Biomedical subjects

L Wise

Publications and source records attributed to L Wise.

At least 109 records · Page 6Linked to original sources

PubMed1989

Hospital costs, resource characteristics, and the dynamics of death for hospitalized patients in cardiology Diagnosis-Related Groups.

A number of complex health policy questions face the nation regarding the Diagnosis-Related Group (DRG) prospective hospital payment system. An ongoing debate ensues at the federal level of the utility of improving the DRG system, given the "budget neutrality" provision of the DRG law. We analyzed hospital resource consumption for 5809 cardiology inpatients by outcome (i.e., survival vs death). Hospital resource use was greater and financial risk under DRG pricing schemes was substantial for the 312 deaths compared with the 5497 survivors. Only cases in which the patient died within 1 week of admission to the hospital were profitable under DRGs. A long hospital length of stay for patients who eventually died was very unprofitable (those who died after more than a 60-day hospital length of stay generated a $24,688 loss per patient). Patients who died after emergency admission tended to have a similar hospital length of stay and to be similar financial risk under DRGs, compared with nonemergency patients who died. Those patients who had been referred from other clinical services and who died caused greater resource use and financial risk under DRGs, compared with patients who were not referred and who died. These data suggest significant inequities in the current DRG prospective payment system for patients in cardiology DRGs who die. Variables predictive of greater hospital resource use for cardiology patients who die include longer hospital lengths of stay and referral from another clinical service. Health policy leaders should attempt to improve the equity of cardiology DRGs regarding outcome in the future.

Aged↗

PubMed1989

Hospital costs, resource characteristics, and the dynamics of death for patients with a primary diagnosis of congestive heart failure.

Although substantial changes have been recommended in the diagnosis related group (DRG) prospective hospital payment system related to very expensive care for some patients, no major change in payment for these patients has been implemented by the US Congress. Both the Health Care Financing Administration and the Prospective Payment Assessment Commission continue to study issues related to DRG stratification along the lines of severity of illness, outcome (lived or died), or complications and/or comorbidities. We analyzed hospital resource consumption for 599 patients with a primary diagnosis of congestive heart failure (CHF) by outcome (ie, survivors vs mortalities). The 68 mortalities had a much greater intensity of hospital resource utilization, and a substantial financial risk under DRG pricing schemes, compared to the 531 survivors. Only mortalities within one week of admission to the hospital were profitable under DRGs. A long hospital length of stay (LOS) for mortalities was very unprofitable (mortalities with a greater than 60-day LOS generated a +42,028 loss per patient). Emergency patients who died tended to have a shorter hospital LOS and less financial risk under DRGs, compared to patients who died who were not admitted as emergencies. These data suggest significant inequities in the DRG prospective payment system vis-a-vis CHF mortality. Variables predictive of greater hospital resource utilization for mortalities included longer hospital lengths of stay and urgent admission. Health policy leaders should be encouraged to further stratify DRG hospital resource consumption for appropriate variance in hospital costs.

Aged↗

PubMed1989

Surgonomics as a health care financing policy for hospitalized surgical patients.

The Medicare system of prospective payment to hospitals based on diagnostic related groups (DRG) has been severely criticized at a number of levels. Many states are using DRG prospective "All Payor Systems" for reimbursement to hospitals with the federal DRG system as a model. In All Payor Systems, Medicare, Medicaid, Blue Cross and other commercial insurers pay by the DRG mode; the state of New York has been All Payor since 1 January 1988. This study simulated DRG All Payor methods on a large sample (N = 17,560) of surgical patients for a two year period, using both federal and New York DRG reimbursement methods currently in effect. Both Medicare and Medicaid patients had, on average, a longer length of stay in the hospital and higher total cost of hospitalization compared with patients from Blue Cross and other commercial payors. Medicare and Medicaid patients also had a greater severity of illness compared with patients from Blue Cross or other payors. All except commercial insurors (that is, Medicaid, Blue Cross and Medicare) had greater financial risk under the DRG All Payor scheme. Results from our study suggest that federal, state and private payors may not be adequately reimbursing health care providers for the care of the hospitalized surgical patient under the DRG prospective scheme of hospital payment. It appears that the financing policy for health care, especially at the federal and state level, could limit both the access and quality of care for surgical patients.

