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Biomedical subjects

J A Alexander

Publications and source records attributed to J A Alexander.

At least 55 records · Page 3Linked to original sources
PubMed1997

Usefulness of cytopathology and histology in the evaluation of Barrett's esophagus in a community hospital.

BACKGROUND: Brush cytology and histology have been found to be complementary in the evaluation of Barrett's esophagus at a referral medical center. This study evaluated the usefulness of brush cytology and histology in a community hospital setting. METHODS: One hundred consecutive patients with Barrett's esophagus underwent esophagogastroscopy performed by four staff gastroenterologists. Four quadrant biopsy specimens for histopathology at 3-cm intervals throughout the Barrett's segment and one brushing for cytology were obtained. All specimens were interpreted by four board-certified staff pathologists in a blinded fashion. RESULTS: Histologic diagnosis included three adenocarcinomas, one high-grade dysplasia, six low-grade dysplasias, and one indeterminate dysplasia. Cytology diagnosed the same three adenocarcinomas, no high-grade dysplasia, three low-grade dysplasia, and two indeterminate dysplasias. The case of high-grade dysplasia on histology was diagnosed as normal by cytology. The six patients found to have low-grade dysplasia by histology were found to have low-grade dysplasia (3), indeterminate dysplasia (2), and no abnormality (1) by cytology. In no case was a higher grade of dysplasia diagnosed by cytology than by histology. CONCLUSION: Adding brush cytology to histology increased the cost but not the diagnostic yield in the evaluation of Barrett's esophagus in a community hospital setting.

Adenocarcinoma↗
PubMed1997

Nurse staffing patterns and hospital efficiency in the United States.

The objective of this exploratory study was to assess the effects of four nurse staffing patterns on the efficiency of patient care delivery in the hospital: registered nurses (RNs) from temporary agencies; part-time career RNs; RN rich skill mix; and organizationally experienced RNs. Using Transaction Cost Analysis, four regression models were specified to consider the effect of these staffing plans on personnel and benefit costs and on non-personnel operating costs. A number of additional variables were also included in the models to control for the effect of other organization and environmental determinants of hospital costs. Use of career part-time RNs and experienced staff reduced both personnel and benefit costs, as well as total non-personnel operating costs, while the use of temporary agencies for RNs increased non-personnel operating costs. An RN rich skill mix was not related to either measure of hospital costs. These findings provide partial support of the theory. Implications of our findings for future research on hospital management are discussed.

Clinical Competence↗
PubMed1997

Directors' perceptions of the effects of managed care in outpatient substance abuse treatment.

This study examines the perceptions of unit directors' regarding the effects of managed care on outpatient treatment and operations. Specifically, we propose that perceptions vary as a function of managed care penetration, managed care complexity, and the stringency of managed care oversight procedures. Data are from a nationally representative sample survey of 236 outpatient substance abuse treatment organizations conducted in 1995. Study findings support the thesis that directors' perceptions vary systematically with specific attributes of managed care. Specifically, directors' perceptions of positive managed care effects are associated with two managed care oversight procedures: (a) managed care limits on the number of sessions provided; and (b) managed care requirements for follow-up after treatment. Directors perceptions of negative effects of managed care are significantly related to (a) managed care penetration, (b) managed care complexity; and (c) four different managed care oversight procedures. These results have implications for treatment given the rapid growth in managed behavioral care.

Ambulatory Care↗
PubMed1997

Determinants of mental health providers' expectations of patients' improvement.

OBJECTIVE: Characteristics of individual mental health providers and of treatment settings were examined to determine their effects on providers' expectations about the improvement of patients with serious mental illness. METHODS: The sample consisted of 1,567 treatment providers working in 107 inpatient and outpatient units or programs in 29 Veterans Affairs mental health facilities. They completed a questionnaire about their prognostic expectations and a broad range of attitudes toward job satisfaction, professional relations, and team functioning. Unit or program directors of all 107 units completed another questionnaire about the average functional ability of patients, unit workload, and unit size. Hierarchical linear modeling was used to assess the effects of both individual and unit-level attributes on providers' expectations of improvement in clinical symptomatology and social-functional skills of patients in their care. RESULTS: The providers had generally low expectations about the improvement of patients with serious mental illness. Expectations were higher among staff in units or programs that were smaller and that had an outpatient focus, a greater proportion of staff involved in the treatment team, and higher-functioning patients. Individual characteristics significantly associated with prognostic expectations were occupation, age, and membership on the treatment team. CONCLUSIONS: Prognostic expectations among providers of care to persons with serious mental illness vary with identifiable individual and unit or program characteristics. The latter may be amenable to manipulation and intervention to improve mental health providers' prognostic expectations.

Attitude of Health Personnel↗
PubMed1997

Effects of market position and competition on rural hospital closures.

