher diagnostic costs for each episode of illness. Our data suggest that black and Hispanic pediatric patients have a greater hospital resource consumption (adjusted for DRG group case mix) compared with whites, at least at our large medical center in the Northeast. Hospitals that treat greater numbers of black and Hispanic pediatric patients may be at a substantial disadvantage under per-case DRG payment.

Academic Medical Centers↗
PubMed1989

Transsternal radical thymectomy for myasthenia gravis: a 15-year review.

Thymectomy is an accepted therapeutic modality for patients with myasthenia gravis. The selection of patients for operation and the surgical approach are controversial. We reviewed 52 patients (aged 18 months to 82 years; mean age, 34 years) treated with transsternal radical thymectomy between 1972 and 1987. Patients were symptomatically staged according to the modified Osserman classification. There was one hospital death and postoperative follow-up was obtained on 51 patients. Improvement after thymectomy was observed in 3 of 11 patients (27%) in Osserman stage I, 16 of 25 patients (64%) in Osserman stage IIA, and 13 of 15 patients (86%) in combined Osserman stages IIB, III, and IV. Preoperative Osserman stage, patient sex, and thymic histology correlated with postoperative clinical response. Transsternal radical thymectomy is effective therapy for myasthenia gravis. Sustained improvement is obtained in patients with moderate and advanced disease. The majority of patients with ocular disease do not benefit from operation.

Adult↗
PubMed1989

A tone-reducing wrist--hand orthosis.

Orthoses designed on the basis of neurophysiological rationales are being used more frequently (Bronkhorst & Lamb, 1987; Ford et al., 1986; McPherson & Becker, 1985). We have presented a dynamic dorsal orthosis that has been used with 18 CVA patients. The focal point of the dynamic component is on the finger flexors. Our results suggest that in the hypertonic CVA patient, the finger flexors are responsible for hand and some wrist tone. The flexor digitorum profundus and superficialis biomechanically act to flex the wrist as the fingers reach maximum flexion. Varying degrees of tone reduction in the upper and lower limbs were observed and recorded; we feel this resulted from the patients wearing the dorsal dynamic wrist-hand orthosis.

Adult↗
PubMed1989

Hospital costs, resource characteristics, and the dynamics of death for surgical patients.

This article details data that suggest significant inequities in the current DRG prospective payment system vis-à-vis surgical mortalities. Important health policy issues, in addition to the ability of outcome data to function as a proxy for quality, involve the usefulness of stratifying DRGs vis-à-vis outcome or severity of illness in the future. Much interest has emerged in outcome data--especially with regard to its ability to function as a risk-adjusted quality-of-care screen for hospitals. A study of hospital resource consumption comparing survivors and mortalities demonstrated that surgical mortalities had a much greater intensity of hospital resource utilization and a substantial financial risk under Medicare's DRG prospective payment pricing system, as compared to surgical survivors. Hospital length of stay for mortalities proved very unprofitable. Emergency-admitted patients who died tended to have shorter hospital stays and less financial risk under DRGs than nonemergency mortalities. Mortalities referred to surgery from other clinical services tended to have greater resource utilization and financial risk under DRGs than nonreferred mortalities.

Adult↗
PubMed1989

Hospital costs, resource characteristics, and the dynamics of death for patients with a primary diagnosis of congestive heart failure.

Although substantial changes have been recommended in the diagnosis related group (DRG) prospective hospital payment system related to very expensive care for some patients, no major change in payment for these patients has been implemented by the US Congress. Both the Health Care Financing Administration and the Prospective Payment Assessment Commission continue to study issues related to DRG stratification along the lines of severity of illness, outcome (lived or died), or complications and/or comorbidities. We analyzed hospital resource consumption for 599 patients with a primary diagnosis of congestive heart failure (CHF) by outcome (ie, survivors vs mortalities). The 68 mortalities had a much greater intensity of hospital resource utilization, and a substantial financial risk under DRG pricing schemes, compared to the 531 survivors. Only mortalities within one week of admission to the hospital were profitable under DRGs. A long hospital length of stay (LOS) for mortalities was very unprofitable (mortalities with a greater than 60-day LOS generated a +42,028 loss per patient). Emergency patients who died tended to have a shorter hospital LOS and less financial risk under DRGs, compared to patients who died who were not admitted as emergencies. These data suggest significant inequities in the DRG prospective payment system vis-a-vis CHF mortality. Variables predictive of greater hospital resource utilization for mortalities included longer hospital lengths of stay and urgent admission. Health policy leaders should be encouraged to further stratify DRG hospital resource consumption for appropriate variance in hospital costs.

