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As medical schools rely more heavily on clinical revenues for their viability, successful practices will be those that can emulate private practice operations. James Reuschel and Donald Earle offer guidance on measuring productivity in the academic setting.
In June 1984, the Chicago-based American Hospital Association convened a national forum on energy management in health facilities. The conference generated a report titled "Cost Containment through Energy Management: a Guide for Executive Action". Recently, the AHA's Institutional Practices Committee updated the contents of and reaffirmed the message of that management advisory. The following article was adapted from the revised version of the original report.
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BACKGROUND: Between June 1958 and June 1996 we operated many patients affected by pectus excavatum with an original surgical technique. In this study we evaluated the durability of the results. METHODS EXPERIMENTAL DESIGN: Retrospective study with a mean follow-up time of 15.8 years/pt, and 60% complete. SETTING: private and institutional practice. PATIENTS OR PARTICIPANTS: 357 patients (253 males and 104 females, mean age = 18.2+/-5.1 years) affected by pectus excavatum. The grade of PE (Chin classification) was I in 76 patients, II in 165 and III in the remaining 116. Most of the patients required operation for aesthetic reasons only (339 patients; 95%). INTERVENTION: the surgical technique consisted of a double transversal sternotomy at the level of the lowest and highest part of the depression associated with a longitudinal sternotomy. A wedge resection of the ribs was then performed and the sternum was fixed using an original stainless steel strut prosthesis moulded into a seagull wing. The strut was removed 12 months postimplantation. RESULTS: There were no operative deaths. Four patients (1.2%) had sternal wound infection, which was successfully treated. From the aesthetic point of view, the postoperative results were excellent in 262 patients (73.4%), good in 82 (22.9%) and poor in 13 (3.6%). All subjective symptoms, when present, disappeared after surgery. CONCLUSIONS: The seagull wing prosthesis appears to be safe, easy to implant and to remove, and comfortable for the patient. This technique has shown good long-term results independently of type of deformity and patient age.
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A brief description of the growth of family practice over the past 10 years into what is now a major specialty leads into a discussion of the implications of this development for hospitals. A fundamental shift of emphasis to family practice in medical education has already occurred and hospital departments of general practice, traditionally administrative in character, are being reorganized into clinical departments with responsibility for assigning privileges and administering educational and peer review programs.
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BACKGROUND: To study the possible use of transcutaneous carbon dioxide pressure measurements to estimate ventilatory threshold during exercise. METHODS EXPERIMENTAL DESIGN: comparative study. SETTINGS: Institutional practice, ambulatory care. Patients and measures: seventy-nine subjects. INTERVENTION: incremental exercise tests with simultaneous recordings of breath by breath gas exchange and transcutaneous carbon dioxide pressure. MEASURES: Six reviewers determined the ventilatory threshold using both the graphs for the carbon dioxide excretion to oxygen consumption relationship: V slope technique (VTa), and the ventilatory equivalent for oxygen uptake changes over time: (VTb), the respiratory compensation point (RCP) on ventilatory equivalent for carbon dioxide, and the transcutaneous threshold (Ttc) on the transcutaneous carbon dioxide pressure changes over time respectively. RESULTS: A Ttc could be defined by all observers in 85% of the subjects. Correlation between Ttc and VT expressed as oxygen consumption absolute values ranged from 0.971 to 0.975 on the mean values of six observers. Using the Bland-Altmann approach, differences (mean +/- SD) were 13 +/- 215, -40 +/- 204, 231 +/- 221 ml.min-1 between Ttc and VTa, RCP respectively. A difference of 38 +/- 173 ml.min-1 was found between VTa and VTb. This suggests that Ttc shows little difference with VT but not with RCP. CONCLUSIONS: We suggest that a carbon dioxide transcutaneous threshold can be found close to the ventilatory threshold. Potential clinical use of transcutaneous device are vast.
