Labs slow to adopt some system features.
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Clinical Laboratory Information Systems↗
Biomedical subjects
K Carey
Publications and source records attributed to K Carey.
A multilevel modelling approach to analysis of patient costs under managed care.
The growth of the managed care model of health care delivery in the USA has led to broadened interest in the performance of health care providers. This paper uses multilevel modelling to analyse the effects of managed care penetration on patient level costs for a sample of 24 medical centres operated by the Veterans Health Administration (VHA). The appropriateness of a two level approach to this problem over ordinary least squares (OLS) is demonstrated. Results indicate a modicum of difference in institutions' performance after controlling for patient effects. Facilities more heavily penetrated by the managed care model may be more effective at controlling costs of their sicker patients.
Cost Sharing↗
Board takes stance on autopsy service pay.
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Autopsy↗
On measuring the hospital cost/quality trade-off.
This paper explores the relationship between cost and quality of hospital care. A total operating cost function is estimated for 137 US Department of Veterans Affairs hospitals for 1988-1993 using three rate-based measures of quality as regressors. The high likelihood of the existence of measurement error in quality in the cross section leads to the application of novel instrumental variable techniques. Results suggest that mortality and readmission indices are adjusted inadequately for illness severity. The measure on the failure to follow up inpatient discharges with outpatient care, however, appears to increase cost. The results of this paper underscore a number of practical difficulties and challenges facing government or other systems in evaluating the relative performance of their hospitals.
Cost Control↗
Anatomic pathology computer systems.
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Clinical Laboratory Information Systems↗
Blood bank information systems.
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Blood Banks↗
Design of emulsification peptides.
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Amino Acid Sequence↗
Identification of Gas6 as a ligand for Mer, a neural cell adhesion molecule related receptor tyrosine kinase implicated in cellular transformation.
Mer/Nyk/Eyk is an orphan receptor tyrosine kinase expressed at high levels in monocytes and cells derived from epithelial and reproductive tissues. Overexpression of Mer has been associated with lymphoid malignancies. Here we identify Gas6, the product of a growth arrest specific gene, as a ligand for Mer. Gas6 has previously been shown to activate both Axl and Rse/Tyro3, two other receptor tyrosine kinases in the same family as Mer. The apparent relative association and dissociation rate constants of Gas6 for soluble Axl, Rse/Tyro3 and Mer were compared using surface plasmon resonance. Gas6 was shown to induce rapid phosphorylation of Mer expressed in several different types of cells. We also observed a transient activation of p42 MAP kinase following activation of Mer by Gas6. Thus, Gas6 exerts its biological effects through multiple receptor tyrosine kinases.
Animals↗
A telecommunications system for monitoring and counseling patients with hypertension. Impact on medication adherence and blood pressure control.
This study was conducted to evaluate the effect of automated telephone patient monitoring and counseling on patient adherence to antihypertensive medications and on blood pressure control. A randomized controlled trial was conducted in 29 greater Boston communities. The study subjects were 267 patients recruited from community sites who were >or= 60 years of age, on antihypertensive medication, with a systolic blood pressure (SBP) of >or= 160 mm Hg and/or a diastolic blood pressure (DBP) of >or= 90 mm Hg. The study compared subjects who received usual medical care with those who used a computer-controlled telephone system in addition to their usual medical care during a period of 6 months. Weekly, subjects in the telephone group reported self-measured blood pressures, knowledge and adherence to antihypertensive medication regimens, and medication side-effects. This information was sent to their physicians regularly. The main study outcome measures were change in antihypertensive medication adherence, SBP and DBP during 6 months, satisfaction of patient users, perceived utility for physicians, and cost-effectiveness. The mean age of the study population was 76.0 years; 77% were women; 11% were black. Mean antihypertensive medication adherence improved 17.7% for telephone system users and 11.7% for controls (P = .03). Mean DBP decreased 5.2 mm Hg in users compared to 0.8 mm Hg in controls (P = .02). Among nonadherent subjects, mean DBP decreased 6.0 mm Hg for telephone users, but increased 2.8 mm Hg for controls (P = .01). For telephone system users, mean DBP decreased more if their medication adherence improved (P = .03). The majority of telephone system users were satisfied with the system. Most physicians integrated it into their practices. The system was cost-effective, especially for nonadherent patient users. Therefore, weekly use of an automated telephone system improved medication adherence and blood pressure control in hypertension patients. This system can be used to monitor patients with hypertension or with other chronic diseases, and is likely to improve health outcomes and reduce health services utilization and costs.