Aged↗
PubMed1989

Race and diagnostic related group prospective hospital payment for medical patients.

The diagnostic related group (DRG) prospective hospital payment system has been on line for five years with no major changes implemented by the federal government. Data suggest that the DRG system may be inequitable to patients of lower socioeconomic status. We studied the consumption of hospital resources by race (ie, white vs black) for hospitalized medical patients using the DRG prospective payment system. All adult medical admissions (N = 30,097) were analyzed for a three-year period at a large academic medical center using the DRG "all payor" classification scheme in effect for New York State. We found that black patients (N = 3,373) had a significantly greater (P less than .0001) mean length of hospital stay and cost per patient (adjusted for DRG weight index) compared with white patients (N = 26,724). Black patients also exposed the medical center to greater (P less than .0001) financial risk compared with white patients, as measured by outliers and losses under DRGs. Black patients (P less than .0001) had a significantly higher proportion of emergency admissions to the hospital, a greater severity of illness (as measured by total International Classification of Diseases-9-Clinical Modification codes) (P less than .0001), and higher diagnostic costs (P less than .0001) for each episode of illness. These data suggest that at our medical center black medical patients may consume more hospital resources (adjusted for DRG case mix) compared with whites. It is important that methods to modify DRG prospective hospital payment for medical diseases be considered to provide more equitable DRG reimbursement for black Americans in the future.

Black or African American↗
PubMed1988

Formation of angiotensin II and other angiotensin peptides from des-leu 10-angiotensin I in rat lung and kidney.

The formation of AII from a metabolite of AI, des-leu10-angiotensin I [A(1-9)] has been studied in centrifugal fractions of rat lung and kidney using gradient elution HPLC to monitor the formation of peptide products. AII-forming activity was present in kidney S2 (22.3 nmol/mg protein/min) but not in kidney P2 centrifugal fractions. Lung S2 fractions showed relatively weak AII-forming activity (0.34 nmole/mg protein/min) whilst no activity was observed in lung P2. Carboxypeptidase N-like activity measured using both Hipp-Arg and Hipp-Lys as synthetic substrates did not parallel AII-forming activity, since this activity was highest in the P2 fractions of both lung and kidney, as were ACE and aminopeptidase activities. Whilst the major peptide produced in kidney S2 was AII (71%) significant amounts of both AIII (23%) and A(2-9) (6%) were also observed. In lung the amounts of these peptides produced as a percentage of the A(1-9) degrading activity were 2.9%, 2.4% and 21% respectively. The AII-forming activity in kidney S2 was not inhibited by enalaprilat, bestatin, amastatin, phosphoramidon or Pro-Phe but was inhibited (31%) by 1 mM cobalt (II). 1,10-Phenanthroline, iodoacetic acid, EDTA and puromycin significantly enhanced the formation of AII and increased the rate of degradation of the substrate, A(1-9). These results support the concept of a sequential carboxypeptidase pathway operating, particularly in kidney, to produce AII from AI. These results provide further evidence of an alternative metabolic pathway for the formation of AII not involving angiotensin converting enzyme.

Aminopeptidases↗
PubMed1988

Hydrolysis of angiotensin I by peptidases in homogenates of rat lung and aorta.

