Effect of ultraviolet B radiation and 100 Hz electromagnetic fields on proliferation and DNA synthesis of Jurkat cells.

The use of ultraviolet B light (UVB) has been proven to be highly effective for treatment of various inflammatory skin diseases, but UVB phototherapy is limited by its carcinogenic side effects. It is necessary to uncover effectors that augment UVB so that similar or improved efficacy can be obtained with lower UVB doses. We found that low frequency, low intensity electromagnetic fields (EMFs) can act as such an effector and synergistically inhibit T lymphocyte proliferation. We first characterized the effects of UVB on Jurkat cells, a model for cutaneous T lymphocytes, and determined UVB's dose dependent inhibition of cell proliferation and induction of apoptosis. Cells exposed to a sublethal UVB dose retained their sensitivity to UVB, but repetitive irradiation seemed to cause accumulation of delayed DNA damage. We then exposed cells to combinations of UVB plus EMFs and found that 100 Hz, 1 mT EMFs decrease DNA synthesis of UVB-activated Jurkat cells by 34 +/- 13% compared to UVB alone. The decrease is, however, most effective when relatively high UVB doses are employed. Since EMFs alone had only a very weak inhibitory effect (10 +/- 2%), the data suggest that EMFs augment the cell killing effects of UVB in a synergistic way. These findings could provide the basis for development of new and improved clinical phototherapy protocols.

Assessing the impact of total quality management and organizational culture on multiple outcomes of care for coronary artery bypass graft surgery patients.

OBJECTIVES: To assess the impact of total quality management (TQM) and organizational culture on a comprehensive set of endpoints of care for coronary artery bypass graft surgery (CABG) patients, including risk-adjusted adverse outcomes, clinical efficiency, patient satisfaction, functional health status, and cost of care. METHODS: Prospective cohort study of 3,045 eligible CABG patients from 16 hospitals using risk-adjusted clinical outcomes, functional health status, patient satisfaction, and cost measures. Implementation of TQM was measured by a previously validated instrument based on the Baldridge national quality award criteria. Organizational culture was measured by a previously validated 20-item instrument. Generalized estimating equations were used to control for potential selection bias, repeated measures, and intraclass correlation. RESULTS: A 2- to 4-fold difference in all major clinical CABG care endpoints was observed among the 16 hospitals, but little of this variation was associated with TQM or organizational culture. Patients receiving CABG from hospitals with high TQM scores were more satisfied with their nursing care (P = 0.005) but were more likely to have lengths of stay >10 days (P = 0.0003). A supportive group culture was associated with shorter postoperative intubation times (P = 0.01) but longer operating room times (P = 0.004). A supportive group culture was also associated with higher patient physical (P = 0.005) and mental (P = 0.01) functional health status scores 6 months after CABG. CONCLUSIONS: There was little effect of TQM and organizational culture on multiple endpoints of care for CABG patients. There is a need to examine further the relationships among individual professional skills and motivations, group and microsystem team processes, specifically tailored interventions, and organization-wide culture, decision support processes, and incentives. Assessing the impact of such multifaceted approaches is an important area for further research.

Molybdenum cofactor deficiency-phenotypic variability in a family with a late-onset variant.

In a family with molybdenum cofactor deficiency, the onset in the index case was delayed until 1 year of age, when the patient presented with an episode of lethargy and inconsolable crying culminating in a seizure. By 17 months she showed mild motor delay, regression in language skills, and feeding difficulties. Progressive global deterioration followed, associated with sustained irritability, dystonic posturing, and further seizures, before her condition subsequently plateaued. Low plasma uric acid, raised urinary xanthine and hypoxanthine, and positive urinary sulphite were found, which, coupled with assay of sulphite oxidase activity in cultured fibroblasts, confirmed the diagnosis. A sibling had isolated lens dislocation and an identical biochemical profile. MRI in both children was strikingly abnormal. Molybdenum cofactor deficiency may present as a late-onset variant with considerable phenotypic variability.

