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Biomedical subjects

L Wise

Publications and source records attributed to L Wise.

At least 127 records · Page 7Linked to original sources
PubMed1988

Preoperative and postoperative medical evaluation of surgical patients.

The purpose of this study was to analyze the cost-benefit of routine preoperative and postoperative medical evaluation of surgical patients. We analyzed the records of 70 patients who underwent selected common general and vascular surgical procedures according to their surgical risk, and assessed the potential change in outcome from medical evaluation. Our findings suggest that for low-risk surgical patients undergoing these procedures, medical evaluation is unlikely to affect outcome and, thus, may be unnecessary. There appears to be some benefit, however, for medium-risk surgical patients. Although we do not suggest the abolishment of all preoperative and postoperative medical evaluations, we do recommend the much more selective use of this valuable resource. Our data suggest that significant improvement in efficiency for many hospitals may be possible by omitting routine preoperative and postoperative medical evaluation for certain patients and by obtaining medical evaluation only in selected medium and higher risk surgical patients (ASA class 3 and above).

Aged↗
PubMed1988

Access and quality of care for urology patients under diagnostic related group reimbursement.

The Diagnostic Related Group payment mechanism is rapidly changing economic incentives for hospitals. We studied resource consumption and age for a large group of urology patients under Diagnostic Related Group reimbursement. Total hospital costs (exclusive of Diagnostic Related Group reimbursement. Total hospital costs (exclusive of physician fees) for the 1,281 urology patients studied were $8,895,264. Older urological patients consumed a disproportionately larger share of hospital resources. Mean hospital cost per patient, mean number of procedures, hospital length of stay and mortality generally increased with age. Under Diagnostic Related Group reimbursement, financial risk increased with age; patients 75 years and older generated significant financial risk to the hospital. Older patients often had a more intense resource use as measured by emergency or surgical intensive care unit admission, and blood and plasma protein requirements. These findings suggest that the current Diagnostic Related Group payment scheme may provide significant financial disincentives to hospitals vis-à-vis older urology patients and, thus, it could limit the access and quality of care for the older urology patient in the future.

Adult↗
PubMed1988

A study of change in clinical service for general surgical patients.

The department of surgery at Long Island Jewish Medical Center in New York City conducted a study examining resource consumption and quality of care for patients referred to surgery from other hospital services, or "referred patients." Referred patients were compared with "nonreferred" surgery patients using several indicators of resource consumption. A quality assessment was also performed on a random sample from both groups using peer review organization guidelines. The study found that referred patients consumed more resources and may have received poorer quality care than nonreferred patients. Previous studies suggest that some resource utilization by referred patients may be avoidable. Thus, referral to the department of surgery may serve as an indicator for identifying patients in need of ongoing quality and/or utilization monitoring.

Health Resources↗
PubMed1988

Diagnosis related groups, resource utilization, age, and outcome for hospitalized nephrology patients.

Economic incentives are rapidly changing for hospitals under the prospective Diagnosis Related Group (DRG) hospital reimbursement scheme. The purpose of this project was to study resource use, age, and outcome for nephrology admissions to a large academic medical center. Total hospital costs for the 784 nephrology admissions (January 1, 1985 to December 31, 1986) were $5,037,460. Mean hospital cost per patient and mortality generally increased with age. DRG payment for patients in the 13 nephrology DRGs analyzed would have produced an aggregate loss of $483,584; however, all age categories of patients 55 years of age and over generated significant losses (the highest was for patients 85 years and above, $5,343 loss per patient). Diabetic nephrology patients generated greater resource consumption compared with nondiabetic nephrology patients, as well as patients in medical and surgical DRGs with chronic renal failure compared with patients in these same DRGs without chronic renal failure. Older nephrology patients also demonstrated higher emergency and ICU admission and blood requirements than younger patients. This study suggests that the current DRG reimbursement scheme may be inequitable vis a vis older nephrology patients, as well as those with diabetes mellitus and chronic renal failure. Financial disincentives by DRGs may affect both the access and quality of care for groups of nephrology patients in the future.

Adolescent↗
PubMed1988

Health care financing policy for hospitalized nephrology patients.

