Biomedical subjects
Publications and source records attributed to J R Wheeler.
Health care organizations that want to position themselves for the future must develop and continuously improve strategic information systems (SIS). The authors consider several problem areas on the current frontier of SIS development and propose solutions that for the most part are expedient and pragmatic.
A modified technique of tunnelling for jugular venous catheters in the newborn is described. The technique eliminates cannula-kinking and offers a more convenient position for the catheter.
PURPOSE: During the past 14 months we conducted a prospective clinical trial to evaluate the efficacy of duplex-directed manual occlusion (DDMO) of iatrogenic femoral false aneurysms (FFAs) as an alternative to standard operative management. METHODS: In all cases DDMO was performed with real-time color-flow imaging while steady, continuous external pressure was applied manually to the neck of the FFA by an experienced vascular technologist for a period of 10 minutes. RESULTS: Ten of the 11 FFAs treated with DDMO in this series were thrombosed successfully, requiring a mean of 30 minutes of compression per aneurysm (three compressions of 10 minutes each). DDMO was unsuccessful in one patient, whose session was terminated because of severe discomfort as a result of the procedure. All 10 patients with successfully thrombosed FFAs are without recurrence at 1-month follow-up color-flow duplex examination, and there has been no morbidity attributable to DDMO. CONCLUSIONS: We conclude that DDMO of postcatheterization FFA can be performed safely and is an inexpensive, effective, nonoperative method of managing such lesions. The precise role of this technique would appear to be as a first-line treatment for uncomplicated iatrogenic FFAs.
A 32-year-old man was transferred to our hospital after a 2.0 by 2.5 cm traumatic false aneurysm of the distal extracranial vertebral artery was noted after a stab wound of the posterior side of the neck. To obviate the need for operative exposure of the distal vertebral artery at the base of the skull, we elected to perform duplex-directed manual occlusion of the lesion. Angiography before and after the procedure, as well as 10-month follow-up duplex ultrasonography, demonstrated satisfactory thrombosis of the false aneurysm without evidence of a residual arterial defect. There was no morbidity associated with the procedure. We conclude that duplex-directed manual occlusion, a new technique recently described for the nonoperative management of postcatheterization femoral false aneurysms, can be applied safely and effectively to false aneurysms in other locations in which the risks and technical difficulties of operative repair render surgery less desirable.
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Duplex scan, arteriography, and graft flow rates were used intraoperatively to assess 56 infrainguinal arterial reconstructions for technical error. Intraoperative duplex scan identified a technical defect or low graft flow velocity in 22 of 56 (39%) grafts. Eleven of the defects were judged to be clinically significant and were corrected. Four of these defects were missed by the completion arteriogram. One technical defect identified by completion arteriography was missed by duplex scan. Fifty percent (5/10) of grafts with an abnormal intraoperative duplex scan which were not corrected occluded within 30 days. Graft flow rates measured by the electromagnetic flowmeter were neither predictive of technical defect nor early graft outcome. Although the sensitivity of arteriography and duplex scan (88% sensitivity for both) were both high for predicting early graft occlusion, the combination of duplex scan and completion arteriography was significantly more accurate (p less than .0001) in predicting early graft outcome than either study alone. Duplex scan identified significant graft defects which were not detected by completion arteriography or graft flow rate measurement. The duplex scan also provided hemodynamic information which was predictive of early graft outcome. The duplex scan can be an important adjunct to completion arteriography for the intraoperative assessment of infrainguinal arterial reconstruction.
Twenty-two patients with intermittent claudication were prospectively enrolled in a 12-week program of supervised, graded treadmill exercise therapy. Severity and distribution of arterial occlusive disease were ascertained by noninvasive determination of segmental lower extremity blood pressures and waveforms. No attempt was made to modify risk factors for atherosclerotic occlusive disease. The exercise-induced reduction of the ankle pressure and its recovery were recorded over time, and the area under this curve, the "ischemic window," represents the severity of the ischemic deficit. Absolute systolic ankle pressure, ankle-brachial index, maximum walking time, claudication pain time, and the ischemic window were measured before and after exercise training in all subjects. Maximum walking time and claudication pain time increased 659% and 846%, respectively, among the 19 patients completing the 12-week program (p = 0.001; p = 0.0002). These patients underwent a mean reduction of 58.7% in the ischemic window after a standardized workload (p less than 0.05), and this correlated with the degree of symptomatic improvement. Absolute ankle pressure and ankle-brachial index were unchanged after exercise training. This study confirms the utility of supervised exercise therapy in the treatment of intermittent claudication. The ischemic window is a useful method for quantifying the ischemic deficit produced by exercise and provides a reproducible means of documenting functional improvement in patients undergoing exercise training.
