Preventive Medicine Specialists
30 years of experience

Centura Health-Litteton Adventist Hospital
20 W Dry Creek Cir
Ste 300
Littleton, CO 80120
303-269-2900
Locations and availability (2)

Education ?

Medical School Score Rankings
University of Colorado (1980)
  • Currently 4 of 4 apples
Top 25%

Awards & Distinctions ?

Associations
American Board of Preventive Medicine

Affiliations ?

Dr. Hughes is affiliated with 3 hospitals.

Hospital Affilations

Score

Rankings

  • Centura Hlth-Porter Adventist Hosp
    2525 S Downing St, Denver, CO 80210
    • Currently 4 of 4 crosses
    Top 25%
  • Centura Health Littleton Adventist Hospital
    7700 S Broadway, Littleton, CO 80122
    • Currently 4 of 4 crosses
    Top 25%
  • Centura Health-Litteton Adventist Hospital
    7700 S Broadway, Littleton, CO 80122
  • Publications & Research

    Dr. Hughes has contributed to 58 publications.
    Title Paying for Outcomes, Not Performance: Lessons from the Medicare Inpatient Prospective Payment System.
    Date June 2011
    Journal Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources
    Excerpt

    Drawing on lessons learned from the implementation of the Medicare Inpatient Prospective Payment System (IPPS), the authors propose principles for the design and implementation of a hospital payment system based on paying for outcomes.

    Title Pictorial Review: 'fishtail Deformity' of the Elbow.
    Date February 2011
    Journal Journal of Medical Imaging and Radiation Oncology
    Excerpt

    Fishtail deformity of the elbow is characterised by a contour abnormality of the distal humerus, which develops when the lateral trochlear ossification centres fails to develop or resorbs. It is an uncommon complication usually following a distal humeral fracture in childhood. Whilst initially presumed to be a benign condition, long-term follow-up suggests that patients with fishtail deformity are prone to functional impairment, ongoing pain and the development of early osteoarthrosis. This paper reviews the imaging findings in fishtail deformity, the proposed aetiology and the potential long-term complications.

    Title Radiological Implications of the Use of Uranium in Vaseline Glass.
    Date January 2011
    Journal Journal of Radiological Protection : Official Journal of the Society for Radiological Protection
    Excerpt

    Uranium oxides have been used as colourants in glassware since the 19th century and this type of glass is commonly referred to as vaseline glass. There are many collectors of vaseline glass in the UK who obtain pieces from the UK antiques market or from abroad. Dose rate measurements were made for a number of items of vaseline glass, and the uranium content of one item was measured. Potential doses to collectors were considered, along with implications for trade and transport due to the uranium content of the glassware. It was concluded that generally items of vaseline glass could give rise to low skin doses from beta radiation, though frequent wearing of necklaces made from vaseline glass may lead to doses in excess of the HPA (Health Protection Agency) dose criterion for consumer products that are not related to safety. Registration under the Radioactive Substances Act will not be required and almost all items of vaseline glass should be suitable for sending through the Royal Mail. For those items not accepted by Royal Mail, it is understood that the transport regulations for radioactive materials would not apply.

    Title The Function of Vitamin C in the Adrenal Cortex.
    Date July 2010
    Journal Science (new York, N.y.)
    Title Intentionality Attributions About Perfect and Imperfect Duty Violations.
    Date May 2010
    Journal The Journal of Social Psychology
    Excerpt

    Intentionality attributions were explored by drawing on the distinction between perfect and imperfect moral duties. Previous research has shown that perfect duty violations carry greater attributional weight than imperfect duty violations (Trafimow & Trafimow, 1999; Trafimow, Bromgard, Finlay, & Ketelaar, 2005). In Studies 1 and 2, the distinction between perfect and imperfect duties was replicated with intentionality judgments, and perfect duty violations received higher intentionality attributions than imperfect duty violations. In Study 3 this effect was reversed by manipulating information about an agent's mental intentions or plans to perform a behavior. That is, participants attributed less intentionality to perfect duty violations compared to imperfect duty violations when a mental intention to perform the behavior was absent.

