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Biomedical subjects

E Munoz

Publications and source records attributed to E Munoz.

At least 37 records · Page 2Linked to original sources
PubMed1990

Economies of scale, physician volume for urology patients, and DRG prospective hospital payment system.

Diagnosis Related Group (DRG) hospital payment has begun to squeeze hospitals financially and is likely to do so in the future. This study analyzed the relationship between the volume of urologic procedures by an individual urologist, hospital costs per patient, and outcome. We used a three-year DRG database of urology patients (N = 2,980) at an academic medical center to analyze these. Low-volume urologists (arbitrarily defined by us) had higher hospital costs per patient, financial losses versus profits under DRGs, and a poorer outcome when compared with high-volume urologists. Pearson correlation showed a positive relationship between cost per patient and physician volume for nonemergency patients (-0.129, p less than 0.0001) and emergency patients (-0.368, p less than 0.0001). This may have been explained (in part) by a greater severity of illness for patients of low-volume urologists. These findings suggest, however, that the volume of urologic procedures per urologist may be related to hospital resource consumption. The health care financing environment of the future should provide substantial interest in this finding for those involved in the consumption of urologic services.

Academic Medical Centers↗
PubMed1990

Regulation of interleukin 6 production in T helper cells.

The cytokine interleukin 6 (IL-6) is a cellular regulatory molecule that is produced by both lymphoid and non-lymphoid cells in response to several stimuli. In this report we present evidence that within the murine T cell compartment T helper type 2 cells (Th2) produce this lymphokine, whereas unprimed CD4+ T cells and a T helper type 1 clone (Th1) do not. Furthermore, IL-6 is not an autocrine growth factor for in vitro cultured Th cells, in contrast to what occurs in freshly isolated CD4+ and CD8+ T cells. We have examined the signal transduction pathways that lead to IL-6 production in activated Th2 cells. We have found that protein kinase C activators, such as PMA, Con A, or IL-1, increase the IL-6 expression in these cells. On the other hand, activation of the cAMP-dependent pathway does not seem to have an effect on the IL-6 production, since forskolin, 8BrcAMP, or TNF-alpha, which in these cells increases the level of intracellular cAMP, do not lead to an accumulation of IL-6 message. These results indicate that the IL-6 gene is more tightly regulated in T cells than in other systems described previously.

Animals↗
PubMed1990

Physicians' patient load per DRG, the consumption of hospital resources, and the incentives of the DRG prospective payment system.

From 1985 through 1987, the authors assessed the relationship between two main variables at a large academic medical center: (1) the numbers (high or low) of patients per diagnosis-related group (DRG) treated by individual physicians and (2) hospital resource consumption of the patients. The patients were classified according to their routes of admission (emergency or non-emergency); the physicians with eight or more patients per DRG were labeled "high-patient-load physicians" (hereafter called "high-load physicians"), and those with five or fewer patients were labeled "low-patient-load physicians," ("low-load physicians"). The resource variables studied were length of stay (LOS) and total hospital cost. For the non-emergency admissions, the low-load physicians' patients had an average LOS that was 56.2% greater and an average hospital cost that was 58.3% greater than were the LOS and cost of the patients of the high-load physicians. (Both LOS and cost per patient were adjusted for DRG weight index.) This was due in part to a greater severity of illness for the patients (as measured by total ICD-9-CM codes per patient) of the low-load physicians. For the emergency admissions, the low-load physicians' patients had an average LOS that was 9.5% greater and an average hospital cost that was 10.5% greater than the LOS and cost of the patients of the high-load physicians. As in the non-emergency admissions group, severity of illness for the patients of the low-load physicians was greater. The only category of patients that was economically profitable to the hospital was the non-emergency admissions group treated by the high-load physicians. Even though these findings were the result of many factors (discussed in the text), they suggest a relationship between hospital resource consumption and the physicians' patient load per DRG.

Academic Medical Centers↗
PubMed1990

Economies of scale, physician volume for neurosurgery patients, and the diagnosis-related group prospective hospital payment system.

Hospitals face an increasingly competitive environment in the era of diagnostic related group (DRG) prospective pricing. Further reductions in Medicare outlays relative to hospital costs are likely, given the looming federal deficit. We analyzed the relationship of individual neurosurgical volume, hospital costs, and outcome. All neurosurgical patients (n = 1002) treated for a 3-year period at our large academic medical center were grouped into those treated by low-volume neurosurgeons versus those treated by high-volume neurosurgeons (arbitrarily defined by us); 95% of patients admitted for neurosurgical procedures fit into one of these two categories. Patients of low-volume neurosurgeons had higher hospital costs (even after correction for DRG case-mix and severity of illness) (P less than 0.01), a much worse financial position under DRGs (P less than 0.01), but a similar outcome for both emergency and nonemergency admissions when compared to patients of higher volume neurosurgeons. Pearson correlation showed an inverse relationship between declining cost per patient and increasing neurosurgical volume for both nonemergency patients -0.340 (P less than 0.0001), and emergency patients, -0.321 (P less than 0.0001). These findings suggest that the volume of neurosurgical procedures performed by an individual neurosurgeon is related to hospital resource utilization. This study also suggests that the DRG prospective payment system could provide incentives that may affect both neurosurgical practice and the access to neurosurgical care.

