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D Draper

Publications and source records attributed to D Draper.

31 records · Page 2Linked to original sources
PubMed1990

Quality of care before and after implementation of the DRG-based prospective payment system. A summary of effects.

In this series we have described changes in the quality of care that have occurred in the treatment of hospitalized elderly Medicare patients with one of five conditions between 1981-1982 and 1985-1986. In this article we report on a mortality analysis, patient and hospital subgroup comparisons, and time series studies we have conducted in an attempt to determine whether changes in quality of care can be linked causally to the introduction of the prospective payment system. Based on these analyses we conclude that (1) mortality following hospitalization has been unaffected by the introduction of the prospective payment system, and improvements in in-hospital processes of care that began prior to the prospective payment system have continued after its introduction, but (2) the prospective payment system has increased the likelihood that a patient will be discharged home in an unstable condition. We recommend that efforts to correct this problem be intensified and that clinical monitoring of the impact of the prospective payment system continue as hospital cost-containment pressures intensify.

Continuity of Patient Care↗
PubMed1990

Changes in quality of care for five diseases measured by implicit review, 1981 to 1986.

We measured quality of care before and after implementation of the prospective payment system. We developed a structured implicit review form and applied it to a sample of 1366 Medicare patients with congestive heart failure, acute myocardial infarction, pneumonia, cerebrovascular accident, or hip fracture who were hospitalized in 1981-1982 or 1985-1986. Very poor quality of care was associated with increased death rates 30 days after admission (17% with very good care died vs 30% with very poor care). The quality of medical care improved between 1981-1982 and 1985-1986 (from 25% receiving poor or very poor care to 12%), although more patients were judged to have been discharged too soon and in unstable condition (7% vs 4%). Except for discharge planning processes, the quality of hospital care has continued to improve for Medicare patients despite, or because of, the introduction of the prospective payment system with its accompanying professional review organization review.

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PubMed1990

Prospective payment system and impairment at discharge. The 'quicker-and-sicker' story revisited.

Since the introduction of the prospective payment system (PPS), anecdotal evidence has accumulated that patients are leaving the hospital "quicker and sicker." We developed valid measures of discharge impairment and measured these levels in a nationally representative sample of patients with one of five conditions prior to and following the PPS implementation. Instability at discharge (important clinical problems usually first occurring prior to discharge) predicted the likelihood of postdischarge deaths. At 90 days postdischarge, 16% of patients discharged unstable were dead vs 10% of patients discharged stable. After the PPS introduction, instability increased primarily among patients discharged home. Prior to the PPS, 10% of patients discharged home were unstable; after the PPS was implemented, 15% were discharged unstable, a 43% relative change. Efforts to monitor the effect of this increase in discharge instability on health should be implemented.

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PubMed1990

Biochemical purification and crystallographic characterization of the fiber-forming protein pilin from Neisseria gonorrhoeae.

Pilus fibers are long protein filaments on many pathogenic bacteria that participate in attachment to host cells. Although the self-assembling protein pilin is the major structural component of the Neisseria gonorrhoeae pilus fiber, several other proteins co-purified with pilin through the repeated solubilization-reassociation steps of the biochemical purification. Pilin solubilized in the nondenaturing detergent n-octyl-beta-D-glucopyranoside remained an aggregate of about 100 kDa at pH 9.5, but was reduced to a 40-kDa dimer at pH 10.5, suggesting that assembly involves electrostatic interactions of lysine, tyrosine, or other side chains with high pKa values. Pilin dimers and aggregates of higher molecular mass were partially stable even in the presence of sodium dodecyl sulfate and beta-mercaptoethanol. Removal of pilus-associated proteins and stabilization of pilin multimers permitted the reproducible crystallization of pilin. Three-dimensional needle- and plate-shaped crystals of purified N. gonorrhoeae pilin (strain MS11 variant C30) grew from 36 to 40% polyethylene glycol 400, pH 8.0-9.0, in space group C222, with cell dimensions a = 126.4, b = 121.2, c = 26.7 A and Vm = 2.84 A3/dalton for one molecule per asymmetric unit. The best crystals diffracted to 2.4 A resolution using synchrotron radiation, were stable to x-ray damage, and appear suitable for determination of the atomic structure. This approach of stabilizing and crystallizing an intermediate assembly state may be useful for other fiber-forming proteins, which have previously not been successfully crystallized in forms that diffract to atomic resolution.