    Title Redesigning the Medicare Inpatient Pps to Reduce Payments to Hospitals with High Readmission Rates.
    Date December 2009
    Journal Health Care Financing Review
    Excerpt

    A redesign of the Medicare inpatient prospective payment system (IPPS) that reduces payments to hospitals that have high-risk adjusted readmission rates is proposed. The redesigned IPPS uses a readmission performance standard from best practice hospitals to determine the risk-adjusted number of excess readmissions in a hospital and determines the payment reduction for a hospital based on its excess number of readmissions. Extrapolating from Florida Medicare 2004-2005 discharge data, the redesigned IPPS is estimated to reduce overall annual Medicare inpatient expenditures nationally by $1.25, 1.92, and 2.58 billion for readmission windows of 7, 15, and 30 days, respectively.

    Title Developing a Prospective Payment System Based on Episodes of Care.
    Date August 2009
    Journal The Journal of Ambulatory Care Management
    Excerpt

    A patient-centered approach to defining episodes of care around a hospitalization can provide the basis for creating expanded bundles of services that can be used as the basis of payment. Paying by episodes of care strengthens the incentive to providers to deliver care efficiently. A hospital-based episode of care prospective payment system can be phased in over time by gradually expanding the services and the time period included in the episode. Establishing equitable prospective episode payment amounts requires that the severity of illness of the patient during the hospitalization and the chronic disease burden of the patient be taken into account.

    Title Hospital Complications: Linking Payment Reduction to Preventability.
    Date June 2009
    Journal Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources
    Excerpt

    The Center for Medicare & Medicaid Services (CMS) policy of denying payment for certain in-hospital complications should be modified, given that complications are not always preventable.

    Title A New Technique for Management of Ulnar Bone Loss in Revision Total Elbow Arthroplasty Using a Tuberized Tricortical Iliac Crest Autograft: a Case Report.
    Date February 2009
    Journal Journal of Shoulder and Elbow Surgery / American Shoulder and Elbow Surgeons ... [et Al.]
    Title Identifying Potentially Preventable Readmissions.
    Date January 2009
    Journal Health Care Financing Review
    Excerpt

    The potentially preventable readmission (PPR) method uses administrative data to identify hospital readmissions that may indicate problems with quality of care. The PPR logic determines whether the reason for readmission is clinically related to a prior admission, and therefore potentially preventable. The likelihood of a PPR was found to be dependent on severity of illness, extremes of age, and the presence of mental health diagnoses. Analyses using PPRs show that readmission rates increase with increasing severity of illness and increasing time between admission and readmission, vary by the type of prior admission, and are stable within hospitals over time.

    Title Locked Intramedullary Nailing for Treatment of Displaced Proximal Humerus Fractures.
    Date November 2008
    Journal The Orthopedic Clinics of North America
    Excerpt

    Controversy surrounds the optimal technique for fixation of displaced fractures, although locked intramedullary nailing is emerging as a preferred technique in managing displaced proximal humerus fractures in appropriately selected patients. This technique provides stable fracture fixation allowing early postoperative mobilization critical in ensuring a pain-free shoulder with a functional range of motion. Additional advantages include the ability to insert by way of a minimally invasive approach with limited soft tissue dissection, achieve accurate anatomic reduction, provide a secure construct even in the situation of osteopenic bone or comminution, and manage fractures of the proximal humerus extending into the shaft.

    Title Review of Trends in the Uk Population Dose.
    Date March 2008
    Journal Journal of Radiological Protection : Official Journal of the Society for Radiological Protection
    Excerpt

    The Radiation Protection Division of the Health Protection Agency (HPA-RPD), formerly the National Radiological Protection Board, has periodically reported the doses to members of the public and workers in the UK from all sources of radiation. This paper is a review of the doses reported in these publications from the 1970s to 2000 or later. The paper aims to present how the estimated doses received by the UK population have changed over this time period, and where possible from earlier years as well, from all sources of radiation. It was not possible to directly compare the doses reported in the earlier reports. There have been changes in the type of doses estimated, the dosimetry (in particular the definition of effective dose) and improvements made in the measurement of natural background doses. In these cases the earlier reported doses have been recalculated using modern dosimetry so that the doses can be compared. The occupational doses reported in this paper are for those workers involved in the civil nuclear power production industry, industrial radiography or from the medical use of radiation sources. For workers it was found that the individual and collective dose has decreased significantly over this time through the introduction of legislation, the improvement in technology and better working practices. Members of the public are exposed to radiation following the atmospheric testing of nuclear weapons, discharges from UK civil nuclear sites and from diagnostic radiology as well as from natural sources. Exposure to anthropogenic sources has decreased over the period considered in this paper. However, the dose to the UK population as a whole, presented as a per caput dose to a population of 55 million, has not changed significantly as it is dominated by the constant level of exposure to natural sources of radiation.

