Managing competition in the health care industry.

Health-care decisions made by consumers are generally not made by informed choice. Hospitals, expanding their market beyond physician referrals, are discovering that consumers are interested in taking a more active role. Managed-competition programs may be one of the first concepts to fine-tune a new broad-based health-care system.

Effective internal marketing: the challenge of the 1990s.

Results of a recent public opinion study suggest that health care provider organizations are not taking advantage of several important public relations and internal marketing channels to educate the public through their employees. As increasing pressures on health care providers from other segments of the health care industry result in reduced revenues, lower margins, and downsizing, health care marketers and public relations managers should reassess their internal marketing efforts.

Nucleoside diphosphatase and 5'-nucleotidase activities of soybean root nodules and other tissues.

Nucleoside diphosphatase and 5'-nucleotidase activities were both found to be very high in extracts of soybean (Glycine max L.) root nodules. Both activities increased early in soybean nodule development, prior to the rise in leghemoglobin, and both were found at equivalent levels in nitrogenfixing and nonfixing nodules. Based on a survey of other tissues, these activities were both highest in soybean nodules (1300 nanomoles per milligram protein per minute, nucleoside diphosphatase and 500 nanomoles per milligram protein per minute, 5'-nucleotidase), but they were not always associated with each other; in some tissues one was high and the other low. Neither activity correlated well with ureide production; both seem, rather, to be primarily involved in some other metabolic function. Both the nucleoside diphosphatase and 5'-nucleotidase of soybean nodules were soluble proteins, and neither appeared to be associated with plastids, mitochondria, or bacteroids.

Purification and characterization of a specific nucleoside diphosphatase from soybean root nodules.

A specific nucleoside diphosphatase was purified from the plant portion of soybean (Glycine max L.) root nodules. This enzyme is highly specific for nucleotide diphosphates; it is unable to hydrolyze nucleotide tri- and monophosphates or a variety of other phosphorylated compounds. It will, however, hydrolyze any nucleotide disphosphate tested. The pH optimum of the enzyme is about 7.5; it requires a divalent cation for activity; and it is neither inhibited nor activated by any of the metabolites tested. It appears that in vivo this enzyme would be very active, but its function is not clear.

Standard planning for new programs.

Health-care executives need to eliminate "gut feel" decisions with a standardized approach to business planning, such as Baxter Healthcare Corp.'s Healthcare Business Planner. The author illustrates how University Hospitals of Cleveland used this model to determine the feasibility of an ambulatory center dedicated to systemic lupus erythematosus.

Site of Synthesis of the Enzymes of the Pyrimidine Biosynthetic Pathway in Oat (Avena sativa L.) Leaves.

Heat-bleached oat (Avena sativa L. cv Porter) leaves lacking 70S chloroplast ribosomes have been used to demonstrate that four chloroplast-localized enzymes of pyrimidine nucleotide biosynthesis: aspartate carbamoyl-transferase, dihydroorotase, orotidine phosphoribosyl-transferase, and orotidine-5'-phosphate decarboxylase, are synthesized on cytoplasmic ribosomes. Two other chloroplast enzymes, carbamoyl phosphate synthetase, involved in both pyrimidine and arginine biosynthesis, and ornithine carbamoyltransferase, an enzyme of arginine biosynthesis, were also shown to be made on 80S ribosomes.

Organization of the pathway of de novo pyrimidine nucleotide biosynthesis in pea (Pisum sativum L. cv Progress No. 9) leaves.

The organization of the enzymes of de novo pyrimidine nucleotide biosynthesis in pea (Pisum sativum L. cv Progress No. 9) has been studied. The first three enzymes of the pathway, carbamoyl-phosphate synthetase, aspartate carbamoyltransferase, and dihydroorotase, are readily separable from one another; they are not part of a multifunctional complex. The final two activities of the pathway, orotate phosphoribosyltransferase and orotidylate decarboxylase, copurify and appear to be complexed in vivo. This organizational pattern is distinct from those reported for bacteria, yeast, and mammals. The differences in organization, in a pathway which is present in all organisms, make the pyrimidine biosynthetic pathway a very interesting candidate for evolutionary studies.

Subcellular localization of the pathway of de novo pyrimidine nucleotide biosynthesis in pea leaves.

