bluuebunny/crossref_metadata_2025 huggingface dataset:
Adjunctive Thalidomide Therapy for Childhood Tuberculous Meningitis: Results of a Randomized Study
Authors: Schoeman Johan F. , Springer Priscilla , van Rensburg Anita Janse , Swanevelder Sonja , Hanekom Willem A. , Haslett Patrick A. J. , Kaplan Gilla
Published: March 2008

Childhood tuberculous meningitis is associated with serious long-term sequelae, including mental retardation, behavior disturbances, and motor handicap. Brain damage in tuberculous meningitis results from a cytokine-mediated inflammatory response, which causes vasculitis and obstructive hydrocephalus. Thalidomide, a potent tumor necrosis factor α inhibitor, was well tolerated and possibly showed some clinical benefit in children with tuberculous meningitis during a pilot study. The purpose of the present study was to assess the effect of adjunctive thalidomide in addition to standard antituberculosis and corticosteroid therapy on the outcome of tuberculous meningitis. Thalidomide (24 mg/kg/day orally) or placebo was administered in a double-blind randomized fashion for 1 month to patients with stage 2 or 3 tuberculous meningitis. The study was terminated early because all adverse events and deaths occurred in one arm of the study (thalidomide group). Thirty of the 47 children enrolled received adjunctive thalidomide, of whom 6 (20%) developed a skin rash, 8 (26%) hepatitis, and 2 (6%) neutropenia or thrombocytopenia. Four deaths (13%) occurred in patients with very severe neurologic compromise at baseline; two deaths were associated with a rash. Motor outcome after 6 months of antituberculosis therapy was similar in the two groups, even though the thalidomide group showed greater neurologic compromise on admission. In addition, the mean IQ of the two treatment groups did not differ significantly (mean IQ thalidomide group 57.8 versus mean IQ control group 67.5; P = 16). These results do not support the use of adjunctive high-dose thalidomide therapy in the treatment of tuberculous meningitis. (J Child Neurol 2004;19:250-257).
Effective Treatment With Oxcarbazepine in Paroxysmal Kinesigenic Choreoathetosis
Authors: Tsao Chang-Yong
Published: March 2008

Paroxysmal kinesigenic choreoathetosis is often responsive to anticonvulsants such as carbamazepine and phenytoin. We report a boy with paroxysmal kinesigenic choreoathetosis, which is dramatically relieved by oxcarbazepine even after unsatisfactory treatment with carbamazepine and other medications. (J Child Neurol 2004:19:300-301).
Polyoma Nephropathy and Progressive Multifocal Leukoencephalopathy in a Renal Transplant Recipient
Authors: Phillips Tonya , Jacobs Richard , Ellis Eileen N.
Published: March 2008

Progressive multifocal leukoencephalopathy is a progressive and ultimately fatal white-matter disease of the brain that is associated with polyomavirus infection. It is uncommon in the general population, and even in the immunosuppressed patient, who is inherently at greatest risk for active infection with the virus, it is rare. The causative agent in progressive multifocal leukoencephalopathy, JC virus, has become increasingly important in recent years as its role in nephropathy in the renal transplant recipient has become better understood. We present a young renal transplant patient who developed nephropathy with renal biopsy changes consistent with polyomavirus lesions and then developed mental status changes and was diagnosed with progressive multifocal leukoencephalopathy. (J Child Neurol 2004;19:301-304).
Corticosteroids Versus Albendazole for Treatment of Single Small Enhancing Computed Tomographic Lesions in Children With Neurocysticercosis
Authors: Singhi Pratibha , Jain Vivek , Khandelwal Narendra
Published: March 2008

Single small enhancing computed tomographic (CT) lesions representing cysticercus granuloma are a common cause of focal seizures in children. Controversy exists regarding the efficacy of various modalities of treatment. We conducted a randomized prospective trial to evaluate the efficacy of corticosteroids, albendazole, and corticosteroids with albendazole in children with focal seizures and single small enhancing CT lesions. The study population consisted of 133 children with focal seizures of recent onset (< 3 months) and single small enhancing CT lesions who presented to the Neurocysticercosis Clinic of Pediatric Neurology Services at the Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, an urban teaching and tertiary care hospital in Chandigarh, North India. All children were randomly assigned to receive corticosteroids (group S), albendazole (group A), or both corticosteroids and albendazole (group SA) for 28 days. CT was done at 3 and 6 months after enrollment in the study. Of the 133 patients enrolled, 23 were lost to follow-up. Of the remaining 110 patients, 38 patients were in group S, 37 in group A, and 35 in group SA. All children were followed up for at least 18 months. Disappearance of the lesion on CT scan was noted in 52.6% of patients in group S, 59.5% in group A, and 62.9% in Group SA (P > .1) at the 3-month follow-up. After the 6-month follow-up, disappearance of the lesion was noted in 76.3% in group S, 75.7% in group A, and 74.2% in group SA (P > .1). Twenty-three patients had seizure recurrence while on antiepilepsy drugs: 36.8% of patients in group S, 13.5% in group A, and 11.4% in group SA (P < .05). Seizure recurrence after antiepilepsy drug withdrawal was seen in seven children (three in group S and two each in groups A and SA). In conclusion, there was no significant difference in resolution of CT lesions in the three therapy groups at 3 and 6 months of follow-up. Children in the corticosteroid group had significantly more seizure recurrences while on antiepilepsy drugs. (J Child Neurol 2004;19:323-327).
Assessment of Child Neurology Outpatients With Headache, Dizziness, and Fainting -
Authors: Fatma Neslihan Inal Emiroglu  , Kurul Semra , Akay Aynur , Miral Süha , Dirik Eray
Published: March 2008

