Tightly regulated and inducible expression of a yoked hormone-receptor complex in HEK 293 cells

We have previously reported the construction of a constitutively active luteinizing hormone receptor by covalently linking a fused heterodimeric hormone to the extracellular domain of the G protein-coupled receptor. This yoked hormone-receptor complex (YHR) was found to produce high levels of cAMP in the absence of exogenous hormone. Stable lines expressing YHR were generated in HEK 293 cells to obtain lines with different expression levels; however, in a relatively short time of continued passage, it was found that YHR expression was greatly reduced. Herein, we describe the development of clonal lines of HEK 293 cells in which the expression of YHR is under the control of a tetracycline-regulated system. Characterization of clonal lines revealed tight control of YHR expression both by dose and time of incubation with doxycycline. These experiments demonstrated a good correlation between expression levels of the receptor and basal cAMP production. Moreover, the reduction in receptor expression following doxycycline removal revealed that YHR mRNA and protein decayed at similar rates, again suggesting a strong linkage between mRNA and protein levels. The controlled expression of YHR in this cell system will allow for a more detailed analysis of the signaling properties associated with constitutive receptor activation and may prove to be advantageous in developmental studies with transgenic animals.

The case for comprehensive quality indicator reliability assessment

To demonstrate the importance of evaluating overall quality indicator reliability, in addition to component or variable level reliability, a comparison of interrater agreement on four chart-abstracted pneumonia-related processes of care was conducted. The hospital medical records of 356 Medicare patients' recent discharges for pneumonia were independently abstracted by different abstractors. Kappa, prevalence and bias-adjusted kappa, P(pos), P(neg), and the Bias Index were used to assess reliability of composite quality indicators and their components. The adjusted kappas for the data elements used to determine eligibility to receive as well as to derive the pneumonia-related processes of care ranged from 0.68 to 1.0. The adjusted kappa associated with overall eligibility to receive the pneumonia-related processes of care was 0.63. The kappa statistics for determining if processes of care were provided ranged from 0.56 to 0.83 and increased to 0.65 and 0.85 upon adjustment for the prevalence effect. Kappas for the composite quality indicators were lower, but improved with adjustment for the prevalence effect. The composite quality indicator with the highest adjusted kappa value was oxygenation assessment (0.93); the composite quality indicator with the lowest adjusted kappa value was antibiotic administration within 8 hours of hospital arrival (0.74). This study establishes the reliability of pneumonia indicators and underscores the need for reliability assessment at the quality indicator level, as well as at the component level.

A statewide initiative to improve the care of hospitalized pneumonia patients: The Connecticut Pneumonia Pathway Project

PURPOSE

A statewide quality improvement initiative was conducted in Connecticut to improve process-of-care performance and to decrease length of stay for patients hospitalized with community-acquired pneumonia.

SETTING AND METHODS

Data were collected on 1,242 elderly (> or =65 years) pneumonia patients hospitalized at 31 of 32 acute care hospitals between January 16, 1995, and March 15, 1996, and on 1,146 patients hospitalized between January 1, 1997, and June 30, 1997. Interventions included feedback of performance data (Qualidigm, the Connecticut Peer Review Organization), dissemination of an evidence-based pneumonia critical pathway (Connecticut Thoracic Society), and sharing of pathway implementation experiences (hospitals). Process and outcome measures included early antibiotic administration, blood culture collection, oxygenation assessment, length of stay, 30-day mortality, and 30-day readmission rates. Analyses were adjusted for severity of illness and hospital-specific practice patterns.

RESULTS

After the statewide initiative, improvements were noted in antibiotic administration within 8 hours of hospital arrival (improvement from 83.4% to 88.8%, relative risk [RR] = 1.21; 95% confidence interval [CI]: 1.10 to 1.32), oxygenation assessment within 24 hours of hospital arrival (93.6% to 95.4%; RR = 1.23, 95% CI: 1.11 to 1.38), and length of stay (7 days to 5 days, P <0.001). There were no significant changes in blood culture collection within 24 hours of hospital arrival, blood culture collection before antibiotic administration, 30-day mortality, or 30-day readmission rates.

CONCLUSIONS

Statewide improvements were demonstrated in the care of hospitalized pneumonia patients concurrent with a multifaceted quality improvement intervention. Further research is needed to separate the effects of the quality improvement interventions from secular trends.

Assessing the quality of asthma care provided to Medicaid patients enrolled in managed care organizations in Connecticut

BACKGROUND

Many states have enrolled Medicaid beneficiaries in managed care organizations (MCOs). Few assessments of the quality of asthma care provided by these new programs are available.

