Use of severity of illness to evaluate quality of care.

This study compared a severity of illness system (APACHE II) and a 10% random sample of charts in terms of their ability to identify cases with quality problems. Using condition-specific data bases of 337 pneumonia, 363 acute myocardial infarction and 266 hip fracture charts, severity of illness information was used to separate cases into those with a high and a low likelihood of a poor outcome. Cases with low admission severity of illness combined with subsequent death were flagged as potential quality problems. Physician evaluation was used as the gold standard to measure flag performance. Flags were tested against a 10% random sample drawn from within the three condition-specific data bases. Analyses focused on a combination of sensitivity and positive predictive value. The low severity plus death flag performed much better than a 10% random sample approach, suggesting that outcomes monitoring flags based on severity of illness could play an important role in screening cases for potential quality problems.

Hospital reimbursement in Alberta: outcomes management is on the way.

The Alberta government has initiated a process to alter fundamentally the way it pays hospitals. As with most provinces, Alberta has been paying hospitals for what they spend. The new Alberta model will initially pay hospitals for what they do and ultimately will pay hospitals for what they ought to do; that is, for the outcomes that should be achieved. This article describes the initial step of what is expected to be a lengthy journey. The principles underlying the model are: it should be a prospective case-based system; there should be performance linkages between types of hospitals; severity should be incorporated into the model; and cost or cost proxies should be used where possible in weight development and clinical concerns, both nursing and medical, should be addressed. For the past two years funding adjustments have been made on the basis of the calculation of a Hospital Performance Index (HPI). The HPI is the average predicted cost per case divided by the unweighted average actual cost per case. The HPI is intended as an interim measure only. Ultimately, the system will evolve into a true prospective case-based system with volume controlled via role statements and linked to clinical outcomes.

Oral glucose tolerance during the menstrual cycle in normal women and women with alleged premenstrual "hypoglycemic" attacks: effects of naloxone.

To resolve existing controversies about the impact of the menstrual cycle on oral glucose tolerance, we examined the glucose, insulin, and glucagon responses to an oral glucose challenge at different phases of the menstrual cycle in five normal women (NW) and six women with premenstrual syndrome and alleged premenstrual hypoglycemic attacks (PMHA). Responses to oral glucose did not differ significantly between follicular and luteal phase studies in either group, nor were significant differences found between the responses of NW and women reporting PMHA. In parallel studies, the possible glucoregulatory effects of endogenous opiates were assessed. Concomitant infusion of naloxone altered neither the basal concentrations of glucose, insulin, and glucagon nor the responses of these measures to the glucose challenge. We conclude that NW and women with premenstrual syndrome and alleged PMHA have no menstrual cycle-related changes in glucose, insulin, or glucagon responses to an oral glucose load. The fact that four of six PMHA subjects had symptoms typical of hypoglycemia at glucose nadirs above 50 mg/dl suggests that an explanation other than hypoglycemia must be sought for such symptomatic episodes. Endogenous opiate peptides appear to exert no glucoregulatory effects at naloxone-sensitive receptor sites.

The pulmonary vascular effects of three prostaglandin I2 analogs in conscious newborn lambs.

Pulmonary and systemic vascular effects of three stable prostaglandin (PG) I2 analogs were studied in normoxic and hypoxic conscious newborn lambs. The three agents were : (5E)-6a-carba-PGI2 (analog I); 9-deoxy-9 alpha, 6-nitrilo-PGF1 hydrochloride (analog II); and (2E,5S)-9-deoxy-5,9 alpha-epoxy-13,14-dihydro-delta 1-PGF1 (analog III). Each component was injected into either a branch pulmonary artery or the ascending aorta. Locally induced alterations in pulmonary vascular tone were assessed from changes in the ratio of blood flow to the injected lung over total flow (delta Qinj/Qt). Each compound was a systemic vasodilator, with thresholds from 1 to 3 micrograms/kg. However, analog III was without local pulmonary vasoactivity, and analog I was a pulmonary vasodilator only at the highest dose used (30 micrograms/kg) and in hypoxic lambs. Analog II, in contrast, was a pulmonary vasodilator in both hypoxic (threshold = 3 micrograms/kg) and normoxic (threshold = 10 micrograms/kg) lambs. Moreover, only analog II mimicked PGI2 during hypoxia by decreasing vascular resistance in the injected lung more than systemic resistance. These results demonstrate that PGI2 analogs are vasodilators with variable activity on the pulmonary and systemic circulations of the newborn lamb. Of the three analogs tested, only analog II resembles PGI2 in being more specific for the pulmonary as opposed to the systemic circulation. Analog II, however, is less active than PGI2 in this regard.