Academic Medical Centers↗
PubMed1990

Prospective payment experience with DRGs in headache patients.

The new Diagnostic Related Group (DRG) Prospective Hospital Payment System pays a set fee to hospitals depending on the patient's diagnosis. Care of certain patients covered by Neurology DRGs has proven to be unprofitable. The purpose of this project was to study hospital resource consumption for hospitalized patients with a principal or secondary diagnosis of headache. We studied various resource parameters for patients in the three neurology DRGs for headache (#24-seizure and headache, age greater than 69 and/or complicating condition; #25 and #26-seizure and headache age 18-69 without complicating condition, and age 0-17, respectively) by whether or not the patients had a diagnosis of headache. As demonstrated in Table 1, patients with headache had (on average) lower hospital resource utilization than patients in these same DRGs without a headache diagnosis. Headache patients had lesser total hospital costs, a lower severity of illness, and generated profits under DRGs compared to non-headache patients. We found that our headache patients were adequately reimbursed by the DRG hospital payment system and suggest that this could be a financially attractive population to hospitals.

Adult↗
PubMed1990

Economies of scale, physician volume for orthopedic surgical patients, and the DRG prospective payment system.

American hospitals face increasing constraints due to a variety of factors. Federal and state diagnostic-related group (DRG) prospective hospital pricing has caused tremendous fiscal pressure on hospitals; many face substantial financial deficits. We analyzed the volume of orthopedic surgical procedures performed by an individual orthopedic surgeon for all patients (N = 2,134) treated for a 3-year period at a large academic medical center; these surgeons were arbitrarily divided into low volume or high volume. Patients of low volume surgeons had a longer hospital length of stay and hospital cost (after correction for DRG case mix and severity of illness), greater financial risk under DRGs, and a poorer outcome, compared with patients of higher volume orthopedic surgeons. Pearson correlation showed an inverse relationship between cost per patient and physician volume for nonemergency patients -0.201 (P less than .0001), and emergency patients, -0.321 (P less than .0001). Although the reasons for these findings appeared multifactoral, they raise important issues related to orthopedic surgical hospital costs, access, and quality of care. In addition, they suggest that hospital cost for these patients (and perhaps outcome) may be related to orthopedic surgical volume, and that DRG hospital payment (on the margin) may affect future orthopedic surgical practice opportunities.

Academic Medical Centers↗
PubMed1990

The DRG hospital payment system, surgical readmissions and cost containment.

We analyzed all adult surgical patients requiring readmission to the surgical service of an acute care academic hospital for a four-year period (1/1/85-12/31/88). We stratified surgical readmissions by the number of times the patient was readmitted to surgery (from one to five times). For surgical patients 41.1 per cent of the readmission population was readmitted more than once, only 4.4 per cent were readmitted five or more times. Patients requiring three or more admissions generally had the greatest hospital resource utilization, financial risk under DRG payment, and mortality, compared with other surgical readmissions. This analysis suggests that within the surgical readmission population resource parameters may differ by the number of readmissions per patient. Factors were identified which corresponded to a greater likelihood of surgical readmission, and possibly allow the focus of outpatient services which may reduce hospital inpatient costs in the future.

Academic Medical Centers↗
PubMed1989

Health care financing policy for hospitalized pediatric patients.

Prospective hospital payment systems using the federal Medicare DRG payment model are changing hospital reimbursement. Currently, many states have adopted diagnosis related group (DRG) prospective "all payer systems" using the federal model. All payer systems, whereby Medicaid, Blue Cross, and other commercial insurers pay by the DRG mode, prevent cost shifting between payers. New York state has used an all payer system since Jan 1, 1988. This study simulated DRG all payer methods for a large sample (N = 16,084) of pediatric patients for a three-year period using the New York DRG all payer reimbursement system now in effect. Medicaid pediatric patients had (adjusted for DRG weight index) a longer hospital stay and greater total hospital cost compared with pediatric patients from Blue Cross and other commercial payers. Medicaid pediatric patients also had a greater severity of illness compared with patients from Blue Cross and other payers. Pediatric patients in all payment groups (ie, Medicaid, Blue Cross, and other commercial insurers) generated financial risk under the DRG all payer scheme. Medicaid pediatric patients generated the greatest financial risk, however. These data suggest that state and private payers may be under-reimbursing for the care of the hospitalized pediatric patient using the DRG prospective hospital payment scheme. Health care financing policy for pediatric patients may limit both access and quality of care.

