Ownership of clinical laboratories by referring physicians: effects on utilization, charges, and profitability.
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Ethics, Medical↗
Biomedical subjects
J M Mitchell
Publications and source records attributed to J M Mitchell.
The prevalence of polycystic ovaries on ultrasound scanning in a population of randomly selected women.
Polycystic ovaries (PCO) diagnosed by ultrasound have been commonly reported amongst healthy women. The study aimed to determine the prevalence of PCO in a population of women from the community, and to relate it to clinical and endocrinological data. Twelve hundred women chosen randomly from electoral rolls were invited to take part in the study. Two hundred and fifty five women (21%) who met eligibility criteria greed to participate and 183 women 916%) finally completed the study. Seventy two women did not attend. An ultrasound scan and blood tests were taken on day 5-9 of their menstrual cycles. Data about their menstrual periods and reproductive history was collected. The prevalence of PCO was 21% (39 of 183). No differences existed between women with PCO and normal ovaries with respect to uterine size, body mass index, luteinizing hormone levels, serum hormone binding globulin levels and fertility status. Hirsutism (Ferriman Gallwey score > 7), elevated testosterone levels and irregular menstrual cycles were significantly more frequent amongst women with PCO. Mean ovarian volume was larger in women with PCO irrespective of the use of hormonal contraception. Fifty nine per cent of women with PCO had irregular menstrual cycles or elevated Ferriman Gallwey scores or both. There was no detectable effect of PCO on parity or miscarriage although only 70% of women with PCO had evidence of an adequate ovulation compared to 95% of women with normal ovaries.
Female↗
Lowering the federally mandated cannabinoid immunoassay cutoff increases true-positive results.
Proposed changes to the Health and Human Services Guidelines for forensic urine drug testing will lower the required cannabinoid immunoassay cutoff concentration from 100 to 50 micrograms/L. We investigated the effect of this change on the sensitivity, specificity, and efficiency of eight cannabinoid immunoassays: Syva Emit d.a.u. 100; Syva Emit II 100; Syva Emit d.a.u. 50; Syva Emit II 50; Roche Abuscreen Online; Roche Abuscreen radioimmunoassay; Diagnostic Reagents; and Abbott ADx. All specimens also were assayed by gas chromatography/mass spectrometry. Lowering the cutoff concentration from 100 to 50 micrograms/L increased efficiencies and sensitivities for all immunoassays, with minor decreases in specificity (1.0-2.6%). There was a 23.2-53.6% increase in the number of true-positive specimens identified. Thus, lowering the cannabinoid immunoassay cutoff concentration from 100 to 50 micrograms/L resulted in detection of a substantial number of additional true-positive specimens, with an accompanying small increase in unconfirmed positive results.
Cannabinoids↗
Augmented femoral venous return.
We present a technique of femoral cardiopulmonary bypass that allows excellent venous drainage. This is accomplished by augmenting the venous return with a centrifugal pump.
Blood Circulation↗
Thickness of tissues intervening between the transducer and fetus and models for fetal exposure calculations in transvaginal sonography.
In transvaginal scanning the tissues intervening between the fetus and transducer are relatively thin. The average thickness in the first trimester is 25 mm and reduces to 15 mm by the third trimester; the minimum thicknesses are 14 and 8 mm, respectively. Two models are proposed for calculating exposure in transvaginal scanning. The models are considered in terms of the overlying tissues and the target tissues. A fixed path, constant attenuation of 0.3 dB/MHz describes the properties of the overlying tissues throughout pregnancy. In the model used in first-trimester scanning, the target tissues of the embryo/fetus are considered to have properties similar to those of soft tissues, and they attenuate the energy at the same rate as the overlying tissues. In the model used in second- and third-trimester scanning, the bony structures of the fetus are the target tissues. These reflect 30% of the incident energy and attenuate all of the transmitted energy at their surface.
Extraembryonic Membranes↗
Validity testing of the EZ-SCREEN cannabinoid test.