BACKGROUND: Little is known about the organization and performance of outpatient substance abuse treatment (OSAT) centers. We examine several performance measures of OSAT units, including clients treated, services provided, revenue sources, financial performance, and access to care, in relation to ownership of the center. METHODS: Data were drawn from a national random sample of 575 OSAT centers (85.8% response rate) participating in a telephone survey conducted in 1988. Analysis of variance by ownership was conducted on each performance measure, with differences subjected to tests of statistical significance. RESULTS: Descriptive results show that major funding sources differ by ownership. Private for-profit centers generate higher profits, charge higher prices, and achieve higher levels of financial performance than public and not-for-profit centers. Public centers provide better access to care for persons who are unable to pay. CONCLUSIONS: There appear to be substantial and interrelated differences by ownership type in the financing and operation of OSAT units.
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Arterial aneurysm formation occurs in 15 to 20% of patients with Takayasu's disease. The timing of surgical intervention of these aneurysms is controversial. A case of ectasia of the descending thoracic aorta in a patient with Takayasu's disease is presented. The diagnosis and timing of surgical intervention of aneurysms associated with Takayasu's disease are discussed.
The clinical, duplex, and angiographic findings in six patients with seven spontaneous extracranial carotid artery dissections are reported. Four dissections resulted in internal carotid artery occlusion. These patients complained of ipsilateral headache followed by contralateral hemiplegia. The other three dissections involved the common carotid artery and resulted in dual (one true and one false) lumens. Two of these dissections were asymptomatic. All dissections were treated nonoperatively with anticoagulant therapy. Neurologic deficits improved or disappeared in all symptomatic patients. On follow-up studies, one of the four internal carotid occlusions completely resolved with normalization of the duplex examination. All three dual lumen dissections remained patent on serial studies. Diagnostic duplex characteristics, both conclusive and supportive, of carotid dissections are described. Duplex scanning is shown to be accurate in diagnosing and ideally suited for serially following spontaneous carotid dissections.
Favorable early results with mechanical angioplasty devices and laser-assisted balloon angioplasty have resulted in aggressive marketing and a rapid increase in the use of these devices for the treatment of femoropopliteal occlusive disease. Recent reports, however, have questioned the durability of these less invasive procedures. Since 1986 we have been involved in the clinical investigation of the Kensey dynamic angioplasty instrument and laser-assisted balloon angioplasty. One hundred two balloon angioplasty procedures assisted by the Nd:YAG laser (n = 56) and the Kensey dynamic angioplasty instrument (n = 46) were performed for the treatment of femoropopliteal occlusive lesions. Both Kensey dynamic angioplasty instrument and laser-assisted balloon angioplasty groups were similar with regard to age, operative indication, preoperative ankle-brachial index, lesion length, and distal runoff. Mean follow-up was 19 months in the Kensey dynamic angioplasty instrument group and 15 months in the laser-assisted balloon angioplasty group. Technically successful recanalization was achieved in 67% of Kensey dynamic angioplasty instrument-assisted balloon angioplasty procedures and 82% of laser-assisted balloon angioplasty procedures. Early hemodynamic and clinical improvement was obtained in 59% of Kensey dynamic angioplasty instrument-assisted balloon angioplasty procedures and 57% of laser-assisted balloon angioplasty procedures. Two-year clinical success by life-table analysis was 37% in the Kensey dynamic angioplasty instrument group and 19% in the laser-assisted balloon angioplasty group. The level of subsequent surgical revascularization was not altered in any patient by Kensey dynamic angioplasty instrument-assisted balloon angioplasty or laser-assisted balloon angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)
The rapid increase in outpatient expenditures has been the focus of growing attention in recent years. This increase has corresponded with public and private efforts to contain hospital inpatient costs, prompting some analysts to suggest that outpatient expenditure growth is the result of a substitution effect; that is, the substitution of outpatient for inpatient care associated with hospital cost containment programs. Claims data on 43 privately insured groups that adopted utilization review (UR) during the latter part of 1984 or early 1985 were analyzed, comparing outpatient expenditures before and after adoption of hospital inpatient UR to quantify the substitution effect associated with UR. UR was not associated with higher physician office expenditures nor with higher outpatient diagnostic expenditures. UR was related to significantly higher hospital outpatient department expenditures. On average, these expenditures were approximately 20% higher (P = 0.01) after the adoption of UR. However, outpatient department expenditures of the groups analyzed represented a fairly small percentage of total medical expenditures; hence, the absolute expenditure increase was quite modest, on the order of $9 per insured person per year. This analysis, admittedly limited in scope, suggests that UR is associated with a measurable substitution effect. It is likely that inpatient hospital cost containment programs have resulted in some substitution of outpatient for inpatient care and thus have played a role in fostering outpatient expenditure growth during recent years.
