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Biomedical subjects

L Wise

Publications and source records attributed to L Wise.

At least 163 records · Page 9Linked to original sources
PubMed1987

Early discharge of the postmastectomy patient: unbundling of hospital services to improve profitability under DRGs.

Cost containment is necessary for health care facilities to remain profitable and, therefore, operable. Thus, newer strategies of providing quality patient care need be developed to achieve this goal. The purpose of this study was to compare the costs and outcome of patients who had modified radical mastectomies, who were discharged home with an indwelling hemovac drain, and whose follow-up was conducted by visiting nurses in contrast to the traditional hospitalization of these patients until the hemovacs were removed. Two groups were compared in a prospective fashion. Twenty patients who had undergone a modified radical mastectomy for stage I or II breast carcinoma and who were discharged home with an indwelling hemovac drain (HWIH) were compared with 20 modified radical mastectomy patients who remained hospitalized with the drains for continuous wall suction (IHWH). Mean length of stay for the HWIH group (2.65 days) was significantly lower than the IHWH group (9.65 days) (P less than .001). Mean total hospital charges (exclusive of physician fees) were significantly lower for the HWIH group ($ 2106) than for the IHWH group ($ 7672) (P less than .001). Under Diagnosis Related Group (DRG) reimbursement allowances, the IHWH group had a loss of $ 355 per patient, whereas the HWIH group had a profit of $ 5211 per patient. One complication in the HWIH group required rehospitalization (a wound infection that was treated with IV antibiotics). This study suggests that significant improvement in efficiency may be accomplished for selected mastectomy patients who are discharged home with the indwelling hemovac drain to be followed as outpatients by both the surgeon and a nurse specialist.

Breast Neoplasms↗
PubMed1987

The identifier concept: clinical parameters to stratify hospital costs within gastroenterology DRGs.

Prospective payment systems using the diagnostic related group (DRG) payment mechanism are changing the incentives offered to hospitals. We studied hospital costs of all gastroenterological (GI) patients (n = 2500) treated during a 2-yr period at our academic medical center. We showed that patients within GI DRGs could be grouped regarding hospital costs by four clinical variables: intensive care unit or emergency admission, and blood or plasma product consumption. Patients within each DRG with the variable usually had higher total hospital costs, a longer stay in the hospital, a greater number of diagnoses, more outliers, and a poorer outcome than patients without the variables. As the variables accumulated, these differences became more pronounced. This study demonstrated that hospital costs may be stratified within GI DRGs by clinical parameters that occur during the patient's hospital stay. These four variables could identify higher cost patients within a DRG; cost containment could then be directed at these patients with, hopefully, resultant savings.

Blood Transfusion↗
PubMed1987

A comparative study of cytologic smears and frozen-tissue sections in the determination of sex steroid receptor status of breast carcinomas.

The estrogen receptor (ER) status of breast cancer is important as an indicator of prognosis and in the selection of patients for endocrine therapy. Biochemical techniques (estrogen receptor analysis [ERA]) are conventionally used to determine ER; however, they have limitations and disadvantages. In this study a monoclonal antibody to ER (estrogen receptor-immunochemical assay [ERICA]) was used to detect the presence of ER on cytologic and frozen tissue specimens of breast cancers and was compared with the dextran-coated charcoal assay. One hundred two breast cancers were studied. Ninety-four specimens were studied by ERA and ERICA; in eight patients in whom tissue was insufficient for ERA, ERICA alone was performed. ERICA correlated remarkably well with ERA: 94% sensitivity, 89% specificity, and 93% accuracy. In the eight patients in whom ERA could not be performed, ERICA was successfully applied to obtain information regarding receptor status. There was uniform agreement between frozen-sectioned tissues and cytologic smears. The results suggest that immunocytochemical determination of ER is a valuable adjunct and/or alternative to the biochemical method for determination of the ER status of breast cancers.

Antibodies, Monoclonal↗
PubMed1987

Characterization of human aortic elastase found in patients with abdominal aortic aneurysms.

Recent evidence indicates that the homeostatic balance between elastase and antiprotease activity is altered in the infrarenal aorta of those patients with different types of aortic pathologic findings. The specific properties of elastase found in the aorta of patients with abdominal aortic aneurysms (AAA) are discussed herein. Activity of elastase extracted from ten pooled AAA specimens was observed when incubated with several inhibitors: 13.2 per cent for phenyl-suphonyl flouride (PSF); 43.3 per cent for ethylenediaminetetraacetic acid (EDTA); 77.7 per cent for pepstatin; 137.0 per cent for leupeptin, and 24.0 per cent for alpha-1-antitrypsin. Irreversible inhibition by PSF indicates that the elastase is a serine protease. The elastase is most likely not a metallo enzyme, since it had no absolute requirement for divalent cations as indicated by only partial inhibition by EDTA. Elastase activity is most likely not due to cathepsins B or D, since cathepsins are active in an acid pH and selectively inhibited by leupeptin and pepstatin. The pH curve revealed a maximum activity at pH 8.2 and elastase activity was significantly inhibited by alpha-1-antitrypsin in a dose response manner determining functional elastase activity. These data indicate that the elastase in the aorta of patients with an AAA has the exact properties of the serine elastase found in the smooth muscle cells of the aorta in rats. These results also confirm the critical role of alpha-1-antitrypsin in determining functional elastase activity. Smooth muscle cell regulation of elastin metabolism may be important in determining why some patients have AAA and others have occlusive aortic disease develop.

