Biomedical subjects
Publications and source records attributed to P D Franklin.
This article evaluates the use of hospital inpatient mortality as an indicator of health care outcomes and describes the development of related data. It demonstrates both the strengths and limitations of mortality as a measure of outcomes. It provides guidance concerning the development of raw and severity adjusted mortality data. It also provides information concerning data related to unexpected mortality and complications.
This article describes the importance and the development of data concerning hospital readmissions as an outcomes indicator. It emphasizes the need for consistent definition of readmissions according to time intervals and diagnostic categories. It describes the development of readmission information using computer abstract databases to ensure consistency of indicators. It also provides examples of data developed through this approach.
OBJECTIVE: Decreasing reimbursement provided by third-party payors necessitates reduction of costs for providing critical care services. If academic medical centers are to remain viable, methods must be instituted that allow cost reduction through practice change. METHODS: We used short cycle improvement methodology to rapidly achieve these goals. Short cycle improvement methodology involves identifying the areas for improvement, defining a mechanism to evaluate outcome, initiating an improvement plan on a small number of patients, and repeating the cycle with new adjustments based on outcome. Baseline data on areas for improvement was prospectively collected, and protocols to initiate change were developed and tested by short improvement cycles. Outcomes were evaluated, protocols were modified, and another cycle was performed. This methodology was continued until the desired goals had been achieved. To adjust outcomes for severity of illness, Acute Physiology and Chronic Health Evaluation II methodology was used. Using this methodology, we focused on three areas for improvement. Standing orders for laboratory studies, electrocardiograms, and chest x-ray films were eliminated. Protocols were developed for the appropriate use of sedation, analgesics, and neuromuscular blocking agents. Finally, a protocol for weaning from mechanical ventilation was developed to allow respiratory therapists to proceed through the weaning process, which was ordered by a physician. RESULTS: Laboratory tests were reduced by 65% (from 510 to 180 tests per day) with an annual cost savings of $21,593. Chest x-ray reduction of 56% resulted in an annual savings of $3,941. There was a 75% reduction in cost of neuromuscular blocking agents. The use of neuromuscular blocking agents resulted in a 75% reduction in drug costs. Ventilator hours were reduced by 35% from 140 to 90 hours. The average length of overall intensive care unit stay was reduced by 1.5 days (5.0 to 3.5 days). The cost per patient day decreased with an annualized cost savings of 4% per patient day. Unexpected outcomes included a reduction in intensive care unit days from 54 days at baseline to 7 days at the 6-month interval. The infection rates for blood stream infections, urinary tract infections, and nosocomial pneumonia were reduced. Using national nosocomial infection data, these rates represented a reduction from the fiftieth percentile to the twenty-fifth percentile for all measured indicators. Acute Physiology and Chronic Health Evaluation II scores were 19.54 at baseline and increased to 21.2 (p = 0.001) at the 6-month interval. Mortality rates were 16.7% at baseline and were 17.6% (p = 0.89) at the 6-month interval. CONCLUSION: We concluded that utilization of short cycle improvement methodology provided an ongoing method for reducing costs of critical care services in our patient population with no change in mortality.
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The advent of magnetic resonance imaging (MRI) prompted the reevaluation of the incidence of popliteal cyst and its associated injuries. We reviewed more than 1000 consecutive MRI examinations of the knee performed on patients referred for evaluation of internal derangement. We report a 5% incidence of popliteal cyst, which is lower than has previously been determined. We believe that the reported higher incidence was due to arthrographic distention of normal, collapsed bursae. The strong association between popliteal cyst and tear of the medial meniscus is confirmed. We report for the first time to our knowledge the 13% association between popliteal cyst and complete tear of the anterior cruciate ligament.
Choline is required to make essential membrane phospholipids. It is a precursor for the biosynthesis of the neurotransmitter acetylcholine and also is an important source of labile methyl groups. Mammals fed a choline-deficient diet develop liver dysfunction; however, choline is not considered an essential nutrient in humans. Healthy male volunteers were hospitalized and fed a semisynthetic diet devoid of choline supplemented with 500 mg/day choline for 1 wk. Subjects were randomly divided into two groups, one that continued to receive choline (control), and the other that received no choline (deficient) for three additional wk. During the 5th wk of the study all subjects received choline. The semisynthetic diet contained adequate, but no excess, methionine. In the choline-deficient group, plasma choline and phosphatidylcholine concentrations decreased an average of 30% during the 3-wk period when a choline-deficient diet was ingested; plasma and erthrocyte phosphatidylcholine decreased 15%; no such changes occurred in the control group. In the choline-deficient group, serum alanine aminotransferase activity increased steadily from a mean of 0.42 mukat/liter to a mean of 0.62 mukat/liter during the 3-wk period when a choline-deficient diet was ingested; no such change occurred in the control group. Other tests of liver and renal function were unchanged in both groups during the study. Serum cholesterol decreased an average of 15% in the deficient group and did not change in the control group. Healthy humans consuming a choline-deficient diet for 3 wk had depleted stores of choline in tissues and developed signs of incipient liver dysfunction. Our observations support the conclusion and choline is an essential nutrient for humans when excess methionine and folate are not available in the diet.