    Title Identifying Potentially Preventable Complications Using a Present on Admission Indicator.
    Date February 2007
    Journal Health Care Financing Review
    Excerpt

    This article describes the development of Potentially Preventable Complications (PPCs), a new method that uses a present on admission (POA) indicator to identify in-hospital complications among secondary diagnoses that arise after admission. Analyses that used PPCs to obtain risk-adjusted complication rates for California hospitals showed that (1) the POA indicator is essential for identifying complications, (2) frequency of complications varies by reason for admission and severity of illness (SOI), (3) complications are associated with higher hospital charges, longer lengths of stay, and increased mortality, and (4) hospital complication rates tend to be stable over time.

    Title Redesigning Medicare Inpatient Pps to Adjust Payment for Post-admission Complications.
    Date February 2007
    Journal Health Care Financing Review
    Excerpt

    Under the Medicare diagnosis-related group (DRG) based inpatient prospective payment system (IPPS), payments to hospitals can increase when a post-admission complication occurs. This article proposes a redesign of IPPS that reduces, but does not eliminate, the increase in payment due to post-admission complications. Using California data that contained a specification of whether each diagnosis was present at admission, and applying a conservative approach to identifying potentially preventable complications, the impact of post-admission complications on DRG assignment was determined. Based on the redesigned IPPS, the increase in Medicare payments due to post-admission complications was reduced by more than one billion dollars annually.

    Title Variations in Radiation Exposures of Adults and Children in the Uk.
    Date January 2007
    Journal Journal of Radiological Protection : Official Journal of the Society for Radiological Protection
    Excerpt

    Members of the UK population receive radiation doses from a number of sources including cosmic radiation, from uranium, thorium and their decay products, particularly radon, and from medical sources. On average, members of the UK population receive an effective dose of about 200 mSv over their lifetime. This results in a risk of fatal cancer of about 1%. However, the radiation dose is not the same to all individuals. Some components give doses that vary systematically from one region to another. Doses may also vary greatly from one individual to another. The rate at which the dose is accumulated may vary as the individual ages. Different organs and tissues do not necessarily receive the same dose. This paper discusses these factors and attempts to quantify them. Cosmic rays deliver doses which vary little across the body or between individuals. Terrestrial gamma rays also deliver more or less uniform whole-body doses, but the difference between individuals can be greater. Radionuclides in food deliver doses which vary both across the body and between individuals. These variations are even more marked in the case of doses from radon and from medical exposures.

    Title Review of the Radiation Exposure of the Uk Population.
    Date April 2006
    Journal Journal of Radiological Protection : Official Journal of the Society for Radiological Protection
    Excerpt

    Since 1974 the National Radiological Protection Board (now the Radiation Protection Division of the Health Protection Agency) has produced reviews of the levels of exposure to ionising radiation in the UK, from sources of natural and artificial origin. The latest review (Watson et al 2005 Ionising Radiation Exposure of the UK Population: 2005 Review HPA-RPD-001 (Chilton: HPA-RPD)) in the series gives estimates of annual doses based predominantly on data collected for the years 2001-2003. The overall average annual dose is rounded to 2.7 mSv, and the average annual dose from natural radiation is found to be 2.2 mSv. The overall average annual dose is slightly increased over that found in the previous, 1999, review. This increase is mainly due to a larger contribution from medical irradiation.

    Title Internal Fixation of Symptomatic Os Acromiale: a Series of Twenty-six Cases.
    Date September 2004
    Journal Journal of Shoulder and Elbow Surgery / American Shoulder and Elbow Surgeons ... [et Al.]
    Excerpt

