Dose-dependent induction of GST-P+ staining foci by the rat hepatocarcinogen methapyrilene in the medium-term bioassay.

Previous studies have demonstrated that methapyrilene hydrochloride (MP) is a rat-specific nongenotoxic carcinogen which induces liver tumors in a dose-dependent manner following chronic exposure in the diet. This study was conducted to determine the dose response of MP in the medium-term bioassay and to compare the response to tumor incidence. Two weeks following a single initiating dose of diethylnitrosamine (DEN), male F344 rats were administered MP at doses of 0, 62.5, 125, 250, or 1000 ppm in the diet for 6 weeks. A 2/3 partial hepatectomy was performed 3 weeks post-DEN. At termination, sections from the remaining three lobes were stained with GST-P antibody. Number and size of foci were measured using an image analysis system with a digitizing board. MP induced a dose-dependent increase in the number of GST-P+ foci/cm2 (0 ppm = 0.85 foci/cm2; 62.5 ppm = 1.29 foci/cm2; 125 ppm = 1.59 foci/cm2; 250 ppm = 6.55 foci/cm2; 1000 ppm = 28.23 foci/cm2). A significantly greater number of foci were observed in the caudate lobe than in the anterior and posterior lobes. The size of individual foci was largely unaffected. This study demonstrates a strong correlation between foci induction and tumor incidence and suggests that this assay may have utility in predicting dose responses for the chronic bioassay.

Methods of control for hospital quality assurance systems.

The major failure of hospital quality assurance systems is the failure to influence physicians' therapeutic decision making in a way that will ensure their ordering necessary and only necessary services. The primary reason for this is insufficient recognition of the "intensive" technology used to treat acute patients, a technology characterized by the interdependence of therapeutic services and the patient's response to these services. In such situations, the appropriate method of achieving quality control is to provide performance feedback to the physician on a regular basis. To the extent that there is uncertainty about the impact of therapeutic services on the patient's response, the physician should be allowed discretion over the therapeutic process. In contrast, when process-outcome relations in the therapeutic process are relatively certain, feedback should be reinforced with sanctions.

Direction-sensitive displacement analysis by multiple frequency holographic interferometry.

A method for determining the directions of displacement in double exposure holographic interferometry is described. The technique requires the use of different frequencies in each of the two holographic exposures and thus can be thought of as a combination of conventional multifrequency contouring and holographic interferometry. The necessary equations to describe the resulting fringe pattern are developed. Two deformation fields, one theoretical and one experimental, are used to illustrate the phenomena. The experimental deformation was the result of a Rayleigh surface wave propagating in a rock specimen. The holograms were obtained with a Q-switched, multifrequency pulsed ruby laser.

Barriers to appropriate utilization of an acute facility.

Professional Standards Review Organizations (PSROs) have been mandated to assure appropriate utilization of health resources. In order to meet this objective, PSROs must be able to determine when and why health resources are misutilized so that corrective action may be taken. This paper describes a study designed to identify and measure the significance of factors causing the misutilization of beds at one hospital. Using explicit Medicare levels of care criteria, a utilization review nurse coordinator determined the appropriate location (hospital, skilled nursing facility, home health care, home with outpatient or no care) or a sample of hospital patients. When a patient was judged inappropriately located on a particular day the nurse coordinator identified the barrier(s) to appropriate utilization, i.e., the reason(s) the patient remained in the hospital. Approximately 10 per cent of the 1,902 patient days were judged inappropriate at a hospital level of care. The most significant barriers to appropriate utilization were 1) the unavailability of skilled nursing facilities with the necessary amount of nursing services, and 2) the attending physician's conservative medical management of the patient. The implications for reduction of hospital misutilization are discussed.

Development of hospital levels of care criteria.

A modification of the Nominal Group/Delphi Technique can be applied to the problem of developing among physicians levels-of-care criteria for use in "concurrent review" activities. UR requirements can be rationalized through a process that uses physicians' scarce time effectively, allows for cyclical feedback on their peers' views, and insures input from both dominant and reticent individuals.

Emphasizing "level of care" over "length of stay" in hospital utilization review.

Utilization review has heretofore emphasized "length of stay" as the criterion for deciding when the patient is ready to leave the hospital. We suggest that "level of care" (the type, number, and/or intensity of a combination of physician, skilled nursing, and ancillary services) received by the patient should replace length of stay as the major "decision" criterion for deciding on continued hospitalization: "appropriate hospital placement" means the patient is currently receiving a level of care available only in the hospital. Length of stay should be the criterion for signaling intervals when patients are (re) reviewed to determine the currently needed level of care. Explicit criteria for determining when a patient is receiving a hospital level of care should be developed. Explicit criteria will increase objectivity, provide guidance to utilization review coordinators, and assist the hospital in defending its utilization review decisions to an intermediary or Professional Standards Review Organization (PSRO). Level of care will be reflected in a patient's "service profile," a listing of all the services being received by the patient on any given day of hospitalization. The services profile varies throughout hospitalization; hospitalization is appropriate when a patient's current services profile constitutes a level of care available only in the hospital.

Evaluating an information system for medical care evaluation studies.

The purpose of this study was to evaluate a computerized information system, the Professional Activity Study-Medical Audit Program (PAS-MAP), when used by the medical staff of a hospital to conduct medical care evaluation studies. PAS-MAP was compared to a manual system for collecting data not contained on the face sheets of medical records. The results indicated that, compared to the manual system, PAS-MAP: was less costly if more than 41 per cent of hospitalized patients were included in medical care evaluation studies; was as timely as the manual system for data it could provide but provided fewer clinical data elements than physicians requested; and was less protective against human error. Three decision makers assigned weights indicating the relative importance of these results. The weights were combined in an additive model to arrive at a score for each system. Based on these scores, the manual system was recommended for implementation.

A decision theory approach to measuring severity in illness.

The purpose of this study was to evaluate the applicability of a multiattribute utility model for measuring the severity of a patient's illness. A single medical problem (an analysis of the costs and benefits of different burn care systems) was used to test the model. Physicians estimated the relative importance of and severity functions for criteria influencing severity. The model's estimates of severity were compared with survival rates of more than 6000 actual patients and with physicians' rankings of hypothetical patients. Although continued validation is needed, the multiattribute utility model appears to have potential as an index for illness severity and, possibly, health status.