Straight talk. New approaches in healthcare. Enterprise-wide collaboration is key to successful reengineering

When employees from clinical operations, process improvement, finance and health information management join forces with physicians to reengineer processes, they wind up with a successful project. That's what executives at Kaleida Health in Buffalo, N.Y. learned when they redesigned the revenue cycle with a focus on coding and documentation practices, leading to an increase in revenues. In this installment of Straight Talk, we look at the reengineering efforts of the five-hospital system, which catapulted from a $62 million loss in 2001 to a $2 million surplus in 2003. Modern Healthcare and PricewaterhouseCoopers present Straight Talk. The session on enterprise-wide collaboration was held on May 11, 2004 at Modern Healthcare's Chicago headquarters. Charles S. Lauer, publisher of Modern Healthcare, was the moderator.     

Trust and satisfaction with physicians,insurers, and the medical profession

BACKGROUND: Conceptual or theoretical analysts of trust in medical settings distinguish among markedly different objects or types of trust. However, little is known about how similar or different these types of trust are in reality and the relationship of trust with satisfaction. OBJECTIVES: This exploratory study conducted a comparison among trust in one's personal physician, health insurer, and in the medical profession, and examined whether the relationship between trust and satisfaction differs according to the type of trust in question. RESEARCH DESIGN: Random national telephone survey using validated multi-item measures of trust and satisfaction. SUBJECTS: A total of 1117 individuals aged 20 years and older with health insurance and reporting 2 healthcare professional visits in the past 2 years. RESULTS: Rank-order correlation analyses find that both physician and insurer trust are sensitive to the amount of contact the patient has had and their adequacy of choice in selecting the physician or insurer. Trust in the medical profession stands out as being uniquely related to patients' desire to seek care and their preference for how much control physicians should have in making medical decisions. Adding satisfaction to the models reduced the number of significant predictors of insurance trust disproportionately. CONCLUSIONS: Consistent with theory, we found both substantial similarities and notable differences in the sets of factors that predict 3 different types of trust. Trust and satisfaction are much less distinct with respect to health insurers than with respect to physicians or the medical profession.     

An attempt to employ the Zung Self-Rating Depression Scale as a "lab test" to trigger follow-up in ambulatory oncology clinics: criterion validity and detection

We examined issues of criterion validity and detection of depression employing the Zung Self-Rating Depression Scale (ZSDS) as a "lab test" to trigger follow-up interviews of ambulatory oncology patients by oncology staff and the possibility of subsequent algorithm-based antidepressant treatment. Sixty oncology patients were screened with the ZSDS and then interviewed using the Mini-International Neuropsychiatric Interview (MINI). We examined the sensitivity and specificity of various cutoffs on the ZSDS and a briefer version, the Brief Zung Self-Rating Depression Scale (BZSDS) as they predicted results of the MINI, which was used as the criterion. Mean age of patients was 58.3 years (SD = 11.9). Thirty-two were female (53.3%) and 28 were male (46.7%). The correlation of the ZSDS (r = -0.66, P <.0001) and BZSDS (r = -0.57, P <.0001) with the MINI overall suggested acceptable levels of criterion validity. Additionally, we examined various cutoff scores on the ZSDS and BZSDS to explore the false negative and false positive rates that are associated with each. For example, using the mild cutoff on the Zung (score > 48) to determine depression or adjustment disorder, 14 false negatives and 2 false positives were found. When the more stringent moderate cutoff (score > 56) was used, 25 false negatives and 0 false positives were found. Oncology staff can utilize such data to make decisions about where to set cut-offs that trigger follow-up based on the amount of error that is allowable in their attempts to identify depressive symptoms in their patients. We discuss that such decisions might be based on many factors including the resources available in a particular site for follow-up or the comfort of particular oncologists and nurses managing and prescribing psychotropic medications, or in providing supportive counseling.     

Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial

Context  Ethics consultations increasingly are being used to resolve conflicts about life-sustaining interventions, but few studies have reported their outcomes. Objective  To investigate whether ethics consultations in the intensive care setting reduce the use of life-sustaining treatments delivered to patients who ultimately did not survive to hospital discharge, as well as the reactions to the consultations of physicians, nurses, and patients/surrogates. Design  Prospective, multicenter, randomized controlled trial from November 2000 to December 2002. Setting  Adult intensive care units (ICUs) of 7 US hospitals representing a spectrum of institutional characteristics. Patients  Five hundred fifty-one patients in whom value-related treatment conflicts arose during the course of treatment. Interventions  Patients were randomly assigned either to an intervention (ethics consultation offered) (n = 278) or to usual care (n = 273). Main Outcome Measures  The primary outcomes were ICU days and life-sustaining treatments in those patients who did not survive to hospital discharge. We examined the same measures in those who did survive to discharge and also compared the overall mortality rates of the intervention and usual care groups. We also interviewed physicians and nurses and patients/surrogates about their views of the ethics consultation. Results  The intervention and usual-care groups showed no difference in mortality. However, ethics consultations were associated with reductions in hospital (-2.95 days, P = .01) and ICU (-1.44 days, P = .03) days and life-sustaining treatments (-1.7 days with ventilation, P = .03) in those patients who ultimately did not survive to discharge. The majority (87%) of physicians, nurses, and patients/surrogates agreed that ethics consultations in the ICU were helpful in addressing treatment conflicts. Conclusion  Ethics consultations were useful in resolving conflicts that may have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU.      

Superoxide stress identifies neurons at risk in a model of ataxia-telangiectasia

Ataxia-telangiectasia (A-T) is an autosomal recessive disorder caused by mutations in the ATM gene. A-T children demonstrate sensitivity to ionizing radiation, predisposition to hematological malignancies, and telangiectasias. However, the hallmark of A-T is fulminant degeneration of cerebellar Purkinje cells accompanied by a progressive ataxia with features of both cerebellar and basal ganglia dysfunction. Although the ATM gene product (ATM) is known to be involved in DNA repair, the mechanisms that link loss of ATM with neurodegeneration remain unknown. Recently, it has been suggested that abnormalities in redox status contribute to the A-T phenotype. To address this question in the nervous system, we measured reactive oxygen species (ROS) in brain regions and specific neuronal populations in ATM-/- mice. We found increased ROS levels in cerebellum and striatum but not cortex of ATM-/- mice compared to ATM+/+ mice. Confocal microscopic examination revealed elevated superoxide levels in cerebellar Purkinje cells and nigral dopaminergic neurons but not cortical neurons, thus mapping increased superoxide levels onto the neuronal populations selectively affected in A-T. These data are the first demonstration of elevated levels of ROS in neurons at risk in any genetic neurodegenerative disorder and, furthermore, suggest that ATM acts as a pro-survival signal in post-mitotic Purkinje cells and dopaminergic neurons by modifying superoxide radical handling in these selectively vulnerable neurons.     

Multicenter phase II trial of temozolomide in patients with glioblastoma multiforme at first relapse

Background:Recurrent glioblastoma multiforme (GBM) is resistantto most therapeutic endeavors, with low response rates and survival rarelyexceeding six months. There are no clearly established chemotherapeuticregimens and the aim of treatment is palliation with improvement in thequality of life. Patients and methods:We report an open-label, uncontrolled,multicenter phase II trial of temozolomide in 138 patients (intent-to-treat[ITT] population) with glioblastoma multiforme at first relapse and aKarnofsky performance status (KPS) 70. One hundred twenty-eight patientswere histologically confirmed with GBM or gliosarcoma (GS) by independentcentral review. Chemotherapy-naïve patients were treated withtemozolomide 200 mg/m²/day orally for the first five days ofa 28-day cycle. Patients previously treated with nitrosourea-containingadjuvant chemotherapy received 150 mg/m²/day for the first fivedays of a 28-day cycle. In the absence of grade 3 or 4 toxicity, patients onthe 150 mg/m² dose schedule were eligible for a 200mg/m² dose on the next cycle. Results:The primary endpoint was six-month progression-freesurvival assessed with strict radiological and clinical criteria. Secondaryendpoints included radiological response and Health-related Quality of Life(HQL). Progression-free survival at six months was 18% (95%confidence interval (CI): 11%–26%) for theeligible-histology population. Median progression-free survival and medianoverall survival were 2.1 months and 5.4 months, respectively. The six-monthsurvival rate was 46%. The objective response rate (complete responseand partial response) determined by independent central review ofgadolinium-enhanced magnetic resonance imaging (MRI) scans was 8% forboth the ITT and eligible-histology populations, with an additional 43%and 45% of patients, respectively, having stable disease (SD).Objectively assessed response and maintenance of a progression-free statuswere both associated with HQL benefits (characterized by improvements overbaseline in HQL domains). Temozolomide had an acceptable safety profile, withonly 9% of therapy cycles requiring a dose reduction due tothrombocytopenia. There was no evidence of cumulative hematologictoxicity. Conclusions:Temozolomide demonstrated modest clinical efficacy,with an acceptable safety profile and measurable improvement in quality oflife in patients with recurrent GBM. The use of this drug should be exploredfurther in an adjuvant setting and in combination with other agents.     

