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Biomedical subjects

J A Alexander

Publications and source records attributed to J A Alexander.

At least 73 records · Page 4Linked to original sources
PubMed1996

Determinants of profound organizational change: choice of conversion or closure among rural hospitals.

Because of severe operating and resource constraints, many rural community hospitals are confronted with pressures to abandon core strategies related to acute inpatient care. Little is known, however, about why hospitals would choose to convert to organizations that provide non-acute care health services as an alternative to closure. We argue that rural hospitals are more likely to convert when conditions are in place that enable them to make major shifts from their current domains to ones that are more hospitable. To the extent that resources are available in alternative domains and rural hospitals possess the strategies necessary to exploit these resources, rural hospitals are more likely to convert rather than close. To examine our proposed hypotheses, we analyze national data from all rural hospitals from 1984 through 1991. Results indicate that conversion is more likely to occur than closure when resources in the market are abundant, competition for hospital resources is high, and hospitals have established strategies to provide alternative forms of health care. Findings from this study indicate that environmental and organizational factors can increase a rural hospital's risk of conversion as an alternative to closure.

Health Care Reform↗
PubMed1996

Continuous negative extrathoracic pressure in neonatal respiratory failure.

OBJECTIVE: In uncontrolled clinical trials, negative extrathoracic pressure has been shown to be an effective respiratory support. We aimed to assess its role in the context of current neonatal intensive care. DESIGN: A randomized controlled trial, with sequential analysis of matched pairs of infants. Matching was undertaken by stratified randomization from 15 groups divided according to gestational age, oxygen requirement, and whether patients were intubated at 4 hours of age. SETTING: Two neonatal intensive care units. PATIENTS: Two hundred forty-four patients (birth weight 1.53 +/- 0.69 kg (mean +/- SD); gestational age 30.4 +/- 3.5 weeks) with respiratory failure. INTERVENTIONS: Patients were randomized at 4 hours of age to receive either standard neonatal intensive care, or standard care plus continuous negative extrathoracic pressure (CNEP, -4 to -6 cmH2O) applied within a purpose-designed neonatal incubator. OUTCOME SCORES: Clinical scores were calculated for each infant at 56 days of age, or death if earlier. Scores included measures for mortality, respiratory outcome, the presence of cerebral ultrasound abnormalities, patent arterial duct, necrotizing enterocolitis, and retinopathy. The treatment given for the higher score for each pair was recorded and the cumulative net number of pairs favoring CNEP plotted in the sequential analysis to provide an ethical early termination strategy. Individual components of the outcome score and other secondary measurements were analyzed on completion of the trial. RESULTS: The sequential analysis reached a decision boundary after 122 out of a possible maximum of 124 pairs were completed. The overall outcome score showed an overall significant benefit for CNEP. Secondary analysis showed that the use of CNEP was associated with an increase in mortality, cranial ultrasound abnormalities, and pneumothoraces, which were not statistically significant. However, 5% fewer patients were intubated (95% confidence interval [CI], 0-10), and the total duration of oxygen therapy among surviving infants at 56 days was lower (20.5 days, compared with 38.9 in controls; difference 18.4 days, 95% CI 3.8 to 33.0). Among all infants, the mean total duration of oxygen therapy was 18.3 days among CNEP-treated infants compared with 33.6 days among the controls (difference -15.3 days, 95% CI -0.2 to -30.4). This reduction in mean levels is entirely attributable to substantially fewer patients requiring prolonged oxygen therapy, the median duration of treatment being very similar in the two groups. As a result, commensurately fewer surviving infants showed chronic lung disease of prematurity. CONCLUSIONS: The use of continuous negative pressure improves the respiratory outcome for neonates with respiratory failure.

Female↗
PubMed1995

Loosening the Gordian Knot of governance in integrated health care delivery systems.

A new organizational species is emerging--the integrated health care delivery system. Aligned with both the anticipated provisions of federal and state health care reform initiatives and emerging purchaser demands, integrated delivery systems could dominate many health care markets by the end of this decade. Integration is both the defining feature and key imperative of such systems. Because of the unique position of boards, governance is potentially the ultimate integrator. Yet little attention had been focused on integrated delivery system governance. Accordingly, this article will address the governance of integrated delivery systems through three questions: (1) What are the distinguishing characteristics of integrated health care delivery systems? (2) What are the distinctive issues and challenges associated with governing integrated delivery systems? and (3) What different forms of governance can be employed by these systems and what factors influence the effectiveness of these forms?