OBJECTIVE

To describe the quality of care provided to asthmatic Medicaid children enrolled in MCOs.

METHODS

For this cross-sectional survey, a chart abstraction tool was developed to evaluate fulfillment of key performance measures chosen from a national guideline for asthma diagnosis and management. These measures were prescription of an inhaled anti-inflammatory medication, accomplishment of patient education, evaluation of exposure to environmental triggers of asthma, and administration of influenza vaccination. From State of Connecticut administrative databases, a random sampling of Medicaid children, ages 5 to 18 years, enrolled in four MCOs was selected. Chart entries from July 1, 1996 to June 30, 1997 were reviewed using the abstraction tool. Accomplishment of performance measures was evaluated for the total sample and for children who were high utilizers of medical services (at least one ED visit or hospitalization during the study period).

RESULTS

For 80 high utilizers among 315 children, completion of performance measures was suboptimal: 46% were prescribed inhaled steroids; an action plan was outlined for 43%; evaluation of patient or family tobacco use was documented for 56%; evaluation of the presence of a pet for 43% or mite exposure for 19%; and allergy skin testing or RAST was accomplished for 15%.

CONCLUSIONS

This information suggests that opportunities exist to improve the quality of care for these children.

Factors influencing mammography use among women in Medicare managed care

This article presents findings about the mammography screening experience of Medicare members of a health maintenance organization (HMO). Based on a mail survey of 309 women, we assessed factors that may be facilitators or barriers to this service for older women. The results indicate that these respondents generally are receiving timely mammograms; over three-quarters (79 percent) reported having a mammogram in the past 2 years. Multivariate analysis showed that women who were younger (under 75 years of age), believed in the importance of screening, had been told by a physician to obtain a mammogram, and were more satisfied with their physician and more likely to report mammography use.

Temporal trends in outcomes of older patients with pneumonia

BACKGROUND

It is unclear how outcomes of care for patients hospitalized for pneumonia have changed as patterns of health care delivery have changed during the 1990s. This study was performed to determine trends in outcomes of care for older patients hospitalized for pneumonia.

METHODS

This retrospective analysis was based on Medicare claims and included most patients with pneumonia who were older than 65 years and admitted to acute care hospitals in Connecticut between October 1, 1991, and September 30, 1997 (fiscal years 1992-1997). We assessed the trends in hospital costs, discharge destination, hospital mortality rates, mortality rates within 30 days of discharge, and 30-day readmission rates for pneumonia. Multivariate logistic regression analyses were used to adjust for differences in patient characteristics.

RESULTS

The mean (+/- SD) length of stay declined from 11.9 + 11.4 days to 7.7 + 7.2 days between 1992 and 1997. During this period, adjusted in-hospital mortality rates declined (P =.02), while the adjusted risk of discharge to a nursing facility increased (P<.001) and the adjusted risk of hospital readmission for pneumonia within 30 days of discharge increased (P =.05). The adjusted risk of death 30 days after discharge increased, although the difference was not statistically significant (P =.09).

CONCLUSIONS

Between 1992 and 1997, the adjusted risks of mortality after discharge, placement in a nursing facility, and hospital readmission for pneumonia increased among older patients hospitalized for pneumonia, in association with a decline in mean hospital length of stay. These findings raise the question of whether the declining hospital length of stay has negatively affected patient outcomes. Arch Intern Med. 2000;160:3385-3391.

The status of prenatal care among Medicaid Managed Care patients in Connecticut

Providing quality prenatal care to high-risk, pregnant adolescents represents an important challenge to health care providers and health plans. Using national prenatal care guidelines, this study sought to evaluate the quality of important processes and outcomes of prenatal care delivered to women age 21 years and younger enrolled in three health plans serving the Connecticut Medicaid population. Some important findings include 93% compliance with recommended processes of prenatal care, an 11% C-section rate, an average length of hospital stay of 4.0 days for women having a C-section, and a 10% premature delivery rate. Opportunities for improvement include 40% failing to begin prenatal care in the first trimester, 31% not receiving the recommended number of prenatal care visits, and 8% delivering a low-birth-weight infant. This study provides important descriptive information on processes and outcomes of care for pregnant adolescents within Medicaid Managed Care and also identifies opportunities for improvement.