    Twenty-six patients who presented to our shoulder service with a symptomatic meso-os acromiale were reviewed. All had been initially treated for impingement symptoms. Nonoperative treatment had failed in all patients. One patient had also undergone an arthroscopic acromioplasty without benefit. The diagnosis of symptomatic os acromiale was made on the basis of radiographs and point tenderness over the acromion coupled with signs of rotator cuff pathology. We assessed these patients after treatment by internal fixation and bone grafting. Fixation was achieved with either K-wires or screws and tension banding with either wire or suture. Fifteen patients had associated rotator cuff tears. The clinical and radiologic results are reported. The rate of union was 96% (25/26), and 24 of 26 patients (92%) were satisfied with their results. The mean time to union was 4 months. There were two postoperative fractures. Eight patients (thirty-one percent) had postoperative pain that was subsequently relieved by wire or screw removal. Seventeen patients had concomitant rotator cuff tears. Eleven cuff tears were repaired, and six were irreparable. One of these six was extensively debrided. We conclude that open reduction-internal fixation of the symptomatic meso-acromion yields satisfactory results, and with the exception of hardware discomfort necessitating removal, minimal complications arise in the majority of cases.

    Title Regional Antibiotic Prophylaxis in Elbow Surgery.
    Date May 2004
    Journal Journal of Shoulder and Elbow Surgery / American Shoulder and Elbow Surgeons ... [et Al.]
    Excerpt

    In this study we describe a technique for the delivery of regional antibiotic prophylaxis in patients undergoing elbow surgery and compare tissue antibiotic concentrations achieved by this technique with those achieved by standard systemic intravenous prophylaxis. We collected bone and fat samples from patients undergoing elective elbow surgery who had received regional antibiotic prophylaxis and measured the tissue antibiotic concentration. For comparison, we measured the antibiotic concentration in bone and fat samples taken from patients undergoing elective shoulder surgery who had received systemic prophylaxis. Mean tissue antibiotic concentrations were significantly higher in the regional antibiotic group (bone, 1484 microg/g vs 35.8 microg/g; fat, 1422.7 microg/g vs 10.7 microg/g; P <.05). No adverse effects were encountered with regional antibiotic delivery. The delivery of regional antibiotic prophylaxis in elbow surgery achieves higher tissue antibiotic concentrations than those achieved with standard systemic delivery. This technique may help reduce the risk of perioperative infection in elbow surgery.

    Title Clinical Risk Groups (crgs): a Classification System for Risk-adjusted Capitation-based Payment and Health Care Management.
    Date January 2004
    Journal Medical Care
    Excerpt

    OBJECTIVE: To develop Clinical Risk Groups (CRGs), a claims-based classification system for risk adjustment that assigns each individual to a single mutually exclusive risk group based on historical clinical and demographic characteristics to predict future use of healthcare resources. STUDY DESIGN/DATA SOURCES: We developed CRGs through a highly iterative process of extensive clinical hypothesis generation followed by evaluation and verification with computerized claims-based databases containing inpatient and ambulatory information from 3 sources: a 5% sample of Medicare enrollees for years 1991-1994, a privately insured population enrolled during the same time period, and a Medicaid population with 2 years of data. RESULTS: We created a system of 269 hierarchically ranked, mutually exclusive base-risk groups (Base CRGs) based on the presence of chronic diseases and combinations of chronic diseases. We subdivided Base CRGs by levels of severity of illness to yield a total of 1075 groups. We evaluated the predictive performance of the full CRG model with R2 calculations and obtained values of 11.88 for a Medicare validation data set without adjusting predicted payments for persons who died in the prediction year, and 10.88 with a death adjustment. A concurrent analysis, using diagnostic information from the same year as expenditures, yielded an R2 of 42.75 for 1994. CONCLUSION: CRGs performance is comparable to other risk adjustment systems. CRGs have the potential to provide risk adjustment for capitated payment systems and management systems that support care pathways and case management.

    Title Can the Veterans Affairs Health Care System Continue to Care for the Poor and Vulnerable?
    Date January 2004
    Journal The Journal of Ambulatory Care Management
    Excerpt

    Can the Veterans Affairs (VA) health care system, long an important part of the safety net for disabled and poor veterans, survive the loss of World War II veterans--once its largest constituency and still its most important advocates? A recent shift in emphasis from acute hospital-based care to care of chronic illness in outpatient settings, as well as changes in eligibility allowing many more nonpoor and nondisabled veterans into the VA system, will be key determinants of long-term survivability. Although allowing less needy veterans into the system runs the risk of diluting services to those most in need, the long-run effect may be to increase support among a larger and younger group of veterans, thereby enhancing political clout and ensuring survivability. It may be that the best way to maintain the safety net for veterans is to continue to cast it more widely.