The hydrolytic cleavage of angiotensin I has been studied in homogenate preparations of rat lung and aorta using gradient elution HPLC to monitor the formation of peptide products. Fresh crude homogenate preparations produced a rapid breakdown of angiotensin I to largely unidentifiable fragment peptides. Neither His-Leu nor angiotensin II was observed in these preparations even in the presence of captopril (20 microM) and the amino-peptidase inhibitors, puromycin, amastatin and bestatin. However, in freeze-thawed homogenates, angiotensin II and His-Leu were detectable together with the tetrapeptide, angiotensin (1-4). The addition of captopril (20 microM) reduced the amount of angiotensin II produced but did not completely block its formation. Higher concentrations of captopril or the addition of enalaprilat or EDTA did not further reduce the amount of angiotensin II produced. In the presence of captopril a peptide corresponding to des-Leu(10)angiotensin I was formed in relatively large amounts (equivalent to 40% of angiotensin I catabolized). Homogenates purified by concanavalin A affinity chromatography gave a clean hydrolysis of angiotensin I to angiotensin II and His-Leu which was completely blocked by captopril. These results suggest an ACE-like activity in rat lung and aorta that is not sensitive to converting enzyme inhibitors.

Angiotensin I↗
PubMed1988

Site-specific distribution of large-bowel adenomatous polyps. Emphasis on ethnic differences.

The anatomic distribution of adenomatous polyps occurring in the large intestine of 98 consecutive patients was studied. Fifty-two of the patients were black and 46 were white. Seventy-nine percent of lesions in whites were found in the distal colon and rectum, whereas in blacks this occurred in only 47 percent. The difference was significant (P less than .01). Black patients also displayed a greater frequency of synchronous polyps and had a higher incidence of previous colorectal polyps. The findings suggest that the total colonic surveillance is essential in black patients to adequately screen for large-bowel neoplasia.

Black or African American↗
PubMed1988

A study of change in clinical service for general surgical patients.

The department of surgery at Long Island Jewish Medical Center in New York City conducted a study examining resource consumption and quality of care for patients referred to surgery from other hospital services, or "referred patients." Referred patients were compared with "nonreferred" surgery patients using several indicators of resource consumption. A quality assessment was also performed on a random sample from both groups using peer review organization guidelines. The study found that referred patients consumed more resources and may have received poorer quality care than nonreferred patients. Previous studies suggest that some resource utilization by referred patients may be avoidable. Thus, referral to the department of surgery may serve as an indicator for identifying patients in need of ongoing quality and/or utilization monitoring.

Health Resources↗
PubMed1988

DRGs, orthopedic surgery, and age at an academic medical center.

The federal Medicare Diagnostic Related Group (DRG) hospital reimbursement system has been on line for 5 years. Hospitals contend that profit margins have dropped to dangerously low levels, due to the federal DRG Prospective Payment System. The authors analyzed all orthopedic surgical admissions to a large academic medical center under DRG reimbursement and characterized patients by age, resource utilization, and outcome. Total costs for the 1,040 orthopedic patients analyzed during a 15-month period added up to $9,718,800. Mean hospital cost per patient, mean hospital length of stay, percent outliers, and mortality generally increased with age. All age categories of patients 65 years of age and above generated financial losses under DRGs. Older orthopedic patients consumed a disproportionately larger share of resources than younger patients, and were more frequent users of the SICU and blood. The current DRG reimbursement scheme may be inequitable in relation to the older orthopedic surgery patient. If these findings are demonstrated at other medical centers, older orthopedic surgical patients could be limited in both their access and quality of care in the future.

Academic Medical Centers↗
PubMed1988

The epidemiological information system.

Increasing demand for health care services coupled with limited resources require that services should be planned and delivered on the basis of a priority of needs. The Eastern Health Board is developing an Epidemiological Information System in order to measure such needs. The system will bring together computerized health data from diverse sources into an integrated information system and powerful software will be used to analyse and map the data on a small area basis. Pilot work suggests that this approach can be useful in identifying areas of greater need.