Neurologic symptoms such as headache, vertigo, dizziness, and fainting can create a diagnostic problem in pediatric neurology practice because they are also the most common presenting symptoms of psychiatric disorders. Children, especially adolescents, who are often admitted with such autonomic symptoms, are frequently misdiagnosed. In this study, we aimed to investigate the psychiatric morbidity and comorbidity rate in children and adolescents presenting with neurologic symptoms such as headache, vertigo, and syncope. We investigated 31 children who presented with these symptoms. All children were evaluated for their medical history and had a physical and neurologic examination. We attempted to rule out a possible organic etiology. All patients received a complete laboratory examination (blood count, electroencephalography), pediatric cardiology and otorhinolaryngology consultations, and a caloric test. All patients were assessed according to Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria. The majority of the patients (93.5%) received a psychiatric diagnosis according to the DSM-IV criteria. Most of these patients were adolescents and female. Psychosocial stressors such as academic problems, familial dysfunction, parental psychopathology, and child sexual abuse were associated with somatic symptoms. The results of this study demonstrated the importance of differential diagnosis and psychiatric comorbidity in a pediatric neurologic outpatient population. Treatment should be directed at biopsychosocial integrity, and a multidisciplinary treatment approach should be applied. (J Child Neurol 2004;19:332-336).
Molecular Biology and Ontogeny of Glutamate Receptors in the Mammalian Central Nervous System
Authors: Simeone Timothy A. , Sanchez Russell M. , Rho Jong M.
Published: March 2008

Glutamate is the principal excitatory neurotransmitter in the mammalian central nervous system. After release from presynaptic terminals, glutamate binds to both ionotropic and metabotropic receptors to mediate fast, slow, and persistent effects on synaptic transmission and integrity. There are three types of ionotropic glutamate receptors. N-Methyl-D-aspartate (NMDA), α-amino-3-hydroxy-5-methyl-4-isoxazoleproprionic acid (AMPA), and kainate receptors are principally activated by the agonist bearing its name and are permeable to cationic flux; hence, their activation results in membrane depolarization. All ionotropic glutamate receptors are believed to be composed of four distinct subunits, each of which is topologically arranged with three transmembrane-spanning and one pore-lining (hairpin loop) domain. In contrast, metabotropic glutamate receptors are G protein (guanine nucleotide-binding protein) -coupled receptors linked to second-messenger systems. Group I metabotropic glutamate receptors are linked to phospholipase C, which results in phosphoinositide hydrolysis and release of calcium from intracellular stores. Group II and group III metabotropic glutamate receptors are negatively linked to adenylate cyclase, which catalyzes the production of cyclic adenosine monophosphate. Each metabotropic glutamate receptor is composed of seven transmembrane-spanning domains, similar to other members of the superfamily of metabotropic receptors, which includes noradrenergic, muscarinic acetylcholinergic, dopaminergic, serotonergic (except type 3 receptors), and γ-aminobutyric acid (GABA) type B receptors. This review summarizes the relevant molecular biology and ontogeny of glutamate receptors in the central nervous system and highlights some of the roles that they can play during brain development and in certain disease states. (J Child Neurol 2004;19:343-360).
Should Autistic Children Be Evaluated for Mitochondrial Disorders?
Authors: Lerman-Sagie Tally , Leshinsky-Silver Esther , Watemberg Nathan , Lev Dorit
Published: March 2008

Autism is etiologically heterogeneous; medical conditions are implicated in only a minority of cases, whereas metabolic disorders are even less common. Recently, there have been articles describing the association of autism with mitochondrial abnormalities. We critically review the current literature and conclude that mitochondrial disorders are probably a rare and insignificant cause of pure autism; however, evidence is accumulating that both autosomal recessive and maternally inherited mitochondrial disorders can present with autistic features. Most patients will present with multisystem abnormalities associated with autistic behavior. Finding biochemical or structural mitochondrial abnormalities in an autistic child does not necessarily imply a primary mitochondrial disorder but can also be secondary to technical inaccuracies or another genetic disorder. Clinicians should be careful in diagnosing a mitochondrial disorder in an autistic child because it has important implications for accurate genetic counseling, prognosis, and therapy. (J Child Neurol 2004;19:379-381).
Infectious Acute Hemicerebellitis
Authors: Garcia-Cazorla Angels , Olivan José Antonio , Pancho Cristina , Sans Anna , Boix Christina , Campistol Jaume
Published: March 2008

