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Biomedical subjects

J Hurley

Publications and source records attributed to J Hurley.

At least 19 recordsLinked to original sources
PubMed1997

Defining the practice population in fee-for-service practice.

OBJECTIVE: To develop and validate a technique for defining a practice population of discrete individuals based on multiyear family practice fee-for-service billings data. DATA SOURCES/STUDY SETTING: Nineteen family physicians in Ontario, Canada who converted from fee-for-service to capitation payment. Data sources were fee-for-service billings data for the three-year period prior to the conversion from fee-for-service to capitation payment and the rosters of enrolled patients for the first and third years after the change to capitation payment. STUDY DESIGN: The billings-based definition of the physician's practice population was compared against the Year 1 roster. We also compared the billings-based practice population and the Year 1 roster to the physician's Year 3 roster to identify patients who might have been missed during the roster development process. Our principal analyses were an assessment of the sensitivity of the billings-based definition of the practice population (EPP), the positive predictive value of EPP, and the agreement between EPP and the rostered patient population (RPP). We also examined the ratio between EPP and RPP to determine EPP's accuracy in estimating the practice denominator. DATA COLLECTION/EXTRACTION METHODS: The practice population for each physician at the time of conversion from fee-for-service to capitation payment was defined as (a) all persons for whom the physician billed the provincial health insurance plan for at least one visit during the year immediately prior to joining the capitation-funded program; and (b) all additional patients for whom the physician billed the plan for at least one service in each of the two preceding years. Data extraction was carried out within the Ministry of Health in order to preserve the anonymity of patients and physicians. Data were provided to the investigators stripped of patient and physician identifiers. PRINCIPAL FINDINGS: The mean sensitivity and positive predictive value of EPP were 95.3 percent and 87.4 percent, respectively. The level of agreement between EPP and RPP averaged 84.4 percent. The mean ratio of EPP to RPP was 1.21 (95 percent C.I. 1.030-1.213). Correction for roster false-negatives increased the sensitivity, positive predictive value, and agreement between EPP and the practice population, and reduced the mean ratio of EPP to the practice population to 1.068 (95 percent C.I. 1.010-1.127). CONCLUSIONS: The practice population can usefully be defined in fee-for-service family practice on the basis of multiyear fee-for-service billings data. Further research examining alternative encounter-based practice population definitions would be valuable.

Adolescent↗
PubMed1997

Investigation of a listeriosis epizootic in sheep in New York state.

OBJECTIVE: To investigate potential sources of an epizootic of listerial encephalitis, using molecular diagnostic and typing methods. SAMPLE POPULATION: A flock of about 655 sheep. PROCEDURE: An epizootiologic investigation was performed. Clinical, feed, and environmental samples were tested for Listeria monocytogenes, using polymerase chain reaction and culture methods; recovered isolates were "fingerprinted," using an automated ribotyping system. RESULTS: Listeria monocytogenes was recovered from brain specimens of 7 sheep with clinical signs of listerial encephalitis. All clinical isolates had fingerprints identical to those of isolates from farm equipment used to transport silage. Corn silage, which was not fed to the sheep, also contained L monocytogenes of the same pattern type as defined by ribotyping. Listeria monocytogenes was not isolated from the stored haylage designated for feeding the sheep (the cut-off point for isolation being < 10(2) colony-forming units/g). CONCLUSIONS: Corn silage was implicated as the source of a listeriosis epizootic. It appears to have cross-contaminated the haylage destined for the sheep during handling with a front-end loader. Suspension of silage feeding coincided with cessation of listeriosis cases. CLINICAL RELEVANCE: Use of advanced molecular techniques can help to identify the sources and restrict the scope of an epizootic. In epizootics, a single L monocytogenes strain can lead to infection of multiple animals, with rapid progression of the disease.

Animals↗
PubMed1996

Global physician budgets as common-property resources: some implications for physicians and medical associations.

Since 1990 payment for physician services in the fee-for-service sector has shifted from an open-ended system to fixed global budgets. This shift has created a new economic context for practising medicine in Canada. A global cap creates a conflict between physicians' individual economic self-interest and their collective interest in constraining total billings within the capped budget. These types of incentive problems occur in managing what are known in economics as "common-property resources." Analysts studying common-property resources have documented several management principles associated with successful, long-run use of such resources in the face of these conflicting incentives. These management principles include early defining the boundaries of the common-property resource, explicitly specifying rules for using the resource, developing collective decision-making arrangements and monitoring mechanisms, and creating low-cost conflict-resolution mechanisms. The authors argue that global physician budgets can usefully be viewed as common-property-resources. They describe some of the key management principles and note some implications for physicians and the provincial and territorial medical associations as they adapt to global budgets.

