Performance of succinylacetone assays and their associated proficiency testing outcomes.

BACKGROUND: Succinylacetone (SUAC) is the primary metabolic marker for hepatorenal tyrosinemia. MATERIALS AND METHODS: We used results reported for dried-blood-spot proficiency testing (PT) specimens and hepatorenal tyrosinemia patients' newborn screening (NBS) samples to demonstrate analytic biases in SUAC recoveries and differences in presumptive clinical classifications. RESULTS: SUAC recoveries from non-kit and NeoBase™ kit tandem mass spectrometry methods were markedly different. Kit users that set high cutoff values submitted discordant clinical assessments of "within normal limits" for PT specimens enriched with 10-15 µmol SUAC/L in blood. SUAC levels in tyrosinemia patients' NBS samples analyzed by NeoBase™ kit were lower than those in samples analyzed by non-kit methods. CONCLUSIONS: From 2009 to 2011, analytic biases in SUAC recoveries were consistent. Discordant clinical assessments of PT specimens were associated with high cutoff values for NeoBase™ kit results. Method-related differences in SUAC concentrations of tyrosinemia patients' samples were consistent with those of PT specimens.

The stability of markers in dried-blood spots for recommended newborn screening disorders in the United States.

OBJECTIVE: We aimed to measure separately the contributions of heat and humidity to changes in levels of 34 markers of inborn disorders in dried-blood-spot (DBS) samples. DESIGN AND METHODS: We stored paired sets of DBSs at 37°C for predetermined intervals in low-humidity and high-humidity environments. Marker levels of all samples in each complete sample set were measured in a single analytic run. RESULTS: During the 30 ± 5 day studies, galactose-1-phosphate uridyltransferase and biotinidase lost almost 65% of initial activities in low-humidity storage; most of the degradation in 27 other markers was attributable to adverse effects of high-humidity storage; seven markers in DBSs stored at high humidity lost more than 90% of initial levels by the end of the study and 4 of the 7 lost more than 50% of initial levels within the first week of storage. CONCLUSIONS: Minimizing both humidity and temperature in DBS transportation and storage environments is essential to maintaining sample integrity.

The preparation and storage of dried-blood spot quality control materials for lysosomal storage disease screening tests.

OBJECTIVE: We aimed to prepare dried-blood spot (DBS) quality control (QC) materials for lysosomal storage disease (LSD) screening tests and to determine optimum blood and DBS storage conditions. METHODS: We compared enzyme activities of five LSD markers in adult blood, umbilical-cord blood, and leukocyte-reduced blood. We measured activities in liquid blood and DBSs after predetermined intervals at controlled temperatures and humidities. RESULTS: Lysosomal-enzyme activity levels in umbilical-cord blood mimicked those in newborn screening samples. Lysosomal-enzyme activities in leukocyte-reduced blood were lower than in LSD-positive patient samples. Enzyme activities were stable in refrigerated liquid blood for 32 days and in frozen DBSs stored at low humidity for a year. Activity losses from DBSs after 34 days at 37±1°C were 35%-66% in low humidity and 61%-100% in high humidity. CONCLUSIONS: Umbilical-cord blood is the preferred matrix for LSD-normal DBS QC materials. Leukocyte-reduced blood is lysosomal enzyme-deficient. Failure to control humidity during DBS storage results in loss of lysosomal-enzyme activities.

A cost-effectiveness analysis of the application of nitric oxide versus oxygen gas for near-term newborns with respiratory failure: results from a Canadian randomized clinical trial.