We report the case of a 5-year-old girl with initial symptoms of encephalitis who presented 24 hours later with hemiataxia, unilateral dysmetria, and hemiparesis. Brain magnetic resonance image (MRI) revealed a high T2 weighted signal in the ipsilateral hemicerebellar cortex. Forty-five days later, a second MRI disclosed signs of hemiatrophy and cortical gliosis. The clinical outcome was favorable, with only a slight lack of motor coordination in the involved hand remaining. Three other cases of hemicerebellitis have been reported in the literature, two of them presenting with hemicerebellar symptoms and one mimicking a tumor. Follow-up imaging studies some months later have shown hemiatrophy of the cerebellar cortex, except in one case with a normal control MRI. The pathophysiology of this unilateral involvement is difficult to explain. We underline the need to consider this rare entity in asymmetric cerebellar clinical presentations and to perform MRI rather than computed tomography to reach the correct diagnosis. (J Child Neurol 2004; 19:390-392).
Familial Segmental Neurofibromatosis
Authors: Oguzkan Sibel , Cinbis Mine , Ayter Sükriye , Anlar Banu , Aysun Sabiha
Published: March 2008

Segmental neurofibromatosis is considered to be the result of postzygotic NF1 gene mutations. We present a family in which the proband has generalized neurofibromatosis 1, whereas members of previous generations manifest segmental skin lesions. All, including the clinically asymptomatic grandmother, carry the same haplotype. This is the only case in the literature in which a parent with segmental skin findings has a child with full-blown neurofibromatosis 1 disease. The genetic mechanisms underlying this association are discussed. This family can be further investigated by examination of tissue samples from affected and unaffected sites for mutations. (J Child Neurol 2004; 19:392-394).
Appropriate Utilization of Resources Program
Authors: Borok Gerald M.
Published: March 2008

Southern California Kaiser Permanente developed a regionwide Appropriate Utilization of Resources (AUR) Program that links quality assurance to utili zation control. The initial program goal is to signifi cantly reduce the regional inpatient utilization rate across all age groups without sacrificing quality of care or service. Objectives include increasing outpa tient surgery and same-day admissions for scheduled surgery, eliminating unnecessary medical admissions and days of hospitalization, optimizing utilization of critical care units, and ensuring continued high qual ity of care and service. The components of the pro gram are detailed, as is the review process itself. The author concludes with a description of the plan to expand the Program.
Cost Containment and Child Health
Authors: Fox Vardith L.
Published: March 2008

Children, as consumers of health resources, have special developmental, psychological, and medical needs different from those of adults. Thus, cost con tainment efforts can affect children differently. Data related to insurance benefits changes, intensified market forces, and reductions in federal funding are cited. Their analysis focuses on the importance of accountability in applying cost constraints to services that can have a significant effect upon the health and well-being of one quarter of the next generation.
Quality Assurance Principles for the Laboratory—A Brief Overview
Authors: Stump Michael M.
Published: March 2008

Under the Omnibus Budget Reconciliation Act of 1986, the Unites States Congress has called for a study of the quality of care of Medicare beneficiaries and a strategy to assure it. The quality of laboratory services is an important component of that assessment and assurance, and hospitals need a methodology for it. The Guidelines for Quality Assessment of the Coun cil on Medical Service of the American Medical As sociation can be used as a basis for a model that links structure, process, and outcome criteria to the inter play of people, equipment, and systems that comprise the laboratory. This can then support the develop ment of a monitoring and evaluation program for its services.
Quality Review in the Peer Review Organization Program
Authors: Kelly John T. , Feldman Sanford E. , Ross Jo Ellen H.
Published: March 2008

Several major, national forces have created the mandate of the Peer Review Organizations (PROS) for the evaluation of the quality of care received by Medicare patients. The shift of the Medicare Program to prospective payment to hospitals has caused con cern that this change in financial incentives may have adverse effects on quality. An analysis and review of the experience of the California PRO (California Medical Review, Inc.)-including the application of sanctions—suggests that corrective actions have been successful in addressing quality deficiencies. However, the relationship between those deficiencies and the prospective payment mechanism remains un clear.
Quality Issues in Discharge Planning
Authors: Middleman Edward L.
Published: March 2008