Adolescent↗
PubMed1989

Pediatric patients, race, and DRG prospective hospital payment.

The diagnosis related group (DRG) prospective hospital payment system contains inequities in hospital payment for certain groups of patients. Patients of lower socioeconomic status may be underreimbursed by DRGs. We analyzed pediatric patients and hospital resource consumption by race (white, Hispanic, and black) using a DRG prospective payment "all payer" system. All hospitalized pediatric admissions over a 3-year period (N = 14,489) were analyzed by race at a large academic medical center. Mean hospital length of stay and cost per patient (adjusted for DRG weight index) was significantly greater for black and Hispanic pediatric patients compared with whites. Financial risk as measured by outliers and losses under DRGs was greater for blacks and Hispanics compared with whites. Black and Hispanic patients had a higher proportion of emergency admission to the hospital compared with whites, a greater severity of illness (as measured by total International Classification of Diseases, ninth revision, Clinical Modification codes), and (on average) higher diagnostic costs for each episode of illness. Our data suggest that black and Hispanic pediatric patients have a greater hospital resource consumption (adjusted for DRG group case mix) compared with whites, at least at our large medical center in the Northeast. Hospitals that treat greater numbers of black and Hispanic pediatric patients may be at a substantial disadvantage under per-case DRG payment.

Academic Medical Centers↗
PubMed1989

Pediatric patients, DRG hospital payment, and comorbidities.

To determine whether the diagnosis related group (DRG) hospital payment system is causing financial pressure on pediatric hospitals similar to that shown in our previous work in other settings, we analyzed resource consumption for pediatric patients in any of the 251 DRGs not stratified by comorbidities. The new DRG prospective "all payor system" is in effect at our hospital. Analysis of 12,771 pediatric patients by payer (Medicaid and commercial insurance such as Blue Cross) in these DRGs for a 3-year period demonstrated that, as a group, pediatric patients with more comorbidities generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, financial risk under DRG payment, more outliers (expensive patients), and a higher mortality rate than pediatric patients in the same DRGs with fewer comorbidities. This study confirms major inequities in DRG prospective hospital payment for many pediatric patients.

Child↗
PubMed1989

Financial risk and hospital cost in stratified, peripheral vascular surgical DRGs without complications and comorbidities.

The purpose of this study was to analyze hospital resource consumption in any of the nine non-complicating conditions covered under stratified, peripheral vascular surgical Diagnosis-Related Groups (DRGs) using the new DRG prospective All Payer System in effect in New York. There is significant health policy debate at the level of the United States Congress regarding the improvement of the equity of DRG hospital payment. Although there have been a number of recommendations by federal advisory bodies to further stratify DRGs by complications and comorbidities, no major revision of DRGs along these lines has been implemented. The all payer system uses the DRG format to pay for all patients. We analyzed 788 peripheral vascular surgical patients by payer (Medicare, Medicaid, Blue Cross and commercial insurance) in these stratified, peripheral vascular surgical DRGs with no complications or comorbidities for a three year period. Our study demonstrated that patients within each DRG with more complications and comorbidities generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, financial risk under DRG payment, more outliers, and a higher mortality, compared to patients in these same DRGs with fewer complications and comorbidities. These findings suggest that new, prospective DRG all payer systems may be inequitable to certain groups of patients or types of hospitals in these stratified peripheral vascular surgical DRGs with no complication or comorbidities. This analysis suggests that these peripheral vascular surgical DRGs should be stratified by the numbers and types of complications and comorbidities to more equitably reimburse hospitals under DRGs.(ABSTRACT TRUNCATED AT 250 WORDS)

Costs and Cost Analysis↗
PubMed1989

Socioeconomic concerns in vascular surgery: a survey of the role of age, resource consumption, and outcome in treatment cost.

Surgical hospital payment issues and socioeconomic concerns are likely to attract more attention in the future, especially regarding access and the quality of surgical care. We analyzed all peripheral vascular surgical admissions (n = 1240) by age treated at the Long Island Jewish Medical Center from 1985 to 1987. Hospital cost and length of stay per patient increased with age, as did losses under diagnostic related group (DRG) prospective hospital payment. Hospital cost by hospital service showed considerable variation by age category; outliers, mortality, and the number of diagnoses and procedures generally rose with age. Use of hospital resources, such as emergency or surgical intensive care unit admission, or the need for blood or plasma products was high in general for patients undergoing peripheral vascular surgery. This study demonstrates a number of findings regarding the socioeconomic factors for hospitalized patients undergoing peripheral vascular surgery. Surgical health policy analysis of this specialty vis-a-vis current changes proposed to the federal medicare DRG system in the U.S. Congress and Health Care Financing Administration suggests a relatively greater impact on the specialty of peripheral vascular surgery demonstrated in this study by the use of higher resources of the same.