Aged↗

PubMed1989

Health care financing policy for hospitalized rheumatology patients.

The federal Medicare Diagnostic Related Group (DRG) prospective payment model is changing hospital payment. Currently many states are using DRG prospective "All Payor Systems" for hospital reimbursement. In All Payor Systems, Medicare, Medicaid, Blue Cross and other commercial insurers, pay by the DRG mode; New York State has been All Payor since January 1, 1988. This study simulated DRG All Payor methods on a sample (N = 298) of rheumatology patients for a 3-year period using both federal and New York DRG reimbursement now in effect. Both Medicare and Medicaid patients had (on average) a longer hospital length of stay and total hospital cost compared to patients from Blue Cross and other commercial payors. All payors (i.e., Medicaid, Blue Cross, Medicare and commercial insurors) generated significant financial risk under the DRG All Payor scheme. If these findings are replicated at other hospitals, rheumatology patients could suffer a decline in both access and quality of care.

Aged↗

PubMed1989

Race and diagnostic related group prospective hospital payment for medical patients.

The diagnostic related group (DRG) prospective hospital payment system has been on line for five years with no major changes implemented by the federal government. Data suggest that the DRG system may be inequitable to patients of lower socioeconomic status. We studied the consumption of hospital resources by race (ie, white vs black) for hospitalized medical patients using the DRG prospective payment system. All adult medical admissions (N = 30,097) were analyzed for a three-year period at a large academic medical center using the DRG "all payor" classification scheme in effect for New York State. We found that black patients (N = 3,373) had a significantly greater (P less than .0001) mean length of hospital stay and cost per patient (adjusted for DRG weight index) compared with white patients (N = 26,724). Black patients also exposed the medical center to greater (P less than .0001) financial risk compared with white patients, as measured by outliers and losses under DRGs. Black patients (P less than .0001) had a significantly higher proportion of emergency admissions to the hospital, a greater severity of illness (as measured by total International Classification of Diseases-9-Clinical Modification codes) (P less than .0001), and higher diagnostic costs (P less than .0001) for each episode of illness. These data suggest that at our medical center black medical patients may consume more hospital resources (adjusted for DRG case mix) compared with whites. It is important that methods to modify DRG prospective hospital payment for medical diseases be considered to provide more equitable DRG reimbursement for black Americans in the future.

Black or African American↗

PubMed1989

Diagnosis-related groups, costs, and outcome for patients in the intensive care unit.

Our purpose was to analyze hospital cost, resource utilization, and outcome by age for a large group of patients who required intensive care unit (ICU) services. Patients in the ICU (N = 6331) were stratified by age groups. Mean hospital cost per patient generally increased with age. Older patients (65 years of age and older) who were treated in the ICU had longer hospital lengths of stay, higher mortality rates, and a greater percentage of outlier patients, as compared with younger patients (under 65 years of age). Patients in the ICU would have produced a substantial loss for our medical center under a diagnosis-related group (DRG) all payer prospective payment scheme. Although higher mean costs were associated with older patients, every age group of patients in the ICU that we examined demonstrated a loss under DRGs. As a whole for the 3-year period, patients in the ICU would have generated more than +30 million in losses for our medical center. These losses were a result of a variety of factors, including a greater severity of illness and greater hospital resource utilization. The current DRG hospital payment system appears to be inequitable for the patient who receives treatment in the ICU during the hospital stay. As hospital operating margins continue to decline because of federal and state DRG hospital payment systems, additional pressures may be applied for physicians, nurses, and health care professionals to cut expenses for these patients. In this effort to watch the bottom line, physicians and nurses must not sacrifice the quality of or the access to care for patients who require ICU services.

Academic Medical Centers↗

PubMed1989

The equity of diagnostic related group "All Payor" hospital payment and gynecology diagnostic related groups.