Aorta, Abdominal↗
PubMed1987

Altered aortic protease and antiprotease activity in patients with ruptured abdominal aortic aneurysms.

Aortic elastase, antiprotease (a-1-antitrypsin) and total protein were assayed in 37 patients who underwent an operation on the abdominal aorta for ruptured abdominal aortic aneurysms (AAA), an elective procedure for AAA or aortofemoral bypass for occlusive disease. Aortic elastase modified by local antiprotease activity (elastase/a-1-antitrypsin) was significantly higher in patients with a ruptured AAA compared with patients with an elective AAA or occlusive aortic disease: 241 nanograms per milligram of tissue in AAA-rupture versus 57 nanograms per milligram of tissue in AAA-elective versus 32 nanograms per milligram of tissue for occlusive (p less than 0.003). Patients with a ruptured AAA had the highest elastase activity (354 nanograms per milligram of tissue) and the lowest a-1-antitrypsin (1.07 nanograms per milligram of tissue) compared with patients with an elective AAA and occlusion (p less than 0.05). These data suggest that the homeostatic balance between elastase and antiprotease may be significantly altered in the aortic wall at the time of aneurysm rupture. Increased elastase unchecked by low antiprotease results in increased elastin breakdown which may be the inciting event for rupture of a compromised, thin aortic aneurysm wall.

Aorta, Abdominal↗
PubMed1986

Lumpectomy vs mastectomy. The costs of breast preservation for cancer.

Current data on the surgical management of breast carcinoma support the selective use of conservative surgery, ie, lumpectomy, axillary sampling, plus irradiation, rather than modified radical mastectomy. An economic comparison of these two forms of surgical therapy was conducted. Total charges for treatment (hospital and physician) of 79 patients with stage I or II breast cancer at our hospital during 1983 and 1984 utilizing either therapy demonstrated that mean total charges per patient for lumpectomy (N = 49) were $14,176 +/- $4262, and for mastectomy (N = 30) were $10,345 +/- $3134. Although hospital inpatient fees were significantly less for lumpectomy ($5741) than for mastectomy ($7328), mean total physician fees were significantly higher for lumpectomy ($4505). Radiotherapist fees and the substantial radiation therapy hospital outpatient charge for lumpectomy ($5015) made the mean total charges for lumpectomy significantly higher than for mastectomy.

Breast Neoplasms↗
PubMed1986

Factors affecting recurrence following resection for Crohn's disease.

The records of 187 patients with Crohn's disease who underwent resectional surgery were analyzed to evaluate the effect of several clinical and histologic features on the recurrence rate. Recurrence was defined as the need for re-resection. The data were analyzed by the life-table method. Age, sex, age at onset of disease and at time of resection, family history, presence of granuloma, and microscopic involvement at the line of resection did not affect the recurrence rate. The distribution of the disease and duration of symptoms before primary resection did influence the rate of re-resection. Patients with predominantly large bowel disease (N = 56) were found to have a higher rate of re-resection (45 percent) when compared with 32 percent in patients with small bowel involvement (N = 94) and with 35 percent in patients with both small and large bowel involvement (N = 37) (P = 0.04). A detailed review, an analysis of the literature, and a comparison with our results are made.

Adolescent↗
PubMed1986

Mode of admission and cost for surgical DRGs.

The purpose of this study was to confirm the hypothesis that emergency department admissions were more expensive than their nonemergency counterparts per diagnosis-related group (DRG) and to see if this characteristic was displayed across many hospitals. All surgical admissions (N = 39,682) to the 11 acute-care hospitals of the New York City Health and Hospitals Corporation were analyzed during an 18-month period to yield a study population (N = 26,569) of matched DRG subgroups (ED vs nonED) at each hospital of at least five patients per variable for that particular DRG. A cost-per-patient analysis was conducted for each admission. Total costs for the study population were $163,360,636. A total of 75.8% of surgical admissions (N = 20,143) were admitted in DRGs in which ED admissions were more costly than their nonED-matched counterparts. The following was the trend in percentage of total specialty admissions in DRGs in which ED admissions were more costly than nonED admissions: urology (88.4%); ear, nose, and throat (86.2%); general and vascular (80.1%); cardiothoracic (78.0%); orthopedics (75.6%); plastic surgery (62.1%); neurosurgery (60.5%); and ophthalmology (46.0%). Route of admission (ED vs nonED) was an identifier of higher-cost patients per DRG across hospitals in a large public hospital system. These data demonstrate that hospitals with substantial numbers of surgical ED admissions may face significant financial risk under DRG reimbursement, and suggests that the DRG system does not adequately compensate hospitals for the higher cost of the emergency surgical admission.