OBJECTIVE: To conduct a cost-effectiveness analysis of the use of inhaled nitric oxide (NO) vs. oxygen administered to near-term (gestational age > or =34 wks) newborns with severe respiratory illness that were referred for consideration of extracorporeal membrane oxygenation (ECMO). DESIGN: The cost-effectiveness analysis is based on outcome and utilization data from two multicentered randomized clinical trials conducted by the Canadian Inhaled Nitric Oxide Study group, one for patients with congenital diaphragmatic hernia (CDH) and one for patients without CDH. Data from the western Canadian ECMO center were used to establish costs. SETTING: Patients were cared for in Canadian regional neonatal intensive care units, including two ECMO centers. Air transport was used for transporting patients between centers. PATIENTS: Term and near-term newborns with severe respiratory illness who were receiving maximum conventional therapy and whose oxygenation index was >40. INTERVENTIONS: Patients randomly received NO or oxygen. If their conditions deteriorated, they qualified for ECMO. Not all that qualified for ECMO received it because of individual parent/ physician preferences. MEASUREMENTS AND MAIN RESULTS: The cost-effectiveness ratio was the ratio of net cost (including neonatal intensive care, ECMO, and transport) to net outcome (survival) for the two interventions. For non-CDH cases, the cost-effectiveness ratio was $36,613 (Canadian) per life saved; the confidence intervals were wide and the results were not statistically significant. For CDH patients, the death rate was lower for oxygen and the oxygen patients cost less; the results were not statistically significant. CONCLUSIONS: The small numbers of patients in the trials precluded significant results. Further, our results have a short-term time horizon (discharge to home or death). Thus, for non-CDH patients, the favorable ratio provides very qualified evidence in favor of NO.

Dialectic between conceptual and causal inquiry in psychosocial work-environment research.

In this article, the authors discuss the ongoing tension between etiologically oriented research--particularly that focused on the demand-control model--and the need to conceptually expand the work stress field to include gender and class-specific exposure contexts. Epidemiological research on the effects of low levels of work control is critically reviewed, and new methods of long-term psychosocial work-exposure assessment are presented. The process of conceptually expanding the demand-control model is discussed with respect to including other important variables, such as work-related social support, and specifying the nature of the gendered work process that involves developing new concepts and measures of the invisible and emotional labor often performed by women.

Long-term psychosocial work environment and cardiovascular mortality among Swedish men.

OBJECTIVES: This study examined the effect of cumulative exposure to work organization--psychological demands, work control, and social support on prospectively measured cardiovascular disease mortality risk. METHODS: The source population was a national sample of 12517 subjects selected from the Swedish male population by Statistics Sweden in annual surveys between 1977 and 1981. Over a 14-year follow-up period, 521 deaths from cardiovascular disease were identified. A nested case-control design was used. Work environment exposure scores were assigned to cases and controls by linking lifetime job histories with a job exposure matrix. RESULTS: Conditional logistic regression analysis was used in examining cardiovascular mortality risk in relation to work exposure after adjustment for age, year last employed, smoking, exercise, education, social class, nationality, and physical job demands. In the final multi-variable analysis, workers with low work control had a relative risk of 1.83 (95% confidence interval [CI] = 1.19, 2.82) for cardiovascular mortality. Workers with combined exposure to low control and low support had a relative risk of 2.62 (95% CI=1.22, 5.61). CONCLUSIONS: These results indicate that long-term exposure to low work control is a risk factor for cardiovascular disease mortality.

PIP: The physical effects of aspects of work organization in Sweden is explored using data on a sample of 12,517 individuals. The data were drawn from official surveys carried out between 1977 and 1981 and followed up for 14 years. The results indicate that long-term exposure to such psychosocial factors as low levels of work control in the work place is associated with increased risk of mortality from cardiovascular disease.

Estimating the cost of outpatient hospital care.

Hospital services can be divided into inpatient, outpatient and non-patient areas; outpatient care can be further subdivided into emergency room care, general and special clinic care, day procedures and non-admitted day/night care. Using 1992-93 Statistics Canada data on expenditures and outpatient activity from the Part One form for 29 Alberta hospitals, we estimated the average cost of each of the four outpatient areas. The estimated cost per visit was $183 for clinic visits, $166 for day/night care, $69 per emergency visit and $627 per day procedure. These estimates can be used in cost-effectiveness studies and, if supplemented with outpatient case weights and volumes, in provincial funding systems.