OBJECTIVE: To examine the dynamic effects of competition and hospital market position on rural hospital closures. DATA SOURCE/STUDY SETTING: Analysis of all rural community hospitals operating between 1984 and 1991, with the exception of sole-provider hospitals. Data for the study are obtained from four sources: the AHA Annual Surveys of Hospitals, the HCFA Cost Reports, the Area Resource File, and a hospital address file constructed by Geographic Inc. DATA COLLECTION AND ANALYSIS: Variables are merged to construct pooled, time-series observations for study hospitals. Hospital closure is specified as a function of hospital market position, market level competition, and control variables. Discrete-time logistic regressions are used to test hypotheses. PRINCIPAL FINDINGS: Rural hospitals operating in markets with higher density had higher risk of closure. Rural hospitals that differentiated from others in the market on the basis of geographic distance, basic services, and high-tech services had lower risks of closure. Effects of market density on closure disappeared when market position was included in the model, indicating that differentiation in markets should be taken into account when evaluating the effects of competition on rural hospital closure. CONCLUSIONS: Our findings suggest that rural hospitals can reduce competitive pressures through differentiation and that accurate measures of competition in geographically defined market areas are critical for understanding competitive dynamics among rural hospitals.

American Hospital Association↗
PubMed1997

Effects of inhaled nitric oxide in patients with hypoxemia and pulmonary hypertension after cardiac surgery.

BACKGROUND: Cardiopulmonary bypass can increase pulmonary vascular tone and decrease ventilation-perfusion matching by impairing the pulmonary endothelial production of nitric oxide. OBJECTIVES: We tested the hypothesis that inhalation of exogenous nitric oxide decreases the ratio of mean pulmonary arterial pressure to mean system arterial pressure and the intrapulmonary shunt fraction and increases the ratio of arterial blood oxygen tension to fraction of inspired oxygen in patients in whom the ratio of mean pulmonary arterial pressure to mean systemic arterial pressure is more than 0.50, and the ratio of arterial blood oxygen tension to fraction of inspired oxygen is less than 300 mm Hg in the first 24 hours after cardiopulmonary bypass surgery. METHODS: Only those patients who had estimates of the ratio of mean pulmonary arterial pressure to mean systemic arterial pressure and the ratio of arterial blood oxygen tension to fraction of inspired oxygen determined preoperatively were enrolled. Hemodynamic variables were recorded, and blood samples were obtained for oximetric analysis 5 minutes before and 30 minutes after inhalation of nitric oxide began. The concentration of nitric oxide inhaled was maintained at 20 parts per million. The data were analyzed by using Friedman's repeated measures analysis of variance. RESULTS: Thirteen patients were enrolled in the study. The mean preoperative ratio of mean pulmonary arterial pressure to mean systemic arterial pressure was 0.63 +/- 0.08 (standard error of the mean), and the mean preoperative ratio of arterial blood oxygen tension to fraction of inspired oxygen was 131 +/- 15 mm Hg. No differences between preoperative and postoperative values were detected. Inhalation of nitric oxide decreased the ratio of mean pulmonary arterial pressure to mean systemic arterial from 0.53 +/- 0.07 to 0.39 +/- 0.5 and increased the ratio of arterial blood oxygen tension to fraction of inspired oxygen from 167 +/- 35 mm Hg to 235 +/- 45 mm Hg. Inhalation of nitric oxide also decreased the intrapulmonary shunt fraction from 0.29 +/- 0.05 to 0.19 +/- 0.04. CONCLUSIONS: Inhalation of nitric oxide selectively decreases pulmonary vascular tone and increases ventilation-perfusion matching in patients with persistent pulmonary hypertension and hypoxemia after surgery requiring cardiopulmonary bypass. Inhalation of nitric oxide may be a valuable adjunctive therapy for these patients.

Administration, Inhalation↗
PubMed1996

Determinants of rural hospital conversion. A model of profound organizational change.

One widely discussed response to the severe problems faced by many rural hospitals is to convert them into organizations that provide health services other than general, acute inpatient care. This study identifies conversions that occurred nationally from 1984 to 1991. The study also empirically examines the determinants of conversion, using rural hospitals that did not convert (between 1984 and 1991) as a comparison group. The authors examine a set of factors that makes radical organizational change necessary (eg, poor performance) and reduces resistance to such change (eg, proximity to other hospitals). Results from discrete-time logistic regression show that converters are more likely than nonconverters to: have poor performance and fewer beds; be located very near to or very distant from similar hospitals; operate in larger communities; devote more of their care to areas other than acute inpatient care; and be members of multihospital systems. Converters also are less likely to be government owned. The need for future research on the effects of conversion is discussed.

Bed Conversion↗
PubMed1996

State legislation and policy affecting rural hospital conversion and closure.