Adolescent↗
PubMed1989

Desensitization of alpha 1 adrenoceptor-stimulated glycogen phosphorylase activity in vascular smooth muscle.

Desensitization of alpha 1-adrenoceptor-mediated activation of glycogen phosphorylase was investigated in rabbit aorta. Activation of glycogen phosphorylase by epinephrine was antagonized by the alpha 1-receptor selective antagonist prazosin but not by yohimbine (alpha 2-receptor selective) or by propranolol (beta-receptor antagonist). Preincubation of rabbit aortic ring segments for 5 h with norepinephrine (NE, 10(-5) M) led to a 30-fold loss in sensitivity and a 55% decrease in maximal activation of the enzyme by alpha agonists. Preincubation of aortic ring segments with phenylephrine (10(-5) M) in the presence of propranolol (10(-6) M) also caused desensitization of glycogen phosphorylase activation. The desensitization was heterologous since maximal activation of the enzyme by histamine or KCl was also markedly diminished in segments preincubated with NE. In contrast to these results, catecholamine-induced desensitization to alpha 1-adrenoceptor-mediated smooth muscle contraction in aortic ring segments resulted in loss in sensitivity but not maximal force of contraction on subsequent stimulation by alpha 1 agonists. These results suggest that the mechanism responsible for desensitization of glycogen phosphorylase is distal to receptor activation and may involve attenuation of responses to intracellular Ca2+-dependent enzymes which have limited reserve.

Animals↗
PubMed1989

Effect of yeast hulls on stuck and sluggish wine fermentations: importance of the lipid component.

The effect of yeast hulls (yeast ghosts) on sluggish or stuck white wine fermentations was studied. The enhancing effect on yeast growth and fermentation rate displayed by the hulls was shown to be similar to the effect provided by lipid extract from the same hulls. Unsaturated fatty acids and sterols were incorporated into the yeast from lipid extracts during fermentation carried out under oxygen-limited conditions. Adsorption of toxic medium-chain fatty acid (decanoic acid) onto the yeast hulls took place through a dialysis membrane. However, when the hulls were placed inside a dialysis bag, the increase in yeast growth and fermentation rate seen when freely suspended hulls were used did not occur. Accordingly, the effect of yeast hulls in preventing stuck fermentations cannot be attributed only to the adsorption and consequent removal of medium-chain fatty acids from the juice.

Journal Article↗
PubMed1989

Health care financing policy for hospitalized rheumatology patients.

The federal Medicare Diagnostic Related Group (DRG) prospective payment model is changing hospital payment. Currently many states are using DRG prospective "All Payor Systems" for hospital reimbursement. In All Payor Systems, Medicare, Medicaid, Blue Cross and other commercial insurers, pay by the DRG mode; New York State has been All Payor since January 1, 1988. This study simulated DRG All Payor methods on a sample (N = 298) of rheumatology patients for a 3-year period using both federal and New York DRG reimbursement now in effect. Both Medicare and Medicaid patients had (on average) a longer hospital length of stay and total hospital cost compared to patients from Blue Cross and other commercial payors. All payors (i.e., Medicaid, Blue Cross, Medicare and commercial insurors) generated significant financial risk under the DRG All Payor scheme. If these findings are replicated at other hospitals, rheumatology patients could suffer a decline in both access and quality of care.

Aged↗
PubMed1989

The equity of diagnostic related group "All Payor" hospital payment and gynecology diagnostic related groups.

Previous work by our group had suggested that some Diagnostic Related Groups did not adequately compensate for patients with multiple complications and comorbidities. However, this question had never been studied for gynecology Diagnostic Related Groups. We analyzed resource consumption in the 15 gynecology Diagnostic Related Groups that were not stratified for complications or comorbidities using the new Diagnostic Related Group prospective "All Payor System" in effect at our hospital. Analysis of 2920 gynecology patients for a 3-year period by payor (Medicare, Medicaid, Blue Cross, and commercial insurance) in the gynecology Diagnostic Related Groups that were not stratified for complications or comorbidities demonstrated that patients with more complications and comorbidities per Diagnostic Related Group for each payor generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, financial risk under Diagnostic Related Group payment, more outliers, and a higher mortality compared with patients in these same Diagnostic Related Groups with fewer complications and comorbidities. These findings suggest that new prospective Diagnostic Related Group All Payor Systems may be inequitable for certain groups of gynecology patients. Gynecology Diagnostic Related Groups should be stratified by the numbers and types of complications and comorbidities to more equitably reimburse hospitals under Diagnostic Related Group All Payor Systems.

Adult↗