The psychosocial work environment of physicians. The impact of demands and resources on job dissatisfaction and psychiatric distress in a longitudinal study of Johns Hopkins Medical School graduates.

This study examines the relationship between the psychosocial work environment and cross-sectional job dissatisfaction and prospective psychiatric distress in a cohort of Hopkins Medical School graduates in midcareer. An instrument was constructed consisting of five scales: psychological job demands, patient demands, work control, physician resources, and coworker support. The results of scale reliability and factor analysis are presented. Higher job demands were found to be associated with increases in job dissatisfaction and psychiatric distress and greater resources were associated with decreased levels of dissatisfaction and distress. In multiple-regression analysis, only work control and social support were found to be independently associated with dissatisfaction and distress. These results suggest that the presence of control and social support at work protects physicians from developing job dissatisfaction and psychiatric distress.

Alberta's acute care funding plan: update to December 1994.

From 1990 until 1994 Alberta Health adjusted the acute care portion of hospital budgets based on a case mix index, initially called the Hospital Performance Index (HPI). The HPI formula method was a temporary measure; in November 1993, Alberta Health announced that, commencing in 1994, hospitals would be funded on a prospective basis, although they would still use the core of the HPI in the setting of funding rates. The creation of 17 health regions in June 1994 created the need for a new system of funding which would supplant the modified prospective system. In this paper we review the evolution of the HPI plan and its individual components-patient data, patient classification, funding weights, inpatient costs and adjustment factors.

Emergency care episodes: an economic profile.

A new "episode of care" definition of emergency care was developed, consisting of the emergency department encounter and all subsequent, related care delivered within 48 hrs from the initial contact. Data were analyzed by ICD-9-CM Major Diagnostic Category (MDC) and surgical intervention using 1.6 million episodes generated by 809,145 separate patients from a national claims database. Secondary/adjunct services were a major component of episode charges. For several MDCs, hospitalization and/or surgical procedures were also major determinants of overall episodic charges. Results support the premise that economic analysis and reimbursement of emergency care benefits from the use of episodic data.

Key operating and financial ratios for Alberta hospitals.

Comparative financial and operating ratios in Canadian hospitals are examined to reveal sources of increased efficiency. The study involved 70 Alberta hospitals, which were divided into three groups: teaching hospitals, regional hospitals and smaller rural hospitals. Data were obtained from HS-1 and HS-2 reports. Hospitals across Canada can calculate their own ratios to give them a general idea of how they compare with the hospitals in this report.

Women, occupation, and risk of cardiovascular morbidity and mortality.

Despite the many investigations of male workers, little is known about cardiovascular risk attributable to occupational class or occupational exposures among women. Results from a previous investigation suggest that the relationship between these factors may be different in women, for whom lack of workplace social support may be important in cardiovascular morbidity. The finding that women in blue-collar occupations had over three times the rate of coronary heart disease compared with their white-collar equivalents is intriguing. Modest and inconclusive data about the relationship between occupational stress and health status in women suggest that class and level of control may be of importance in women's experience of occupational stress.

Funding in-hospital same-day surgery in Canada.

The significant advantage of replacing global (i.e., cost-based) ambulatory funding with the same dollar value of case mix (i.e., input-based) ambulatory funding is that the fundamental basis for funding has been altered. First of all, it is widely believed that case mix-based funding establishes even more compelling incentives for hospitals to control resource utilization and costs without reducing service volumes than global systems. Case mix also represents a more precise policy instrument for ministries of health because incentives (e.g., different funding rates for various types of day surgery) can easily be incorporated to direct the composition of services rather than merely limit total hospital day surgery expenditures, as is currently done. Using the hybrid global/case mix day surgery funding system described above, funding policies can be designed to control both total cost and case mix composition while at the same time introducing incentives toward increasing ambulatory services. Although historical funding inequities remain unrectified, further inequities as ambulatory surgery volumes or case mixes change can be avoided.

Degradation of nitriles and amides by the immobilized cells of Pseudomonas putida.