What's happening in quality improvement at the local hospital: a state-wide study from the Cooperative Cardiovascular Project

The objective of this study was to investigate what happened to improve the quality of care for acute myocardial infarction (AMI) at all 32 nonfederal hospitals in Connecticut and to assess the impact of the Cooperative Cardiovascular Project (CCP) on quality improvement (QI) activities for AMI. We performed a questionnaire study with secondary analyses using the CCP database. On-site interviews were conducted with QI directors at all 32 Connecticut nonfederal hospitals that participated in the Health Care Financing Administration's Cooperative Cardiovascular Project (CCP) in 1992-93 and 1995. The interviews sought information about the makeup of QI departments, specific approaches used to improve the care of patients with AMI, and the perceived value of the CCP to each individual hospital. Results showed that the number of full-time equivalents (FTEs) and FTEs per beds employed in QI departments ranged from 1 to 30 and from 0.4 to 7.9, respectively, with a registered nurse most often serving as the department head (27/32). Over half of the departments (17/32) had additional responsibilities. The majority (25/32) used some combination of physician champions, multidisciplinary QI teams, standing orders, or critical pathways to effect change in AMI care. Finally, 26 of the 32 hospitals believed the CCP was valuable because it provided credible benchmark data, a catalyst for change, or a specific focus on processes of care needing improvement in AMI. Despite great variability in institutional resources, all 32 hospitals used a similar combination of QI approaches to effect change in AMI care. However, there is variable scientific evidence supporting these approaches. Externally sponsored projects such as the CCP appear to play a useful role for individual hospitals. Defining the optimal methods of QI is difficult given that hospitals are using complex combinations of nonstandardized improvement interventions.

Process of care performance, patient characteristics, and outcomes in elderly patients hospitalized with community-acquired or nursing home-acquired pneumonia

STUDY OBJECTIVES

To compare process of care performance, patient characteristics, and outcomes in a contemporary cohort of elderly (> or = 65 years) patients hospitalized with community-acquired pneumonia (CAP) or with nursing home-acquired pneumonia (NHAP).

DESIGN

State-wide retrospective cohort study.

SETTING

Thirty-four acute-care hospitals in Connecticut.

PATIENTS

Elderly Medicare patients hospitalized in 1995-1996 with CAP (1,131) or with NHAP (528).

MEASUREMENTS

Antibiotic administration within 8 h of hospital arrival, blood culture collection within 24 h of hospital arrival, oxygenation assessment within 24 h of hospital arrival, demographic and clinical characteristics, in-hospital complications, mortality, and length of stay.

RESULTS

Process of care performance rates for patients with CAP and NHAP were equivalent for antibiotic administration within 8 h of hospital arrival (76.8% vs 76.3%, respectively; p = 0.82), blood culture collection within 24 h of hospital arrival (78.1% vs 81.1%, respectively; p = 0.31), and oxygenation assessment within 24 h of hospital arrival (94.7% vs 95. 3%, respectively; p = 0.70). Patients with CAP were younger than those with NHAP (median age, 80 vs 84 years, respectively; p < 0. 001), had less cerebrovascular disease (16.8% vs 34.7%, respectively; p < or = 0.001), and lower mortality risk scores at hospital presentation (median, 100 vs 137, respectively; p < or = 0. 001) than patients with NHAP. The median length of stay was equivalent (7 days), but the in-hospital mortality rate was lower in patients with CAP than in patients with NHAP (8.0% vs 18.6%, respectively; p < or = 0.001).

CONCLUSION

Initial hospital processes of care are performed at the same rate in patients hospitalized with CAP or NHAP. However, patients with CAP are younger, are less acutely and chronically ill, and have lower in-hospital mortality rates than patients with NHAP.

Associations between initial antimicrobial therapy and medical outcomes for hospitalized elderly patients with pneumonia

BACKGROUND

Although medical practice guidelines exist, there have been no large-scale studies assessing the relationship between initial antimicrobial therapy and medical outcomes for patients hospitalized with pneumonia.

OBJECTIVE

To determine the associations between initial antimicrobial therapy and 30-day mortality for these patients.

METHODS

Hospital records for 12945 Medicare inpatients (> or = 65 years of age) with pneumonia were reviewed. Associations between initial antimicrobial regimens and 30-day mortality were assessed with Cox proportional hazards models, adjusting for baseline differences in patient characteristics, illness severity, and processes of care. Comparisons were made with patients treated with a non-pseudomonal third-generation cephalosporin alone (the reference group).