The Medicare diagnosis-related group (DRG) prospective payment system is now entering its 6th year, with no reported major adverse effects on the health status of the American people. Currently 13 states are using DRG prospective "all-payer systems" for hospital reimbursement; other state may adopt DRG all payer systems. In DRG all-payer systems, Medicare, Medicaid, Blue Cross, and other commercial insurers pay by the DRG mode; New York state has been all-payer since January 1, 1988. This study simulated DRG all-payer methods on a large sample (n = 558) of adult nephrology patients for a 2-year period using both federal and New York DRG reimbursements now in effect. Both Medicare and Medicaid patients had (on average) longer hospital lengths of stay and higher total hospital costs compared with patients from Blue Cross and other commercial payers. Medicare and Medicaid patients also had greater severity of illness than patients from Blue Cross or other payers. However, all payers (ie, Medicaid, Blue Cross, Medicare, and commercial insurers) generated significant financial risk under our DRG all-payer scheme. These data suggest that federal, state, and private payers may be underreimbursing for the care of hospitalized nephrology patients using the DRG prospective hospital payment scheme. As DRG payment rates are further reduced compared with the real hospital costs of treating patients, both the access to and the quality of care for many nephrology patients may be jeopardized.

Aged↗
PubMed1988

Activation of rabbit aortic elastase by nonaortic intraabdominal surgery.

The purpose of this study was to determine whether aortic elastase could be activated by distant operative trauma unrelated to direct aortic injury. One hundred rabbits were divided into five groups: group I - anesthesia only; group II - laparotomy only; group III - cecal resection; group IV - aortic mobilization; and group V - aortotomy with repair. Animals were sacrificed at one hour, three hours, six hours, one day, two days, and five days after surgery, and the aorta was analyzed for elastase activity. Operative trauma such as laparotomy, bowel resection, and mobilization of the aorta without direct aortic injury resulted in a significant increase in rabbit aortic elastase. The pattern of activation of rabbit aortic elastase within the laparotomy, aortic mobilization, and aortotomy groups was one of a slow rise to peak activation at 6-24 hours with a subsequent fall towards baseline at five days after surgery. This pattern differed in the cecal resection group in which activation occurred immediately with a slow fall towards baseline at five days. In none of the four surgical groups did the elastase activity return to baseline by five days after surgery. These data suggest that aortic elastase in rabbits can be activated by intraabdominal surgery unrelated to direct aortic injury.

Abdomen↗
PubMed1988

Mesenteric shunting during thoracoabdominal aortic clamping to prevent disseminated intravascular coagulation in dogs.

The current study was undertaken to determine if cold crystalloid perfusion of the mesenteric circulation or continuous arterial shunting into the superior mesenteric artery would prevent the subsequent development of disseminated intravascular coagulation in a dog model. Twenty-two dogs were divided into four groups: those with distal aortic occlusion; those with isolated washout of the mesenteric circulation via the superior mesenteric artery with cold crystalloid; those with continuous isolated arterial perfusion of the superior mesenteric artery via an open proximal aorta; and those with shunting of blood into the superior mesenteric artery from the proximal aorta with an Inahara-Pruitt shunt. Coagulation parameters were measured for 24 hours and compared to the results with 32 dogs in the following groups: sham operation; supraceliac aortic occlusion for 30 minutes, 60 minutes, 90 minutes; superior mesenteric occlusion for 90 minutes; and celiac axis occlusion for 90 minutes. Shunting or direct arterial perfusion of the superior mesenteric artery prevented disseminated intravascular coagulation from occurring. Infrarenal aortic occlusion resulted in no change in any of the coagulation factors, whereas crystalloid perfusion of the superior mesenteric artery resulted in death in all animals. These results indicate that the disseminated intravascular coagulation that occurs with supraceliac aortic occlusion or superior mesenteric occlusion of greater then one hour can be prevented by continuous arterial perfusion of the superior mesenteric artery during proximal aortic clamping.

Animals↗
PubMed1988

Elastin metabolism of the infrarenal aorta.

Aortic tissue elastase and alpha 1-antitrypsin were assayed in 67 patients with different types of infrarenal aortic disease; occlusive disease, elective abdominal aortic aneurysms (AAAs), multiple aneurysms, and ruptured aneurysms. Elastase modified by alpha 1-antitrypsin (elastase/alpha 1-antitrypsin) increased significantly as the type of aortic disease changed from occlusive to aneurysmal disease. Aortic elastase was significantly higher in patients with AAAs, multiple aneurysms, and ruptured AAAs compared with occlusive disease. The alpha 1-antitrypsin, was significantly lower in patients with multiple aneurysms and ruptured AAAs. These data suggest that the ratio between elastase and its major serum inhibitor, alpha 1-antitrypsin, is significantly altered in the aortic wall in different types of infrarenal aortic disease. In addition, the ratio between these two enzyme systems changes in favor of more proteolytic activity as the type of infrarenal disease changes from occlusive to aneurysmal.

Aorta, Abdominal↗
PubMed1988

Financial risk, hospital cost, complications, and comorbidities in surgical noncomplication- and noncomorbidity-stratified diagnostic related groups.