The subcellular distribution of the enzymes of de novo pyrimidine nucleotide biosynthesis was investigated in pea (Pisum sativum L. cv Progress No. 9) leaves. Aspartate carbamoyltransferase, the committed step of the pathway, was found to be strictly confined to the chloroplasts. Dihydro-orotase, orotate phosphoribosyl transferase, and orotidine decarboxylase activities were also found only in the plastids. The remaining enzyme of the pathway, dihydroorotate dehydrogenase, was shown to be mitochondrial.

Implications of DRG payments for medical intensive care.

Patients in the most prevalent DRGs in a Medical Intensive Care Unit (MICU) were compared with their counterparts who received only routine hospital care on adjusted total hospital costs and length of stay. Costs for both groups were compared with estimated DRG payments under an all-payer system. For patients in three DRGs, measures of severity of illness were examined as predictors of costs. Significant differences between MICU and routine care patients were found in 10 of 13 DRGs studied; intensive care costs were substantially above overall payment rates. The severity of illness measures varied widely in their correlation with costs, depending on DRG and whether the patients were MICU or routine care. These apparent differences in accounting costs may result in hospital decisions to restrict the number of MICU beds. Severity of illness adjustments to DRGs might produce more equitable payments. The most useful measure of severity may differ, however, depending on DRG.

Health care 2000.

During the past two decades, the health care industry has become an economic giant growing from 6.1% ($42.0 billion) of the gross national product in 1965 to an estimated 10.7% ($354.6 billion) in 1983. The industry is now the nation's third largest. The underlying causes of this remarkable growth include an open-ended reimbursement system, insatiable demand, and the lack of traditional market forces that encourage efficiency. Unfortunately, the nation cannot continue to allocate an increasing share of its gross national product to health care, for to do so would mean that other important sectors of the economy would experience either retarded growth or a decline in real terms. By the 2000, fundamental elements of the health care system will have undergone a major metamorphosis which hopefully will result in a more efficient and effective allocation of the health care dollar. This article will offer an overview of the changes likely to occur in sections of the health care environment of major concern to the health care planner.

Strategic market planning for hospitals.

The application of strategic market planning to hospital management is discussed, along with features of the strategic marketing management process. A portfolio analysis tool, the McKinsey/G.E. Business Screen, is presented and, using a large urban hospital as an example, discussed in detail relative to hospital administration. Finally, strategic implications of the portfolio analysis are examined.

Data quality. An illustration of its potential impact upon a diagnosis-related group's case mix index and reimbursement.

The Health Care Finance Administration has developed a Medicare reimbursement methodology that will include an adjustment factor for hospital case mix. The patient classification scheme proposed for use in determining a hospital's case mix is the AUTOGRP Diagnosis-Related Groups (DRG) methodology developed at Yale University. The reliability of a case mix measure calculated using the DRG methodology is dependent on complete and accurate diagnostic and surgical data. The source of this data for the HCFA data base (MEDPAR) is the Medicare billing form, which is based on the patient medical record. Data from the MEDPAR file, the original medical record discharge order, and a reabstracted record are compared and analyzed for their effect upon DRG classification and the resultant Medicare reimbursement ceiling for one large teaching hospital. The study results show widely divergent diagnostic and surgical data that results in a significant variation in DRG classification and reimbursement ceilings.

DRGs may be raising false expectations.

The development of diagnosis related groups has fed what may be unrealistic hopes for their wide application.

Evidence that sulfisoxazole, an antibacterial sulfonamide, can adversely affect the development of Brugia pahangi in Aedes aegypti mosquitoes.

The average number of infective larvae recovered from Brugia pahangi-infected Aedes aegypti was approximately one-half that recovered from the controls after the former group of infected mosquitoes had ingested a 1.0% solution of sulfisoxazole diolamine (SXZ) in 10% sucrose-water for 4 consecutive days, beginning 4 days after infection. Most of the filarial larvae from the SXZ-treated mosquitoes were small and sluggish compared with those from the controls. There was no increased mortality of mosquitoes that ingested 1.0% SXZ in sugar-water for 4 days. Average filarial larval burdens were not decreased in mosquitoes that ingested a solution of 10(-6) M methotrexate (MTX), a potent dihydrofolate reductase inhibitor, in sugar-water for 4 days, beginning 4 days after infection. The distributional pattern of larval burdens in mosquitoes that ingested combined 1.0% SXZ and 10(-6) M MTX in sugar-water for 4 days closely resembled that seen in mosquitoes that had imbibed 1.0% SXZ only. Average filarial larval burdens were not decreased in mosquitoes with 4-day-old B. pahangi infections that fed upon jirds which received intraperitoneal injections of SXZ (2 g/kg) and MTX (1 mh/kh), alone and in combination, 1 hr previously. Survival of the mosquitoes that fed upon the drug-treated hosts was unaffected, as was the hatchability of their eggs and subsequent growth and development of the mosquito larvae.