Budgets↗
PubMed1996

Do physician-payment mechanisms affect hospital utilization? A study of Health Service Organizations in Ontario.

OBJECTIVES: To determine whether payment of primary care physicians based on capitation, with an additional incentive payment for low hospital-utilization rates, resulted in lower hospital-utilization rates among patients of these physicians than among patients of physicians still paid on a fee-for-service basis. DESIGN: Retrospective cohort study. SETTING: Capitation-based and fee-for-service primary care practices in Ontario. SUBJECTS: Thirty-nine physicians whose method of payment was converted from fee-for-service to capitation during the period from June 1985 to January 1989 and 7 physicians who remained in fee-for-service practice, two of whom were matched with one physician in capitation-based practice on the basis of practice location, type of practice (academic v. community), hours of practice (part-time v. full-time), years since graduation, physician group size, practice size (number of patients), type of group (primary care v. multispecialty), sex, certification in family medicine, country of graduation (Canada v. other) and age. One physician in capitation-based practice was matched with only one physician in fee-for-service practice. OUTCOME MEASURES: Annual hospital-utilization rates (hospital separations or hospital days per 1000 patients in each practice) for the physicians paid on a capitation basis 3 years before, 1 year before and 3 years after they converted from fee-for-service payment and at corresponding periods for the matched physicians still paid on a fee-for-service basis. RESULTS: The mean annual rate of hospital days used, adjusted for the age and sex of patients as well as for their social-program-recipient status, fell from 1085 per 1000 patients (3 years before the conversion date) to 1030 (1 year before conversion) and to 954 (3 years after conversion) in capitation-based practices. For the matched physicians in fee-for-service practice, the rates during the corresponding periods were 1085, 1035 and 956 hospital days per 1000 patients. The pattern was similar for rates of hospital separations, adjusted for patient's age, sex and social-program-recipient status. There were no statistically significant differences between the rates of hospital utilization among patients of physicians in capitation-based practices and the rates among those of physicians in fee-for-service practices during each of the three periods, nor were there significant differences in the changes in rates. CONCLUSION: Capitation payment, with an additional incentive payment to encourage low hospital-utilization rates, did not reduce hospital use. Factors other than the method of physician payment appear to be responsible for the variations in hospital utilization among practices.

Adult↗
PubMed1996

Phase II trial of mitoxantrone and cisplatin in advanced non-small-cell lung cancer.

Because in vitro data suggest that mitoxantrone may be synergistic with cisplatin, a Phase II trial of mitoxantrone and cisplatin was conducted in patients with advanced or metastatic non-small-cell lung cancer (NSLC). Twenty-four patients were evaluable for response. Toxicity was tolerable. Partial response occurred in three patients (13%). This response rate is similar to that reported for cisplatin alone in NSLC. Mitoxantrone did not improve the response rate when combined with cisplatin for patients with advanced NSLC.

Adenocarcinoma↗
PubMed1996

Primary care in London: an evaluation of general practitioners working in an inner city accident and emergency department.

OBJECTIVE: To determine the characteristics of primary care attenders to St Mary's Hospital accident and emergency (A&E) department, evaluate the effects of the introduction of general practitioners (GPs) on patient care in A&E, and make recommendations for the provision of GPs in appropriate A&E departments. DESIGN: Prospective survey over a six week period. METHODS: Data collected from the attendances of 970 consecutive patients triaged with "minor" primary care problems, whether seen by A&E doctors or by GPs working in A&E, were analysed. RESULTS: During the study period 1078 patients (16.6%) were triaged as suitable for primary care. The A&E GPs saw 58.4% of these patients. The majority of primary care patients were young British residents, 71.1% of whom were registered with a GP. Sixty per cent of patients lived within St Mary's catchment area. Of those registered patients asked why they attended A&E, 27.1% thought their problem inappropriate for their GP. A&E doctors were more likely to investigate patients and arrange hospital follow up than GPs, who arranged community follow up in 80% of patients needing further care. CONCLUSIONS: The demand for primary care at St Mary's necessitates the provision of a primary care service, albeit for the first visit only. This can be provided by GPs in A&E. The features of the patients using the service suggests that discouraging first attendance is unrealistic, but using the visit to educate patients and return them to the care of the community is not.