Data Collection↗
PubMed1986

Surgonomics: the cost dynamics of craniotomy.

Prospective payment systems using the diagnostic related group (DRG) mechanism are being phased in for Medicare inpatient hospital care. The purpose of this study was to examine a common neurosurgical procedure (001), craniotomy without trauma, and characterize the cost dynamics of this DRG. All patients (n = 50) treated in this DRG at the Long Island Jewish Medical Center during 1983 had their financial charges exclusive of physician fees examined. The findings were: (a) each hospital service category had wide charge variances around the mean; (b) emergency (ER) admissions were 200% more expensive than nonemergency (non-ER) admissions; (c) ER admissions seemed to have no greater severity of illness than non-ER admissions, but had a significantly different referral pattern (i.e., admission from the ER to a nonneurosurgical service with a subsequent neurosurgical referral); (d) this DRG when grouped into clinical "subproducts" (i.e., craniotomy for tumor, hematoma, hydrocephalus, aneurysm, benign cyst, and other) showed marked charge differences; and (e) the most expensive 25% of patients had five times higher charges than the least expensive 25% for both ER and non-ER admissions. This type of financial analysis may give surgeons a methodology with which to address the problems of cost containment in a more serious manner.

Adult↗
PubMed1986

Source of admission and cost: public hospitals face financial risk.

We studied all admissions to the 11 acute care hospitals of the New York City Health and Hospitals Corporation (April 1983-September 1984) matching emergency room (ER) admitted diagnostic related group (DRG) subgroups in each hospital with at least five non-ER admitted patients (N = 222,961). Mean cost per ER patient ($8,385) was greater than non-ER mean cost per patient ($4,386) for Medicare and non-Medicare. Our data suggest that public hospitals with a high proportion of ER admissions may be at a financial disadvantage under DRG reimbursement.

Costs and Cost Analysis↗
PubMed1986

Surgonomics and cost containment.

The implementation of Diagnostic Related Groups (DRGs) and ALL PAYOR SYSTEMS will force surgeons to examine the consumption of hospital resources. Previous study results at our institution indicated that almost 90 per cent of common surgical DRGs would be unprofitable under the Prospective Payment System (PPS). This study was done to examine the financial components of a common surgical DRG that would be unprofitable, examine appropriateness of hospital expenditures and propose strategies for cost containment without sacrificing quality of care. We studied all patients (215) in DRG 162 (inguinal and femoral hernia procedures, ages 18 to 69 years, without a complicating condition) at the Long Island Jewish-Hillside Medical Center from 1 January 1983 until 31 December 1983. Hospital charges were examined by hospital service category and aggregated by total dollars per category, patient mean dollars plus or minus standard error of mean per category and patient totals. Total hospital charges for this DRG were $493,432.00, DRG reimbursement (1983 Federal Register) would have been $447,799.00, resulting in a net loss (deficit) to the hospital of $47,434.00 or $212.00 per patient. Hospital services (room and board, laboratory and ancillaries) were overused in the treatment of this DRG. Strategies involving quite modest decreases in length of stay and use of ancillary services (laboratory, x-ray, electrocardiogram) would save at least $60,000.00 and make this a profitable DRG.

Adolescent↗
PubMed1986

The costs and dynamics of surgical morbidity and mortality.

The implementation of prospective payment systems for hospitals, most notably the Medicare diagnosis-related group (DRG) mechanism, will encourage surgeons and hospitals to characterize populations that create financial risk. Our previous studies have demonstrated that certain factors (identifiers) such as emergency admission or necessity for blood transfusion would predict higher cost patients per DRG and that some populations (i.e., surgical intensive care unit admissions) would generate significant financial risk under DRG reimbursement. The purpose of this project was to test the assumption that surgical complications and deaths would generate financial risk under DRGs and that the degree of risk would vary by the dynamics of the complications and death. We examined all surgical admissions (n = 5596) to a large voluntary teaching hospital to determine all general and vascular surgical complications and deaths (170 admissions; complication rate 3.1%) for 1983 and 1984. Total charges (exclusive of physicians' fees) of these patients were $4,683,670 (mean per patient, $27,551) versus DRG revenues of $2,378,703 (mean per patient, $13,992) resulting in a loss of $2,304,967 (mean per patient, $13,558). Charges and financial risk generated by the origin of the surgical morbidity and death differed as follows: iatrogenic origin only (N = 41)--mean charge per patient, $15,321 (19.5% of whom had unusually long hospital stays or unusually high costs [outliers]; origin intrinsic to the patient's disease only (N = 75)--mean charge per patient, $28,391 (38.7% outliers); and combined iatrogenic origin and patient's disease (N = 54)--mean charge per patient, $35,669 (48.0% outliers) (group 1 versus groups 2 and/or 3; p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Costs and Cost Analysis↗
PubMed1986