Recently, a number of "quick tests" became available for use in on-site drug testing. These tests offer advantages in simplicity, ease of performance, and rapid access to test results. However, there is a paucity of data on the validity of these tests for the detection of drugs of abuse. This report describes a validity study of the EZ-SCREEN cannabinoid test for the detection of cannabinoids in urine. Three healthy, male volunteers with a history of marijuana use participated in the study. Each subject smoked 1, 2, or 4 marijuana cigarettes (2.6% THC) on each test day. Urine samples were collected and incorporated into a specimen set consisting of 178 clinical urine samples, 72 urine samples containing known amounts of drug, and 50 drug-free urine samples. The specimen set was randomized and analyzed under blind conditions by the EZ-SCREEN test and by GC/MS for 11-nor-9-carboxy-delta 9-tetrahydrocannabinol (THCCOOH). Results were interpreted independently by three readers. Concordance analysis was performed by comparison of results of the EZ-SCREEN test with GC/MS. The EZ-SCREEN test was highly sensitive and produced positive results at a standard THCCOOH concentration of 5 ng/mL. While showing high sensitivity to THCCOOH, the assay demonstrated low cross-reactivity with delta 9-tetrahydrocannabinol (THC) and other cannabinoids. No false-positive results were recorded with 50 drug-free urine samples, but one reader recorded eight undecided results. Overall agreement between the three readers for the EZ-Screen results was approximately 80%. Delayed readings and photocopy readings tended to be less accurate than readings obtained at 3 min.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Consequences of physicians' ownership of health care facilities--joint ventures in radiation therapy.
BACKGROUND: Physicians are increasingly the owners of health care facilities to which they refer patients for services but at which they do not practice. We studied such ownership arrangements, known as "joint ventures," in the field of radiation therapy, examining their effects on access, use of services, costs, and quality. METHODS: Because 44 percent of free-standing facilities providing radiation therapy in Florida in 1989 were joint ventures, as compared with 7 percent elsewhere (95 percent confidence interval, 3 to 10 percent), we compared data for Florida with comparable data for the remainder of the United States. We also compared radiation-therapy facilities in Florida that were established as joint ventures with those that were not. Since most data were derived from entire populations rather than from samples, any differences found were of necessity statistically significant. RESULTS: No joint-venture facilities providing radiation therapy were located in inner-city neighborhoods or rural areas, but 11 percent of other free-standing facilities and hospital-based facilities were located in such areas. Among free-standing facilities, joint ventures received 39 percent of their revenues from patients with well-paying insurance coverage, as compared with 31 percent for facilities that were not joint ventures (P < 0.01). The frequency and costs of radiation-therapy treatments at free-standing centers were 40 to 60 percent higher in Florida than in the rest of the United States; there was no below-average use of radiation therapy at hospitals or higher cancer rates that explained the higher rates of use or higher costs in Florida. Radiation physicists at joint-venture facilities (the principal personnel involved in quality control other than physicians) spent 18 percent less time with each patient over the course of treatment than did their counterparts at free-standing facilities that were not joint ventures (P < 0.05). Mortality among patients with cancer in Florida was not lower than the U.S. average, even though joint ventures are much more common in that state. CONCLUSIONS: Joint ventures in radiation therapy appear to have adverse effects on patients' access to care. They also appear to increase the use of services and costs substantially. Some indicators show that joint ventures cause either no improvement in quality or a decline. Our results add to the evidence indicating that physicians' self-referral generally has negative consequences. We recommend legislation to ban ownership of joint ventures by referring physicians. Such legislation needs to be carefully designed in order to achieve its objectives and forestall new, financially abusive arrangements.
Ambulatory Care Facilities↗
Physician ownership of physical therapy services. Effects on charges, utilization, profits, and service characteristics.
