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Numbers seldom tell the whole story, but they certainly point out the direction you're going. Our 1998 Benchmarking Guide to Managed Care gives you the lowdown on top performers in markets already dominated by managed care and those yet to turn the corner.
A study was undertaken to determine if healthcare resource groups (HRGs) are reliable, reproducible in different centres and accurately reflect clinical activity. During a 3 month period, 385 finished consultant episodes (FCEs) were assessed. Of these, 17 (4.4%) were grouped to U01, i.e. no group allocated as the primary diagnosis was not recorded. For 271 of these episodes, a clinician had also allocated a choice of what he thought the HRG should be. These choices of HRG were then compared with the official grouping determined by the software provided by the National Casemix Office (NCMO). Disparities between 'automatic grouping' and proposed HRG assignment by the consultants occurred in 20.66% (56/271). Version 3 should see some of these disparities and actual grouping software errors reduced, in particular through the introduction of a new vascular surgery chapter. However, the absence of a primary diagnosis will still produce the allocation of group U01 in version 3. Caution should be observed in using the HRG software and in the interpretation of data obtained from it. This could be especially important in benchmarking or contractual settings as there may be adverse implications to the unit/hospitals involved.
OBJECTIVE: To determine benchmarks and factors that influence morbidity, mortality, and length of stay (LOS) for head and neck surgical procedures. METHODS: A specific database for head and neck surgical procedures was extracted from the National Hospital Data Survey database for 1995 through 1997. Records of inpatient admissions for patients undergoing head and neck surgery were examined to determine demographics, incidence of medical complications, mortality, and LOS. Data were statistically examined for the influence of medical complications on mortality and LOS. RESULTS: A total of 3932 patients underwent head and neck procedures. The overall medical morbidity and mortality rates were 5.65% and 2.98%, respectively. The presence of a major medical complication increased the odds of death by 5.65 (P<.001). Postoperative pneumonia was the most common medical complication (3.26%) and was associated with a mortality rate of 10.94% (odds ratio for mortality, 4.4). Acute myocardial infarction and stroke were rare (combined incidence, 1.86%) and were not statistically associated with increased mortality. Procedures that involved the esophagus carried the highest mortality rate (8.38%). The overall mean LOS was 6.15 days. This increased to 17.7 days when a major medical complication occurred (P<.001). Increasing age was associated with increased rates of medical complications and mortality (P<.001). CONCLUSIONS: Medical complications in patients undergoing head and neck surgical procedures are associated with increased mortality rates and longer LOS. Mortality rates in head and neck surgery are low but may be improved by preventing medical complications.
The understanding of protein-protein interactions is a major goal in the postgenomic era. The prediction of interaction from sequence and the subsequent generation of full-length dimeric models is therefore of great interest especially because the number of structurally characterized protein-protein complexes is sparse. A quality assessment of a benchmark comprised of 170 weakly homologous dimeric target-template pairs is presented. They are predicted in a two-step method, similar to the previously described MULTIPROSPECTOR algorithm: each target sequence is assigned to a monomeric template structure by threading; then, those templates that belong to the same physically interacting dimer template are selected. Additionally we use structural alignments as the "gold standard" to assess the percentage of correctly assigned monomer and dimer templates and to evaluate the threading results with a focus on the quality of the alignments in the interfacial region. This work aims to give a quantitative picture of the quality of dimeric threading. Except for one, all monomer templates are identified correctly, but approximately 40% of the dimer templates are still problematic or incorrect. Preliminary results for three full-length dimeric models generated with the TASSER method show on average a significant improvement of the final model over the initial template.