RESULTS

Initial treatment with a second-generation cephalosporin plus macrolide (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.52-0.96), a non-pseudomonal third-generation cephalosporin plus macrolide (HR, 0.74; 95% CI, 0.60-0.92), or a fluoroquinolone alone (HR, 0.64; 95% CI, 0.43-0.94) was independently associated with lower 30-day mortality. Adjusted mortality among patients initially treated with these 3 regimens became significantly lower than that in the reference group beginning 2, 3, and 7 days, respectively, after hospital admission. Use of a beta-lactam/beta-lactamase inhibitor plus macrolide (HR, 1.77; 95% CI, 1.28-2.46) and an aminoglycoside plus another agent (HR, 1.21; 95% CI, 1.02-1.43) were associated with an increased 30-day mortality.

CONCLUSIONS

In this study of primarily community-dwelling elderly patients hospitalized with pneumonia, 3 initial empiric antimicrobial regimens were independently associated with a lower 30-day mortality. The more widespread use of these antimicrobial regimens is likely to improve the medical outcomes for elderly patients with pneumonia.

Use of critical pathways to improve the care of patients with acute myocardial infarction

PURPOSE

While critical pathways have become a popular strategy to improve the quality of care, their effectiveness is not well defined. The objective of this study was to investigate the effect of a critical pathway on processes of care and outcomes for Medicare patients admitted with acute myocardial infarction.

SUBJECTS AND METHODS

A retrospective cross-sectional and longitudinal cohort study was made of Medicare patients aged 65 years and older hospitalized at 32 nonfederal Connecticut hospitals with a principal diagnosis of myocardial infarction during two periods: June 1, 1992, to February 28, 1993, and August 1, 1995, to November 30, 1995. The main endpoints of the cross-sectional analyses for the 1995 cohort were the proportion of patients without contraindications who received evidence-based medical therapies, length of stay, and 30-day mortality. Hospitals with specific critical pathways for patients with myocardial infarction were compared with hospitals without critical pathways. The main endpoints of the longitudinal analyses were change between 1992-93 and 1995 in the proportion of patients receiving evidence-based medical therapies, length of stay, and 30-day mortality.

RESULTS

Ten hospitals developed critical pathways between 1992-93 and 1995. Eighteen of 22 nonpathway hospitals employed some combination of standard orders, multidisciplinary teams, or physician champions. Patients admitted to hospitals with critical pathways did not have greater use of aspirin within the first day, during hospitalization, or at discharge; beta-blockers within the first day or at discharge; reperfusion therapy; or use of angiotensin-converting enzyme inhibitors at discharge in 1995. The mean (+/- SD) length of stay in 1995 was not significantly different between pathway (7.8 +/- 4.6 days) versus nonpathway hospitals (8.0 +/- 4.2 days), and the change in length of stay between 1992-93 and 1995 was 2.2 days for pathway hospitals and 2.3 days for nonpathway hospitals. Patients admitted to critical pathway hospitals had lower 30-day mortality in 1995 (8.6% versus 11.6% for nonpathway hospitals, P = 0.10) and in 1992-93 (12.6% versus 13.8%, P = 0.39), but the differences were not statistically significant.

CONCLUSIONS

Hospitals that instituted critical pathways did not have increased use of proven medical therapies, shorter lengths of stay, or reductions in mortality compared with other hospitals that commonly used alternative approaches to quality improvement among Medicare patients with myocardial infarction.

Improving the care of patients with community-acquired pneumonia: a multihospital collaborative QI project

BACKGROUND

Performance of several processes of care was measured in eight acute care hospitals in Connecticut which provided inpatient treatment to 713 elderly patients with community-acquired pneumonia (CAP). BASELINE DATA ABSTRACTION AND FEEDBACK: Chart review feedback was provided, and the hospitals were requested to design their own quality improvement (QI) interventions, after which re-examination of process of care performance was conducted. HOSPITAL QI INTERVENTIONS: Six of the eight hospitals had submitted QI plans. The quality indicators dealing with timeliness of antibiotic delivery were specifically addressed by five hospitals. However, each hospital also picked one or two other process of care for intervention.

RESULTS

The mean time to antibiotic administration decreased from 5.5 hours (+/- 0.2) to 4.7 hours (+/- 0.3; P < 0.0001), and the percentage of patients who received antibiotics within four hours increased from 41.5% to 61.6% (P < 0.0001).

DISCUSSION

This project called for obtaining buy-in from both the clinician and administrative representatives of each hospital early in the process. In this way, the targeted processes of care were likely to have relevance for each of the participating hospitals. Education of practicing physicians and other health professionals, as the method chosen by each hospital to address delays in antibiotic administration, appears to have been successful in this project as part of a multifaceted intervention. The project also helped establish a collegial environment that has served as the basis for more ambitious pneumonia QI projects.