The Medicare and Medicaid laws were intended to eliminate inferior medical care for the elderly and the indigent. The success of these programs, however, has led to more expense than the government had anticipated. To control this cost, the government has designed several utilization review processes that, by necessity, have also required quality assurance mech anisms. On the assumption that fewer hospital days would cost fewer dollars, discharge planning has evolved. Although physicians may find this somewhat time consuming, they must participate in discharge planning because of the consumers' demand, the legal requirement, the attempt to reduce litigation, and the potential income. All patients need discharge plan ning to some extent. The evaluation of the quality of discharge planning must look at its structure, its process, and its outcome. Most early studies seem to be looking at the in-hospital process, but we must also evaluate process-centered, patient-centered, commu nity-centered, and cost effectiveness-related out comes.
Uses of the Peer Review Organization Medicare Database
Authors: Kelly John T. , Moncrief William H. , Ross Jo Ellen H.
Published: March 2008

The Medicare database, which is comprehensive, current, and easily manipulated by computer tech nology, contains enormous amounts of information regarding hospital and physician practices. Access to the Medicare database greatly increased with the es tablishment of the Peer Review Organization pro gram. Recent Medicare data releases by the Health Care Financing Administration and the California Peer Review Organization demonstrate the potential usefulness of the Medicare database. Although analy sis of the Medicare database is in the early develop mental stages, the utility of the database will expand as analytic techniques improve.
Assuring Quality in Proprietary Managed Care Systems
Authors: Ottensmeyer David J. , Key Martha Kathryn
Published: March 2008

This paper defines quality assurance (QA) and dis cusses state-of-the art QA programs in managed care organizations today. Utilization management (UM) is distinguished from QA, although they are interre lated. While UM is process-oriented and focuses on efficiency and cost-effectiveness, QA is directed more to the result or outcome of medical care. The major abstracts in the transition from process to outcome- oriented QA are agreed upon standards of care and data systems. The medical profession would seem a logical candidate to develop these systems, but the profession has resisted such efforts, showing an ina bility to enforce true accountability. The impact of QA/UM on clinical decision-making is discussed, with implications for the profession of medicine.
Tracking Quality Assurance Activity
Authors: Freed Ruth , Adwers James
Published: March 2008

The difficulty of gathering together, organizing, and collating hospital quality assurance information is a common problem for hospital quality assurance departments. Trying to assemble and compare quality data, appearing in multiple locations, from multiple sources, across a time-line often measured in months, may prevent recognition of care patterns indicative of real problems. We describe our development of PC- based software to help deal with collecting and col lating information from the medical records depart ment, infection control, medical audit committees, the medical staff, the nursing units, peer review organi zation data, and multiple other scattered sources. This paper explains how the quality monitors were se lected and the types of statistical reports that such software can generate.
The Timeliness of Discharge Planning
Authors: Fisher Lois E. , Middleman Edward L.
Published: March 2008

The prospective payment system for the reimburse ment of hospitalizations has stimulated utilization re view and quality assurance activities. Patients are definitely being discharged more quickly, but the pri mary concern is that they would be discharged pre maturely. In either case increased posthospitalization support is required. This study reviewed the timeli ness of the request for the consultation with the dis charge planner, the timeliness of the process of relay ing the consultation to the discharge planner, and the timeliness of the response of the discharge planner to the consultation. The discharge planner was asked to see 35 of the 72 patients in this study during the first week of their hospitalizations. Of the 69 patients who were discharged, 33 were discharged either the same day of or the following day after the consultation request. Although several systems have been devised for early recognition of patients' needs for discharge planning, none would be necessary if physicians would identify appropriate patients early during their hospitalizations.
A Contemporary Credo of Clinical Ethics in Terminal Care
Authors: McCartney James J.
Published: March 2008

This article summarizes the convictions of a profes sional ethicist and director of a hospital-based bioeth ics institute with regard to decisions of clinical ethics, especially those surrounding care of the terminally ill.

An ethical and legal distinction is made between refusal of treatment on the one hand, and assisted suicide and euthanasia on the other. However, no ethical distinction is maintained between withholding treatment or withdrawing it when it seems inappro priate.

The importance of consent for all invasive medical treatment is emphasized, including all artificial deliv ery of nutrition and hydration. The rights of patients and legitimate proxies to refuse treatment on the basis of burdensomeness and uselessness are under scored.

The importance of palliative care is noted, brain death is considered, organ donation is encouraged, and the article ends with a reminder that life is a basic, but not absolute, value.
Credentialing: A Current Perspective and Legal Background
Authors: Pelberg Arthur L.
Published: March 2008

This article reviews the development of physician credentialing for hospital privileges over the last 30 yr. Important developments are discussed in the ad mitting and clinical privilege areas. The second part of the article considers the legal aspects to creden tialing and the avenues for challenging credentialing denials. Finally, a generic credentialing form for phy sicians is presented for use by health care organiza tions.
Office Quality Assurance and Utilization Review for the Beginning Oral and Maxillofacial Surgeon
Authors: Kelner Barry I.
Published: March 2008