The developmental toxicity of the alternative motor vehicle fuel methanol was assessed in mice by the inhalation route. Pregnant CD-1 mice were exposed to 1,000, 2,000, 5,000, 7,500, 10,000, or 15,000 ppm methanol for 7 hr/day on days 6-15 of gestation. Sham-exposed controls were exposed to filtered air under similar conditions. Additional control groups were left in their home cages either unhandled or food-deprived for 7 hr/day to match the food deprivation experienced by the exposed mice. Dams were observed twice daily and weighed on alternate days during the exposure period. Blood methanol concentrations were determined in some mice on gestation days 6, 10, and 15. On day 17, the remaining mice were weighed and killed and the gravid uteri removed. Implantation sites, live and dead fetuses and resorptions were counted, fetuses were examined externally and weighed as a litter. Half of each litter was examined for skeletal morphology and the other half of each litter was examined for internal soft tissue anomalies. One dam died in each of the 7,500, 10,000, and 15,000 ppm methanol exposure groups, but no dose-response relationship was evident for maternal death. The sham-exposed and food-deprived controls as well as all methanol exposed dams gained less weight than did unexposed dams fed ad libitum, but methanol did not exacerbate this effect. Significant increases in the incidence of exencephaly and cleft palate were observed at 5,000 ppm and above, increased embryo/fetal death at 7,500 ppm and above (including an increasing incidence of full-litter resorptions), and reduced fetal weight at 10,000 ppm and above. A dose-related increase in cervical ribs or ossification sites lateral to the seventh cervical vertebra was significant at 2,000 ppm and above. Thus, the NOAEL for the developmental toxicity in this study was 1,000 ppm. A log-logistic dose response model was applied to the incidence data for exencephaly, cleft palate, resorption and cervical rib, and maximum likelihood estimates (MLEs) and benchmark dosages (BDs, the lower 95% confidence interval of the MLEs) corresponding to 1% and 5% added risk above background were calculated. The MLE for 5% added combined risk of having either exencephaly or cleft palate or being resorbed was 3667 ppm, and the corresponding BD was 3,078 ppm. For cervical rib, the 5% added risk values for the MLE and BD were 824 and 305 ppm, respectively. The BDs for 1% added risk were 1915 ppm for exencephaly, cleft palate or resorption, and 58 ppm for cervical rib.(ABSTRACT TRUNCATED AT 400 WORDS)
Developmental toxicity risk assessment has typically relied on the estimation of reference doses or reference concentrations based on the use of no-observed-adverse-effect levels (NOAELs) divided by uncertainty factors. The benchmark dose (BMD) approach has been proposed as an alternative basis for reference value calculations. In this analysis of the developmental toxicity observed in rats exposed to boric acid in their diet, BMD analyses have been conducted using two existing studies. By considering various end points (rib XIII effects, variations of the first lumbar rib, and fetal weight changes) and various modeling approaches for those end points, the best approach for incorporating all of the information available from those studies could be determined. Particular emphasis has been placed on methods for combining data across studies and for combining potentially related effects (on rib XIII and on the first lumbar rib). The issues of study and end point selection are ones that will arise frequently in the process of estimating reference values. This example of boric acid suggests that the BMD approach provides a reasonable basis for appropriately comparing and combining study data, as opposed to ad hoc combinations of study results. Moreover, it is shown that the BMD approach can be used with combinations of end points considered to differ in severity. In this case, the preferred approach involved combining the data from the two studies, which were similarly designed and were conducted in the same laboratory, to calculate BMDs that were more accurate and more precise than those that could be derived from either study alone. It was determined that decreased fetal body weight provided the best basis for BMD calculations; BMDs calculated for fetal body weight changes were less than those for all other relevant end points. The appropriate BMD to use as the basis for boric acid reference dose calculation appears to be 59 mg/kg/day, which is very similar to the NOAEL observed in the second of the two studies (55 mg/kg/day). Although the first study failed to establish a NOAEL, the BMD approach could have been applied to that study, thereby avoiding the need for a repeat study. Similar BMD results were obtained in both studies.
The benchmark dose (BMD) corresponding to a low level of the risk of induced disease, e.g., 1 to 10%, has been proposed by various authors as a replacement for the no observed adverse effect level for noncancer endpoints in the regulation of the conditions of exposure to chemicals. This paper focuses on the variability of estimates of the BMD for nonquantal (continuous measurements) of biological endpoints such as are encountered for hematological data, clinical chemistry, and studies of neurotoxic effects. For biological endpoints that can be described by a normal distribution, estimates of the mean and standard deviation are required to calculate the BMD. Estimates of the standard deviation generally are quite variable, particularly for small sample sizes. The purpose of this paper is to examine the precision of the estimates of risk and of the BMD resulting from the inherent variability of the estimates of the standard deviations particularly for bioassays that employ a small number of animals. When the standard deviation is underestimated, the BMD and the regulatory "safe" dose are underestimated. Conversely, when the standard deviation is overestimated, the BMD and safe dose are overestimated. Overestimation of the BMD can be reduced or eliminated by using a lower confidence limit. The worst cases arise where only a few animals are used per dose and the dose response is supralinear (changes rapidly at low doses and levels off at higher doses). If the standard deviation is constant across doses (for lognormally distributed data if the coefficient of variation is constant), a pooled estimate across doses of the standard deviation can be used. In this case, for bioassays employing a total of 40 to 50 animals, the calculation of the BMD will generally be within a factor of 2 of the true value. When the standard deviation is not constant across dose groups, it is desirable to have more than 10 animals per dose group.
