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Biomedical subjects

L Wise

Publications and source records attributed to L Wise.

At least 73 records · Page 4Linked to original sources
PubMed1990

Effect of verapamil on the gastric mucosal level of PGE2 during stress.

Prostaglandin E2 is one of the factors in the maintenance of gastric mucosal integrity and verapamil, a calcium channel blocker, has been shown to reduce gastric mucosal ulcerations during stress. To investigate whether this protective effect of verapamil is mediated via PGE2, four groups of 20 Holtzman rats were given either 1 ml of normal saline (NS) intraperitoneally (ip): 1 mg/kg of indomethacin (I) ip; 2 mg/kg of verapamil (V) ip or I followed by V. Then 10 animals from each group were submitted to stress by the cold-restraint method. After sacrifice, gastric mucosal ulcerations were counted and specimens of nonulcerated mucosa were assayed for PGE2 by HPLC. Stress-induced mucosal ulcerations were associated with a significant decrease in the gastric mucosal levels of PGE2 (from 64.2 to 32.7 pg; P less than 0.05). This effect was magnified by the administration of indomethacin (down to 21.0 pg). Verapamil significantly increased PGE2 levels both in the stressed (48.0 pg) and unstressed (99.9 pg) animals and significantly reduced ulcerogenesis when compared to either NS- or I-treated groups. This effect of verapamil was completely blocked by the administration of indomethacin. In conclusion, verapamil stimulates PGE2 synthesis and its protective effect against stress-induced mucosal damage seems to be mediated by PGE2.

Animals↗
PubMed1990

Route of admission and hospital costs for urologic patients.

This study of 2,549 urology patients examined resource consumption by route of admission into the hospital. Almost all urologic admissions were more expensive as emergencies. These more expensive emergency urologic admissions had higher diagnostic costs, a longer hospital length of stay, and a greater severity of illness than their less expensive non-emergency counterpart. The more expensive emergency admission had a high referral rate to urology from non-urologic clinical services. These findings suggest that efficiency might be improved in the emergency urologic patients by increasing the speed of diagnosis and admission of patients to the appropriate clinical service (urology).

Costs and Cost Analysis↗
PubMed1990

Economies of scale, physician volume for urology patients, and DRG prospective hospital payment system.

Diagnosis Related Group (DRG) hospital payment has begun to squeeze hospitals financially and is likely to do so in the future. This study analyzed the relationship between the volume of urologic procedures by an individual urologist, hospital costs per patient, and outcome. We used a three-year DRG database of urology patients (N = 2,980) at an academic medical center to analyze these. Low-volume urologists (arbitrarily defined by us) had higher hospital costs per patient, financial losses versus profits under DRGs, and a poorer outcome when compared with high-volume urologists. Pearson correlation showed a positive relationship between cost per patient and physician volume for nonemergency patients (-0.129, p less than 0.0001) and emergency patients (-0.368, p less than 0.0001). This may have been explained (in part) by a greater severity of illness for patients of low-volume urologists. These findings suggest, however, that the volume of urologic procedures per urologist may be related to hospital resource consumption. The health care financing environment of the future should provide substantial interest in this finding for those involved in the consumption of urologic services.

Academic Medical Centers↗
PubMed1990

The calcium messenger system and the kinetics of elastase release from human neutrophils in patients with abdominal aortic aneurysms.

Aortic elastase and neutrophil elastase is higher in patients with abdominal aortic aneurysms. The purpose of this study was to determine if these proteolytic elevations occur after abdominal aortic aneurysms have been repaired. Specifically, we studied the stimulation and inhibition of elastase degranulation from neutrophils in postoperative abdominal aortic aneurysm patients compared to aortic occlusive disease patients. Neutrophil elastase was determined in postoperative abdominal aortic aneurysm and aortic occlusive disease patients in response to calcium and the ionophore A23187. Inhibition of elastase release was determined with the calcium channel blocking agent Verapamil. Neutrophil elastase secretion was significantly higher in the abdominal aortic aneurysm patients (47%) versus aortic occlusive disease (20%) (p less than .05), while the effect of Verapamil in blocking this response was significantly lower in the abdominal aortic aneurysm patients (14%) compared to aortic occlusive disease patients (27%) (p less than .02). The time for degranulation to occur was longer in the abdominal aortic aneurysm patients (14.7 minutes) versus aortic occlusive disease patients (3.5 minutes), but the rate of secretion was not different between the two groups. These data indicate that, (1) neutrophils secrete more elastase in response to a calcium stimulus in abdominal aortic aneurysm patients; (2) it takes longer to secrete the increased amount of elastase in abdominal aortic aneurysm patients since the rate of secretion is similar between the two groups; and (3) Verapamil blocks elastase secretion ineffectively in abdominal aortic aneurysm patients. We conclude that the proteolytic alterations in abdominal aortic aneurysm patients are more likely a primary event and not a response to the abdominal aortic aneurysm and that Verapamil is a poor drug to use to medically manipulate the protease system in abdominal aortic aneurysm patients.