American Hospital Association↗
PubMed1995

The challenges of governing integrated health care systems.

As health care delivery organizations develop into integrated health care systems, new and significant challenges arise with respect to how such systems should be governed. This article explores several key governance issues that organizations are likely to encounter as they attempt to effect the transition from hospital or multihospital system governance arrangements to those appropriate for integrated systems.

Communication↗
PubMed1994

The changing strategies in operation for transposition of the great vessels.

Between July 3, 1985, and February 24, 1994, a total of 55 infants underwent arterial switch procedures for the repair of transposition of the great vessels. Thirty-five infants had an intact ventricular septum and 20 had ventricular septal defects. To date, there have been three late deaths, one in the group with an intact ventricular septum and two in the group with a ventricular septal defect. Early postoperative complications included atrial dysrhythmias, prolonged ventilation, inability to close the sternum, and tension on the coronary arteries. Follow-up echocardiographic data for 44 patients indicate that pulmonary artery gradients are a worrisome postoperative problem, especially in infants who have ventricular septal defects.

Child, Preschool↗
PubMed1993

Midazolam sedation for percutaneous liver biopsy.

Control of patient respiration is needed to safely perform percutaneous liver biopsy (PLB) and may be adversely affected by sedation. The purpose of this study was to evaluate the safety of PLB with intravenous midazolam and to evaluate patient acceptance of PLB with and without sedation. Two hundred seventeen consecutive patients underwent 301 percutaneous liver biopsies. One hundred fifty-one of the biopsies were done after the patients were sedated with intravenous midazolam immediately before the biopsy. The last 61 patients were questioned after the biopsy to evaluate the discomfort of the procedure, their memory of the procedure, and their willingness to undergo another PLB. The major complication rate was similar in the midazolam-treated (0.7%) and untreated (0.7%) groups. The midazolam-treated patients had a numerically lower mean pain score (1.5 +/- 0.4 vs 4.0 +/- 0.7) (mean +/- SEM) (P = 0.07) and significantly lower mean memory score (4.8 +/- 0.7 vs 9.9 +/- 0.1) (P < 0.01) than the untreated patients. The treated and untreated groups had similar mean willingness for repeat PLB scores (9.3 +/- 0.3 vs 9.1 +/- 0.6). We conclude that: (1) there is no increased risk of PLB with midazolam and (2) patients have less memory of the procedure with midazolam.

Anesthesia, Intravenous↗
PubMed1993

Identifying Blalock-Taussig shunts using a Silastic band.

Placement of an encircling Silastic band around Blalock-Taussig shunts facilitates identification and ligation of the shunt at the time of corrective operation. This technique of "shunt banding" is particularly useful for left-sided shunts, both native and modified. We have noted no complications, specifically shunt constriction. Placement of the band adds minimal operative time during shunt placement and substantially lessens the time and amount of dissection required during subsequent procedures.

Anastomosis, Surgical↗
PubMed1993

Leadership instability in hospitals: the influence of Board-CEO relations and organizational growth and decline.

This study tested whether leadership instability--a systemic pattern of frequent succession in the top management position of an organization--was associated with sociopolitical structures that define the relationship between the board and chief executive officer (CEO), controlling for temporal patterns of the organizational life-cycle stage. In organizations that are not profit maximizing and subject to considerable uncertainty, such governance properties were hypothesized to affect leadership instability independent of organizational growth or decline. Results of regression analyses demonstrate strong main effects of board-CEO relations, net of the impact of organizational life cycle, on leadership instability.

Chi-Square Distribution↗
PubMed1993

Corporate and philanthropic models of hospital governance: a taxonomic evaluation.