A statistical analysis of the NIOSH (National Institute for Occupational Safety and Health) carbon disulfide (CS2) exposure database was conducted for purposes of establishing a benchmark concentration (BMC) for CS2. The analysis addressed the effects of CS2 exposure on the peripheral nervous system and on ischemic heart disease risk factors. The BMC is based on models relating response to exposure determined from statistical analysis of the continuous exposure data for individuals recorded in the NIOSH database. The results demonstrate that changes in the responses associated with increases in CS2 exposure at levels represented in the NIOSH database are relatively small after adjustment for confounders. The only response variables that had statistically significant relationships with CS2 were the peroneal nerve MCV (motor conduction velocity) and the peroneal nerve amplitude ratio. Based on these results, BMCs of 16.2 and 18.5 ppm were derived for MCV and amplitude ratio, respectively.
Reproductive, including developmental, toxicity risk assessment has typically relied on estimation of toxicity criteria values derived from no-observed-adverse-effect levels (NOAELs). The benchmark dose (BMD) approach has been proposed as an alternative that avoids problems with NOAELs. In this analysis of the reproductive and developmental toxicity observed in a multigeneration study of rats exposed to isopropanol, the BMD approach has been applied to all effects exhibiting significant dose-response relationships. The BMD estimates were very consistent across models and across end points; they were within the range of doses (100 to 500 mg/kg/day) that has been suggested as being the NOAEL. The use of the BMD approach for analysis of isopropanol reproductive toxicity is shown to avoid the experiment-specific argument of whether a particular treatment has induced statistically significant differences, compared to controls, in favor of the estimation of experiment-independent doses corresponding to risk levels of interest. The consistency of the BMD estimates, with values of about 420 mg/kg/day, suggests that, for isopropanol, the available multigeneration study data may provide a suitable basis for considering safe exposure.
Safety assessment for noncancer health effects generally has been based upon dividing a no observed adverse effect (NOAEL) by uncertainty (safety) factors to provide an acceptable daily intake (ADI) or reference dose (RfD). Since the NOAEL does not utilize all of the available dose-response data, allows higher ADI from poorer experiments, and may have an unknown, unacceptable level of risk, the benchmark dose (BD) with a specified, controlled low level of risk has become popular as an adjunct to the NOAEL or the low observed adverse effect level (LOAEL) in the safety assessment process. The purpose of this paper is to summarize statistical procedures available for calculating BDs and their confidence limits for noncancer endpoints. Procedures are presented and illustrated for quantal (binary), quasicontinuous (proportion), and continuous data. Quasicontinuous data arise in developmental studies where the measure of an effect for a fetus is quantal (normal or abnormal) but the experimental unit is the mother (litter) so that results can be expressed as the proportion of abnormal fetuses per litter. However, the correlation of effects among fetuses within a litter poses some additional statistical problems. Also, developmental studies usually include some continuous measures, such as fetal body weight or length. With continuous data there generally is not a clear demarcation between normal and adverse measurements. In such cases, extremely high and/or low measurements at some designated percentile(s) can be considered abnormal. Then the probability (risk) of abnormal individuals can be estimated as a function of dose. The procedure for estimating a BD with continuous data is illustrated using neurotoxicity data. When multiple measures of adverse effects are available, a BD can be estimated based on a selected endpoint or the appearance of any combination of endpoints. Multivariate procedures are illustrated using developmental and reproductive toxicity data.