Aorta, Abdominal↗
PubMed1990

Physicians' patient load per DRG, the consumption of hospital resources, and the incentives of the DRG prospective payment system.

From 1985 through 1987, the authors assessed the relationship between two main variables at a large academic medical center: (1) the numbers (high or low) of patients per diagnosis-related group (DRG) treated by individual physicians and (2) hospital resource consumption of the patients. The patients were classified according to their routes of admission (emergency or non-emergency); the physicians with eight or more patients per DRG were labeled "high-patient-load physicians" (hereafter called "high-load physicians"), and those with five or fewer patients were labeled "low-patient-load physicians," ("low-load physicians"). The resource variables studied were length of stay (LOS) and total hospital cost. For the non-emergency admissions, the low-load physicians' patients had an average LOS that was 56.2% greater and an average hospital cost that was 58.3% greater than were the LOS and cost of the patients of the high-load physicians. (Both LOS and cost per patient were adjusted for DRG weight index.) This was due in part to a greater severity of illness for the patients (as measured by total ICD-9-CM codes per patient) of the low-load physicians. For the emergency admissions, the low-load physicians' patients had an average LOS that was 9.5% greater and an average hospital cost that was 10.5% greater than the LOS and cost of the patients of the high-load physicians. As in the non-emergency admissions group, severity of illness for the patients of the low-load physicians was greater. The only category of patients that was economically profitable to the hospital was the non-emergency admissions group treated by the high-load physicians. Even though these findings were the result of many factors (discussed in the text), they suggest a relationship between hospital resource consumption and the physicians' patient load per DRG.

Academic Medical Centers↗
PubMed1990

Economies of scale, physician volume for neurosurgery patients, and the diagnosis-related group prospective hospital payment system.

Hospitals face an increasingly competitive environment in the era of diagnostic related group (DRG) prospective pricing. Further reductions in Medicare outlays relative to hospital costs are likely, given the looming federal deficit. We analyzed the relationship of individual neurosurgical volume, hospital costs, and outcome. All neurosurgical patients (n = 1002) treated for a 3-year period at our large academic medical center were grouped into those treated by low-volume neurosurgeons versus those treated by high-volume neurosurgeons (arbitrarily defined by us); 95% of patients admitted for neurosurgical procedures fit into one of these two categories. Patients of low-volume neurosurgeons had higher hospital costs (even after correction for DRG case-mix and severity of illness) (P less than 0.01), a much worse financial position under DRGs (P less than 0.01), but a similar outcome for both emergency and nonemergency admissions when compared to patients of higher volume neurosurgeons. Pearson correlation showed an inverse relationship between declining cost per patient and increasing neurosurgical volume for both nonemergency patients -0.340 (P less than 0.0001), and emergency patients, -0.321 (P less than 0.0001). These findings suggest that the volume of neurosurgical procedures performed by an individual neurosurgeon is related to hospital resource utilization. This study also suggests that the DRG prospective payment system could provide incentives that may affect both neurosurgical practice and the access to neurosurgical care.

Academic Medical Centers↗
PubMed1990

Economies of scale, physician volume for orthopedic surgical patients, and the DRG prospective payment system.

American hospitals face increasing constraints due to a variety of factors. Federal and state diagnostic-related group (DRG) prospective hospital pricing has caused tremendous fiscal pressure on hospitals; many face substantial financial deficits. We analyzed the volume of orthopedic surgical procedures performed by an individual orthopedic surgeon for all patients (N = 2,134) treated for a 3-year period at a large academic medical center; these surgeons were arbitrarily divided into low volume or high volume. Patients of low volume surgeons had a longer hospital length of stay and hospital cost (after correction for DRG case mix and severity of illness), greater financial risk under DRGs, and a poorer outcome, compared with patients of higher volume orthopedic surgeons. Pearson correlation showed an inverse relationship between cost per patient and physician volume for nonemergency patients -0.201 (P less than .0001), and emergency patients, -0.321 (P less than .0001). Although the reasons for these findings appeared multifactoral, they raise important issues related to orthopedic surgical hospital costs, access, and quality of care. In addition, they suggest that hospital cost for these patients (and perhaps outcome) may be related to orthopedic surgical volume, and that DRG hospital payment (on the margin) may affect future orthopedic surgical practice opportunities.

Academic Medical Centers↗
PubMed1990

The DRG hospital payment system, surgical readmissions and cost containment.