Implementation of total quality management: conventional wisdom versus reality.

Hospitals nationwide are beginning to implement continuous quality improvement (CQI) (Barsness et al. 1993; Kosta 1992). In large part this is due to the belief that the implementation of CQI will lead to higher quality patient care, improved patient satisfaction, better employee morale, and lower cost service delivery. However, to date there have been few empirical studies of CQI implementation efforts in healthcare (Shortell et al. 1994).

Keys for successful implementation of total quality management in hospitals.

This article reports the findings of an analysis of the implementation of continuous quality improvement (CQI) or total quality management (TQM) programs in 10 hospitals. This analysis is the result of a 2-year study designed to identify and assess the ingredients that lead to the successful implementation of CQI programs in acute care hospitals.

Assessing the impact of continuous quality improvement/total quality management: concept versus implementation.

OBJECTIVE: This study examines the relationships among organizational culture, quality improvement processes and selected outcomes for a sample of up to 61 U. S. hospitals. DATA SOURCES AND STUDY SETTING: Primary data were collected from 61 U. S. hospitals (located primarily in the midwest and the west) on measures related to continuous quality improvement/total quality management (CQI/TQM), organizational culture, implementation approaches, and degree of quality improvement implementation based on the Baldrige Award criteria. These data were combined with independently collected data on perceived impact and objective measures of clinical efficiency (i.e., charges and length of stay) for six clinical conditions. STUDY DESIGN: The study involved cross-sectional examination of the named relationships. DATA COLLECTION/EXTRACTION METHODS: Reliable and valid scales for the organizational culture and quality improvement implementation measures were developed based on responses from over 7,000 individuals across the 61 hospitals with an overall completion rate of 72 percent. Independent data on perceived impact were collected from a national survey and independent data on clinical efficiency from a companion study of managed care. PRINCIPAL FINDINGS: A participative, flexible, risk-taking organizational culture was significantly related to quality improvement implementation. Quality improvement implementation, in turn, was positively associated with greater perceived patient outcomes and human resource development. Larger-size hospitals experienced lower clinical efficiency with regard to higher charges and higher length of stay, due in part to having more bureaucratic and hierarchical cultures that serve as a barrier to quality improvement implementation. CONCLUSIONS: What really matters is whether or not a hospital has a culture that supports quality improvement work and an approach that encourages flexible implementation. Larger-size hospitals face more difficult challenges in this regard.

Assessing the evidence on CQI: is the glass half empty or half full?

Review of the literature on CQI/TQM in both health care and non-health care settings reveals some evidence of a positive impact for selected dimensions of CQI/TQM. There is little research, however, that examines CQI/TQM as a holistic integrated approach to quality improvement, nor are there many studies that go beyond single or small sample case studies. Using a conceptual framework involving cultural, technical, strategic, and structural dimensions, a number of barriers to CQI implementation are identified along with suggestions for high-priority areas of research.

An integrative model for organization-wide quality improvement: lessons from the field.

This article describes a model of CQI that is designed to characterize the elements necessary for successfully improving quality at an organization-wide level; describe and understand the organizational dynamics in implementing an organization-wide effort; and aid in diagnosing and solving common implementation challenges. Three cases illustrate the model and how it can be used.

The impact of managed care on dermatology.

The goal of managed care is to find the most effective mix of the factors of production to provide quality care to its members. The aforementioned information on the impact of managed care on dermatology suggests that the future of dermatology need not be bleak. The supply of dermatologists in the nation is far more consistent with the demand of classic MCOs for dermatologists than for almost all other specialties. In addition, any form of health care reform that increases access to health care for the uninsured and underinsured will increase the demand for dermatologic care. Similarly, a well-functioning managed care plan will move to establish the boundary line between skin care by PCPs and dermatologists in a consensual, objective, and mutually respectful process. The attempt to define this boundary will give added impetus to the development of outcomes measurement and management in managed care and serve to advance the interests of all parties concerned, including the patient. A well-defined boundary line between care appropriately rendered by PCPs and that provided by dermatologists will result in dermatologists treating a higher severity of illness--the cases for which dermatologists were trained to treat. The higher level of severity of illness could be associated with a higher level of professional satisfaction. Similarly, capitated arrangements between dermatologists and PCPs create incentives for cooperative education and communication initiatives between both parties to define appropriate ranges of care and referral timing. Where capitated arrangements do not exist, it is also important to define such appropriate ranges of care.(ABSTRACT TRUNCATED AT 250 WORDS)