We used the benchmark dose (BMD) methodology devised by Crump (Fundam. Appl. Toxicol. 4, 854-871, 1984) to estimate BMDs for 90-day toxicological data and several fabricated data sets. From a toxicological perspective, dose-response modeling offers certain advantages over using a point estimate, such as the currently used no-observable-adverse-effect level (NOAEL) approach. However, there are many variables associated with the BMD that could be set to produce unreasonable BMD estimates. Some of these variables and decisions are examined in this study. BMDs were calculated for discrete and continuous endpoints using a variety of different variables (e.g., maximum likelihood estimates [MLEs], lower-confidence limits [LCLs], and different risk levels). In addition, the fabricated data sets were manipulated (i.e., dose groups eliminated) and the BMDs recalculated. This process tested how the BMD estimates varied using different forms of the data. For the 90-day toxicological studies, the BMDs were typically within an order of magnitude of the NOAEL for discrete endpoints. For the discrete endpoints, the MLEs were typically greater than the NOAEL and the LCLs were typically less than the NOAEL. The BMD was insensitive to changes in the data points one to two dose groups beyond the NOAEL/LOAEL. With the continuous data, the ratios of MLEs and LCLs to the NOAEL were highly variable, and no general trend could be determined. The BMD methodology offers potential improvements in the risk assessment process since dose-response characteristics are used to calculate the BMD. Depending upon how the BMD is defined, i.e., the form of the dose-response model, and how the BMD is used in the risk assessment process, BMD estimates may produce reference doses/concentrations that are more or less conservative than the NOAEL approach. Active involvement in discussions with regulatory agencies is needed to ensure that inappropriate models and unreasonable BMDs are not used. In addition, further discussions on how BMDs should be used in the risk assessment process are needed.
The search for models or "benchmarks" that reflect the successful application of total quality management (TQM) to the mental health field is one that goes largely unrewarded. This article describes a case study of one comprehensive mental health center that has made a serious commitment to the philosophy and principles of TQM and that is reaping significant benefits from that effort.
The dose-effect relationships were analysed for several noncarcinogenic endpoints, such as immunological and biochemical responses at subchronic, low dose exposure of female C57BL/6 mice to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). The animals were treated i.p. with TCDD according to the initial- and maintenance-dose principal for a period of 135 days. The initial doses were 1, 10 and 100 ng TCDD/kg, the weekly maintenance doses were 0.2, 2 and 20 ng TCDD/kg, respectively. At days 23, 79 and 135 of TCDD/kg, treatment 10 animals of each dose group were killed. As immunological parameters the number of thymocytes and the pattern of thymocyte subpopulations were determined. In liver, lung and thymus, mRNA expression of TGF-alpha, TGF-beta(1), TGF-beta(2), TGF-beta(3), TNF-alpha, IL-1 beta and different CYP1 isoforms (CYP1A1, CYP1A2, CYP1B1) was analysed. In the livers, activities of 7-ethoxyresorufin-O-deethylase (EROD) and 7-methoxyresorufin-O-demethylase (MROD) were measured. TCDD content in the liver was determined. The main results are summarized as follows: (1) The TCDD doses were not sufficient to elicit dose-dependent changes of pattern of thymocyte subpopulation. (2) TCDD failed to change the mRNA expression of TGF-alpha, TGF-beta and TNF-alpha, but led to an increase of IL-1 beta mRNA expression in liver, lung and thymus. The results show that the TCDD induced IL-1 beta mRNA increase is at least as sensitive a marker as the induction of CYP1A isoforms. (3) The expression of CYP1B1 mRNA remained unchanged at the doses tested, while CYP1A1 and CYP1A2 mRNA expression was dose-dependently enhanced. EROD and MROD activities in the liver paralleled the increases of CYP1A1 and CYP1A2 mRNA expression. (4) Regression analysis of the data showed that most of the parameters tested fit a linear model. (5) From the data, a benchmark dose for EROD/MROD activities in the livers of female C57BL/6 mice of about 0.03 ng TCDD/kg per day was calculated.
The CPU time required to complete a cycle of restrained least-squares refinement of a protein structure from X-ray crystallographic data using the FORTRAN codes PROTIN and PROLSQ are reported for 48 different processors, ranging from single-user workstations to supercomputers. Sequential, vector, VLIW, multiprocessor, and RISC hardware architectures are compared using both a small and a large protein structure. Representative compile times for each hardware type are also given, and the improvement in run-time when coding for a specific hardware architecture considered. The benchmarks involve scalar integer and vector floating point arithmetic and are representative of the calculations performed in many scientific disciplines.