We analyzed all adult surgical patients requiring readmission to the surgical service of an acute care academic hospital for a four-year period (1/1/85-12/31/88). We stratified surgical readmissions by the number of times the patient was readmitted to surgery (from one to five times). For surgical patients 41.1 per cent of the readmission population was readmitted more than once, only 4.4 per cent were readmitted five or more times. Patients requiring three or more admissions generally had the greatest hospital resource utilization, financial risk under DRG payment, and mortality, compared with other surgical readmissions. This analysis suggests that within the surgical readmission population resource parameters may differ by the number of readmissions per patient. Factors were identified which corresponded to a greater likelihood of surgical readmission, and possibly allow the focus of outpatient services which may reduce hospital inpatient costs in the future.

Academic Medical Centers↗
PubMed1990

The inactivation of antithrombin III by serum elastase in patients with surgical infections.

The relationship between serum elastase and antithrombin III was determined in septic surgical patients as a possible mechanism for intravascular thrombosis and hypercoagulability during sepsis. Eighteen patients with surgical infections and elevated white blood cell counts had their blood assayed daily for white blood cell count, serum elastase, and antithrombin III, until the patient's white blood cell count returned to normal. Antithrombin III was significantly lower (0.87%) when elastase was above the normal range (greater than 14.2 micrograms/ml). Elastase was significantly higher (30.6 micrograms/ml), when antithrombin III was less than normal. These data indicate that elevated serum elastase is associated with a significant reduction in circulating antithrombin III. Stimuli that increase serum elastase, i.e. surgery, trauma, or sepsis may promote intravascular thrombosis by the inhibition of antithrombin III at the blood-endothelial cell interface.

Antithrombin III↗
PubMed1990

Arterial reconstruction in patients with polycythemia vera.

The natural history of polycythemia vera (PV) with its inherent arterial and venous complications are well described but the results of arterial surgical treatment in patients with PV are not known. This study was done to determine the outcome of arterial surgical treatment in patients with PV. During the last six and one-half years, of 2,603 extensive vascular procedures performed, seven reconstructions were performed upon six patients with PV. Extensive complications occurred in 57 per cent of this group. All of the complications occurred in patients with disease of the lower extremity and resulted in extensive amputation in one-half of the patients. The average preoperative platelet count was higher (420,000) in patients with complications as compared with those who did well (303,000). All of the patients requiring chemotherapeutic control of the PV (hydroxyurea) had extensive complications. These results indicate that vascular operations in patients with PV carry a high complication rate. A platelet count of more than 330,000, more than 70 years of age, infrainguinal reconstruction and PV requiring hydroxyurea for control seem predictive of a poor outcome. Although this series is small, we believe that great caution should be exercised before attempting vascular reconstructions in patients with PV and the aforementioned risk factors.

Aged↗
PubMed1989

Determination of elastase activity by reversed-phase high-performance liquid chromatography.

The action of elastase on elastin was measured by high-performance liquid chromatography with on-line post-column derivatization. After alkaline hydrolysis, a 20-ml sample was injected into a ODS-2 gel column. An elastin-specific dipeptide, Val-Pro, and the internal standard, Gly-Leu, were eluted by a linear gradient of 0 to 10% of 1-propanol in 50 mM heptafluorobutyrate (pH 3) at a flow-rate of 1 ml/min. The eluent was reacted with fluorescamine, and the fluorescent products were measured. Retention times for Val-Pro and Gly-Leu were 17.33 and 23.54 min. The peak areas of 0.2-16 micrograms of Val-Pro gave a straight-line plot. Elastase activity was constant from 6 to 24 h and was 0.95 +/- 0.02 (S.D.) micrograms/h. The method may be useful for the measurement of the elastolytic activity in some diseased tissues.

Chromatography, High Pressure Liquid↗
PubMed1989

Diagnosis related group 'all payor' hospital payment and medical diseases. Financial risk and hospital cost in medical noncomplicating condition-stratified diagnosis related groups.

There are many health policy issues related to diagnosis-related group (DRG) hospital payment. Previous work by our group had suggested that some DRGs did not adequately comorbidities. Despite recommendations by federal advisory committees, the secretary of Health and Human Services has proposed no major changes to DRGs along these lines. We analyze resource consumption in any of the 88 non-complicating condition (CC)-stratified medical DRGs using the DRG prospective "all payor system" in effect at our hospital. Analysis of 12,340 medical patients by payor (Medicare, Medicaid, Blue Cross, and commercial insurance) in these non-CC-stratified medical DRGs for a three-year period demonstrated that patients with more CCs per DRG for each payor generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, higher financial risk under DRG payment, and a higher mortality, compared with patients in these same DRGs with fewer CCs. These findings suggest that new prospective DRG all payor systems may be inequitable to certain groups of patients or types of hospitals vis-à-vis the non-CC-stratified medical DRGs. Health policy leaders should be encouraged to stratify many medical DRGs by the numbers and types of CCs to more equitably reimburse hospitals under DRG all payor systems.