SUMMARY AND CONCLUSIONS

Widespread improvements in process of care performance can result from hospitals' participation in a Quality improvement Organization collaboration.

Improving the care of patients with community-acquired pneumonia: a multihospital collaborative QI project

BACKGROUND

Performance of several processes of care was measured in eight acute care hospitals in Connecticut which provided inpatient treatment to 713 elderly patients with community-acquired pneumonia (CAP). BASELINE DATA ABSTRACTION AND FEEDBACK: Chart review feedback was provided, and the hospitals were requested to design their own quality improvement (QI) interventions, after which reexamination of process of care performance was conducted. HOSPITAL QI INTERVENTIONS: Six of the eight hospitals had submitted QI plans. The quality indicators dealing with timeliness of antibiotic delivery were specifically addressed by five hospitals. However, each hospital also picked one or two other processes of care for intervention.

RESULTS

The mean time to antibiotic administration decreased from 5.5 hours (+/- 0.2) to 4.7 hours (+/- 0.3; p < 0.0001), and the percentage of patients who received antibiotics within four hours increased from 41.5% to 61.8% (p < 0.0001).

DISCUSSION

This project called for obtaining buy-in from both the clinician and administrative representatives of each hospital early in the process. In this way, the targeted processes of care were likely to have relevance for each of the participating hospitals. Education of practicing physicians and other health professionals, as the method chosen by each hospital to address delays in antibiotic administration, appears to have been successful in this project as part of a multifaceted intervention. The project also helped establish a collegial environment that has served as the basis for more ambitious pneumonia QI projects.

SUMMARY AND CONCLUSIONS

Widespread improvements in process of care performance can result from hospitals' participation in Quality Improvement Organization collaboration.

Sex differences in mortality after myocardial infarction: evidence for a sex-age interaction

BACKGROUND

Studies of sex differences in mortality after myocardial infarction (MI) have shown conflicting results.

OBJECTIVES

To test the hypothesis that sex differences in mortality after MI vary according to patients' age, with younger women, but not older women, having a higher mortality compared with men.

METHODS

We performed a retrospective cohort study of 1025 consecutive patients who met accepted criteria for MI in 1992 and 1993 in 15 Connecticut hospitals. Data for the study were abstracted from medical records.

RESULTS

Women had a 40% higher hospital mortality rate than men. Simple age adjustment eliminated the sex difference in mortality rate (odds ratio, 0.99; 95% confidence interval, 0.66-1.48). However, when the sample was subdivided into 2 age groups, women younger than 75 years showed twice as high a mortality rate as men in the same age group, while among older patients no difference in mortality was found. In multivariate analyses the interaction of sex with age was highly significant, even after adjusting for comorbid conditions, clinical severity, process of care, and hospital characteristics. In the fully adjusted model, this interaction indicated that among patients younger than 75 years women had 49% higher odds of hospital death than men, while in the age group 75 years or older women had 46% lower odds of death compared with men.

CONCLUSIONS

A higher mortality of women compared with men after MI is confined to the younger age groups. The sex-age interaction should be considered when examining sex differences in mortality after MI.

Quality of care, process, and outcomes in elderly patients with pneumonia

CONTEXT

Pneumonia is a frequent cause of hospitalization and death among elderly patients, but the relationships between processes of care for pneumonia and outcomes are uncertain, making quality improvement a challenge.

OBJECTIVES

To assess quality of care for Medicare patients hospitalized with pneumonia and to determine whether process of care performance is associated with lower 30-day mortality.

DESIGN

Multicenter retrospective cohort study with medical record review.

SETTING

A total of 3555 acute care hospitals throughout the United States.

PATIENTS

A total of 14069 patients at least 65 years old hospitalized with pneumonia.

MAIN OUTCOME MEASURES

Four processes of care: time from hospital arrival to initial antibiotic administration; blood culture collection before initial hospital antibiotics; blood culture collection within 24 hours of hospital arrival; and oxygenation assessment within 24 hours of hospital arrival. Associations between processes of care and 30-day mortality were determined with logistic regression analysis.

RESULTS

National estimates of process-of-care performance were antibiotic administration within 8 hours of hospital arrival, 75.5% (95% confidence interval [CI], 73.1-77.9); blood cultures before antibiotics, 57.3% (95% CI, 54.5-60.1); initial blood culture collection, 68.7% (95% CI, 66.2-71.2); and initial oxygenation assessment, 89.3% (95% CI, 87.5-90.9). Lower 30-day mortality was associated with antibiotic administration within 8 hours of hospital arrival (odds ratio [OR], 0.85; 95% CI, 0.75-0.96) and blood culture collection within 24 hours of arrival (OR, 0.90; 95% CI, 0.81-1.00). State and territory performance estimates varied from 49.0% to 89.7% for antibiotics given within 8 hours and from 45.6% to 82.6% for blood cultures drawn within 24 hours.