The purpose of this study was to analyze resource consumption in the 147 non-complicating condition-stratified surgical diagnostic related groups (DRGs). Analysis of 2647 surgical patients in these non-CC-stratified surgical DRGs demonstrated that patients with more CCs per DRG generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, financial risk under DRG payment, more outliers, and a higher mortality rates than patients in these same DRGs with fewer CCs. These findings suggest that the current DRG classification system may be inequitable to certain groups of patients or types of hospitals vis-à-vis the non-CC-stratified surgical DRGs. Financial disincentives to treat these patients may affect both their access and quality of care in the future.

Academic Medical Centers↗
PubMed1988

Starvation and mucosal prostaglandin-E2 in gastric stress ulceration.

To determine whether starvation increases the susceptibility of the gastric mucosa to stress ulceration and whether this effect is linked to a change in the mucosal level of prostaglandin-E2 (PGE2), 100 Holtzman rats were divided into five groups and deprived of food for 0, 12, 24, 48 and 72 h. Then, ten animals within each group were stressed by cold restraint. At the end of the stress period, all these animals as well as their unstressed counterparts were killed, the number of gastric ulcers were counted, and mucosal levels of PGE2 were assayed. Fasting alone caused no ulcerations but a decrease in mucosal PGE2 during the initial 24 h (p less than .05). However, there was a subsequent increase in mucosal PGE2, possibly related to the release of free fatty acids during starvation. Starvation and stress caused a marked and consistent reduction of the mucosal PGE2 and an increase in the number of mucosal ulcerations directly related to the duration of starvation (p less than .05).

Animals↗
PubMed1988

Effect of increasing inspired oxygen concentration on hemodynamics and regional blood flows.

Previous reports suggest that in response to increasing FIO2, peripheral resistance increases, cardiac output falls, and regional blood flow decreases. This study examined the influence of varying FIO2 on pulmonary and systemic vascular resistances (PVR, SVR), cardiac output, ventricular work, and regional blood flows in ten anesthetized Yorkshire white pigs. Each animal served as its own control, and was exposed to varying FIO2 in random order. PCO2 was maintained at 40 +/- 5 torr and body temperature at 38.5 degrees C. Heart rate, systemic arterial pressure, pulmonary artery pressure (PAP), pulmonary capillary wedge pressure, thermodilution cardiac output, and blood flows in the femoral, carotid, renal and superior mesenteric arteries were measured at each FIO2. SVR, PVR, left and right ventricular stroke work (LVSW, RVSW) were calculated. One-way analysis of variance-randomized block design (F-test) showed significant decreases in PAP, PVR, and RVSW with increased FIO2. No change was noted in regional flows, cardiac output, SVR, or LVSW. We conclude that in this animal model administration of oxygen up to an FIO2 of 1.0 had no adverse effect on hemodynamic performance.

Animals↗
PubMed1988

Glucose and alanine absorption following massive small bowel resection.

A 90% small bowel resection in 8 dogs resulted in a significant decrease (p less than 0.05) in D-xylose and D-glucose absorption during the early postoperative period. The absorptive capacity of the residual gut with regard to L-alanine, however, remained unchanged. Anemia and hypoalbuminemia also occurred in time, suggesting a malabsorptive state. Control studies were performed in 8 dogs with small bowel transections. The results suggest that a high protein diet might be of benefit during the early postoperative period after massive small bowel resection.

Absorption↗
PubMed1988

Hospital costs, cancer patients and medical diagnosis-related groups.

This study analyzed hospital resource consumption for 5,065 Medicare patients in 90 noncancer designated medical diagnosis-related groups (DRGs) by whether or not patients had a diagnosis of a malignancy (i.e. cancer). Patients with cancer had greater hospital resource utilization than noncancer patients in these medical DRGs. Cancer patients had a greater percentage of outliers (p less than 0.02), twice the financial loss under DRGs, more diagnoses (p less than 0.001) and procedures (p less than 0.0001) per patient, and a greater mortality (p less than 0.0001) than noncancer patients. These findings raise the question of the equity of DRG payment vis-à-vis medical cancer patients in many medical DRGs, and whether the DRG scheme may provide disincentives to treat some elderly Americans with cancer.

Costs and Cost Analysis↗
PubMed1988

Costs of pulmonary medicine and DRGS. Access and quality of care for the future.