Costs and Cost Analysis↗
PubMed1989

Age, resource consumption, and outcome for medical patients at an academic medical center.

At the national level debate is growing about the effects of the diagnosis related group (DRG) hospital payment system on patient access and quality of care. Recent changes to the DRG system have dropped any stratification by age and have delayed any other major change to improve payment equity. We characterized hospital resource consumption and outcome by age for all medical admissions (N = 31,838) to a large academic medical center (January 1, 1985, through December 31, 1987) using the DRG format. Mean hospital cost per patient, hospital length of stay, percentage of outliers, and mortality increased with age. The mean DRG case-mix index and the number of diagnostic codes per patient also rose with age. The DRG payment for all patients would have produced an aggregate profit of $34,426,951 ($1081 profit per patient); however, patients aged 71 years or older generated loses (the highest with patients aged 85 years or older--a $2177 loss per patient). As the financial position of American hospitals continues to deteriorate, these data suggest that the current DRG payment scheme may be inequitable for the medical patient aged 71 years or older, thus providing financial disincentives to treat the elderly medical patient and perhaps limiting their access and quality of care in the future.

Academic Medical Centers↗
PubMed1989

Hospital resource consumption and outcome. Route of admission and age for hospitalized otolaryngology patients.

Hospitals and physicians face new payment mechanisms that provide incentives to study health policy, management, and economics. The purpose of this study was to analyze hospital resource consumption and outcome based on age and the route of hospital admission (emergency [ER] vs nonemergency [non-ER]). We analyzed all adult otolaryngology hospital admissions (N = 1589) during a three-year period (1985 through 1987) to a large northeastern academic medical center. Hospital resource consumption, measured by hospital length of stay and total hospital cost per patient, rose with age for ER and non-ER admissions. Severity of illness, clinical resource utilization, and mortality demonstrated these same characteristics. Diagnosis related group prospective hospital payment generated financial risk for ER admissions and elderly patients. Analysis demonstrated ER admission as more predictive of subsequent hospital resource consumption and outcome with changes in age compared with non-ER admission. Our findings suggest that in the future physicians and hospitals may find that age and the route of admission may be useful in stratifying patients regarding cost and outcome.

Academic Medical Centers↗
PubMed1989

Health care financing policy for hospitalized pediatric patients.

Prospective hospital payment systems using the federal Medicare DRG payment model are changing hospital reimbursement. Currently, many states have adopted diagnosis related group (DRG) prospective "all payer systems" using the federal model. All payer systems, whereby Medicaid, Blue Cross, and other commercial insurers pay by the DRG mode, prevent cost shifting between payers. New York state has used an all payer system since Jan 1, 1988. This study simulated DRG all payer methods for a large sample (N = 16,084) of pediatric patients for a three-year period using the New York DRG all payer reimbursement system now in effect. Medicaid pediatric patients had (adjusted for DRG weight index) a longer hospital stay and greater total hospital cost compared with pediatric patients from Blue Cross and other commercial payers. Medicaid pediatric patients also had a greater severity of illness compared with patients from Blue Cross and other payers. Pediatric patients in all payment groups (ie, Medicaid, Blue Cross, and other commercial insurers) generated financial risk under the DRG all payer scheme. Medicaid pediatric patients generated the greatest financial risk, however. These data suggest that state and private payers may be under-reimbursing for the care of the hospitalized pediatric patient using the DRG prospective hospital payment scheme. Health care financing policy for pediatric patients may limit both access and quality of care.

Adolescent↗
PubMed1989

Pediatric patients, race, and DRG prospective hospital payment.

The diagnosis related group (DRG) prospective hospital payment system contains inequities in hospital payment for certain groups of patients. Patients of lower socioeconomic status may be underreimbursed by DRGs. We analyzed pediatric patients and hospital resource consumption by race (white, Hispanic, and black) using a DRG prospective payment "all payer" system. All hospitalized pediatric admissions over a 3-year period (N = 14,489) were analyzed by race at a large academic medical center. Mean hospital length of stay and cost per patient (adjusted for DRG weight index) was significantly greater for black and Hispanic pediatric patients compared with whites. Financial risk as measured by outliers and losses under DRGs was greater for blacks and Hispanics compared with whites. Black and Hispanic patients had a higher proportion of emergency admission to the hospital compared with whites, a greater severity of illness (as measured by total International Classification of Diseases, ninth revision, Clinical Modification codes), and (on average) higher diagnostic costs for each episode of illness. Our data suggest that black and Hispanic pediatric patients have a greater hospital resource consumption (adjusted for DRG group case mix) compared with whites, at least at our large medical center in the Northeast. Hospitals that treat greater numbers of black and Hispanic pediatric patients may be at a substantial disadvantage under per-case DRG payment.

Academic Medical Centers↗