Value of routine pathology in herniorrhaphy performed upon adults.

The value of routine pathologic study of specimens taken at herniorrhaphy performed upon adults was assessed. All 789 patients who underwent inguinal or femoral herniorrhaphy at the Long Island Jewish Medical Center from January 1983 through July 1984 were studied. Patients were classified into five groups; 1, no specimen was sent for pathologic evaluation; 2, confirmation of hernia sac; 3, confirmation of hernia sac with additional expected pathologic findings (such as lipoma or hydrocele); 4, unexpected additional pathologic findings which appeared abnormal at operation, and 5, unexpected additional pathologic findings which appeared normal at operation. During this time period there were 935 herniorrhaphy procedures performed. Three of 1,020 specimens examined contained unexpected pathologic findings (groups 4 and 5): non-Hodgkin's lymphoma, liposarcoma and atypical lipoma. Only one specimen (group 5) with an abnormal pathology report showed an atypical lipoma which appeared normal at operation (0.098 per cent). The outcome of the operation was not altered by the pathology results in these three patients from either group 4 or 5. Aggregate charges for all specimens was $30,528.00 (a mean charge per patient of $48.00). Annual savings to the health care system of the United States by omitting routine pathologic examination of specimens from groups 1, 2 and 3 would be $18 million. Although there may be some justification for routine tissue testing for medical and legal reasons and quality assurance purposes or for specimens which appeared abnormal at operation, these data suggest that for patients who undergo herniorrhaphy, little positive effect on the outcome is gained from routine pathologic examination of specimens which appeared normal at operation.

Adult↗
PubMed1985

The financial effects of emergency department-generated admissions under prospective payment systems.

The purpose of this study was to assess the financial impact (revenues vs expenses) as measured by hospital charges and costs vs diagnosis-related group (DRG) revenues of prospective payment systems on emergency department-generated admissions for a large teaching hospital under two payment systems: Medicare and an all-payor system. All emergency department admissions were analyzed for the years 1983 (N = 4,273) and 1984 (N = 4,125) under both systems, using standard DRG methodology. Our findings were as follows: (1) With charges as a measure of expense under both payment schemes, all clinical departments had large groups of unprofitable patients: Medicare, $12,895,038; all-payor system, $15,553,893. (2) When costs were computed as the expense measure (using our hospital's cost-to-charge ratio), Medicare patients produced a deficit ($2,363,163); however, under an all-payor system there was a small net profit ($4,267,859). (3) The implementation of federalized DRG reimbursement rates increased our losses for this population from 1983 to 1984. (4) Reductions in outlier reimbursement (10%) and teaching costs (25%) caused our revenues to drop substantially, potentiating our losses. These findings suggest that hospitals with large emergency department admission populations, particularly Medicare patients, may be at a significant financial disadvantage under prospective payment systems.

Costs and Cost Analysis↗
PubMed1985

Surgical management of perforated colonic diverticulitis.

Between 1960 and 1983, 116 patients had surgical treatment for acutely perforated colonic diverticulitis. Sixty-five patients had immediate or primary resection and 51 had delayed or staged resection. The two groups were comparable as to age, sex, and associated diseases. The mortality rate (12% v 20%), duration of hospital stay (36 days v 52 days), and duration of disability (81 days v 148 days) were all lower for the primary resection than the staged resection group. We believe that, whenever possible, the perforated segment of colonic diverticulitis should be resected primarily.

Acute Disease↗
PubMed1985

Surgonomics. Money down the drains.

The importance of delivering cost-effective quality surgical care has increased with the introduction of new payment mechanisms designed to slow the rise in health care costs. We examined the reasons for the use of a commonly used surgical input--a drain--to determine surgeons' feelings about the importance of costs. Both resident and attending general surgeons felt that the cost of the input was not an important consideration in the decision-making process of choosing the input. We believe that these findings are applicable across the range of inputs (hospital days, laboratory tests, ancillary procedures) used by surgeons in their practices. Unless this changes in the future, surgeons will not be able to provide quality surgical care within economic constraints.

Attitude of Health Personnel↗