Adolescent↗
PubMed1995

Comparison of activity level and service intensity of male and female physicians in five fields of medicine in Ontario.

OBJECTIVE: To examine the extent to which physician's sex explains variation in the activity level and service intensity of a cohort of physicians in each of five medical fields after other sources of variation are taken into account. DESIGN: Data from the Ontario Ministry of Health (MOH) and the CMA were analysed by means of multivariate regression techniques for panel data. SETTING: Ontario. PARTICIPANTS: A total of 137 dermatologists, 974 general internists, 330 pediatricians and 941 psychiatrists and a random sample of 2771 family physicians and general practitioners who met the eligibility criteria. Physicians were eligible if they billed the MOH for at least three quarters in 1983, did not bill as a medical laboratory director, provided direct patient care, did not have an alternative funding arrangement with the MOH, remained in the same specialty throughout the study period (1983-90) and billed from an Ontario address. OUTCOME MEASURES: Three measures of total activity level (annual number of services provided, annual fee-for-service billings and annual mean number of patients seen per quarter) and one measure of service intensity (annual mean number of services per patient per quarter). RESULTS: Although several variables (e.g., full-time work status, age, type of practice and recent practice move) influenced the four measures examined, physician's sex contributed significantly to explaining variation in activity in 70% of the regression equations. The women provided 33.0% fewere services per year than the men in family and general practice (p < 0.001), 25.0% fewer services in general internal medicine (p < 0.01), 22.1% fewer services in pediatrics (p < 0.05) and 22.3% fewer services in psychiatry (p < 0.001). Total billings by the women in these fields were also significantly less than those of their male colleagues, the difference being greatest among the family physicians and general practitioners (28.0%) and the general internists (27.0%) (p < 0.001). The women in these four fields saw significantly fewer patients per quarter than their male colleagues, the difference being greatest in psychiatry (33.0%) (p < 0.001). Sex affected service intensity in three fields. The female psychiatrists (14.8%) (p < 0.001) and general intenists (5.5%) (p < 0.10) provided more services per quarter than their male colleagues, whereas the female family physicians and general practitioners delivered 2.2% fewer services per patient per quarter than their male colleagues (p < 0.01). In two specialties differences between women aged 40 years or less and those over 40 years were observed. In general internal medicine the younger women had higher activity levels than the older women (p < 0.01). Conversely, in dermatology the younger women had lower activity levels (p < 0.05) and provided fewer services per patient per quarter (p < 0.001) than the older women. CONCLUSIONS: Although physician's sex explained much of the variation in activity level and service intensity, even after other important correlates were controlled for, the type and extent of differences observed between female and male physicians depended on the particular medical field examined. To understand the effect of the large increase in the number of women on the physician workforce, more detailed analyses by medical field are needed of the volume, mix and intensity of services provided by men and women, with adjustment for any possible differences in the patients seen in their practices.

Age Factors↗
PubMed1995

Geographically-decentralized planning and management in health care: some informational issues and their implications for efficiency.

Geographically decentralized planning and management is an emerging theme within the health sector in many OECD countries. Advocates of decentralization argue that providing greater authority to local decision-making bodies can improve both the technical and allocative efficiency with which health care systems operate. Using concepts drawn from organizational theory and the economics of organizations, we examine the potential of centralized and decentralized planning and management structures to be efficient in light of the informational problems that must be overcome to allocate resources efficiently. We focus in particular on the need to integrate information regarding: (1) the effectiveness and efficiency of alternative clinical interventions and of alternative ways organize the delivery of health care; (2) the needs, values, and preferences in the population; and (3) local circumstances that affect delivery of care across regions. Informational concerns suggest that decentralized structures have greater potential to be efficient. We then briefly discuss some principles for the design of decentralized structures to aid in realizing these potential efficiency gains.

Decision Making, Organizational↗
PubMed1995

Morphologic change in rabbit femoral arteries induced by storage at four degrees Celsius and by subsequent reperfusion.