Previous work by our group had suggested that some Diagnostic Related Groups did not adequately compensate for patients with multiple complications and comorbidities. However, this question had never been studied for gynecology Diagnostic Related Groups. We analyzed resource consumption in the 15 gynecology Diagnostic Related Groups that were not stratified for complications or comorbidities using the new Diagnostic Related Group prospective "All Payor System" in effect at our hospital. Analysis of 2920 gynecology patients for a 3-year period by payor (Medicare, Medicaid, Blue Cross, and commercial insurance) in the gynecology Diagnostic Related Groups that were not stratified for complications or comorbidities demonstrated that patients with more complications and comorbidities per Diagnostic Related Group for each payor generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, financial risk under Diagnostic Related Group payment, more outliers, and a higher mortality compared with patients in these same Diagnostic Related Groups with fewer complications and comorbidities. These findings suggest that new prospective Diagnostic Related Group All Payor Systems may be inequitable for certain groups of gynecology patients. Gynecology Diagnostic Related Groups should be stratified by the numbers and types of complications and comorbidities to more equitably reimburse hospitals under Diagnostic Related Group All Payor Systems.

Adult↗

PubMed1989

A modified retention suture technique with external and internal "booties" to close difficult abdominal wounds.

In a patient with acute hemorrhagic pancreatitis complicated by pancreatic abscess, closure of the abdominal wall 7 days following marsupialization was difficult owing to the marked distension and edema of the bowel wall, especially the transverse colon. A simple technique using retention sutures with internal and external rubber "booties" above and below the fascia was used to prevent injury to the edematous bowel. The rubber catheters, or "booties," were removed at the bedside, thus making it a simple procedure in a difficult situation.

Abdominal Muscles↗

PubMed1989

The effect of cigarette smoking on rabbit aortic elastase activity.

Twenty rabbits were divided into three groups: (1) cage controls, (2) machine controls, and (3) cigarette exposed. The cigarette-exposed group was exposed to two 2-R1 reference cigarettes a day for 6 weeks on a Walton-II (Process and Instruments Corp., Brooklyn, N.Y.) smoking machine. Rabbits in the machine control group were placed in the smoking machine for the same period of time without cigarettes. Cage control animals were not placed in the smoking machine. Aortic elastase was significantly higher in the cigarette-exposed group (21.11 +/- 6.15) compared to both the cage control group (3.11 +/- 1.11) and machine control group (14.66 +/- 4.69). Aortic elastase in the machine control group was significantly higher in smoke-exposed rabbits than in both cage control and machine control rabbits. These data indicate that cigarette smoking increases aortic elastase activity in rabbits. If these data were to be extrapolated to humans, then patients with abdominal aortic aneurysms who smoke may have an accelerated rate of aneurysm growth or earlier rupture or both.

Animals↗

PubMed1989

Urinary L-valyl proline in patients with aortic aneurysms.

Recent evidence indicates that metabolism of elastin may be altered in patients with different types of infrarenal aortic disease and that the phenotypic expression of aortic disease may be dependent on the balance between aortic elastase and antiprotease activity. The dipeptide L-valyl proline (LVP) is a specific amino acid sequence for elastin and can be quantitated by high performance liquid chromatography analysis of the urine. This study was done to determine if alterations in systemic elastin metabolism could be detected in patients with different types of infrarenal aortic disease by quantitating urinary LVP. Patients were divided into one of five groups and had urine analyzed for LVP. These are control, no known aortic disease (n = 12); occlusive aortic disease (n = 10); elective abdominal aortic aneurysms (AAA) (n = 26); ruptured AAA (n = 5), and multiple aneurysms (n = 4). Urine values were correlated with aortic elastase and aortic antiprotease activity. Urinary LVP was significantly higher in patients with multiple aneurysms (1,209 micrograms per milliliter of urine) as compared with all of the other groups. Patients with elective AAA had significantly higher urinary LVP (40.5 micrograms per milliliter of urine) than patients with occlusive disease (9.1 micrograms per milliliter of urine) and those in the control group (4.2 micrograms per milliliter of urine). Patients with ruptured AAA did not have significantly elevated urinary LVP compared with other groups (18.6 micrograms per milliliter of urine). Urinary LVP increased significantly as aortic elastase and aortic elastase and antiprotease activity increased. These data suggest that elastin metabolism, as reflected by urinary LVP, is altered in patients with aortic aneurysmal disease and provide further evidence to support the concept that systemic elastin metabolism is altered in patients with different types of infrarenal aortic pathologic findings.