CONCLUSIONS

Administering antibiotics within 8 hours of hospital arrival and collecting blood cultures within 24 hours were associated with improved survival. The fact that states varied widely in the performance of these measures suggests that opportunities exist to improve hospital care of elderly patients with pneumonia.

A collaborative project in Connecticut to improve the care of patients with acute myocardial infarction

BACKGROUND

State-based peer review organizations (PROs) and individual hospitals are challenged to achieve their quality improvement (QI) goals with shrinking resources. In 1993-1994 the Connecticut PRO and 15 local hospitals generated a comparative QI database on acute myocardial infarction (AMI) care for 1,202 Medicare and non-Medicare patients discharged in 1992 and 1993.

METHODS

A steering committee composed of hospital and PRO representatives was assembled to provide oversight. PRO staff developed a chart abstraction tool and trained hospital abstracters who collected and submitted data to the PRO for comparative analyses. Written feedback was provided to all hospitals and supplemented with onsite presentations when requested. Each hospital prepared a written QI plan based on its unique data profile.

RESULTS

Opportunities for improvement were identified at all hospitals. The most commonly targeted areas for improvement included the use of thrombolytics at presentation, aspirin at presentation and at discharge, and beta blockers at discharge. Improvement interventions included staff education sessions, development of AMI critical paths and standing orders, and storage of appropriate medications in emergency departments. Self-report data from the hospitals indicate improvements in care.

DISCUSSION

PROs and hospitals can augment their individual QI activities by working together to share data, resources, and lessons learned. Twenty-three hospitals are now collaborating with the Connecticut PRO on a similarly designed QI project aimed at improving the care of patients hospitalized with atrial fibrillation. This project includes a more formal means of communicating QI interventions.

Strategies for ovulation induction and oocyte retrieval in the lowland gorilla

PURPOSE

Ovulation induction and oocyte retrieval were performed in a lowland gorilla in an attempt to propagate and potentially cryopreserve embryos from an infertile animal and to advance techniques to help preserve this endangered species.

RESULTS

Following 34 days of leuprolide acetate suppression, human menopausal gonadotropins were administered for 14-days in a 32-year-old wild-born lowland gorilla. Ten oocytes were retrieved by transrectal ultrasound-guided aspiration. Other approaches to oocyte recovery were not feasible in this case. A serum estradiol concentration of 4700 pg/ml at the time of human chorionic gonadotropin administration did not induce ovarian hyperstimulation. Mature oocytes were recovered from follicles measuring 14 to 24 mm in diameter, with a corresponding average serum estradiol concentration of approximately 300 pg/ml for each mature follicle. Cryopreservation of a gorilla embryo was effected from cryopreserved gorilla spermatozoa.

CONCLUSIONS

Parameters for monitoring ovulation induction in the gorilla appear to be similar to those for humans. The results indicate that the use of a gonadotropin releasing hormone agonist and higher doses of gonadotropins than previously used in gorillas appear to improve oocyte recovery.

Polyclonal lymphoid tumor of the choroid plexus presenting as an intraventricular mass in a young gorilla

An unusual lymphoid lesion with reactive germinal centers, occurring in the choroid plexus of a young gorilla, is reported. It presented as a large mass in the lateral ventricle with hydrocephalus and neurological symptoms. A work-up did not reveal any underlying cause for this lesion. No similar lesion of the choroid plexus has been reported in either human or veterinary literature. Histological work-up, including flow cytometry, gene rearrangement studies and T and B cell markers, favored the lesion being a non-neoplastic lymphoid proliferation of unknown etiology. The prognosis is unknown, although, following complete removal, the animal is well and free of tumor at the time of this report.

A collaborative project in Connecticut to improve the care of patients with acute myocardial infarction

BACKGROUND

State-based peer review organizations (PROs) and individual hospitals are challenged to achieve their quality improvement (QI) goals with shrinking resources. In 1993-1994 the Connecticut PRO and 15 local hospitals generated a comparative QI database on acute myocardial infarction (AMI) care for 1,202 Medicare and non-Medicare patients discharged in 1992 and 1993.

METHODS

A steering committee composed of hospital and PRO representatives was assembled to provide oversight. PRO staff developed a chart abstraction tool and trained hospital abstractors who collected and submitted data to the PRO for comparative analyses. Written feedback was provided to all hospitals and supplemented with onsite presentations when requested. Each hospital prepared a written QI plan based on its unique data profile.