Laser thermal-assisted balloon angioplasty (LABA) was prospectively applied in the treatment of 56 atherosclerotic femoropopliteal occlusive lesions in 51 consecutive patients. All procedures were performed in the operating room using a neodynium:yttrium-aluminum-garnet (Nd:YAG) laser source, and patients were evaluated for immediate and long-term hemodynamic and clinical improvement. Technically successful recanalization was achieved in 82% of cases, with 57% of all patients (32 of 56) obtaining early hemodynamic and clinical improvement. Long-term clinical success (by life-table analysis) was obtained by only 22.5% at 6 months, and only 13.5% at 12 months. Patients presenting with intermittent claudication did significantly better than those presenting for limb salvage (p = 0.01), and trends toward improved outcome were noted for short versus long lesions as well as for patients with "good" versus "poor" distal runoff (NS). Procedure-related morbidity occurred in 14%, and there was one peri-procedural mortality (1.8%). We conclude that the use of LABA is associated with long-term clinical success in only a small proportion of patients, and that widespread clinical application of this technique is not indicated at the present time.
Over the 48-month period from January 1983 through December 1986, 51 single-lumen (SL) and 94 double-lumen (DL) indwelling central venous (Hickman) catheters were placed in 118 patients with malignant disease. We reviewed these cases retrospectively to determine the types and frequency of complications requiring catheter removal. The catheters were in place a total of 18,397 days. Overall, 14% (7/51) of SL and 21% (20/94) of DL catheters were removed due to infection. Of those catheters becoming infected, DL catheters were infected earlier. SL catheters that became infected averaged 213 days of use before removal, whereas DL catheters becoming infected averaged only 78 days before removal (P less than or equal to .02). The infection rate was significantly less in SL (one infection per 1,210 days) than in DL catheters (one infection per 496 days) (P less than or equal to .02). Thus because of its significantly reduced risk of infection, the single-lumen Hickman may be the preferred catheter for long-term venous access in many patients.
Utilization review (UR) has become a prominent approach to cost containment now used by almost 65% of private group insurance plans. Although insurers have increasingly relied on UR to contain health care costs, until recently little was known about the effects of this cost containment approach. This article reviews some of the key findings of a UR evaluation, based on analysis of claims data on 223 insured groups for the years 1984 through 1986. The evaluation found that UR reduced admissions by 12%, inpatient expenditures by 8%, and total expenditures by 6%. It was estimated that UR generated net savings of $115 per employee per year. Groups adopting UR with high baseline rates of hospital use had larger expenditure reductions and greater net savings. It appears that UR can play an important role in private cost containment and help improve medical care resource consumption.
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This paper presents an exploratory analysis of the relationships between several health care market characteristics and the effectiveness of utilization review programs directed at controlling hospital use and expenditures. The analysis is based on claims data from 223 insured groups over 12 quarters. Results indicate that UR is associated with larger reductions in utilization and expenditures in markets with low HMO enrollment, high admissions per capita, and low hospital occupancy rates. These results suggest that health care market conditions that permit unnecessary use are the ones under which UR programs can be most effective.