Comparative activity and properties of lactate dehydrogenase, xanthine dehydrogenase, and dihydrofolate reductase in normal and Brugia pagangi-infected Aedes aegypti.

The amount of xanthine dehydrogenase (XDH), dihydrofolate reductase (DHFR), and lactate dehydrogenase (LDH) in crude extracts of 4- to 5-day-old adult Aedes aegypti was determined, and the properties of these enzymes were partially characterized. It was then found that the amount and other selected characteristics of XDH and LDH in extracts of female Ae. aegypti processed 5 to 7 days and 12 to 14 days after they had fed upon either normal or Brugia pahangi-infected jirds were indistinguishable from those of these two enzymes in extracts of female mosquitoes that did not have a blood meal. Under the same circumstances, the selected characteristics of DHFR were also unaffected. However, there was a suggestion that the amount of DHFR was slightly increased in extracts of female Ae. aegypti processed 5 to 7 days after they had fed upon B. pahangi-infected jirds; by 12 to 14 days after the blood meal, there was a consistent 30% to 60% increase in the amount of DHFR inextracts of infected mosquitoes. DHFR activity could not be detected in a similarly prepared extract of 4,000 to 5,000 infective (L-3) B. pagangi larvae, the approximate number present in the infected mosquito extracts. It would appear, therefore, that the increased amount of turnover of DHFR in the mosquito host occurs in response to advanced infection with B. pahangi.

Activity of tubercidin against immature Fasciola hepatica in mice.

HaM/ICR females mice (20 to 25 g), infected with from 3 to 5 Fasciola hepatica metacercariae per os, were treated with a single dose of thepurine nucleoside analog tubercidin (7-deaza-adenosine; Tu) 7, 14, 21, and 28 days postexposure.Tu was administered either by direct intravenous injection or intraerythrocytically. Most of the flukes were killed and host survival rates were markedly increased if treatment was started within 3 weeks postexposure. The minimal single intravenous dose of Tu that was maximally effective was between 10 and 20 mg/kg.

Treatment of schistosomiasis mansoni and japonica in baboons with tubercidin given by direct intravenous injection.

Baboons (Papio cyanocephalus and P. anubis), infected with Schistosoma mansoni or S. japonicum, were treated with single doses of tubercidin (7-deazaadenosine; Tu), 1, 3, and 5 mg per kg of body weight, administered by intravenous drip. Crystalline Tu was dissolved in sterile 0.9% NaCl solution (1 mg per ml), and the solution was delivered at a rate of 4 ml per minute. Detectable short-term host toxicity was limited to the 5 mg per kg dose, mainly in the form of reversible mild to moderate kidney damage. Only this 5 mg per kg dose administered to baboons with relatively heavy S. mansoni infections was capable of completely suppressing fecal egg excretion for 6 to 8 weeks, eliminating the female worms, and terminating active disease, as indicated by histopathological findings. Comparable effects were achieved following the administration of the 3 mg per kg dose to baboons with moderate to heavy S. japonicum infections.

Long-term efficacy of tubercidin against schistosomiasis japonica and mansoni in primates.

Schistosomiasis japonica in capuchin msnkeys (Cebus apella) and schistosomiasis mansoni in baboons (Papio cyanocephalus and P. hamadryas) were completely arrested for 6 months in every infected primate receiving a single treatment with tubercidin (Tu), administered after prior absorption into 20% of their red cells. It is very likely that a single treatment with Tu sequestered in only 15% of the hosts' red cells would also be 100% effective for prolonged periods of time, but that with lower doses some relapses would be expected. Babbons with patent Schistosoma mansoni infections were rechallenged with S. mansoni cercariae 4 months after treatment with Tu. Although Tu eliminated almost all the sexually mature female worms from the primary infection but spared most of the males for continuing sojourn within their hosts, the baboons retained their full susceptibility to reinfection, as indicated by worm burdens and fecal egg excretion. However, the granulomatous reaction in the rechallenged Tu-treated baboons to new masses of eggs trapped in their livers appeared to be less intense than was seen in animals with primary infections.