A new transducer capable of direct measurement of time-dependent loads in human lumbar facet joints was developed and tested. The transducer was comprised of a force-sensitive resistor (FSR) in series with a pressure-sensitive film. A wide range of experiments revealed the performance attributes and limitations of the FSR. The output signal of the FSR is actually sensitive to both force and area of contact independently. Therefore, a pressure-sensitive film was used to quantify the contact area. At least two transformation equations were calculated for each FSR corresponding to known contact areas. Each equation was a linearization of the log of the FSR output vs the log of the applied ramp loads. Coefficients of determination (CD) were calculated for small (21 mm2) and large (32 mm2) contact areas, and were found to exceed 0.900 for all data. The average of nine cycles was nearly linear for some FSRs (CD of 0.999). FSR output signal and contact area were recorded in cadaveric lumbar facets under ramp load. The appropriate transformation equation was determined by a linear interpolation between benchmark equations based on the contact area measured in vitro. Facet force measurements compared well with those of other researchers. The transducer was found to be quite easy to use.
The field of computational neurobiology has advanced to the point where there are several general-purpose simulators to choose from. These cater to various niches in the world of realistic neuronal models, which range from the molecular level to descriptions of entire sensory modalities. In addition, there are numerous custom-designed simulations, adaptations of electrical circuit simulators, and other specific implementations of neurobiological models. As a first step towards evaluating this disparate set of simulators and simulations, and towards establishing standards for comparisons of speed and accuracy, we describe a set of benchmarks. These have been given the name 'Rallpacks' in honor of Wilfrid Rall, who pioneered the study of neuronal systems through analytical and numerical techniques.
The benchmark dose (BMD) concept was applied to 246 prenatal-developmental toxicity (DT) datasets from government, industry and commercial laboratories. Five modeling approaches were used, 2 generic and 3 specific to DT models. BMDs for both quantal and continuous data were compared with statistically derived no observed adverse effect levels (NOAELs) to determine similarities. Quantal (Q) endpoints included litter responses (e.g., one or more dead or malformed implants), and QBMDs were calculated using a Q Weibull (QW) model. Two types of continuous (C) data were modeled, the proportion of implants affected per litter, and the change in fetal weight (both mean and distribution); continuous power (CP) and DT models were used to calculate CBMDs. QBMDs for a 5% change in response (QBMD05) were 6-fold lower, on average, than the corresponding NOAEL. CBMD05s on average were similar to the corresponding NOAELs, and CBMD05s from different models were similar to each other. Including litter size but not threshold improved the fit of the DT models. For fetal weight data, specific cutoff values were used to calculate BMDs that were similar on average to the corresponding NOAELs: (1) changes from the control mean (5% of the mean, 25th percentile of the control distribution, or a decrease of 0.5 standard deviation), and (2) a 5 or 10% decrease in the proportion of fetuses below the 5th or 10th percentile, respectively, of the control distribution. These results support the use of BMDs as providing a more consistent basis for risk assessment than do NOAELs.
In the previous study, we found the feasibility of a cyclotron-based BNCT using the Ta(p,n) neutrons at 90 degrees bombarded by 50 MeV protons, and the iron, AlF(3), Al and (6)LiF moderators by simulations using the MCNPX code. In order to validate the simulations to realize the cyclotron-based BNCT, we measured the epithermal neutron energy spectrum passing through the moderators with our new spectrometer consisting of a (3)He gas counter covered with a silicon rubber loaded with (nat)B and polyethylene moderator and the depth distribution of the reaction rates of (197)Au(n,gamma)(198)Au in an acrylic phantom set behind the rear surface of the moderators. The measured results were compared with the calculations using the MCNPX code. We obtained the good agreement between the calculations and measurements within approximately 10% for the neutron energy spectra and within approximately 20% for the depth distribution of the reaction rates of (197)Au(n,gamma)(198)Au in the phantom. The comparison clarified a good accuracy of the calculation of the neutron energy spectrum passing through the moderator and the thermalization in a phantom. These experimental results will be a good benchmark data to evaluate the accuracy of the calculation code.