OBJECTIVE: To evaluate the effects of physician ownership of freestanding physical therapy and rehabilitation facilities on utilization, charges, profits, and three measures of service characteristics for physical therapy treatments. DESIGN: Statistical comparison by physician joint venture ownership status of freestanding physical therapy and comprehensive rehabilitation facilities providing physical therapy treatments in Florida. PARTICIPANTS: A total of 118 outpatient physical therapy facilities and 63 outpatient comprehensive rehabilitation facilities providing services in Florida during 1989. The data from the facilities were collected under a legislative mandate. MAIN OUTCOME MEASURES: Visits per patient, average revenue per patient, percent operating income, percent markup, profits per patient, licensed therapist time per visit, and licensed and nonlicensed medical worker time per visit. RESULTS: Visits per patient were 39% to 45% higher in joint venture facilities. Both gross and net revenue per patient were 30% to 40% higher in facilities owned by referring physicians. Percent operating income and percent markup were significantly higher in joint venture physical therapy and rehabilitation facilities. Licensed physical therapists and licensed therapist assistants employed in non-joint venture facilities spend about 60% more time per visit treating physical therapy patients than licensed therapists and licensed therapist assistants working in joint venture facilities. Joint ventures also generate more of their revenues from patients with well-paying insurance. CONCLUSION: Our results indicate that utilization, charges per patient, and profits are higher when physical therapy and rehabilitation facilities are owned by referring physicians. With respect to service characteristics, joint venture firms employ proportionately fewer licensed therapists and licensed therapist assistants to perform physical therapy, so that licensed professionals employed in joint venture businesses spend significantly less time per visit treating patients. These results should be of interest to the medical profession, third-party payers, and policymakers, all of whom are concerned about the consequences of physician self-referral arrangements.
Conflict of Interest↗
New evidence of the prevalence and scope of physician joint ventures.
Physician ownership of health care businesses (outside their own practice) to which they refer patients has attracted considerable attention in the medical literature, in the media, and from federal and state policymakers. Despite the concerns raised about these ownership arrangements, known as joint ventures, the prevalence and scope of joint ventures involving physicians is not well documented. This report examines the prevalence and scope of physician joint ventures in Florida based on data collected under a legislative mandate. Our results indicate that physician ownership of health care businesses providing diagnostic testing or other ancillary services is common in Florida. While this conclusion is based on our comprehensive survey of health care businesses in Florida, it is at least indicative that such arrangements are likely to occur elsewhere. We find that at least 40% of Florida physicians involved in direct patient care have an investment interest in a health care business to which they may refer their patients for services; over 91% of the physician owners are concentrated in specialties that may refer patients for services. About 40% of the physician investors have a financial interest in diagnostic imaging centers. The estimates reported here indicate that the proportion of referring physicians involved in direct patient care who participate in joint ventures is much higher than previous estimates suggest.
Data Collection↗
Ethical aspects of resuscitation.
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Advance Directives↗
Inhibitory effect of topical application of a green tea polyphenol fraction on tumor initiation and promotion in mouse skin.
A green tea polyphenol fraction was evaluated for its ability to inhibit tumor initiation by polycyclic aromatic hydrocarbons and tumor promotion by a phorbol ester in the skin of CD-1 mice. Topical application of the green tea polyphenol fraction inhibited benzo[a]pyrene- and 7,12-dimethylbenz[a]-anthracene-induced tumor initiation as well as 12-O-tetradecanoylphorbol-13-acetate (TPA)-induced tumor promotion. Topical application of the green tea polyphenol fraction also inhibited TPA-induced inflammation, ornithine decarboxylase activity, hyperplasia and hydrogen peroxide formation. Studies with individual polyphenolic compounds in green tea indicated that topical application of (-)-epigallocatechin gallate, (-)-epigallocatechin and (-)-epicatechin gallate inhibited TPA-induced inflammation in mouse epidermis.
9,10-Dimethyl-1,2-benzanthracene↗
Effects of military experience on mental health problems and work behavior.
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Adult↗
Physician self-referral: empirical evidence and policy implications.