For the senior oral and maxillofacial surgery resi dent, the task of establishing a well functioning pri vate practice is filled with great challenges and op portunities. The purpose of this article is to make the beginning oral and maxillofacial surgeon aware of the concepts of quality assurance and utilization re view and their application to private practice. Dis cussions, methods, and examples of evaluating one's office are presented.
Missed Myocardial Infarction in the Emergency Room
Authors: Pelberg Arthur L.
Published: March 2008

Sixty-four cases of missed myocardial infarction in the emergency room were identified from the records of a major insurance company. The records were reviewed by three health care professionals using established standards of care for myocardial infarc tion. The diagnosis of myocardial infarction was missed in many cases due to the lack of diagnostic test ordering, poor interpretation of diagnostic tests, and the young age of the patients. Most patients were presented with symptoms compatible with myocar dial ischemia. There was an 83% mortality rate in the 64 cases. The cost of settlement and litigation far exceeded the cost of safe, effective, medical care in the cases studied.
Utilization Management in the Small Group Insurance Market
Authors: Spiro Alan
Published: March 2008

Small businesses are the most rapidly growing seg ment of the economy, providing one half of all jobs in the United States. The health insurance industry must address issues which are unique to this market. The health insurance product for small businesses must have simple administration for the owners and easy access to quality medical care for the employees. Small businesses have been adversely affected by the high cost of health care. Numerous studies have shown that a major factor contributing to the high cost of health care is inappropriate and unnecessary utilization of health care. Until recently, techniques of utilization management have been difficult to adapt to the small group market. The Celtic Life Insurance Company has been using a managed care fee for serv ice arrangement for the past three years. Celtic has been able to tailor a program for small businesses and maintain complete administrative coordination, in stead of contracting with a private utilization review company. Our program maintains freedom of choice of providers and easy access to health care, without limiting access to specialists. Cost containment fea tures have assisted insureds in selecting appropriate health care, in the appropriate setting while not in terfering with the doctor-patient relationship.
The Causes of Cancelled Elective Surgery
Authors: Hand Roger , Levin Philip , Stanziola Alex
Published: March 2008

We reviewed causes of cancelled elective surgery in a community hospital. Over a 6-month period, during which 4100 operating room procedures were completed, cancellations occurred in 13% of cases scheduled for outpatient surgery, 9% of cases sched uled for admission the same day, and 17% of cases scheduled for inpatient surgery. Dental procedures had significantly higher rates of cancellation among outpatient procedures, and cardiovascular surgical procedures had significantly higher rates among in patient procedures. Chart review of cancelled inpa tient cases showed 43% due to administrative reasons with unsigned consent the most common cause. Med ical factors were responsible in the remaining cases, with reevaluation of the surgical condition and asso ciated medical illnesses equally common as reasons in this category. Appreciation of the usual reasons for cancellation can improve utilization by permitting administrators and providers to anticipate those cases in which problems might arise so that additional at tention can be paid to them.
Generic Screening as an Integral Part of Quality Management
Authors: Chirico-Post Jeannette A. , Creech Deborah F. , Stoelting H. Ingrid
Published: March 2008

Comprehensive quality management programs are vital to the evaluation and improvement of the deliv ery of health care today and in the future. These programs must address issues which include quality assurance, risk management, and utilization manage ment. The programs should be designed to promote and assist in the safe delivery of patient care as well as the provision of a safe environment for all patients, visitors, and employees.

Various methodologies have been advocated to en sure quality care, the majority of which are retro spective evaluations. One of the more recent meth odologies developed is generic screening. The Boston Veterans Medical Center has utilized generic screen ing since 1986 in its Quality Management Program.

Our generic screening program has been successful as a result of multidisciplinary collaboration, com mitment, and support from the medical center's top management, both administrative and clinical. We have developed a credible system that may be used to fulfill many requirements of both internal and exter nal reviews. The program is easily reproducible and provides a basis for trend analysis within specific groups in order to better plan and meet patient care needs, minimize risk, and maximize outcome.
Successful Strategies for Effective Management of Hospital Utilization
Authors: Smith James C.
Published: March 2008

Providing high-quality, cost-effective medical care is the challenge facing all managers of health care, physicians and administrators alike. Meeting this challenge will help determine the financial success of any health care delivery system. Innovative program ming to successfully decrease hospitalization and the length of stay is one of the keys to successfully meet ing this challenge. This article provides an overview of programs which, if implemented, will do much to either eliminate or shorten hospital days.
Head and Neck Pathology Interactions with Clinical Outcomes
Authors: Rosenblum Ralph H
Published: March 2008

The relationships between craniofacial and other medical pathologies are not always obvious but may be very significant as they influence the extent of disease, accuracy of differential diagnoses, treatment schedules, and appropriateness and utilization of health-care resources. Among the relationships dis cussed are periodontal and endodontic infections, bacteremias and antibiotics, iatrogenics, viral and fungal infections, oncological interactions, temporo mandibular joint disease, dental implants, antide pressant therapy, psychiatric and neurological influ ences, and dental restorations.
Medical Review and the Newly Revised Emergency Care Obligations of Medicare Hospitals
Authors: Schneider Kenneth C.
Published: March 2008