Many rural hospitals have closed or converted to organizations that provide health services other than general, acute inpatient care. However, little is known about why rural hospitals convert rather than close. This study evaluates the relationship between state policy and rates of rural hospital conversion relative to rates of rural hospital closure. The expectation was that the relationship among state policies and rates of conversion and rates of closure differs as a function of whether a state policy facilitates rural hospital transition to alternative models of care or supports them in their existing form. National data were analyzed for all rural hospitals from 1984 to 1991. Results indicate that state policies have done little to facilitate widespread adoption of conversion among rural hospitals. Despite these findings, results also indicate that some state policies have resulted in an increase in the rate of rural hospitals conversions as an alternative to closure.

Data Collection↗
PubMed1996

The effects of treatment team diversity and size on assessments of team functioning.

Team-based health care assumes that groups representing multiple disciplines can work together to implement care plans that are comprehensive and integrated. It also assumes that professionals can function effectively in an interdependent relationship with members of other occupational groups. However, we know little about what makes effective team functioning. This article examines the factors related to health care team functioning, with specific emphasis on team demographic composition and size. Hierarchical linear modeling is used to analyze 106 Veterans Affairs (VA) hospitals. Results indicate that individuals who operate on more heterogenous and larger teams have lower perceptions of team functioning.

Age Factors↗
PubMed1996

An exploratory analysis of market-based, physician-organization arrangements.

The growth of physician-organization arrangements (e.g., PHOs, MSOs) by physician specialty groups and delivery organizations is widely acknowledged. Yet, little is known about these new organizational forms. This paper presents a descriptive analysis of physician-organization arrangements (POAs) using survey data obtained from 79 organizations. The analysis examines the extent to which healthcare delivery organizations are engaged in the development of POAs, the number of physicians involved in POAs, and the decision-making control and strategies associated with POAs. These attributes are examined for the sample as a whole and relative to the institutional and market conditions facing study participants. Results are discussed in terms of their implications for health services managers.

Bed Occupancy↗
PubMed1996

The short-term effects of merger on hospital operations.

OBJECTIVE: The short-term effects of merger on three areas of hospital operations - scale of activity, personnel/staffing practices, and operating efficiency - is examined. DATA SOURCES: Secondary data obtained from the AHA Annual Surveys (1980-1990) were applied to analyze 92 hospital mergers over the period 1982-1989. STUDY DESIGN: The study employed a multiple time-series design involving a six-year longitudinal assessment of change in hospital operating characteristics before and after merger, and a parallel analysis of change in a randomly selected group of nonmerging hospitals. DATA COLLECTION: Pooled, cross-sectional data files were constructed. Comparisons were evaluated using paired and two-sample t-tests. PRINCIPAL FINDINGS: General merger effects occurred primarily in areas related to operating efficiency. Merger resulted in slowing rates of preexisting trends, rather than dramatic improvements in operating practices. CONCLUSIONS: The short-term impact of merger was generally modest but differed by the conditions under which the merger occurred. Specifically, mergers occurring later in the study period and mergers between similarly sized hospitals displayed greater change in operating characteristics than those occurring earlier in the study period and those between hospitals of dissimilar size. Such differences are attributed respectively to increased competitive pressures after PPS and to greater opportunities for consolidation and efficiencies in mergers involving similarly sized hospitals.

American Hospital Association↗
PubMed1996

Hepatitis C and inclusion body myositis.

Hepatitis C is known to be associated with a myriad of autoimmune diseases. Inclusion body myositis is an inflammatory myopathy of unknown etiology. We report the first case of chronic hepatitis C with inclusion body myositis.

Adult↗
PubMed1996

Adult cerebrovascular disease: role of modified rapid fluid-attenuated inversion-recovery sequences.

PURPOSE: To compare a rapid fluid-attenuated inversion-recovery (FLAIR) sequence with T1-weighted, fast spin-echo proton density-weighted, and T2-weighted images in the evaluation of cerebrovascular disease. METHODS: All patients underwent standard T1-, proton density-, and T2-weighted fast spin-echo and fast FLAIR MR imaging at 1.5 T. Images were compared for lesion size, location, and conspicuity. RESULTS: Forty-five infarctions were identified on T2-weighted and fast FLAIR sequences. Lesion size was comparable on the proton density-weighted, fast T2-weighted, and fast FLAIR sequences, although lesion conspicuity was superior on the fast FLAIR images in 43 (96%) of the lesions. Associated periventricular and pontine hyperintensities were more extensive on the fast FLAIR images. CONCLUSION: Our modified fast FLAIR technique provided improved conspicuity of infarctions and white matter disease as compared with T1-, proton density-, and T2-weighted spin-echo images, and a reduced scan time compared with conventional FLAIR sequences in patients with cerebrovascular disease.

Adult↗