    Title Displacement of Microcalcifications During Stereotactic 11-gauge Directional Vacuum-assisted Biopsy with Marking Clip Placement: Case Report.
    Date May 2001
    Journal Radiology
    Excerpt

    A 53-year-old woman with right breast microcalcifications of intermediate concern underwent stereotactic directional vacuum-assisted biopsy with marking clip placement. Postbiopsy mammograms showed displacement of a few of the targeted microcalcifications adjacent to misplaced marker clips. Mammography following stereotactic breast biopsy is important to document the location and number of residual calcifications and to determine the adequacy and location of clip placement.

    Title The Prospective Risk Adjustment System.
    Date June 1999
    Journal The Journal of Ambulatory Care Management
    Excerpt

    The Episode Classification System is intended to perform two tasks. First, it will be a prospective capitation risk adjuster and predict future health care costs. It will do this by assigning each individual a single capitation risk adjustment category based on an analysis of the medical history and of health care services rendered during a specific period of time. Second, the Episode Classification System will create retrospective severity adjusted Episodes of illness or Episodes of Care. These latter Episodes will provide a framework for relating patient characteristics to the amount, type, and duration of services provided during the treatment of a specific disease. These Episodes will give users the ability to understand past costs and the risk of mortality. As such they will form the basis for provider profiling by allowing users to analyze a complete clinical episode.

    Title Breast Imaging Case of the Day. Spontaneously Disappearing Benign Calcifications of the Breast.
    Date January 1999
    Journal Radiographics : a Review Publication of the Radiological Society of North America, Inc
    Title A Toxicity Reduction Evaluation for an Oily Waste Treatment Plant Exhibiting Episodic Effluent Toxicity.
    Date October 1998
    Journal The Science of the Total Environment
    Excerpt

    A Toxicity Reduction Evaluation (TRE) was conducted on the oily wastewater treatment plant (Plant) at a Naval Fuel Depot. The Plant treats ship and ballast wastes, berm water from fuel storage areas and wastes generated in the fuel reclamation plant utilizing physical/chemical treatment processes. In the first period of the project (Period I), the TRE included chemical characterization of the plant wastewaters, monitoring the final effluent for acute toxicity and a thorough evaluation of each treatment process and Plant operating procedures. Toxicity Identification Evaluation (TIE) procedures were performed as part of the overall TRE to characterize and identify possible sources of toxicity. Several difficulties were encountered because the effluent was saline, test organisms were marine species and toxicity was sporadic and unpredictable. The treatability approach utilizing enhancements, improved housekeeping, and operational changes produced substantial reductions in the acute toxicity of the final effluent. In the second period (Period II), additional acute toxicity testing and chemical characterization were performed through the Plant to assess the long-term effects of major unit process improvements for the removal of toxicity. The TIE procedures were also modified for saline wastewaters to focus on suspected class of toxicants such as surfactants. The TRE was successful in reducing acute toxicity of the final effluent through process improvements and operational modifications. The results indicated that the cause of toxicity was most likely due to combination of pollutants (matrix effect) rather than a single pollutant.

    Title Importance of Functional Measures in Predicting Mortality Among Older Hospitalized Patients.
    Date April 1998
    Journal Jama : the Journal of the American Medical Association
    Excerpt

    CONTEXT: Measures of physical and cognitive function are strong prognostic predictors of hospital outcomes for older persons, but current risk adjustment and burden of illness assessment indices do not include these measures. OBJECTIVE: To evaluate and validate the contribution of functional measures to the ability of 5 standard burden of illness indices (Charlson, Acute Physiology and Chronic Health Evaluation [APACHE] II, Disease Staging, All Patient Refined Diagnosis Related Groups, and a clinician's subjective rating) in predicting 90-day and 2-year mortality among older hospitalized patients. DESIGN: Two prospective cohort studies. SETTING: General medicine service, university teaching hospital. PATIENTS: For the development cohort, 207 consecutive patients aged 70 years or older, and for the validation cohort, 318 comparable patients. MAIN OUTCOME MEASURE: Death within 90 days and 2 years from the index admission. RESULTS: In the development cohort, 29 patients (14%) and 81 patients (39%) died within 90 days and 2 years, respectively. A functional axis was developed using 3 independent risk factors: impairment in instrumental activities of daily living, Mini-Mental State Examination score of less than 20, and shortened Geriatric Depression Scale score of 7 or higher, creating low-, intermediate-, and high-risk groups with associated mortality rates of 20%, 32%, and 60%, respectively (P<.001); the C statistic for the final model was 0.69. The corresponding mortality rates in the validation cohort, in which 59 (19%) and 138 (43%) died within 90 days and 2 years, respectively, were 24%, 45%, and 60% (P<.001); the C statistic for the final model was 0.66. For each burden of illness index, the functional axis contributed significantly to the predictive ability of the model for both 90 days and 2 years. When the functional axis and each burden of illness measure were analyzed in cross-stratified format, mortality rates increased progressively from low-risk to high-risk functional groups within strata of burden of illness indices (double-gradient phenomenon). The contributions of functional and burden of illness measures were substantive and interrelated. CONCLUSIONS: Functional measures are strong predictors of 90-day and 2-year mortality after hospitalization. Furthermore, these measures contribute substantially to the prognostic ability of 5 burden of illness indices. Optimal risk adjustment for older hospitalized patients should incorporate functional status variables.