The "anti-dumping" provisions under Section 1867 of the Social Security Act have been clarified and strengthened by recent amendments. Medicare-par ticipating hospitals must post signs informing the public of their obligation to examine, treat, and ap propriately transfer individuals who request emer gency services in the emergency department. Inquir ies about an individual's method of payment or insur ance source may not delay examination or treatment. Qualified personnel must perform medical screening of all emergency patients, and those to be transferred with emergency medical conditions which have not been stabilized must receive treatment to minimize the risk of transfer. There are stepped-up require ments for informed patient consent and documenta tion that the medical benefits of a transfer outweigh the risks. In physician-initiated transfers, the receiv ing hospital must be sent certification by a physician that the benefits of transfer outweigh the risks. Since there is evidence that medically appropriate transfers of persons with emergency medical conditions may actually be underutilized, particularly in rural set tings, medical reviewers should avoid an anti-trans fer bias.
Postoperative Hospital Retention Following Ambulatory Surgery in a Hospital-Based Program
Authors: Levin Philip , Stanziola Alex , Hand Roger
Published: March 2008

In an effort to learn more about resource utilization on ambulatory surgery in hospital departments of surgery and its impact on quality of care, we re viewed the causes of postoperative hospital retention following ambulatory surgery in a hospital-based program. Of 1971 patients operated on in a 6-month period, 188 were retained for a rate of 9.5%. Of these, 71 (3.6%) were retained for observation and 42 (2.1%) for surgery more extensive than planned. The remaining 75 (3.8%) patients represent complications of surgery or anesthesia. The age distribution of pa tients with complications was the same as the group overall with a single mode at about 30 years, while the distribution of patients retained for observation or who were admitted the day of surgery was bimodal with a second peak at about 70 years. All surgical specialties had comparable rates of postoperative re tention, except gynecology which was significantly lower. Many of the patients had multiple procedures or surgery more extensive than planned.
What Constitutes a Laboratory Quality Monitoring Program?
Authors: Bernstein Larry H.
Published: March 2008

A program of quality assurance for the laboratory is described that addresses both process and outcome validation. It begins by an analyses of the workload processing sequence, i.e., ordering, collecting, trans porting, analyzing specimens, reporting tests results in a timely manner, and reduction of instrument, staff, and system-related errors in the generation of laboratory information. The observable medical staff requirements for effective utilization of the labora tory is the basis for defining outcome measures.
Education in Science Information Management
Authors: Williamson John
Published: March 2008

This article explores the need for health care qual ity assurance professionals to keep up with scientific information related to both quality management and clinical medicine. Using data from a recent survey of this nation's primary practitioners and their national opinion leaders, the three basic functions of science information management are reviewed and related to QA tasks. The article suggests that education and training for QA professionals in "science information management" might substantially enhance their im pact in terms of improved outcomes of health care. Finally, several basic educational goals are listed for those who wish to develop proficiency in this devel oping field of information management.
Quality Assurance A New Role for the Hospital Epidemiologist
Authors: Keller Martin D.
Published: March 2008

Quality assurance may be viewed as a method for the surveillance of healthcare provided in hospitals and other settings. The processes involved in quality assurance are in many ways analogous to the concepts and techniques that comprise the discipline of epide miology. As yet, there has been little interaction be tween these specialty areas, and the lack of recogni tion of their relevance to one another is exemplified by the fact that hospital epidemiologists are rarely called upon to assist in the planning and operation of quality assurance programs. This loss of opportunity may be remedied by the inclusion of quality assurance methodology in the training of epidemiologists, and the introduction of certain epidemiologic concepts and methods into the quality assurance curricula. The intersection of these two disciplines will enlarge the scope of both and foster advances in theory and prac tice in this field.
The Design and Effectiveness of a Graduate Survey Course in Quality Assurance and Utilization Review
Authors: Ziegenfuss James T. , Bentley J. Marvin , Trautlein Joseph J. , Kruger Nancy R. , Jones David , Schneider Arthur J.L.
Published: March 2008

This paper reports on the design, presentation, and evaluation of a graduate university course in quality assurance and utilization review. The authors cite the need for expanded course offerings in this field and present descriptions of the course design and student participants, including program location, objectives, learning themes and content, instructor team, stu dents, and course process. Student feedback is re ported including comments on course strengths and needs, teaching methods, and learning evaluation. Additional work requirements are cited.
Hospital Response Variation to the Demands of Preadmission Certification
Authors: Hurley Robert E. , Michelman Jeffrey E.
Published: March 2008