Aorta, Abdominal↗

PubMed1988

Financial risk and hospital cost for elderly patients. Age- and non-age-stratified medical diagnosis related groups.

The purpose of this study was to analyze hospital resource consumption for Medicare patients in non-age- and age-stratified medical diagnosis related groups (DRGs). This study of patients in 74 non-age-stratified DRGs (N = 3643) and 113 age-stratified DRGs (N = 2898) demonstrated that older medical patients (usually greater than or equal to 75 to 80 years of age) had (on average) higher total hospital costs, a longer hospital length of stay, more diagnoses per patient, a greater percentage of outliers, and a higher mortality compared with younger patients in these same DRGs. These findings raise the question of the equity of DRG payment vis-à-vis older Medicare patients in both non-age- and age-stratified medical DRGs. Financial disincentives to treat older medical patients may limit both their access and quality of care in the future.

Aged↗

PubMed1988

Hospital costs, resource characteristics, and the dynamics of death for patients with hypertension.

A great deal of interest has begun to focus on outcome data for hospitals. We analyzed hospital resource consumption for 4289 patients with hypertension by outcome (ie, survivors vs mortalities). The 211 mortalities had a much greater intensity of hospital resource utilization and a substantial financial risk under diagnosis related group (DRG) pricing schemes compared with the 4078 survivors. Only mortalities within one week of admission to the hospital were profitable under DRGs. A long hospital length of stay (LOS) for mortalities was very unprofitable (mortalities with greater than 60-day LOS generated a $40,673 loss per patient). Patients admitted under emergency conditions who died tended to have a shorter hospital LOS and less financial risk under DRGs compared with those who were not emergency admissions and died. Mortalities referred from other clinical services tended to have greater resource utilization and financial risk under DRGs compared with nonreferred mortalities. These data suggest notable inequities in the DRG prospective payment system vis-à-vis patients who died with hypertension. They also demonstrated variables predictive of greater hospital resource utilization for patients who died with hypertension, including longer hospital LOS, nonemergency admission, and referral from another clinical service.

Aged↗

PubMed1988

Surgonomics. Health care financing policy for hospitalized otolaryngology patients.

The Medicare diagnosis related group (DRG) prospective payment model is changing hospital payment. Currently many states are using DRG prospective "All Payor Systems" for hospital reimbursement. In All Payor Systems, Medicare, Medicaid, Blue Cross, and other commercial insurers pay by the DRG mode; New York State has been All Payor since Jan 1, 1988. This study simulated DRG All Payor methods on a large sample (N = 1074) of adult otolaryngology patients for a two-year period using both federal and New York DRG reimbursement now in effect. Both Medicare and Medicaid patients had (on average) a longer hospital stay and total hospital cost compared with patients from Blue Cross and other commercial payors. Medicare and Medicaid patients also had a greater severity of illness compared with patients from Blue Cross or other payors. All payors (ie, Medicaid, Blue Cross, and commercial insurers), except Medicare, generated financial risk under the DRG All Payor scheme. These data suggest that state and private payors may be underreimbursing for the care of the hospitalized otolaryngology patient using the DRG prospective hospital payment scheme. Health care financing policy described in this study may limit both the access and/or the quality of care for many otolaryngology patients in the future.

Diagnosis-Related Groups↗

PubMed1988

Diagnosis related groups and the transfer of general surgical patients between hospitals.

This study tested the hypothesis that financial risk would be generated by surgical patients transferred to our hospital from other acute care hospitals under diagnosis related group (DRG) reimbursement. Hospital costs by DRG (exclusive of physician fees) were analyzed for all adult general surgical patients transferred to our medical center from another acute care hospital between Jan 1, 1985, and Dec 31, 1986. Transferred patients (n = 97) had significantly higher resource utilization (ie, hospital costs) than nontransferred patients (n = 2976) within the same surgical DRGs as follows: total mean cost per patient, $17,348 vs $9,460; mean length of stay 21.4 days vs 10.9 days; mean laboratory cost per patient, $1849 vs $975; and mean radiologic cost per patient, $794 vs $397. Transferred patients generated a yearly deficit of $238,717 ($4922 loss per patient) for the hospital, whereas other patients within the same DRGs generated a profit of $727,632 ($489 profit per patient). These data support the hypothesis that DRG reimbursement will provide a financial disincentive for teaching hospitals to accept surgical transfer patients from other acute care hospitals, thus potentially decreasing the access of care for the complexly ill surgical patient.