Pseudomonas putida, capable of utilizing acetonitrile as a sole source of C and N, was immobilized in calcium alginate and the rates of degradation of nitriles, including acetonitrile, and their respective amides were studied. All the organic nitriles and amides tested were converted into NH3 and CO2.

Double exposure: the combined impact of the home and work environments on psychosomatic strain in Swedish women and men.

This study investigates the relative distribution of home responsibilities and psychosocial work environment characteristics and their associations with psychosomatic strain in a random sample of the female and male working population of Sweden (N = 12,772). Occupational variables investigated were psychological and physical demands, job control, social support, and job hazards. Home characteristics included measures of household work, number and age of children, and child care resources. A sex-pooled logistic regression analysis was performed to detect sex differences in the effects of the variables upon strain. Gender was no longer associated with psychosomatic strain after adjusting for work and home characteristics and their interactions, and while there were some similarities between the sexes with respect to the main effects of the home and work characteristics, in 52 of 60 combined effect comparisons women had a greater combined odds ratio for strain than men.

Alberta's Acute Care Funding Project.

Alberta initiated the Acute Care Funding Project (ACFP) in 1988, a new hospital funding system that institutes case mix budgeting adjustments to the global budget so that hospitals can be treated more equitably. The initiative is a significant departure in principle from the former method of funding. The ACFP is summarized and critiqued, and focuses on the inpatient side of the picture. The various elements of the project are discussed, such as the hospital performance index, the hospital performance measure, the Refined Diagnostic Related Group, case weights, typical and outlier cases, and the costing mechanisms. Since its implementation, the ACFP has undergone substantial changes; these are discussed, as well as some of the problems that still need to be addressed. Overall, the system offers incentives to reduce length of stay and to increase the efficiency with which inpatient care is provided.

A hospital capital price index.

This paper describes the development of a price index for hospital equipment. Based on 10 years of hospital capital acquisition data from a large teaching hospital, equipment acquisitions were categorized and weights derived for each category. Using national producer price indexes for each of these categories, a national hospital equipment index was derived for 1981 to 1991. Forecasts for 1991 and 1992 were then made. The resulting index indicated that price movements of our hospital capital equipment index were very similar to the Implicit Gross Domestic Product Deflator, an index that measures price changes for the nation's Gross Domestic Product. However, because of the relative importance of several categories of equipment (scientific instruments, computers), more widespread data on hospital equipment expenditure patterns would be desirable in order to validate these results.

Smoking and sedentary behavior as related to work organization.

There is little research which has investigated whether working life may affect health behaviors. However, there is data suggesting that smoking as well as leisure activities are affected during times of stress. Both theoretical work and research suggests that work may socialize people such that the use of leisure time for active pursuits, including exercise, may be contingent upon jobs which promote interaction, learning, and activity on the job. In investigating whether the psychosocial structure of work might affect smoking and sedentary behavior, a subsample (n = 7.201) of a representative sample of the Swedish population aged 16-65 years was selected for study. Reports on job characteristics and health behaviors were obtained in personal or telephone interviews and a logistic regression analysis was performed. In general, job demands like shift work, piece work, hazardous exposure, and physical load tended to be associated with smoking and sedentary behavior, whereas job resources, including personal autonomy, were predictive of regular exercise, but unrelated to smoking behavior. Correlational patterns varied somewhat between sexes. The implications of these findings with respect to work organization, considerations in epidemiological research, and the conduct of health promotion programs are discussed.

Estimating replacement costs for hospital equipment.

This paper presents a methodology for predicting future replacement costs of hospital capital equipment. The methodology is applied to the equipment inventory of a large Canadian teaching hospital. The authors used forecasted Producer Price Indexes for several equipment categories, and applied them to the estimated equipment replacement needs. The Canadian Management Information System schedule and the American Hospital Association schedule were used to determine the estimates, which varied considerably between the two schedules. However, the test case demonstrated that such estimates can help hospitals to document capital funding needs in relation to available funds.