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Biomedical subjects

M Ullman

Publications and source records attributed to M Ullman.

At least 19 recordsLinked to original sources
PubMed2006

Assessing the costs for clinical care of patients with high-responding factor VIII and IX inhibitors.

The costs of haemophilia-related care and the impact of unusually expensive, or outlier, patients on these costs have been explored in numerous European, American and Canadian studies during the last decade. In particular, antibodies that neutralize infused factor VIII or IX (high-responding inhibitors) make treatment responses, and thereby costs, much less predictable. There is little debate that the health care costs of haemophilic patients with high-responding inhibitors are routinely higher and more variable than those of non-inhibitor patients. However, the extent to which this is attributable to the few outlier inhibitor patients whose expenditures tend to skew the data is not as clear. To compare the variation and range in health care expenditures among patients with inhibitors and those without, we reviewed data originally gathered during a 24-month period in 1995-1997 from a prospectively created cohort as part of a broader cost and utilization study conducted at a large haemophilia treatment centre. We conclude that although the use of outpatient factor replacement products was not significantly greater or more expensive among inhibitor patients, their hospital-related costs greatly increased overall expenditures. Among our study population, the overall costs associated with inhibitor patients are not only higher in absolute monetary terms, but also in terms of the degree of variation. This variation was demonstrated by: (i) the extremely wide range of costs over an extended timeframe among individual inhibitor patients when compared with those without inhibitors, and (ii) the much larger year-to-year variation in costs among the inhibitor group.

Adolescent↗
PubMed1999

Different paths to justice: the ADA, employment, and administrative enforcement by the EEOC and FEPAs.

Under Title I of the ADA, individuals who believe they have been subjected to disability-based employment discrimination may file an administrative charge. This article looks at who files charges; over what issues, and with what outcomes in both Equal Employment Opportunity Commission (EEOC) field offices, and state and local fair employment practice agencies (FEPAs). The data for the article are computerized records of all ADA charges filed through March 31, 1998. The data indicate that individuals who rely on a FEPA to investigate their charge have a greater likelihood of obtaining a beneficial outcome than individuals who rely on the EEOC, but proportionately more individuals receiving a beneficial outcome are likely to receive monetary benefits from the EEOC than from a FEPA. Further, those who receive beneficial outcomes will probably receive greater monetary benefits from charges investigated by the EEOC than from those investigated by a FEPA.

Civil Rights↗
PubMed1999

Outcomes of employment discrimination charges filed under the Americans With Disabilities Act.

OBJECTIVE: The outcomes of employment discrimination charges filed under the Americans With Disabilities Act (ADA) by individuals with psychiatric disabilities and those with other disabilities were compared. METHODS: Data obtained from the Equal Employment Opportunity Commission (EEOC) consisted of all ADA employment claims closed as of March 31, 1998. Charges were categorized by whether they were investigated by the EEOC or by a Fair Employment Practice Agency (FEPA). RESULTS: Of the 175,226 charges filed, 83.2 percent were closed by March 31, 1998. Of these, 15.7 percent brought some kind of benefit to charging parties, although only 1.7 percent resulted in new hires or reinstatements. Of charges investigated by FEPAs, 23.3 percent led to some benefit, compared with 11.5 percent of charges investigated by the EEOC. Of charges investigated by the EEOC, the median actual monetary benefit was $5,646, compared with $2,400 for charges investigated by FEPAs. A total of 13.6 percent of charges filed by individuals with psychiatric disabilities resulted in benefits, compared with a benefit rate of 16 percent for persons with other disabilities. The median actual monetary benefit received by persons with psychiatric disabilities was $5,000, compared with $3,500 for those with nonpsychiatric disabilities. Individuals whose charges were investigated in the first three years of ADA implementation were more likely to receive benefits than individuals whose charges were investigated more recently. CONCLUSIONS: Most employment discrimination charges filed under the ADA do not result in benefits or a finding of reasonable cause. Outcomes for people with psychiatric disabilities do not differ substantially from those for people with other disabilities.

Databases as Topic↗
PubMed1998

Performance measurement in pneumonia care: beyond report cards.