Recently six radiographic criteria were presented which, when present, indicated that additional imaging of the traumatized adult elbow by means of CT was useful. We applied these 6 criteria to 10 cases of trauma to the pediatric elbow. CT evaluation will not change the therapy dictated by the clinical findings and conventional radiography.
Improving patient outcomes while controlling the costs of care requires a partnership between clinical researchers and hospital management. To this end, Strong Memorial Hospital in Rochester, New York, dedicated hospital operating funds to a program of small grants designed to align the patient care and academic interests of clinicians with the goals of efficient hospital management. The grants gave clinicians an opportunity to test the efficacy of specific patient care maneuvers. These studies resulted in improved guidelines for the use of diagnostic and therapeutic modalities, new technology, and length of hospitalization. Annual marginal cost savings from implementing the first-year study results are projected to be $587,255, an 8 to 1 return on the first year's expenses. The authors conclude that a hospital-funded applied research program encourages those delivering patient care to identify inefficiencies and introduce change while ensuring quality patient care. This joint faculty-management effort can augment the hospital's quality-assurance, utilization management, and technology assessment programs while advancing the scholarship of faculty members.
The advent of magnetic resonance imaging (MRI) has improved imaging of the Achilles tendon. Various pathologic conditions of the Achilles tendon and their MRI characteristics are described. The superior resolution of the tendon provided by MRI can aid in the diagnosis of Achilles tendon disorders, which include complete or partial rupture of the tendon as well as postoperative assessment of tendinous healing, tendinitis and tenosynovitis, and various tumors of the Achilles tendon.
Because of a family history of neurologic problems and the documentation of three vascular lesions in one patient, we evaluated 18 members representing three family generations with magnetic resonance imaging. Of these, eight were normal, two had abnormalities probably not related to arteriovenous malformation, one scan was suboptimal, and the remaining eight had evidence of hemorrhagic lesions characteristic of arteriovenous malformation. Four of these patients had multiple lesions, and three patients with lesions had no neurologic symptoms. The findings suggest an autosomal dominant mode of inheritance in this unique case of familial cerebral arteriovenous malformation.
We report a patient with absence of the external carotid artery. The major external branches originate from the internal carotid artery which is really a common arterial trunk. The embryology and clinical significance of this rare vascular anomaly are discussed.
To study the role of CT in the radiographic evaluation of the elbow, a technique was developed for producing axial scans of the elbow in flexed and extended positions. Computed tomography was performed on a total of 75 patients with acute or subacute elbow injuries. All scans were compared to their respective plain radiographs, and results correlated with each patient's clinical management. Based on these observations, six radiographic criteria were developed which, when present, should prompt further study of the elbow by CT. Under these six conditions, the information provided by CT may change the diagnosis and subsequent management of a patient's injuries.
Magnetic resonance imaging effectively defines and characterizes musculoskeletal pathologic lesions, particularly meniscal tears. Most studies comparing the efficacy of magnetic resonance imaging and arthroscopic evaluation have been performed on high-field (1.5-T) systems. The effectiveness of a low-field (0.2-T), dedicated, extremity magnetic resonance imaging device in diagnosing meniscal tears was studied prospectively on 35 patients with knee symptoms who subsequently had arthroscopic evaluation. Magnetic resonance imaging examinations were performed before surgery and were read by an experienced radiologist who was blinded to the results of the arthroscopic evaluations. Specificity was 100% for both the medial and lateral menisci. Sensitivity was 86% for the medial menisci, 89% for the lateral menisci, and 87% for both. Accuracy was 91% for the medial menisci, 97% for the lateral menisci, and 94% overall. The positive predictive values were 100% for the medial menisci, 100% for the lateral menisci, and 100% for both. The negative predictive values were 81% for the medial menisci, 96% for the lateral menisci, and 91% for both. The low-field magnetic resonance imaging system provided specificity and sensitivity that were equal to or better than previous reports with high-field systems. In particular, this low-field system eliminated the problem of false-positive results that has been found in some studies using high-field systems.
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