Bacterial Outer Membrane Proteins↗
PubMed1989

The relation between hospital experience and in-hospital mortality for patients with AIDS-related PCP.

There is marked debate by physicians and policymakers regarding the creation of regionalized acquired immunodeficiency syndrome (AIDS) centers. A central issue is whether outcomes of care, particularly mortality, differ as a function of hospital experience with patients with AIDS. We evaluated the experience of 257 patients with AIDS and Pneumocystis carinii pneumonia treated at 15 California hospitals between October 1986 and October 1987. An overall 15.2% in-hospital mortality rate was observed. However, a markedly lower in-hospital mortality rate was observed in the group of patients treated at hospitals that had a high level of experience with patients with AIDS (greater than or equal to 30 human immunodeficiency virus-related discharges per 10,000 hospital discharges) relative to the group treated at hospitals with less experience (less than 30 human immunodeficiency virus-related discharges per 10,000 hospital discharges): 12% vs 33%. Other factors significantly associated with in-hospital mortality included intensive care unit use, admission from an emergency department or through an interhospital transfer, and a history of hospitalizations. A logistic regression model indicated that, after controlling for severity indicators, AIDS experience remained significantly related to mortality. Our findings suggest that policymakers should consider three options: creating regional AIDS centers, implementing policies that promote a rapid but carefully monitored increase in experience of low-volume hospitals with human immunodeficiency virus-infected individuals, or providing highly focused educational efforts at low-AIDS-experience facilities. Without such policy initiatives, differences in mortality rates like those we have found might persist as cases of AIDS begin to occur in every area of the country.

Acquired Immunodeficiency Syndrome↗
PubMed1987

Hospital inpatient mortality. Is it a predictor of quality?

Various potential measures of quality of care are being used to differentiate hospitals. Last year, on the basis of diagnostic and demographic data, the Health Care Financing Administration identified hospitals in which the actual death rate differed from the predicted rate. We have developed a similar model. To understand why there are high-outlier hospitals (in which the actual death rate is above the predicted one) and low-outlier hospitals (in which the actual death rate is below the predicted one), we reviewed 378 medical records from 12 outlier hospitals treating patients with one of three conditions: cerebrovascular accident, myocardial infarction, and pneumonia. After adjustment for the severity of illness, the death rate in the high outliers exceeded that predicted from the severity of illness alone by 3 to 10 percent, and in the low outliers, the actual death rate fell short of the severity-adjusted predictions by 10 to 15 percent (P less than 0.01). Reviews of the process of care using 125 criteria revealed no differences between the high and low outliers. However, detailed reviews by physicians of the records of patients who died during hospitalization revealed a higher rate of preventable deaths in the high outliers than in the low outliers. For the three conditions studied, we project that 5.7 percent of a standard cohort of patients admitted to the high-outlier hospitals would have preventable deaths, as compared with 3.2 percent of patients admitted to the low-outlier hospitals (P less than 0.05). A meaningful comparison of hospital death rates requires adjustment for severity of illness. Our findings indicate that high-outlier hospitals care for sicker patients. However, these same hospitals or their medical staffs may also provide poorer care. Our results need confirmation before death-rate models can be used to screen hospitals.

Hospitals↗
PubMed1976

A psychodynamic approach to suicide prevention.

This paper sets forth a new theoretical approach to understanding the psychological etiology of suicide. The theory is demonstrated by an in-depth clinical case example, and its implications for the management of the suicidal candidate in his acute interim and long-term care are described. The theory assumes that the primary motivation to suicide comes from a clinically characteristic, unremitting psychological pain. The role of the suicidal prevention center is discussed with specific emphasis on the quality of the engagement between a center staff person and the suicidal patient. A future course for suicide centers is suggested based on the theory.