OBJECTIVE: To compare the medical management of bacteremic pneumococcal pneumonia at a university-based and a community-based teaching hospital and evaluate strategies for performance measurement and subsequent improvement. DESIGN: We conducted a retrospective cohort study involving a 450-bed university hospital in the inner city and a 400-bed private hospital in a rural community. MATERIAL AND METHODS: The medical records of all adults with bacteremic pneumococcal pneumonia admitted to a university and a community hospital during a 5-year period were reviewed. Information about patient age, sex, underlying medical condition, severity of disease, health-care insurance, management, and outcome was collected and analyzed. RESULTS: Patients at the two hospitals were similar in underlying illnesses and severity of disease. In comparison with the community hospital, resource expenditure was greater at the university hospital, where all 11 identified diagnostic measures and treatment resources were used more often. This difference was statistically significant for sputum cultures, all cultures, and lumbar punctures. Despite the greater intensity of care, in-hospital mortality was higher at the university hospital (26%) than at the community hospital (12%) (P>0.1). CONCLUSION: The outcome of bacteremic pneumococcal pneumonia did not differ significantly at a university hospital in comparison with a community teaching hospital, even though resource expenditure at the university hospital was greater. Our findings suggest that hospital "report cards" based solely on outcome comparisons provide inadequate information. In contrast, examination of variations in profiles of resource utilization can detect important differences in hospitals and can be used to guide continuous quality improvement efforts and ultimately improve hospital care.

APACHE↗
PubMed1997

Approaches to prostate cancer by managed care organizations.

OBJECTIVES: Managed care organizations (MCOs) are developing population-based approaches to illnesses with large numbers of patients, wide variations in care and outcomes, and high costs. This is the first survey that evaluates current prostate cancer approaches by MCOs. METHODS: Case studies and a survey of corporate medical directors at large MCOs were conducted. RESULTS: Two approaches, broadly based on disease management strategies for men with prostate cancer, have been implemented in managed care settings on the West Coast. While both have provided comprehensive approaches to the disease, assessment of improvement in outcomes will require longer follow-up. A survey of corporate medical directors of MCOs indicates that population-based disease approaches nationwide for malignant prostate disease lag behind more well-developed efforts for nonmalignant illnesses such as diabetes and asthma. CONCLUSIONS: Prostate cancer may be a feasible area for development and evaluation of population-based approaches. MCOs have the potential to improve clinical care and outcomes for large numbers of men with prostate cancer. While limitations exist related to specific managed care considerations of data needs and lack of medical and surgical consensus on disease management, programs based on shared decision making have the potential to improve patient care and outcomes.

Health Care Surveys↗
PubMed1997

Service system performance and integration: a baseline profile of the ACCESS demonstration sites. Access to Community Care and Effective Services and Supports.

OBJECTIVE: Networks of agencies at the 18 demonstration sites in the Access to Community Care and Effective Services and Supports (ACCESS) program for homeless persons with serious mental illness were surveyed to profile baseline levels of systems performance and integration as part of a longitudinal evaluation of systems change and client outcomes. METHODS: Interviews were conducted with a representative from each of 875 agencies in the 18 service networks. Information was obtained about the perceived performance of the service system and the extent of systems integration as measured by client referrals, funds exchanges, and information sharing between agencies. Measures consisted of two multi-item scales assessing the accessibility and coordination of services for the target population in each community and four indexes of interagency relationships. RESULTS: Services at baseline for homeless mentally ill persons at the program sites were rated as relatively inaccessible, and the coordination of services between agencies was rated as even more problematic. Interagency ties were largely based on client referrals and information exchanges, with very few instances of funding transfers in the form of contracts or grants. On average, at baseline agencies that had received an ACCESS grant were better connected to their local service network than were other agencies. CONCLUSIONS: Consistent with the premise of the ACCESS demonstration, services for persons who are homeless and mentally ill in urban America are fragmented and not very accessible. The longitudinal design of the evaluation will allow for an assessment of efforts to improve services and systems integration and of the effects of these improvements on client outcomes.

Adult↗
PubMed1997

Variations in medical care for HIV-related Pneumocystis carinii pneumonia: a comparison of process and outcome at two hospitals.