RESULTS

Opportunities for improvement were identified at all hospitals. The most commonly targeted areas for improvement included the use of thrombolytics at presentation, aspirin at presentation and at discharge, and beta blockers at discharge. Improvement interventions included staff education sessions, development of AMI critical paths and standing orders, and storage of appropriate medications in emergency departments. Self-report data from the hospitals indicate improvements in care.

DISCUSSION

PROs and hospitals can augment their individual QI activities by working together to share data, resources, and lessons learned. Twenty-three hospitals are now collaborating with the Connecticut PRO on a similarly designed QI project aimed at improving the care of patients hospitalized with atrial fibrillation. This project includes a more formal means of communicating QI interventions.

Aspirin for secondary prevention after acute myocardial infarction in the elderly: prescribed use and outcomes

OBJECTIVES

To determine how often aspirin was prescribed as a discharge medication to eligible patients 65 years of age and older who were hospitalized with an acute myocardial infarction; to identify patient characteristics associated with the decision to use aspirin; and to evaluate the association between prescription of aspirin at discharge and 6-month survival.

DESIGN

Observational study.

SETTING

All 352 nongovernment, acute care hospitals in Alabama, Connecticut, Iowa, and Wisconsin.

PATIENTS

5490 consecutive Medicare beneficiaries who survived an acute myocardial infarction, were hospitalized between June 1992 and February 1993, and did not have a contraindication to aspirin.

MEASUREMENTS

Medical charts were reviewed to obtain information on the prescription of aspirin at discharge, contraindications, patient demographic characteristics, and clinical factors.

RESULTS

4149 patients (76%) were prescribed aspirin at hospital discharge. In a multivariable analysis, an increased prescribed use of aspirin at discharge was correlated with several indicators of better overall health status (better left ventricular ejection fraction, absence of diabetes, shorter length of hospital stay, higher albumin level, and discharge to the patient's home). The prescribed use of aspirin at discharge was also associated with several specific patterns of care, including the use of cardiac procedures, beta-blocker therapy at discharge, and aspirin during the hospitalization. The prescribed use of aspirin at discharge was associated with a lower mortality rate 6 months after discharge compared with no prescribed aspirin (odds ratio, 0.77; 95% CI, 0.61 to 0.98), even after adjustment for baseline differences in demographic, clinical, and treatment characteristics between the two groups.

CONCLUSIONS

Aspirin was not prescribed at discharge to 24% of elderly patients who were hospitalized with an acute myocardial infarction and did not have a contraindication to aspirin. Several patient characteristics were associated with a higher risk for not being prescribed aspirin. Increasing the prescription of aspirin for these patients may provide an excellent opportunity to improve their care.

Aspirin in the treatment of acute myocardial infarction in elderly Medicare beneficiaries. Patterns of use and outcomes

BACKGROUND

Although aspirin is an effective, inexpensive, and safe treatment of acute myocardial infarction, the frequency of use of aspirin in actual medical practice is not known. Elderly patients, a group with low rates of utilization of effective therapies such as thrombolytic therapy, also may be at risk of not receiving aspirin for acute myocardial infarction. To address this issue, we sought to determine the current pattern of aspirin use and to assess its effectiveness in a large, population-based sample of elderly patients hospitalized with acute myocardial infarction.

METHODS AND RESULTS

As part of the Cooperative Cardiovascular Project Pilot, a Health Care Financing Administration initiative to improve quality of care for Medicare beneficiaries, we abstracted hospital medical records of Medicare beneficiaries who were hospitalized in Alabama, Connecticut, Iowa, or Wisconsin from June 1992 through February 1993. Among the 10,018 patients > or = 65 years old who had no absolute contraindications to aspirin, 6140 patients (61%) received aspirin within the first 2 days of hospitalization. Patients who were older, had more comorbidity, presented without chest pain, and had high-risk characteristics such as heart failure and shock were less likely to receive aspirin. The use of aspirin was significantly associated with a lower mortality (OR, 0.78; 95% CI, 0.70 to 0.89) after adjustment for potential confounders.

CONCLUSIONS

About one third of elderly patients with acute myocardial infarction who had no contraindications to aspirin therapy did not receive it within the first 2 days of hospitalization. The elderly patients with the highest risk of death were the least likely to receive aspirin. After adjustment for differences between the treatment groups, the use of aspirin was associated with 22% lower odds of 30-day mortality. The increased use of aspirin for patients with acute myocardial infarction is an excellent opportunity to improve the delivery of care to elderly patients.