This paper reports findings from a study of the impact of preadmission certification programs from the perspective of the hospital—a deeply affected party. A series of field studies was undertaken to explore and delineate the range of hospital responses to the challenges posed by this third-party payer man date and to identify factors associated with variation in responses. The evidence presented suggests wide variation in how hospitals chose to share responsibil ity for pre-certification with physicians and patients. The findings are broadly consistent with a proposed model that hospital response is determined by both external and internal considerations, but a larger scale hospital survey is necessary to test the hy potheses that can be derived from this study.
This Owl Would Not Fly Environmental Factors Foil Attempt to Shift Unnecessary Inpatient Days to the Outpatient Setting
Authors: Baigelman Walter , Coldiron John S.
Published: March 2008

The last days of many appropriate hospital admis sions have been identified as unnecessary when uti lized for providing diagnostic or therapeutic modali ties that could be provided in an outpatient setting. An outpatient work-up liaison team (OWL) was es tablished to facilitate the completion of evaluations or therapy in the community. In spite of the commit ment of experienced personnel and the cooperation of the staff physicians and hospital departments, the effort was unsuccessful. The failure is attributed to the socioeconomic environment in the immediate community that could not support the transfer of medical efforts. It is recommended that before any institution undertakes shifting hospital-based serv ices to the community a realistic assessment be made of the socioeconomic milieu.
A Multifaceted Approach to Managed Mental Health Care
Authors: Spiro Alan H. , Stokes Linda Q.
Published: March 2008

While many HMOs and insurance companies have contracted with outside managed mental health firms to control mental health utilization, ConnectiCare, an IPA Model HMO with nearly 100,000 members, man ages its own mental health utilization with a multi faceted approach. How the system has evolved and preliminary results are presented to illustrate how an HMO can manage its own mental health care program while using local providers.
Development of Clinical Practice Standards for Nurses
Authors: Taylor Joyce Waterman
Published: March 2008

Nursing, with leadership from the American Nurses Association (ANA), has a long-standing com mitment to the development of standards. The first nursing practice standards were published in 1973. Since that time, both the ANA and specialty nursing organizations have developed standards. However, the proliferation of standards, reflecting a wide di vergence of intent, format, and scope, has limited their usefulness. In 1989, the ANA appointed a Task Force (now a Committee) to address this issue. The Committee, working with representatives of the spe cialty nursing organizations, has developed a frame work for development of both nursing practice stand ards and guidelines. Standards and guidelines are defined and differentiated. The relationship of stand ard and guidelines development to the federal gov ernment's effectiveness initiative is discussed.
Do Hospitals Adhere to the Blue Cross/ Blue Shield Association's Guidelines for Admission Chest X-rays and ECGs?
Authors: Edmiston Robert B. , Beam Leta M. , Shapiro Edward P.
Published: March 2008

In 1987, the Blue Cross and Blue Shield Association (BCBSA) promulgated guidelines for some common diagnostic studies, including preoperative and gen eral hospital admission chest x-rays and electrocar diograms. Pennsylvania Blue Shield, through re views of patients' charts at 10 hospitals in Pennsyl vania, examined whether chest x-ray and ECG studies were being ordered routinely upon hospital admission, without regard to medical necessity, and whether those that had been ordered fell within the BCBSA guidelines. Most charts reviewed (82%) had no studies that fell outside the guidelines' indications. In 24% of the cases, neither study had been per formed. Some 23% of chest x-rays and 14% of ECGs performed were found to be unindicated. However, performances of the hospitals were quite variable, ranging from 8-31% of admissions with at least one unindicated study. At no hospital was there evidence that studies were ordered routinely on all admissions.
The Impact of Managed Care on Physicians
Authors: Jensen Harold L.
Published: March 2008

This article examines the forces that led to managed care and considers its two main thrusts: traditional indemnity, with controls and constraints through uti lization review, and controlled access and reimburse ment, as seen in the HMO model. The strategies avail able to the physician are discussed, suggesting how managed care can itself be managed. Finally, the evolution of managed care is shown to be in a final phase, wherein efficient and effective physicians are identified by computer data for selective contracting, leaving a sizeable minority of (potentially) unem ployed physicians.
Organizational Barriers to Quality Improvement in Medical and Health Care Organizations
Authors: Ziegenfuss James T.
Published: March 2008

This paper identifies organizational barriers to quality improvement in medical and health care or ganizations. Quality is now recognized as one of the most challenging issues of the 1990s. The push for quality improvement rests on the significant assump tion that large and small medical and health care organizations will engage in quality assessment and assurance. Both researchers and practitioners must consider the organizational barriers the quality movement will encounter, particularly those major impediments to be overcome in the next 5-10 years. This paper organizes the analysis of organizational barriers to quality assessment and assurance accord ing to a five-part systems model of the organization. The barriers are categorized as technical, structural, psychosocial, managerial, and goals and values. Fol lowing a mapping of the barriers, education, training, and research and development needs to support qual ity improvement are identified.
Quality Assessment in the Medical Intensive Care Unit
Authors: Sivak Edward D. , Perez-Trepichio Alejandro
Published: March 2008