Aged↗
Pharmacokinetics, tissue distribution, and expression efficiency of plasmid [33P]DNA following intravenous administration of DNA/cationic lipid complexes in mice: use of a novel radionuclide approach.
The pharmacokinetics, tissue distribution, and efficacy of a systemic gene transfer method were examined in male BALB/c mice (6-8 weeks old) using 33P-labeled plasmid DNA for luciferase. The DNA was delivered via tail vein injection in saline ([33P]DNA) or in a cationic lipid formulation ([33P]DNA/lipid). One group of mice received approximately equal to 1-3 microCi (45 micrograms of DNA) of either formulation, and mice were euthanized at 2 and 20 min, and 1 and 24 h postdose (2 mice/time point). Blood and plasma radioactivity were quantified, and whole body autoradiographic (WBAR) images were obtained from 20-microns whole body sections. A tissue distribution (TD) study was conducted in a second group of mice, which received approximately equal to 4-6 microCi (45-60 micrograms of DNA) of [33P]DNA/lipid. Mice were euthanized at 1.5 h (1 mouse; [33P]DNA/lipid) or 24 h (2 mice/ group), and organ radioactivity and luciferase expression were measured in lung, liver, kidney, spleen thymus, and parotid salivary gland by direct quantitation methods. Microautoradiography (MAR) was performed on a third group of mice (n = 2), which received 3 microCi (45 micrograms of DNA) of [33P]DNA/lipid and were euthanized at 24 h postdose. For WBAR, the [33P]DNA/lipid tissue distribution (% dose equiv/g) at 2 min was lung >> liver > spleen (red pulp) > kidney (cortex); at 24 h the ranking was spleen (red pulp) > liver > lung, kidney (cortex). The [33P]DNA organ distribution observed at 2 min was liver >> spleen (red pulp) > lung, blood > kidney (cortex); at 24 h the ranking was liver, spleen (red pulp) > kidney (cortex) > lung, blood. High levels of radioactivity in bone (cortical, marrow, growth plate) in both groups may represent uptake of the 33P-labeled test articles by the cellular component of the bone marrow, particularly macrophages, as well as deposition of [33P]phosphate in the bone matrix following metabolism of the [33P]DNA. In the luciferase component of the study, no expression was observed in the [33P]DNA group at 24 h. The [33P]- DNA/lip group exhibited expression as early as 1.5 h in the lung; at 24 h, expression was seen in all the organs examined. Microautoradiography of 24-h tissue samples revealed radioactivity in hepatic Kupffer cells, reticuloendothelial system cells in the marginal zone of the spleen, and diffusely along alveolar septae with scattered accumulations in alveolar macrophages. The results of the WBAR, TD, MAR, and luciferase assay show that the use of cationic lipids significantly altered the biodistribution and resulting expression of the DNA plasmid. Further, 33P (0.25 MeV beta, half-life = 25 days) was shown to be an excellent radionuclide for quantitative WBA and MAR, providing sharp images with less personal hazard and greater ease of handling than 32P (1.71 MeV beta, half-life = 14.3 days).
Animals↗
"Occult" hepatitis B virus as source of infection in liver transplant recipients.