Academic Medical Centers↗

PubMed1988

Site-specific distribution of large-bowel adenomatous polyps. Emphasis on ethnic differences.

The anatomic distribution of adenomatous polyps occurring in the large intestine of 98 consecutive patients was studied. Fifty-two of the patients were black and 46 were white. Seventy-nine percent of lesions in whites were found in the distal colon and rectum, whereas in blacks this occurred in only 47 percent. The difference was significant (P less than .01). Black patients also displayed a greater frequency of synchronous polyps and had a higher incidence of previous colorectal polyps. The findings suggest that the total colonic surveillance is essential in black patients to adequately screen for large-bowel neoplasia.

Black or African American↗

PubMed1988

Financial risk, hospital cost, and complications and comorbidities in medical non-complications and comorbidity-stratified diagnosis-related groups.

A number of methods are being studied to modify and improve the accuracy of the Medicare Diagnosis-Related Group (DRG) hospital classification system. This study analyzed resource consumption for 2,431 medical Medicare patients in the 53 non-complicating condition-stratified (i.e., non-complication and comorbidity) medical DRGs. Resource consumption per patient increased as the number of complications and comorbidities per patient per DRG increased, as measured by total hospital cost, hospital length of stay, the number of diagnoses and procedures per patient, the percent outliers, and mortality. Patients with more than four complications and comorbidities generated significant financial risk ($5,667 loss per patient) under DRG reimbursement. This study raises the question of the equity of DRG reimbursement for the medical non-complication and comorbidity-stratified DRGs. A method for DRG adjustment based on complications and comorbidities should be implemented by Congress to assure equitable payment for patients in these medical DRGs.

Costs and Cost Analysis↗

PubMed1988

The identifier concept: clinical parameters to stratify hospital patient costs within gynecology diagnosis-related groups.

The purpose of this study was to analyze whether clinical variables could stratify hospital costs within gynecology diagnosis-related groups. We analyzed 3171 gynecologic admissions to a large teaching hospital and found that the parameters of nonemergency and intensive care unit admission and blood or plasma product utilization could stratify hospital costs and outcome within a gynecology diagnosis-related group. Patients with the variables had higher total hospital costs, a longer hospital length of stay, more procedures per patient, a greater proportion of outliers, and a higher mortality than patients without the variables. This study demonstrates that these four clinical variables could be used to focus cost-containment efforts on gynecologic patients incurring higher costs in the coming era of limited resources.

Blood Transfusion↗

PubMed1988

Financial risk, hospital cost, complications and comorbidities (CCc) in non-CC stratified urology diagnostic related groups.

The federal Medicare Diagnosis Related Group payment mechanism is undergoing constant change. Significant interest has been generated at the health policy level regarding reimbursement for patients with complications and comorbidities. The purpose of this study was to analyze hospital resource consumption for patients in the seventeen urology non-complicating condition (CC) stratified Diagnostic Related Groups (DRGs), currently 45 percent of urology DRGs. We analyzed 185 Medicare patients in these non-CC stratified urology DRGs and found that patients with more CCs per patient had higher total hospital costs per patient, financial risk under DRGs, a greater percentage of outliers, and a higher mortality, than patients in these same DRGs with fewer CCs per patient. These findings suggest that the current DRG system is inequitable to some patients and certain hospitals vis-a-vis non-CC stratified urology DRGs. The Health Care Financing Administration has not significantly changed the complicating condition urology DRG classification, as of its recent May, 1988 legislation. Financial disincentives to treat these patients may affect both their access and quality of care in the future.

Centers for Medicare and Medicaid Services, U.S.↗