Community Mental Health Services↗
PubMed1976

Effects of phototherapy on platelet counts in low-birthweight infants and on platelet production and life span in rabbits.

The effects of conventional phototherapy on platelets in vivo were studied in rabbits and in low-birthweight infants. Rabbits were divided into three groups and individually treated continuously for 96 hours, with blue light, daylight, or no phototherapy. Incorporation of selenomethionine Se75 was used to evaluate platelet production and life span. Platelet turnover was significantly increased in the blue-light phototherapy group, and was also increased in the daylight group but to a lesser degree. Daily platelet counts and hematocrits were performed in infants weighing less than 2,000 gm at birth randomized at 24 +/- 12 hours of life to receive daylight phototherapy continuously for 96 hours (31 infants) or no phototherapy (26 infants). In 12 treated infants (38.7%) platelet counts fell below 150,000/cu mm whereas this occurred in only 3 (11.5%) of the controls. These two lower platelet count subgroups differed significantly in mean gestational age and birthweight with the phototherapy group being the more mature. Pre-phototherapy, the mean platelet count of these 12 infants was lower than the mean of the entire control group, suggesting that these infants had borderline marrow reserve before phototherapy was given. These results suggest that phototherapy increases the rate of platelet turnover. When bone marrow compensation is inadequate, the platelet count may fall.

Animals↗
PubMedDate not supplied

Predicting hospital-associated mortality for Medicare patients. A method for patients with stroke, pneumonia, acute myocardial infarction, and congestive heart failure.

We created a microcomputer-based system that uses characteristics of the patient at admission to predict death within 30 days of hospital admission for Medicare patients with stroke, pneumonia, myocardial infarction, and congestive heart failure. These conditions account for 13% of discharges and 31% of 30-day mortality for Medicare patients over 64 years of age. The system was calibrated on a stratified, random sample of 5888 discharges (about 1470 for each condition) from seven states, with stratification by hospital type to make the sample nationally representative. The predictors must be specially abstracted from the medical record. The cross-validated R2 for predictions is 0.14 to 0.25, which is better than the values for other systems for which we have data. Risk-adjusted predicted group mortality rates may be useful in interpreting information on unadjusted mortality rates, and patient-specific predictions may be useful in identifying unexpected deaths for clinical review.

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PubMedDate not supplied

Cryopreservation of horse semen under laboratory and field conditions using a Stirling Cycle freezer.

A Stirling Cycle freezer has been developed as an alternative to conventional liquid nitrogen controlled rate freezers. Horse semen samples were cooled in 0.25 ml straws and 15 ml bags in the Stirling Cycle freezer under laboratory conditions and as a portable device, powered from a car battery. For comparison, straws were frozen in a conventional liquid nitrogen controlled rate freezer. Upon thawing, motility and viability of samples frozen in the Stirling Cycle freezer were not significantly different when compared to samples frozen in the liquid nitrogen freezer. Unlike liquid nitrogen systems, the Stirling Cycle freezer does not pose a contamination risk, can be used in sterile conditions and has no need for a constant supply of cryogen. The freezer has potential for use in veterinary and genetic conservation applications.

Animals↗
PubMedDate not supplied

Interpreting hospital mortality data. The role of clinical risk adjustment.

This study uses national Medicare data as well as data that were abstracted to calibrate the Medicare Mortality Predictor System to assess the usefulness of a risk adjustment system in interpreting hospital mortality rates. The majority of variation in annual hospital death rates for the four conditions studied (stroke, pneumonia, myocardial infarction, and congestive heart failure) is chance variability that results from the relatively small numbers of patients treated in most hospitals in a year. For hospitals in the highest and lowest quartiles of observed death rates, the difference between observed rates and those predicted by the Medicare Mortality Predictor System is not quite on third smaller than the difference between observed rates and unadjusted national rates. Risk adjustment methods do not show whether the unexplained difference in mortality rates results from differences in effectiveness of care or unmeasured differences in patient risk at the time of admission. Risk-adjusted mortality rates, therefore, should be supplemented by review of the actual care rendered before conclusions are drawn regarding effectiveness of care.

Aged↗