Hepatitis B virus (HBV) infection almost always recurs after liver transplantation in patients who were surface antigen (HBsAg) positive before surgery but apparent de novo acquisition of infection in a transplant setting has not previously been reported. We have used sensitive techniques to elucidate the origin of such infections in patients in a California transplantation programme. We tested post-transplant serum from 207 patients who had been HBsAg negative and found 20 to be HBsAg positive. The origin of infection was identified in 7 patients, being occult pre-transplant infection in 5 and occult infection in the donor in 2. No pre-transplant patient nor donor with demonstrable HBV DNA had serological markers of hepatitis B. Post-transplant HBV DNA was present in serum from 19 patients. Analysis of the variable pre-S region of HBV demonstrated 100% sequence homology between recipient liver and post-transplant serum (2 patients) and between donor serum and recipient post-transplant serum (2). There was only 84% homology between the 2 different patients infected with subtype adw. 19 patients are alive, 9 without histological evidence of hepatitis (mean follow-up 33 months), and survival was significantly greater than that of a group with recurrent HBV infection. Apparent acquisition of HBV infection with liver transplantation is not rare, and may be due to occult pre-transplant infection or occult infection in the donor. The post-transplant outcome of this infection tends to be benign but our findings do underscore the clinical relevance of HBV infection in the absence of serological markers.
Adolescent↗
Cost allocation patterns between hospital inpatient and outpatient departments.
OBJECTIVE: This study examines changes in hospitals' cost allocation patterns between inpatient and outpatient departments in response to the implementation of the prospective payment system. DATA SOURCES AND STUDY SETTINGS: The analysis was carried out using data for 3,961 hospitals obtained from the Medicare Cost Reports and from the American Hospital Association for the years 1984 through 1988. STUDY DESIGN: A total operating cost function was estimated on the two outputs of discharges and outpatient visits. The estimation results were instrumental in disaggregating costs into inpatient and outpatient components. This was done cross-sectionally for each of the five years. PRINCIPAL FINDINGS: Comparison of this cost breakdown with that of hospital revenue provides evidence of distinct patterns in which nonteaching, rural, and small hospitals increasingly allocated greater costs to outpatient departments than did large, urban, and teaching hospitals. CONCLUSIONS: The results suggest that small rural hospitals turned to the outpatient side in the face of tough economic challenges over the period of study. Because differences in cost allocation patterns occur by particular hospital category, analyses that rely on accounting cost or revenue data in order to identify cost differences among those same categories may come to erroneous conclusions. In particular, because teaching hospitals apportion costs more heavily on the inpatient side, cost allocation differences cause upward bias in the PPS medical education adjustment.
Cost Allocation↗
Measuring inpatient and outpatient costs: a cost-function approach.
In this article, the authors estimate a multiple-output cost function for a sample of 2,235 hospitals during the period 1984-88 to disaggregate total costs into inpatient and outpatient components. The results suggest that outpatient cost growth is roughly proportional to that of inpatient cost, despite much higher relative growth in revenues and utilization on the outpatient side. The stability in the outpatient/inpatient cost ratio implies that the increase in the outpatient-to-inpatient utilization ratio was offset by a decline in their relative unit costs.
Cost Allocation↗
Characterization of a candidate bcl-1 gene.
The t(11;14)(q13;q32) translocation has been associated with human B-lymphocytic malignancy. Several examples of this translocation have been cloned, documenting that this abnormality joins the immunoglobulin heavy-chain gene to the bcl-1 locus on chromosome 11. However, the identification of the bcl-1 gene, a putative dominant oncogene, has been elusive. In this work, we have isolated genomic clones covering 120 kb of the bcl-1 locus. Probes from the region of an HpaII-tiny-fragment island identified a candidate bcl-1 gene. cDNAs representing the bcl-1 mRNA were cloned from three cell lines, two with the translocation. The deduced amino acid sequence from these clones showed bcl-1 to be a member of the cyclin gene family. In addition, our analysis of expression of bcl-1 in an extensive panel of human cell lines showed it to be widely expressed except in lymphoid or myeloid lineages. This observation may provide a molecular basis for distinct modes of cell cycle control in different mammalian tissues. Activation of the bcl-1 gene may be oncogenic by directly altering progression through the cell cycle.
Amino Acid Sequence↗
Cloning of the t(11;14)(q13;q32) translocation breakpoints from two human leukemia cell lines.