PURPOSE: Cold-stored arteries function well as microvascular autografts, but little is known of the morphologic changes that occur in them during cold storage or of further changes during reperfusion. METHODS: In part A of the study, rabbit femoral arteries were stored at 4 degrees C for up to 6 months. In part B rabbit femoral arteries were stored at 4 degrees C for up to 6 months, inserted as end-to-end autografts into contralateral femoral arteries, and reperfused for 24 hours. Tissue was examined by histologic study, transmission and scanning electron microscopy, histochemical study, immunohistochemical study, and tissue culture. RESULTS: Cell viability declined gradually at 4 degrees C, so that by 4 weeks no viable cells remained. However, the extracellular framework and elastic lamellae remain intact. If cold-stored arteries are reinserted as autografts for 24 hours, this accelerates breakdown of necrotic cells and reduces the thickness of the medial wall and internal elastic lamina but does not alter the extracellular framework. CONCLUSIONS: Cold storage results in acellular vascular grafts with intact extracellular frameworks. After 24 hours reperfusion there is no major change to the extracellular framework.

Actins↗
PubMed1995

The haemodynamic effect of prophylactic peri-operative dopexamine in coronary artery bypass patients.

Twenty-three low risk coronary artery bypass graft patients underwent a controlled study of the effects of prophylactic perioperative dopexamine hydrochloride on haemodynamic indices and peripheral perfusion. The infusion commenced following induction of anaesthesia and continued for 24 h postoperatively. The study demonstrated that dopexamine significantly increased cardiac index compared with the control group (P < 0.05) and that this effect was mediated through an increase in both left ventricular stroke volume index and heart rate (P < 0.05). This was associated with a significantly lower systemic vascular resistance (P < 0.05), without an increase in left ventricular stroke work index in the dopexamine group. Despite normal pre-operative left ventricular function, both groups exhibited a fall in pH (P < 0.05) relative to baseline levels. This fall in pH began prior to cardiopulmonary bypass and persisted in the early postoperative period in both groups, suggestive of tissue hypoperfusion and oxygen deficiency. These indices normalized more rapidly in the dopexamine group, suggesting a more rapid reversal of an intra-operative oxygen debt in this group. The study demonstrates the mechanism of action of dopexamine on cardiac function and peripheral perfusion during cardiac surgery and shows that the inodilator properties during cardiac surgery are useful haemodynamically and facilitate early reversal of tissue hypoperfusion and oxygen debt in this environment.

Adult↗
PubMed1995

The acutely burned hand: management and outcome based on a ten-year experience with 1047 acute hand burns.

Optimal hand function has a very positive impact on the quality of survival after burn injury. Over a 10-year period, 659 patients with 1047 acutely burned hands were managed at the Sumner Redstone Burn Center of the Massachusetts General Hospital. Our approach to acutely burned hands emphasizes ranging and splinting throughout hospitalization, prompt sheet autograft wound closure as soon as practical, and the selective use of axial pin fixation and flaps. This approach is associated with normal function in 97% of those with superficial injuries and 81% of those with deep dermal and full-thickness injuries requiring surgery. Although only 9% of those with injuries involving the extensor mechanism, joint capsule, or bone had normal functional outcomes, 90% were able to independently perform activities of daily living.

Acute Disease↗
PubMed1995

Phase II trial of recombinant interferon-alpha with BCNU, cisplatin, DTIC and tamoxifen in advanced malignant melanoma.

Since cytotoxic chemotherapy (BCNU, DTIC and cisplatin, tamoxifen) and interferon-alpha (IFN-alpha) have each produced responses in advanced malignant melanoma, a phase II trial was conducted to evaluate the response and toxicity of simultaneous administration of both therapies. Of 33 assessable patients, two (6%) had complete response (CR) and 12 patients (36%) had partial response (PR), for a total response rate (CR+PR) of 42% (95% confidence interval 26-58). Four patients had minor response (12%). Mixed responses occurred in five patients (15%). The remaining patients had progressive disease. The duration of CR was 3, 7 and 17 (+) months and the duration of PR was 3+ to 19+ months (median 6 months). The median overall survival for all patients entered into the study was 5 months. Main toxicities included myelosuppression and fatigue. Combined simultaneous cytotoxic chemotherapy and IFN produced a high response rate (42%) which is comparable to that reported for chemotherapy alone. Further studies are needed to determine the optimal schedule for combining chemotherapy and immunotherapeutic agents as well as the impact of biological agents on survival in the treatment of melanoma.

Adult↗