OBJECTIVE: We assess the theoretical integrity and practical utility of the corporate-philanthropic governance typology frequently invoked in debates about the appropriate form of governance for nonprofit hospitals operating in increasingly competitive health care environments. DATA SOURCES: Data were obtained from a 1985 national mailed survey of nonprofit hospitals conducted by the American Hospital Association (AHA) and the Hospital Research and Educational Trust (HRET). STUDY DESIGN: A sample 1,577 nonprofit community hospitals were selected for study. Representativeness was assessed by comparing the sample with the population of non-profit community hospitals on the dimensions of bed size, ownership type, urban-rural location, multihospital system membership, and census region. DATA COLLECTION: Measurement of governance types was based on hospital governance attributes conforming to those cited in the literature as distinguishing corporate from philanthropic models and classified into six central dimensions of governance: (1) size, (2) committee structure and activity, (3) board member selection, (4) board composition, (5) CEO power and influence, and (6) bylaws and activities. PRINCIPAL FINDINGS: Cluster analysis and ANCOVA indicated that hospital board forms adhered only partially to corporate and philanthropic governance models. Further, board forms varied systematically by specific organizational and environmental conditions. Boards exhibiting more corporate governance forms were more likely to be large, privately owned, urban, and operating in competitive markets than were hospitals showing more philanthropic governance forms. CONCLUSIONS: Findings suggest that the corporate-philanthropic governance distinction must be seen as an ideal rather than an actual depiction of hospital governance forms. Implications for health care governance are discussed.

Analysis of Variance↗
PubMed1992

Use of transesophageal echocardiography to visualize an anomalous right coronary artery arising from the left main coronary artery (single coronary artery).

This case report demonstrates a role for transesophageal echocardiography in defining the course of anomalous coronary arteries. Origin of the right coronary artery (RCA) from the left main (LM) (single coronary artery) is an exceedingly rare congenital anomaly. It is not always benign and may result in myocardial infarction. This may be due to compression between the aorta and the pulmonary artery. Transesophageal echocardiography offers a low-risk, noninvasive means of imaging the proximal coronary arteries. In the majority of patients, the proximal segments of the three major coronaries can be clearly visualized. With the addition of color flow, it is possible to visualize flow in most patients. Proximal obstructive lesions can be seen in some patients although sensitivity thus far seems low.

Blood Flow Velocity↗
PubMed1992

Familial cardiac myxoma.

The majority of cardiac myxomas occur sporadically as isolated lesions in the left atrium of middle-aged women. However, a "familial" form and a "syndrome" form of this lesion have been identified. The syndrome myxoma can present with pigmented skin lesions and peripheral or endocrine neoplasms. The familial and syndrome forms of cardiac myxomas can usually be distinguished from the sporadic form by the presentation at a younger age, the unusual location and multicentricity of the lesions, and the presence of rare pathological conditions. In addition, a higher rate of recurrent lesions is usually associated with the familial and syndrome forms of this disease. To date, 15 families with cardiac myxomas have been reported in the world's literature. Here we present 2 additional case reports.

Adolescent↗
PubMed1992

The effect of the social organization of work on the voluntary turnover rate of hospital nurses in the United States.

In light of current concerns over nursing shortages and productivity, voluntary turnover among hospital nurses in the United States has assumed renewed importance as a managerial issue. This study examines the thesis that the social organization of work in hospitals is an important determinant of the voluntary turnover rate among registered nurses. This perspective differs from previous work in this area in that both turnover and its determinants are conceptualized at the organizational rather than individual level, thus opening the way for administrative intervention to reduce turnover. The conceptual model is tested using multiple regression techniques on a sample of 435 hospitals. Results suggest that organizational characteristics and environmental conditions are important contributors to turnover. Organizational characteristics are stronger predictors of turnover than are economic factors.

Career Mobility↗
PubMed1992

Oxygen saturation and breathing patterns in preterm infants with cyanotic episodes.