The t(11;14)(q13;q32) translocation has been associated with several subtypes of human leukemia and lymphoma. It has been proposed that this translocation activates a proto-oncogene designated BCL1. In an effort to better understand the mechanism by which this translocation leads to malignancy, we have studied this translocation in two human cell lines. MO1094 and MO2058 were derived from patients with prolymphocytic variants of chronic lymphocytic leukemia. Southern blotting of the MO2058 cell line documented that the translocation linked the Jh region in the immunoglobulin heavy chain gene to the previously described BCL1 major translocation cluster (MTC). Using the polymerase chain reaction, we cloned this translocation and showed that the chromosome 11 breakpoint was within 7 bp of two other samples reported previously. Southern blotting of the MO1094 cell line suggested that the translocation in this cell line might link Jh sequences to a new region in the BCL1 locus on chromosome 11. Therefore, the MO1094 breakpoint was cloned from a genomic library. Comparison with normal cloned DNA from the BCL1 locus showed that the chromosome 11 breakpoint occurred 24 kb telomeric of the MTC. This work reinforces the concept that translocation breakpoints in the BCL1 locus are scattered over at least 63 kb.
Base Sequence↗
Risk for occupational transmission of human immunodeficiency virus type 1 (HIV-1) associated with clinical exposures. A prospective evaluation.
OBJECTIVES: To summarize the results of a 6-year, ongoing, prospective study of the risk for human immunodeficiency virus type 1 (HIV-1) transmission among health care workers, and to estimate the magnitude of the risk for HIV-1 infection associated with different types of occupational exposures. DESIGN: Prospective cohort study; the median follow-up for employees sustaining parenteral exposures was 30.2 months (range, 6 to 69 months). SUBJECTS: Health care workers at the Clinical Center, National Institutes of Health, including those reporting parenteral and nonparenteral occupational exposures to HIV-1. MEASUREMENTS AND MAIN RESULTS: One thousand three hundred and forty-four clinical health care workers reported 179 percutaneous and 346 mucous membrane exposures to fluids from HIV-1-infected patients during a 6-year period. Responding to a supplementary questionnaire, 559 of these workers reported 2712 cutaneous exposures to blood from HIV-1-infected patients and more than 10,000 cutaneous exposures to blood from all patients during a 12-month period. Occupational transmission of HIV-1 occurred in a single worker after a parenteral exposure to blood from an HIV-1-infected patient. No infections occurred after either mucous membrane or cutaneous exposures to blood from HIV-1-infected patients. Use of newer diagnostic technologies (for example, antigen detection, gene amplification) has not resulted in the identification of occupationally transmitted seronegative infections. CONCLUSIONS: Combining our results with those of other prospective studies, the risk for HIV-1 transmission associated with a percutaneous exposure to blood from an HIV-1-infected patient is approximately 0.3% per exposure (95% CI, 0.13% to 0.70%); the risks associated with occupational mucous membrane and cutaneous exposures are likely to be substantially smaller. These data support the use of barrier precautions and suggest a need for strategies that change health care providers' attitudes and behaviors.
Accidents, Occupational↗
A survey of homeless adults in urban emergency shelters.
Following a review of several studies of homeless populations, the authors describe a survey of 68 homeless adults in eight urban emergency shelters in Hennepin County, Minnesota. The results indicated impressive rates of mental illness, alcoholism, minor criminality, and chronic medical and dental problems. More significant, the authors believe, both for the homeless and for public policy planners, is that a majority of the interviewees were disconnected from supportive social networks and were underutilizing medical and welfare programs for which they were eligible. Almost 40 percent of those with chronic health problems were receiving no medical care, and only 6 percent were receiving mental health services, although more than 50 percent needed such care. The authors compare the findings with those of studies discussed in the literature review.
Adult↗
The extent of long-term moderate drinking among alcoholics discharged from medical and psychiatric treatment facilities.
To assess the frequency of an evolution to stable moderate drinking among alcoholics coming to medical or psychiatric treatment facilities, we examined the five- to seven-year outcome for 1289 diagnosed alcoholics treated in our facilities during a two-year period (between 1973 and 1975). We obtained data from personal interviews, records, or both for 83 per cent of the sample. Only 1.6 per cent of the subjects met our definition of stable moderate drinking at follow-up, 15 per cent had become totally abstinent, and 4.6 per cent were mostly abstinent with occasional drinking. The only predictors of moderate drinking that we found were female sex and less severe alcoholism. The evolution to stable moderate drinking appears to be a rare outcome among alcoholics treated at medical or psychiatric facilities.
Adult↗