Phase I dose-escalation and pharmacokinetic study of temozolomide (SCH 52365) for refractory or relapsing malignancies

Temozolomide, an oral cytotoxic agent with approximately 100% bioavailability after one administration, has demonstrated schedule-dependent clinical activity against highly resistant cancers. Thirty patients with minimal prior chemotherapy were enrolled in this phase I trial to characterize the drug's safety, pharmacokinetics and anti-tumour activity, as well as to assess how food affects oral bioavailability. To determine dose-limiting toxicities (DLT) and the maximum tolerated dose (MTD), temozolomide 100-250 mg m(-2) was administered once daily for 5 days every 28 days. The DLT was thrombocytopenia, and the MTD was 200 mg m(-2) day(-1). Subsequently, patients received the MTD to study how food affects the oral bioavailability of temozolomide. When given orally once daily for 5 days, temozolomide was well tolerated and produced a non-cumulative, transient myelosuppression. The most common non-haematological toxicities were mild to moderate nausea and vomiting. Clinical activity was observed against several advanced cancers, including malignant glioma and metastatic melanoma. Temozolomide demonstrated linear and reproducible pharmacokinetics and was rapidly absorbed (mean Tmax approximately 1 h) and eliminated (mean t1/2 = 1.8 h). Food produced a slight reduction (9%) in absorption of temozolomide. Temozolomide 200 mg m(-2) day(-1) for 5 days, every 28 days, is recommended for phase II studies.     

Induction of apoptosis by arachidonic acid in chronic myeloid leukemia cells.

The hallmark of chronic myeloid leukemia (CML) is the presence of the bcr-abl oncogene, which is associated with transforming ability and an intrinsic resistance to induction of apoptosis by genotoxic agents. Arachidonic acid (AA), a biologically active fatty acid, plays a crucial role as a mediator of signaling pathways involved in cell proliferation and survival. In this study, we investigated the potential role of AA as a proapoptotic agent in CML. Pretreatment of human CML isolated progenitor cells with AA (100 microM for 18 h) induced 71-75% inhibition of in vitro colony formation of granulocyte-macrophage colony-forming units, multilineage colony-forming units, and erythroid burst-forming units. This inhibition was significantly greater than the effect on normal progenitor cells (19-39% growth inhibition of erythroid burst-forming units, multilineage colony-forming units, and granulocyte-macrophage colony-forming units). AA also inhibited growth of the bcr-abl-transformed cell line H7.bcr-abl A54. In contrast, a minimal effect of AA on inhibition of cell growth was observed in the parental nontransformed NSF/N1.H7 cell line. The antiproliferative effect of AA was associated with apoptosis. Gamma-linolenic acid, a precursor of AA, also inhibited cell growth, whereas other unsaturated and saturated fatty acids had no effect. Pharmacological inhibition of cyclooxygenase, lipooxygenase, and cytochrome P450 monooxygenase enzymes prior to exposure to AA did not rescue cells from the inhibitory effect of AA. Moreover, 5,8,11,14-eicosatetraynoic acid, a nonmetabolizable arachidonate analogue, also inhibited cell growth, suggesting that the effect of AA did not require further metabolism. Treatment with antioxidants prior to stimulation with AA was also ineffective in preventing its antiproliferative effect. Thus, AA inhibited proliferation of CML cells by inducing apoptotic cell death. The signaling mechanisms of AA-induced inhibition of cell growth appeared to be independent of its conversion into eicosanoids or free radical generation.     

Interobserver variation in the interpretation of abdominal radiographs

A total of 140 sets of abdominal radiographs were reviewed independently by four qualified diagnostic radiologists. The degree of interobserver agreement was determined by calculating kappa values for 19 commonly used radiographic signs and diagnoses. There was fair to excellent interobserver agreement for 11 signs and diagnoses and poor agreement for the remaining eight. The signs and diagnoses for which agreement is poor cannot be considered reliable and include particularly large bowel obstruction and nonspecific gas pattern.     

Protein and elemental analysis of contact lenses of patients with superior limbic keratoconjunctivitis or giant papillary conjunctivitis

Soft contact lenses worn by six patients (12 eyes) diagnosed as having contact lens-induced superior limbic keratoconjunctivitis (SLK) and from four patients (5 eyes) with giant papillary conjunctivitis (GPC) were analyzed for protein concentration and for elemental content. Fifty-five percent water content, ionic lenses containing methacrylic acid had high protein concentration. Calcium was not a common element found on protein-coated lenses. Sulfur and iron were found on used and new lenses. An elevated level of mercury was detected in one gray lens that had been disinfected in thimerosal-preserved saline with a high heat disinfection unit by a patient with SLK.