The pathophysiology of cyanotic/apnoeic episodes in preterm infants was investigated using overnight tape recordings of beat-to-beat arterial oxygen saturation (SaO2), plethysmographic waveforms from the oximeter, breathing movements and nasal airflow. Recordings were made in 16 preterm infants with recurrent cyanotic episodes of unknown cause that had received stimulation or resuscitation, and 15 preterm controls, matched for birth weight, post-conceptional and postnatal age. The recordings were analysed for baseline SaO2, the number of hypoxaemic episodes (SaO2 < or = 80% for > or = 4 s) and the breathing patterns associated with each episode. There was a significant difference in the total number of hypoxaemic episodes between patients and controls (520 versus 100; p < 0.01), but no difference was found for mean baseline SaO2 (98.6 versus 99.0%; p > 0.05). The mean duration of each hypoxaemic episode in the patients was 9.5 s compared with 5.8 s in the controls (p < 0.01). Although most hypoxaemic episodes (62 and 76%) were associated with pauses in breathing movements, a proportion (8 and 18%, respectively) occurred despite continuous airflow and breathing movements in both patients (6 of 16) and preterm controls (2 of 15). The rate of decrease in SaO2 was significantly more rapid during these latter hypoxaemic episodes than during episodes associated with isolated apnoeic pauses (8.5 versus 3.2% per second, p = 0.02). Preterm infants with cyanotic episodes have increased numbers of clinically unapparent hypoxaemic episodes, some of which have continued ventilation and rapid desaturation. The pathogenesis of these episodes warrants further investigation.

Birth Weight↗
PubMed1992

Multihospital system affiliation as a survival strategy for rural hospitals under the prospective payment system.

The introduction of Medicare's Prospective Payment System (PPS) has disproportionately increased financial pressures on rural hospitals and posed challenges to the survival of these institutions. Increasingly, rural hospitals are seeking strategies that can enhance their chances for survival in a turbulent and hostile environment. This study examined the survival effects of one such strategy, multihospital system affiliation. Specifically, we assessed: (1) whether and how different types of system affiliation in the post-PPS era affect the likelihood of rural hospital survival; (2) whether particular structural, environmental and hospital performance characteristics moderate the effects of system affiliation on rural hospital survival; and (3) whether systematic selection by rural hospitals into multihospital systems potentially accounts for observed relationships between system affiliation and survival. Proportional hazards analyses indicate that system affiliation with investor-owned systems significantly reduces survival probabilities of rural hospitals. Affiliation with not-for-profit systems or system affiliation under contract management arrangements does not affect survival probabilities of rural hospitals. These general findings are moderated by the effects of hospital ownership and size at the time of affiliation. Finally, study findings indicated that systematic selection by poor performing rural hospitals into investor-owned systems has occurred in the post-PPS era. No evidence of selection into not-for-profit systems was discovered.

Contract Services↗
PubMed1992

Patient memory before and after cardiac operations.

The memories of 20 patients undergoing elective operations on the heart were assessed by a comprehensive battery of standardized psychometric tests. Testing was conducted 1 to 2 days before, 7 to 10 days after, and 1 month after each operation. Twenty age-matched, healthy control subjects were given the same battery of tests at comparable times. Compared with healthy subjects, the patient group had significantly lower scores on 3 of 19 tests before, 10 of 19 tests 1 week after, and 5 of 19 tests 1 month after surgical intervention. The patient group had similar test performances before and 1 week after the operations and improved on 3 of 19 measures 1 month after the operations. Degrees of illness and cardiopulmonary bypass variables were significantly related to only a small subset of memory measures. Results of this study are consistent with previous reports that underscore the contribution of nonspecific aspects of surgical intervention to neuropsychologic dysfunction in the immediate postoperative period. We conclude that neither the illness nor the surgical variables are directly related to substantial variance in cognitive function after operations on the heart.

Adult↗
PubMed1991

Identification of 7-(2-hydroxyethyl)guanine as a product of alkylation of calf thymus DNA with clomesone.

Evidence at the molecular level is presented in support of alkylation of O6-guanine moieties of DNA as the mechanism of cytotoxicity of Clomesone to HT-29 cells and consists in the isolation and identification of a product resulting from alkylation of calf thymus DNA with Clomesone, followed by depurination to yield 7-(2-hydroxyethyl)guanine, whose formation is reasonably explained by O6-guanine chloroethylation followed by intramolecular alkylation at N7 of guanine and subsequent hydrolysis to the hydroxyethylguanine.

Alkylation↗
PubMed1991

Board makeup plays role in CEO turnover.

Jeffrey A. Alexander explores the impact of board structure and composition on turnover of chief executive officers in this summary of his winning research project in the second Governance Fellowship award, sponsored by the Governance Institute and Modern Healthcare.

Employment↗