Quality assessment and assurance activities in the intensive care unit are complex processes that begin with the definition of the scope of services delivered in the unit with further identification of the impor tant aspects of care. There is also a need to establish indicators of quality, gather data, and finally to or ganize the data into useful information. There are many approaches to these efforts ranging from estab lishment of indicators to data collection and analysis of patterns that lead to clarification of the indicators. We chose the latter pathway, specifically utilizing a previously described data model in which information was grouped according to structure, process, and out come of patient care. In this paper, we focus on the application of the concept of patient days of service for quantification of the utilization of resources as an element of quality. Efficient utilization of resources cannot be effected until data on actual utilization are collected and analyzed.
Potential Conflicts of Interest in the Delivery of Medical Services: An Analysis of the Situation and a Proposal
Authors: Herschberg Seymour
Published: March 2008

One health care issue that has gained recent public and professional attention is that of professional con flicts of interest with regard to financial incentives to either withhold possibly necessary services or per form unnecessary ones. This essay explores the evi dence bearing on the issue, interprets published in formation, and proposes a solution to deal with the issue.
The Best Asthma Care A Case Problem in Continuous Quality Improvement
Authors: Neuhauser Duncan , Headrick Linda , Miller Deborah M.
Published: March 2008

In the future, health care delivery systems may need to respond to requests from payers to demon strate the quality of care they provide for types of patients or diseases. Here, asthma is used as an ex ample of what such a response might look like in the context of continuous quality improvement.
Economic Credentialing
Authors: Doerr Harry L.
Published: March 2008

This article defines economic credentialing, dis cusses current legal standards on its use, and provides suggestions on implementation to best address both physician and institutional needs.
Is Your Organization Ready for Total Quality Management?
Authors: Barrett Mary Jean
Published: March 2008

The evolution to a Total Quality Management (TQM) or Continuous Quality Improvement (CQI) philosophy is particularly attractive in the health care industry in its search for better ways of doing business to ensure financial survival in the current competitive environment. This article, however, sug gests that some organizations may not benefit from attempting to implement methodology to achieve the widely accepted financial and operational benefits, not because of any weakness in the conceptual frame work, but because of the culture and/or lack of dedi cated resources required to ensure the acceptance and success of the approach. As a result, many providers are discovering that after a few years of implemen tation, benefits to the organization are not being rec ognized to the extent possible. Specific issues that have been identified as essential requirements to a successful implementation process or evolution to a continuous improvement culture are described in this article.
Literature Review
Authors: Rodriguez Alex R.
Published: March 2008

Quality assurance and improvement activities involve a continuous loop sequence of clinical care (decisions and application), information monitoring (documentation and assessment), and remediation (education and systems mod ifications). Monitoring and treating clinicians should inter act constantly to improve patient health outcomes through direct communications and other modes of information ex change. This column strives to monitor developments in each of these areas. The following articles represent recent commentaries on these processes.
Apparel Selection by Employed Women: A Typology of Information Search Patterns
Authors: Shim Soyeon , Drake Mary Frances
Published: March 2008

The purposes of this study were: 1) to identify segments of employed women purchasers of apparel who display different information search patterns; and 2) to examine the relationship between information search patterns and consumer, product, situational, and market characteristics. Data from a national random sample of 1034 employed women were analyzed. Using a Principal Components Factor Analysis of information search activities, five factors were extracted and labeled: Print-Oriented, Audio-Visual Oriented, Store Intensive, Professional Advice, and Pal Advice Searchers. Based on the highly significant F-tests for each search pattern, it was concluded that employed female consumers' patterns of search for information to use in apparel selection were influenced by characteristics of the consumer, product, and situation, but not the market. By developing profiles of each search pattern, the research provided a basis for theorizing about the determinants of search strategies among apparel consumers. Three broad sets of implications were examined based on the findings of the study. Marketing strategies for the five information search segments are provided.
Trait Inferences Based on Perceived Ownership of Designer, Brand Name, or Store Brand Jeans
Authors: Workman Jane E.
Published: March 2008

Many products have symbolic as well as utilitarian aspects. The symbolic value of a product can be a major influence on consumers' purchase decisions. Correspondent inference theory was the theoretical basis for examining inferences of owner characteristics based on the selection of one product with its symbolic meanings from available alternatives with different symbolic meanings. One hundred sixteen subjects were given a list of five clothing items and told that it was a partial listing of the clothing in one person's closet. The list contained one type of jean (designer, brand name, store brand, orjeans, the control variation) plus four other items: oxford cloth shirt, wool sweater, blazer, raincoat with zipout lining. Subjects indicated their impressions of the person to whom the clothing belonged by checking a list of traits on 9-point scales. Analysis of variance indicated that inferences about the person varied significantly depending on the type of jeans included in the list. Store brand jeans produced significantly more negative inferences than designer or name brand jeans when compared to the control jeans.