Ownership of health care businesses to which physicians refer patients but at which they do not directly provide services, has become commonplace in recent years. Perhaps these self-referral arrangements, known as "joint ventures," have proliferated because they are lucrative investments whereby physicians can earn legalized kickbacks for patient referrals. This article reviews existing empirical studies documenting the effects of physician self-referral arrangements. The general concensus of the empirical evidence on physician self-referral reveals that the financial incentives inherent in such arrangements are associated with increased utilization of services and higher costs to patients. None of the studies to date, however, has been able to determine whether the increased utilization that accompanies the practice of physician self-referral represents inappropriate or unwarranted services. Policy options which address the problem of physician self-referral are also discussed.
Ambulatory Care Facilities↗
Continuous retrograde blood cardioplegia.
We present a technique of myocardial protection using retrograde cold blood cardioplegia. This safe and simple method allows excellent continuous and homogeneous cooling of the heart during the ischemic period in all types of open heart operations.
Cardiac Surgical Procedures↗
The golden hours of the myocardial infarction: nonthrombolytic interventions.
Emergency care of patients with acute myocardial infarction requires active decision making to use agents that may improve morbidity and mortality. Thrombolysis remains the primary tool to accomplish this goal. Other pharmacologic agents, including lidocaine, nitrates, calcium channel blockers, beta-blockers, and aspirin, have been used acutely in myocardial infarction in the hopes of preventing death and salvaging myocardium. The decision to select one or all of these agents requires a knowledge of the clinical evidence of their efficacy and risk-to-benefit ratios. The clinical studies of the use of these agents acutely in the management of myocardial infarction are reviewed.
Adrenergic beta-Antagonists↗
Work behavior after the onset of arthritis.
Considerable evidence indicates that poor health has significant negative effects on labor force market activity. Nevertheless, because most of these analyses are based on cross-sectional data, their findings only indicate the relationship between poor health and work at a moment in time. This article uses a dynamic hazard model to examine how the onset of arthritis affects work behavior over the life cycle. The results indicate that the deterioration of health over time is the most significant determinant of why men with arthritis leave the labor force earlier than their otherwise healthy counterparts. These findings imply that the health-work relationship should be examined within the context of a life cycle framework to obtain a complete picture of the economic consequences of poor health.
Adult↗
Gas chromatographic-electron-impact mass fragmentometric determination of lysergic acid diethylamide in urine.
A sensitive method for the detection and quantitation of lysergic acid diethylamide (LSD) in urine was developed. After initial solvent extraction, the compound was further purified by liquid-liquid extraction or by solid-phase extraction. The trimethylsilyl derivative of LSD was detected by gas chromatography-mass spectrometry (GC-MS) operated in the electron-impact mode with selected-ion monitoring. The presence of LSD was confirmed by comparing retention times and relative abundances of ions of unknowns with that of a standard. The recovery of this procedure was greater than 89%. The intra-run and inter-run coefficients of variation were less than 5% and less than 7%, respectively. This procedure allows detection of LSD concentrations as low as 29 pg/ml. Quantitation of LSD was linear over the concentration range 50-2000 pg/ml.
Gas Chromatography-Mass Spectrometry↗
Direct ultrasonographic measurement of fetal lung length in normal pregnancies and pregnancies complicated by prolonged rupture of membranes.
Fetal lung length was measured directly with ultrasonography in 20 patients with prolonged rupture of membranes, commencing before 25 weeks' gestation. Measurements were made weekly and compared with data collected from 310 normal pregnancies. Measurement of fetal lung length by ultrasonography was a good predictor of pulmonary hypoplasia, predicting greater than 90% of cases. There was a good correlation between lung size assessed by the last ultrasonographic examination and lung weight postmortem (r = 0.783, p less than 0.05). Lung length measurements were superior to fetal chest circumference measurements in the identification of pulmonary hypoplasia. There was a significant negative association between the amount of amniotic fluid and pulmonary hypoplasia (p less than 0.05). There were fetuses with pulmonary hypoplasia that had respiratory movements seen at the majority of ultrasonographic examinations.
Biometry↗