Catchment Area, Health↗
PubMed1988

Health care financing policy for hospitalized black patients.

The Medicare diagnostic-related group (DRG) prospective payment model is changing hospital payment. Currently many states are using DRG prospective "all payer systems" for hospital reimbursement. In all payer systems, Medicare, Medicaid, Blue Cross, and other commercial insurers pay by the DRG mode; New York State has had an all payer system since January 1, 1988. This study simulated DRG all payer methods on a large sample (N = 6,134) of adult black medical and surgical patients for a three-year period using both federal and New York DRG reimbursement. Both Medicare and Medicaid patients had, on average, a longer hospital stay and total hospital cost compared with patients covered by Blue Cross and other commercial insurers. Medicare and Medicaid patients also had a greater severity of illness compared with those of Blue Cross and others. All insurers (ie, Medicaid, Blue Cross, Medicare, and commercial) generated substantial financial risk under the DRG all payer scheme. These data suggest that federal, state, and private payers may be under-reimbursing for the care of the hospitalized black patient using the DRG prospective hospital payment scheme. Health care financing policy such as that demonstrated in this study may limit both the access and quality of care for many black patients in the future.

Adult↗
PubMed1988

Are routine preoperative laboratory screening tests necessary to evaluate ambulatory surgical patients?

Two hundred twelve consecutive adult patients undergoing a variety of ambulatory surgical procedures were studied prospectively to investigate whether routine preoperative urinalyses, complete blood counts (CBCs), and electrocardiograms (ECGs) were useful in determining the outcomes of their treatments. Urinalyses (U/As) were abnormal in 83 patients (39%); CBCs were abnormal in 19 patients (9%), and ECGs were abnormal in 140 patients (66%). The mean age of the patients was 64 plus or minus 12 years. The majority of patients with abnormalities determined by laboratory tests could have been predicted to have abnormalities on the basis of their histories and physical examinations. In this study, abnormalities indicated by laboratory tests did not influence preoperative cancellations, intraoperative or postoperative complications, or admissions to the hospital from the ambulatory unit after the surgical procedures. We conclude that routine preoperative screening laboratory tests have only a limited value in ambulatory surgical patients and recommend that they be either eliminated or replaced with less costly studies; for example, dipstick urinalyses for urinalyses, spun hematocrits for CBCs, and ECGs should be performed only if indicated by history and physical examination findings or if requested by an anesthesiologist.

Aged↗
PubMed1988

Surgical procedures in patients during the tenth decade of life.

The purpose of this study was to determine the outcome of major surgical procedures in patients 90 years of age or older. The records of 46 patients in this age group who underwent surgical procedures were reviewed to determine the outcome and the postoperative quality of life. Overall, the perioperative mortality was 20%. Mortality was not influenced by such risk factors as diabetes mellitus, chronic obstructive pulmonary disease, renal failure, quantity of blood loss, duration of procedure, or total number of hospital days. However, patients with heart disease had a significantly higher mortality rate (78%). Overall, 39% of the patients experienced a subjective deterioration in their mental status after surgery. Of those patients who were ambulatory before surgery, 73% were ambulatory after surgery. Although this study indicates that the perioperative mortality is high and mental status changes frequent in this very elderly age group, the quality of life and longevity of the majority of these patients are good, and vigorous surgical intervention appears warranted.

Aged↗
PubMed1988

Interracial differences in sex-steroid receptor status of breast cancers.

Fifty-three consecutive patients were studied to determine whether significant racial differences in estrogen receptor (ER) and progesterone receptor (PR) status existed. Unexpectedly, a significant difference was found between the percentages of premenopausal black and white women expressing ER-positivity (ie, 100 percent black women vs 60 percent white women; P <0.05). No significant differences were found between the races in respect to tumor stage, tumor size, tumor differentiation, absolute or mean ER and PR values. These findings differ from previously reported studies and suggest that patients of similar socioeconomic status do not demonstrate ER and PR differences based on race alone. Further prospective studies are indicated.

Adult↗