Many changes are under way for the payment of physician and hospital care of patients in medicine and the medical subspecialties, i.e., the hospitalized pulmonary medicine patient. The purpose of this study was to characterize hospital resource consumption and outcome by age for pulmonary patients. All pulmonary medicine admissions treated at a large academic medical center from January 1, 1985 through December 31, 1986 were analyzed using the Diagnostic Related Group (DRG) format. Total costs (exclusive of physician fees) for the 2,647 pulmonary patients studied were $19,751,192. Mean hospital cost per patient, hospital length of stay, percentage of outliers, and mortality increased with age. Under the DRG reimbursement mechanism (i.e., All Payor System), a loss was incurred for all patients 45 yr of age and older, which led to an overall fiscal deficit for pulmonary medicine admissions. Medicare patients (n = 930) demonstrated a stronger expression of these trends. DRG case-mix index and the mean number of diagnoses per patient increased steadily with age. Emergency admissions were highest for the young (i.e., 18 to 35 yr of age), for some middle-aged (i.e., 45 to 65 yr of age), and for the very old (80 yr of age). Utilization of the intensive care unit and blood transfusions was higher for older patients; utilization of plasma products showed a more variable pattern, although older patients had greater consumption than their younger cohorts. This study demonstrated several trends with regard to resource utilization and age for pulmonary patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Costs and Cost Analysis↗
PubMed1988

Financial risk, hospital cost, and complications and comorbidities (CCs) in the non-CC-stratified pulmonary medicine diagnostic-related group Medicare hospital payment system.

The purpose of this study was to analyze hospital resource consumption in the 8 noncomplicating condition-stratified pulmonary medicine diagnostic-related groups (DRGs). We analyzed 427 Medicare patients treated during a 2-yr period in these 8 noncomplicating condition-stratified DRGs. Patients with a greater number of complicating conditions (CCs) had higher total hospital costs, a longer hospital length of stay, more procedures per patient, increasing financial risk under DRGs, a larger number of outliers, and a higher mortality than did patients in these same DRGs with a fewer number of CCs. These findings raise the question of the equity of DRG reimbursement at our hospital vis-à-vis the non-CC-stratified pulmonary medicine DRGs. If these findings are generalizable at other teaching hospitals, the current DRG system may provide financial incentives to not treat certain types of pulmonary medicine patients likely to have many CCs, and potentially effect these patient's access and quality of care in the future.

Diagnosis-Related Groups↗
PubMed1988

Neurology, age, hospital costs, and DRGs.

The DRG payment scheme is causing hospitals to examine the financial consequences of treating various patient populations. The purpose of this study was to examine resource utilization for hospitalized neurology patients treated during a 2-year period at an academic medical center. All patients (N = 1,993) were stratified by payor (Medicare, Medicaid, Blue Cross, and other) and age (0-35 years, 35-65 years, and 65 years and above). Mean hospital cost per patient (exclusive of MD fees) for each payor generally rose with age. Patients 35 years of age and over consumed a disproportionately larger share of resources than younger patients. DRG payment under an all payor system would have produced a substantial deficit for this group of patients. The mean hospital length of stay, number of diagnoses per patient, and mortality, as well as percent of admission through the emergency department generally rose with age. This study demonstrated that neurology patients 35 years of age and older generated higher resource utilization than their younger counterparts and were underpaid by the current DRG reimbursement. In this study, DRG payment appeared to provide significant financial disincentives to treat older neurology patients. If our findings are widespread, the quality of neurologic care and the elderly's access to it could become limited in the future.

Aged↗
PubMed1988

DRG prospective, "all payor systems," financial risk, and hospital cost in pulmonary medicine non CC stratified DRGs.

Previous work by our group had suggested that some pulmonary medicine diagnosis-related group (DRGs) did not adequately compensate for patients with multiple complications and comorbidities. Congress has recommended no major changes to pulmonary medicine DRGs along these lines. The purpose of this study was to analyze resource consumption in any of the seven noncomplicating conditions (CC), stratified pulmonary medicine DRGs using the new DRG prospective "all payor system" in effect at our hospital. Analysis of 858 pulmonary medicine patients by payor (Medicare, Medicaid, Blue Cross, and commercial insurance) in these non-CC stratified pulmonary medicine 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, financial risk under DRG payment, more outliers, and a higher mortality, compared to patients in these same DRGs with fewer CCs. Both hospital length of stay and total cost per patient (adjusted for DRG weight index) increased with CCs. Financial risk per patient under DRGs also increased as CCs accumulated. These findings suggest that new prospective DRG "all payor systems" may be inequitable to certain groups of patients or types of hospitals vis-a-vis the non-CC stratified pulmonary medicine DRGs. Many pulmonary medicine DRGs should be stratified by the numbers and types of CCs to more equitably reimburse hospitals under DRG all-payor systems.

Academic Medical Centers↗