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BACKGROUND: To elucidate the intertest agreement of the oxygen uptake efficiency slope (OUES) in comparison with those of the maximal oxygen uptake (VO2max) and the ventilatory anaerobic threshold (VAT). METHODS EXPERIMENTAL DESIGN: A comparative study. SETTING: Institutional practice. A total of 19 healthy volunteers underwent two sessions of maximal exercise testing with an interval of no more than 7 days. The testing was conducted on a cycle ergometer with the work rate increased by either 20, 30, or 40 Watts (W)/min so that the subject would reach exhaustion within 9 to 12 min of exercise. VAT was defined as the level of oxygen uptake (VO2) at which either an increase in the ventilatory equivalent for oxygen without a concomitant increase in the ventilatory equivalent for carbon dioxide or a change in the slope of the linear relationship between carbon-dioxide production (VCO2) and VO2 occurred. OUES was determined by the following equation: VO2 = a log VE + b, where VE was minute ventilation and "a" was the OUES. Intertest reproducibility was assessed by coefficient of repeatability (COR). RESULTS: The intertest reproducibility of VO2max and OUES were excellent (COR = 570 ml/min [16%] and 740 [20%], respectively). VAT showed poor agreement between the two tests (COR = 650 ml/min [31%]). CONCLUSIONS: Results show that OUES is reproducible and reliable, supporting the clinical usefulness of this index.
OBJECTIVE: The aim of this study was to analyze the correlation between the peritoneal equilibration test (PET) and the dialysis adequacy and transport test (DATT) for peritoneal transport type characterization, and the degree of patients' acceptance for each test. DESIGN: Cross-sectional, observational multicenter study. SETTING: Five referral (tertiary) dialysis centers of institutional practice. PATIENTS: The study included 107 adult continuous ambulatory peritoneal dialysis (CAPD) patients with a prescription of four exchanges of 2 L per day, irrespective of age, gender, cause of end-stage renal disease, time on dialysis, nutritional status, or residual renal function. Patients on immunosuppressive therapy and those with cancer, hepatitis B, or HIV, and those having a peritonitis episode within the previous 30 days, or three or more episodes during the previous 12 months, were excluded. MAIN MEASURES: Peritoneal transport type as classified by creatinine and urea dialysis-to-plasma (D/P) ratios by PET and DATT. RESULTS: Correlation coefficients between D/P ratios for creatinine and urea, obtained for the PET and the DATT, were 0.73 for D/P creatinine and 0.96 for D/P urea. Patients were classified into high, high-average, low-average, and low transport categories according to the mean and standard deviation of D/P creatinine values obtained from the PET at 4 hours. These values showed excellent concordance with those generated from the DATT data (alpha = 0.82, 95% confidence interval 0.67 - 0.93). Nineteen percent of patients showed discordance in their category when classified according to the PET versus the DATT. Patients' acceptance was better for the DATT than for the PET, as evaluated with a questionnaire. CONCLUSION: The DATT is an easy, inexpensive, and reliable test to assess peritoneal transport type, and it also provides information about peritoneal clearance of solutes and ultrafiltration. The DATT has better patient acceptance than the PET. Since the DATT has only been validated for patients on a fixed CAPD daily schedule of 4 x 2 L, the results should be confined only to patients receiving such a prescription.
BACKGROUND: To discuss the presentation, diagnosis, management modalities and outcomes of the arachnoid cysts. METHODS EXPERIMENTAL DESIGN: Retrospective study with a mean follow-up period of 31 months (ranging between 9 months and 5 years). SETTING: Institutional practice (The Military Medical Faculty Hospital). Patients and the participants: 25 patients with arachnoid cysts treated surgically. INTERVENTION: Fenestration and drainage of the cyst into cisterns in 13 cases, cyst-peritoneal shunting in 8 cases and cyst excision in 4 cases. MEASURE: The arachnoid cysts were followed-up by Computed Tomography or/and Magnetic Resonance Imaging. RESULTS: The results are excellent in 21 cases, moderate in 2 cases and poor in 2 cases. CONCLUSIONS: Regardless of the procedure used for arachnoid cyst treatment, the outcomes are somewhat similar if the surgical indications and techniques are properly selected.