Process and outcome of care for acute myocardial infarction among Medicare beneficiaries in Connecticut: a quality improvement demonstration project

OBJECTIVE

To evaluate the feasibility of linking claims-based pattern analysis with medical record review in the assessment of quality of hospital care among Medicare beneficiaries with acute myocardial infarction.

DESIGN

An analysis of risk-adjusted mortality after hospital admission for acute myocardial infarction using the regression model from the Health Care Financing Administration for predicting mortality rates. Hospital records for 300 patients admitted for myocardial infarction were abstracted to evaluate the accuracy of diagnostic coding and the adequacy of claims data-based risk adjustment and to assess process measures of quality care.

SETTING

Six Connecticut hospitals in the pilot study of the Medicare Hospital Information Project.

PATIENTS

Medicare beneficiaries 65 years of age or older who were hospitalized with a primary diagnosis of acute myocardial infarction from 1989 to 1991.

MAIN OUTCOME MEASURES

Principal diagnosis code verification rates for acute myocardial infarction; observed mortality rates at 30 and 365 days; 30-day standardized mortality ratios; and utilization rates for thrombolytic agents, aspirin, and beta-blockers.

RESULTS

The coding of acute myocardial infarction diagnosis had an overall accuracy of 96%. Little change was noted in relative mortality ratio hospital rank order after the exclusion of 13 patients who did not fulfill criteria for acute myocardial infarction and after additional risk adjustment with Killip class data. Utilization rates for therapies among eligible patients were as follows: aspirin, 73%; beta-blockers, 41%; and thrombolytic agents, 43%. The use of thrombolytic agents was associated with a lower 30-day mortality; the use of thrombolytic agents, aspirin, and beta-blockers was related to lower mortality rates at 1 year after discharge; and the use of these three therapies was lower in the two hospitals with the highest risk-adjusted mortality.

CONCLUSIONS

Medicare principal diagnosis codes for acute myocardial infarction were accurate in the six study hospitals. Therapies that have been endorsed by clinicians in Connecticut were underused in elderly patients. Pattern analysis of Medicare claims data can be useful as a quality-of-care screening tool; however, additional clinical information is required to stimulate quality improvement efforts within hospitals.

Readmission rates, 30 days and 365 days postdischarge, among the 20 most frequent DRG groups, Medicare inpatients age 65 or older in Connecticut hospitals, fiscal years 1991, 1992, and 1993

This report presents readmission rates following inpatient admissions for the 20 most frequent DRG categories among Medicare inpatients age > or = 65 years, at Connecticut acute-care hospitals during the three-year period FY 1991 to FY 1993. We provide frequency distributions of the 30-day and 365-day readmission rates within these 20 DRG categories. Among the 184,490 discharges of elderly Medicare beneficiaries, discharged alive, who were included in the 20 most frequent DRG categories in the three-year study period, the crude 30-day readmission rate was 15.6%; the crude 365-day readmission rate was 46.9%. By gender, the crude 30-day readmission rate for women was 15.1%; the corresponding rate for men was 17.8%. This gender readmission difference occurred in the context of a significant age differential; on average, the females were 2.5 years older than the males. By age group, the crude readmission rates were: age 65 to 74 years, 16.5%; age 75 to 84 years, 16.8%; age > or = 85 years, 14.6%. With the exception of the DRG category representing cancer (all types), within which there was a significant decrease in readmission rates over the three years examined, the crude readmission rates for the DRG categories were found to be stable over the three-year study period.

Periarticular hyperostosis and renal disease in six black lemurs of two family groups

Proliferative periosteal disease was identified in 6 black lemurs (Eulemur macaco macaco) of 2 family groups. Bilaterally symmetric formation of periosteal new bone at the metaphyseal regions of major long bones was first detected at the stifle and tarsal areas and was detected later at the carpal areas. Bony changes were accompanied by progressive renal disease. The syndrome progressed for 6 to 16 months before the lemurs were euthanatized because of debility. Necropsy revealed changes confined to the skeleton and kidneys. Formation of new bone was detected at all affected joints, and chronic renal disease was evident in each lemur. A specific cause was not identified. Although indistinguishable histologically from hypertrophic osteoarthropathy, several important differences were apparent. Distribution of the periosteal new bone was in the metaphyseal rather than diaphyseal areas. Thoracic or gastrointestinal lesions, typically seen with hypertrophic osteoarthropathy, were not detected, and substantial renal disease was evident. A genetic component may be involved in the development of this condition.