Open cholecystectomy. A contemporary analysis of 42,474 patients.

OBJECTIVE: This study evaluated, in a large, heterogeneous population, the outcome of open cholecystectomy as it is currently practiced. SUMMARY BACKGROUND AND DATA: Although cholecystectomy has been the gold standard of treatment for cholelithiasis for more than 100 years, it has recently been challenged by the introduction of several new modalities including laparoscopic cholecystectomy. Efforts to define the role of these alternative treatments have been hampered by the lack of contemporary data regarding open cholecystectomy. METHODS: A population-based study was performed examining all open cholecystectomies performed by surgeons in an eastern and western state during a recent 12-month period. Data compiled consisted of a computerized analysis of Uniformed Billing (UB-82) discharge analysis information from all non-Veterans Administration (VA), acute care hospitals in California (Office of Statewide Planning and Development [OSHPD]) and in Maryland (Health Services Cost Review Commission [HSCRC]) between January 1, 1989, and December 31, 1989. This data base was supplemented with a 5% random sample of Medicare UB-82 data from patients who were discharged between October 1, 1988, and September 30, 1989. Patients undergoing cholecystectomy were identified based on diagnosis-related groups (DRG-197 and DRG-198), and then classified by Principal Diagnosis and divided into three clinically homogeneous subgroups: acute cholecystitis, chronic cholecystitis, and complicated cholecystitis. RESULTS: A total of 42,474 patients were analyzed, which represents approximately 8% of all patients undergoing cholecystectomy in the United States in any recent 12-month period. The overall mortality rate was 0.17% and the incidence rate of bile duct injuries was approximately 0.2%. The mortality rate was 0.03% in patients younger than 65 years of age and 0.5% in those older than 65 years of age. Mortality rate, length of hospital stay, and charges were all significantly correlated (p < 0.001) with age, admission status (elective, urgent, or emergent), and disease status. CONCLUSIONS: These data indicate that open cholecystectomy currently is a very safe, effective treatment for cholelithiasis and is being performed with near zero mortality. The ultimate role of laparoscopic cholecystectomy needs to be defined in the context of current and contemporary data regarding open cholecystectomy.

State experience with Medicare hospital mortality: how does New York State compare?

1987 Medicare hospital mortality statistics for 255 New York hospitals (including 57 hospitals in New York City) were compared with 4,617 hospitals located in other states. An analysis of covariance examined how overall Medicare hospital mortality rates differed across states; these rates were adjusted for expected mortality, hospital bed size, and major teaching status. This study tested for the hypothesis that New York State had an average 30-day post-admission Medicare mortality rate significantly different from the mean hospital mortality rate for all states. The results indicated that New York State was -0.43 percentage points below the average risk-adjusted mortality rate of the other states (p < 0.0001). Although it remains speculative to what extent differences in adjusted Medicare hospital mortality are a function of quality of care, these results indicate that New York's historically high level of hospital regulation has not resulted in inferior patient outcomes.

Regional variation in Medicare hospital mortality.

This study examines variation in severity-adjusted Medicare hospital mortality rates across nine U.S. census regions. The extent to which regional variation is reduced by controlling for differences in hospital resources and structure, county-level population characteristics, and the level of federal SuperPRO-identified hospital quality problems is estimated. Hospital resources, population characteristics, and SuperPro process quality scores are significant predictors of hospital mortality rates, but they do not explain the important, highly significant regional differences observed after controlling for hospital case-mix severity.