BACKGROUND: Institutional variation in the quality of medical care may be evaluated by examining process measures, such as use of diagnostic procedures or treatment modalities, or outcome measures, such as mortality. We undertook this study to examine variations in both process and outcome of care for patients with HIV-related Pneumocystis carinii pneumonia (PCP) at two geographically diverse, HIV-experienced, public municipal hospitals. DESIGN: Retrospective review of hospitalized patients diagnosed as having PCP cared for at two municipal hospitals from 1988 to 1990. At hospital A, charts of all patients diagnosed as having PCP were abstracted (n=209); at hospital B, a random sample of 15% were abstracted (=136). RESULTS: Among all hospitalized patients diagnosed as having PCP, the frequency of making a definitive diagnosis of PCP (as opposed to treating empirically) differed markedly at the two hospitals (85% in hospital A vs 26% in hospital B; p<0.001), as did the use of intensive care (18% vs 3%; p<0.001) and "do-not-resuscitate" orders (39% vs 14%; p<0.001), although the timing of starting anti-Pneumocystis medications (89% vs 88% within the first 2 hospital days) and the use of corticosteroids (21% vs 23%) were similar. Despite differences in the process of care, survival rates were similar at the two institutions (75% vs 76%; p=0.8) and remained similar when logistic regression was used to control for demographic variables and severity of illness (odds ratio for survival, hospital B vs A, 1.2 [95% confidence interval, 0.7, 2.0]). The 95% confidence intervals (0.7, 2.0), however, were consistent with a considerable (and clinically significant) disparity in survival (from 30% lower to a twofold higher odds of survival). Sample size calculations showed that a sample of 10 cases in each hospital would be required to detect the observed difference in definitive diagnosis rates (85% vs 26%), but 722 cases in each hospital would be required to detect a relevant difference in mortality. CONCLUSIONS: The process of care for hospitalized patients with PCP in these two institutions differed considerably, but the survival rates were not significantly different, even after adjusting for confounding factors. While sample sizes available at the individual institutions were sufficient for evaluation of the process of care, they did not provide the power necessary to evaluate outcomes. Comparisons of outcomes such as mortality between individual hospitals may not have the statistical power to exclude important differences.

AIDS-Related Opportunistic Infections↗
PubMed1996

Performance measurement in prostate cancer care: beyond report cards.

OBJECTIVES: Review and analyze various approaches to performance measurement in health care, demonstrating the value of provider-initiated performance measurement in which ongoing monitoring of both processes and outcomes of care coupled with the use of clinical guidelines enhances performance improvement efforts. Describe some of the issues and findings associated with the use of such a methodology in prostate cancer care. METHODS: Literature review and case study. RESULTS: There are a number of significant limitations in the use of a "report card" methodology to improve quality and efficiency in health care. The complementary approach of combining "instrument panels" and clinical guidelines within an overall continuous quality improvement framework appears to have resulted in improved clinical outcomes and reduced costs in a six-physician urology group located in a heavily managed-care penetrated market. CONCLUSIONS: Performance measurement tools are integral to efforts to improve outcomes and efficiency in health care. Providers of care might consider adapting the kind of performance improvement methodology described in this article. Practice benefits including improved clinical and economic outcomes are likely to follow.

Forecasting↗
PubMed1992

Overregularization in language acquisition.