Orientation to priority utilization of economic and medical legal approaches to reformation of dental service is an obligatory condition for effective solution of the problems of Russian dentistry. The priority tasks are: creation of economic and legal models of a dental profession and improvement of its normative and legal basis; development and realization of general Russian and regional programs of transformation of state dental centers into other than state ones and privatization of dental institutions; practical reformation of economic mechanisms of dental service; development of methods for state regulation of dental activities during the transition period; determination of directions and choice of social measures to modify dentistry service; creation of a system of guarantee of high quality of dental care; improvement of legally-based professional protection of dentists.
CONTEXT: Determining variations in quality of care among hospitals can help direct attention to poorly performing institutions. PRACTICE PATTERN EXAMINED: The proportion of patients with congestive heart failure meeting various quality criteria in 69 hospitals. HOSPITAL SELECTION: The hospitals were voluntary participants in a quality improvement program in five states (Colorado, Connecticut, Georgia, Oklahoma, and Virginia). PATIENT SELECTION: All patients with congestive heart failure discharged from the participating hospitals during a 15-month period in 1995 to 1996 (or, for hospitals with more than 50 eligible patients, a random sample of 50 patients). The total sample consisted of 2077 patients. DATA SOURCE: Documentation in the hospital medical record of left ventricular function, discharge medications, and discharge instructions. RESULTS: Left ventricular function was determined in 72% of patients (range across hospitals, 18% to 97%). Among patients with left ventricular systolic dysfunction, 79% were prescribed an angiotensin-converting enzyme inhibitor (range, 54% to 94%). Only 23% of the patients prescribed angiotensin-converting enzyme inhibitors received the target dose (range, 0% to 60%). Sixty-four percent of patients were counseled about the importance of a low-sodium diet at discharge (range, 25% to 97%), but only 8% were counseled about daily weight monitoring (range, 0% to 30%). CONCLUSION: Our results show substantial hospital-to-hospital variation in the quality of care for patients with heart failure.
BACKGROUND: Evaluate the significance of direct intraoperative measurements of aortic and pulmonary blood flows by electromagnetic flowmeter as an absolute decision basis for operability in patients with ventricular septal defect/complete atrioventricular septal defect and severe pulmonary artery hypertension. METHODS EXPERIMENTAL DESIGN: Prospective study. SETTING: Institutional practice. PATIENTS: Eight patients with marginal operability based on preoperative Doppler echocardiography and cardiac catheterization (pulmonary-to-systemic flow ratio=1.1-2.3, pulmonary-to-systemic resistance ratio=0.34-0.91, and pulmonary vascular resistance=4.6-18.2 units x m2) underwent direct intraoperative measurements of aortic and pulmonary blood flows by electromagnetic flowmeter. Operation would be performed according to the results of direct intraoperative measurements in every patient. RESULTS: Aortic flow by direct intraoperative measurements ranged from 0.9 to 3.2 L/min/m2, and pulmonary blood flow from 4.1 to 8.4 L/min/m2. Pulmonary-to-aortic flow ratio was calculated at 2.1-6.6. Pulmonary vascular resistance ranged from 2.6 to 7.7 units x m2. We assessed that all patients still had operability, and performed corrective operations. Postoperative courses corresponded with the data from the direct intraoperative measurements. CONCLUSIONS: When some clinical findings, particularly Doppler echocardiographic findings, of these patients are slightly in favor of reversibility of pulmonary vascular disease despite discrepant data of preoperative cardiac catheterization under a tight control of carbon dioxide tension, we recommend that direct intraoperative measurement of aortic and pulmonary blood flows is especially useful in decision making for the operability of patients with severe pulmonary artery hypertension.