Response to treatment with antihistamines in a family with myotonia congenita.

In a family in which myotonia congenita was found in five generations, both great-grandparents of the index case were affected. In subsequent generations mild and severely affected cases were clearly segregated down parallel lines of this family. The grandmother of the index case had noted improvement with an antihistamine. When the index case was prescribed trimeprazine, she showed a striking reduction in severity of symptoms. Antihistamines seem to deserve further evaluation as a safe and effective treatment for myotonia congenita.

Training house officers to be cost conscious. Effects of an educational intervention on charges and length of stay.

Two annual cost-containment educational programs, featuring involvement of respected senior physicians, lectures, comparative feedback, chart reviews, and small group discussions, were designed to reduce interns' generated costs in a private and a VA university hospital affiliated with Northwestern University Medical School. To evaluate the impact of this randomized educational intervention, hospital data on inpatient charges and length of stay (LOS) were collected for 12 common medical diagnoses and adjusted by the Severity of Illness Index. Interns who were randomized to the program were found to have significantly lower per patient costs and LOS than control group interns at both hospitals. These reductions in resource use and LOS were not associated with differences in patients' residual impairment on discharge, the incidence of inpatient complications, or the percentage of deaths and readmissions within 30 days. Our results suggest that the current hospital cost-containment environment may be far more conducive to physician cost-containment education than indicated by the earlier literature.

The effects of regulation, competition, and ownership on mortality rates among hospital inpatients.

We examined the influence of the regulation of hospital rates, state certificate-of-need programs, competition, and hospital ownership on mortality rates among inpatients receiving care under Medicare for 16 selected clinical conditions that were studied as a group. Data were obtained from the records of 214,839 patients who received care in 981 hospitals in 45 states from July 1, 1983, through June 30, 1984. We found significant associations between higher mortality rates among inpatients and the stringency of state programs to review hospital rates (P less than or equal to 0.05), the stringency of certificate-of-need legislation (P less than or equal to 0.01), and the intensity of competition in the marketplace, as measured by enrollment in health maintenance organizations (P less than or equal to 0.05). Hospitals in the states with the most stringent review procedures for hospital rates had ratios of actual to predicted death rates that were 6 to 10 percent higher than those of hospitals in states with less stringent rate-review programs (P less than or equal to 0.001). Hospitals in the states with the most stringent procedures for reviewing applications for certificates of need had ratios of actual to predicted death rates that were 5 to 6 percent higher than those of hospitals in states with less stringent certificate-of-need procedures (P less than or equal to 0.05). There was no statistically significant association between mortality rates among inpatients and either the type of hospital ownership or the number of hospitals competing in the market area. Additional analyses, which examined alternative explanations for these findings, failed to change the results. These findings raise serious concerns about the welfare of patients who are admitted to hospitals in highly regulated areas and those admitted to hospitals in relatively competitive markets. They suggest that it is important to incorporate quality-assurance procedures and systems to monitor patients' outcomes into public and private programs designed to contain costs or promote competition, or both.

Medicare beneficiary decision making about health insurance. Implications for a voucher system.

A two-phase study involving focus group interviews and a survey of 2,016 Medicare beneficiaries was conducted to examine beneficiary decision making about health insurance under a hypothetical Medicare voucher program. Some of the major findings were that: beneficiaries lack important information about Medicare and health insurance in general; plans with physician restrictions, no restrictions on hospitals, and benefits for custodial long-term care at home or in nursing homes are most preferred when prices are roughly equal to actuarial costs; plan features often interact rather than combined additively to affect choices; price sensitivity is small in comparison with sensitivity to other plan features; price sensitivity is particularly small for plans with custodial long-term care benefits; Medicare would not experience substantial selection bias in a voluntary system containing a wide range of plans preferred by beneficiaries; physician-restricted plans would experience favorable selection; plans with long-term custodial care benefits would experience some adverse selection which might be handled by modest price adjustments in view of the relatively low price elasticity of preferences.