Children extend regular grammatical patterns to irregular words, resulting in overregularizations like comed, often after a period of correct performance ("U-shaped development"). The errors seem paradigmatic of rule use, hence bear on central issues in the psychology of rules: how creative rule application interacts with memorized exceptions in development, how overgeneral rules are unlearned in the absence of parental feedback, and whether cognitive processes involve explicit rules or parallel distributed processing (connectionist) networks. We remedy the lack of quantitative data on overregularization by analyzing 11,521 irregular past tense utterances in the spontaneous speech of 83 children. Our findings are as follows. (1) Overregularization errors are relatively rare (median 2.5% of irregular past tense forms), suggesting that there is no qualitative defect in children's grammars that must be unlearned. (2) Overregularization occurs at a roughly constant low rate from the 2s into the school-age years, affecting most irregular verbs. (3) Although overregularization errors never predominate, one aspect of their purported U-shaped development was confirmed quantitatively: an extended period of correct performance precedes the first error. (4) Overregularization does not correlate with increases in the number or proportion of regular verbs in parental speech, children's speech, or children's vocabularies. Thus, the traditional account in which memory operates before rules cannot be replaced by a connectionist alternative in which a single network displays rotelike or rulelike behavior in response to changes in input statistics. (5) Overregularizations first appear when children begin to mark regular verbs for tense reliably (i.e., when they stop saying Yesterday I walk). (6) The more often a parent uses an irregular form, the less often the child overregularizes it. (7) Verbs are protected from overregularization by similar-sounding irregulars, but they are not attracted to overregularization by similar-sounding regulars, suggesting that irregular patterns are stored in an associative memory with connectionist properties, but that regulars are not. We propose a simple explanation. Children, like adults, mark tense using memory (for irregulars) and an affixation rule that can generate a regular past tense form for any verb. Retrieval of an irregular blocks the rule, but children's memory traces are not strong enough to guarantee perfect retrieval. When retrieval fails, the rule is applied, and overregularization results.

Age Factors↗
PubMed1991

Skeletal muscle regeneration in young rats is dependent on growth hormone.

Skeletal muscle fibres have a well known ability to regenerate after different kinds of injury. This study was undertaken to establish if regenerating skeletal muscle is dependent on growth hormone (GH) in the same manner as normal, growing skeletal muscle in young rats. Muscle regeneration was achieved by injection of notexin into the soleus muscle. Initial necrosis, which included all muscle fibres, was followed by a rapid and uniform regeneration throughout the muscle. Cell proliferation was estimated by scintillation counting and autoradiography of incorporated [3H]thymidine, injected intravenously 1 h before killing, 7 or 27 days after the initiation of regeneration. GH deficiency was accomplished by hypophysectomy 4 days before the [3H]thymidine injection. Cell proliferation was diminished in both regenerating and normal muscle of the hypophysectomized rats compared to control and GH-substituted rats. After 7 days of regeneration the reduction of cell proliferation seen in hypophysectomized rats was less pronounced in the regenerating than in the normal muscle. These findings demonstrate that GH plays an important role for muscle regeneration in young rats, although other substances appear to be of greater importance during the early stages of regeneration.

Animals↗
PubMed1990

Liquid silicone as a lunate prosthesis.

Eleven patients with lunatomalacia were treated by excision of the lunate and instillation of liquid silicone. The silicone vulcanised and formed an in-situ molded prosthesis. The patients were reexamined after a mean of 7.1 years. Four patients were pain-free and two had pain only at work; three had not been improved by the operation and two had undergone arthrodesis. The patients with good results all belonged to group IV pre-operatively. Surprisingly, no patient showed any sign of silicone synovitis, although all the prostheses except one had either fractured or deformed. The reasons for this are discussed and the indications for the operation established.

Follow-Up Studies↗
PubMed1990

Effects of growth hormone on muscle regeneration and IGF-I concentration in old rats.

A study was made of regeneration of skeletal muscle in young adult and old rats and of the effects of administration of growth hormone to old rats. Regeneration was achieved by subjecting the right extensor digitorum longus muscle to ischaemic necrosis. The level of insulin-like growth factor I in serum was markedly decreased in old rats of 27 months of age compared with young adult rats aged 6 months. Daily injections of 4 IE recombinant human growth hormone during the 10 weeks of regeneration increased the level of insulin like growth factor I to almost the same levels as in rats aged 6 months. The body weight increased by 13% in the old rats treated with recombinant human growth hormone, while the weight of the untreated old rats was constant. The regenerating right and the normal left extensor digitorum longus muscles were studied 10 weeks after the ischaemic necrosis. The absolute and relative weights of regenerating muscle were decreased in 27-month-old rats compared with the rats aged 6 months. No significant difference between normal old rats and old rats treated with recombinant human growth hormone was observed either in muscle weight or in maximum contraction force. The results show that old rats have reduced levels of circulating insulin-like growth factor I. Administration of recombinant human growth hormone raises the level of insulin-like growth factor I to that of young adult rats, and causes an increased body weight. Muscle regeneration after ischaemic necrosis is impaired in old rats apparently by the formation of large amounts of connective tissue. Supplementation with growth hormone does not reverse this impairment.

Aging↗
PubMed1989

Muscle regeneration. The effect of hypophysectomy on cell proliferation and expression of insulin-like growth factor-I.

Against the background of the importance of growth hormone (GH) for normal muscle growth, a study was performed to investigate whether lack of GH after hypophysectomy affects the cell proliferation and the local production of insulin-like growth factor-I (IGF-I) in the early stages of muscle regeneration in adult rats. The level of IGF-I in the serum of hypophysectomised rats was reduced to about 30% of that of controls. The incorporation of [methyl-3H]thymidine into the regenerating muscle showed a peak 6 days after the operation and then gradually declined to the end of the period of study 30 days after initiation of regeneration by ischemic necrosis. The DNA content rose to a maximum level after 6-8 days, and remained high after 30 days. There was no major difference in the incorporation of [3H]thymidine in regenerating muscle of hypophysectomised and control rats, but the DNA concentration in the regenerating muscles of hypophysectomised rats was significantly reduced after 30 days. There was a corresponding reduction in the number of nuclei per muscle fibre, indicating that hypophysectomy has a small effect on the cell proliferation during the early stages of muscle regeneration. Immunohistochemical demonstration of IGF-I in the regenerating muscle revealed the transient presence of immunoreactive material in satellite cells and myotubes after 6 to 8 days of regeneration but no immunoreactivity after 30 days. No obvious difference was observed between hypophysectomised and control rats, indicating that the endogenous production of IGF-I in regenerating skeletal muscle can occur independently of GH.

Animals↗
PubMed1989

Effects of growth hormone on skeletal muscle. I. Studies on normal adult rats.

A study was made on the effects of recombinant human growth hormone (rhGH) on fast and slow skeletal muscle in normal adult female rats. Daily injections of 4 IE of rhGH over 36 days resulted in increased levels of insulin-like growth factor I in serum and increased body weight. Morphometric analysis of the muscle fibres of the extensor digitorum longus (EDL) and soleus muscles revealed a significant increase in diameter of both type 1 and type 2 fibres in both muscles. The DNA: protein ratio and the number of satellite cells:muscle fibre in cross-sections was increased in the GH-treated rats in relation to controls. The results show that rhGH has pronounced effects on both cell proliferation and muscle fibre growth in skeletal muscle of normal adults rats.

Animals↗
PubMed1989

Effects of growth hormone on skeletal muscle. II. Studies on regeneration and denervation in adult rats.

The effects of human recombinant growth hormone (rhGH) on regenerating skeletal muscle after ischaemic necrosis and on denervated skeletal muscle were studied in normal adult rats. One group of rats was treated with 4 IE rhGH daily by subcutaneous injections, while control rats were injected with saline. The treatment with rhGH resulted in increased levels of insulin-like growth factor-I (IGF-I) in serum. Ischaemic necrosis was achieved in the extensor digitorum longus (EDL) muscle by cutting the supplying vessels and nerve fascicles at the entrance into the muscle. The wet weight and DNA: protein ration in the regenerating muscle were determined 2 and 4 weeks after the operation. The weight of the regenerating muscles in the rats treated with rhGH during the period of study was larger than in the control rats, while the DNA:protein ratio did not differ significantly between the groups. Denervation of the EDL and soleus muscles followed by subsequent reinnervation was obtained by freezing the sciatic nerve with a forceps chilled in liquid nitrogen. Rats treated with rhGH during the period of denervation and reinnervation, i.e. during the 4 weeks after the freezing of the sciatic nerve, revealed increased weight of both the reinnervated and normal muscles compared to corresponding muscles of control rats. Denervation of the EDL and soleus muscles without subsequent reinnervation was achieved by cutting the sciatic nerve at the level of the thigh. Four weeks after denervation the muscles showed atrophy, mainly affecting type 2 fibres in the EDL muscle and both type 1 and type 2 fibres in the soleus muscle.

Adenosine Triphosphatases↗