    Title Dry Beans Inhibit Azoxymethane-induced Colon Carcinogenesis in F344 Rats.
    Date January 1998
    Journal The Journal of Nutrition
    Excerpt

    Epidemiological studies show a low incidence of colon cancer in many Latin American countries where the consumption of dry beans (e.g., pinto) is high. The purpose of this study was to use rats as an animal model to obtain experimental data on the inhibition of colon carcinogenesis by dry beans. Fifty-three 5-wk-old weanling male F344 rats were randomly assigned by weight to the following groups: control (11 rats), casein diet (21 rats), and bean diet (21 rats). Animals fed the casein and bean diets were treated with the carcinogen azoxymethane (AOM) once weekly for 2 wk. Rats in the control group also consumed the casein diet but were not exposed to AOM. All diets were isocaloric. The protein concentration of the diets was adjusted to 18 g/100 g with casein, and the fat concentration was adjusted to 5 g/100 g with corn oil. Rats fed the bean diet had significantly fewer colon adenocarcinomas (P < 0.05) than rats fed the casein diet (5 vs. 22 tumors), and significantly fewer rats fed the bean diet (P < 0.05) had colonic tumors than did casein-fed rats (24 vs. 50%). Tumor multiplicity was also significantly lower for the bean-fed rats, and significantly fewer (P < 0.05) tumors per tumor-bearing rat were observed in bean-fed rats than in casein-fed rats (1.0 +/- 0.0 vs. 2.5 +/- 0.6). This study demonstrates that dry beans contain anticarcinogenic compounds capable of inhibiting AOM-induced colon cancer in rats. However, the specific anticarcinogenic components within dry beans have not been identified, and it is unclear whether dietary fiber, phytochemicals or other components within dry beans are primarily responsible for the anticarcinogenic properties of beans.

    Title The Clinical Role of Shoulder Ultrasound.
    Date October 1997
    Journal The Australian and New Zealand Journal of Surgery
    Excerpt

    Rotator cuff surgery is facilitated by accurate pre-operative information regarding the presence and size of cuff tears, and the extent of any cuff retraction or lamination.

    Title The Interosseous Membrane in Radio-ulnar Dissociation.
    Date June 1997
    Journal The Journal of Bone and Joint Surgery. British Volume
    Excerpt

    In severe forearm injuries, the diagnosis of disruption of the interosseous membrane is frequently delayed and sometimes missed, giving difficulties in the salvage of forearm stability. We studied the structure and function of the interosseous membrane in 11 cadaver preparations, using mechanical and histological analysis. Seven of the specimens tested in uniaxial tension sustained a mid-substance tear of the central band of the membrane at a mean peak load of 1038 +/- 308 N. The axial stiffness was 190 +/- 44 N/mm with elongation to failure of 10.34 +/- 2.46 mm. These results provide criteria for the evaluation of reconstructive methods. A preliminary clinical investigation of the use of ultrasound suggests that this may be of value in the screening of patients with complex fractures of the forearm, and for investigating the natural history of tears of the interosseous membrane.

    Title Judging Hospitals by Severity-adjusted Mortality Rates: the Influence of the Severity-adjustment Method.
    Date November 1996
    Journal American Journal of Public Health
    Excerpt

    This research examined whether judgments about a hospital's risk-adjusted mortality performance are affected by the severity-adjustment method.

    Title How Severity Measures Rate Hospitalized Patients.
    Date October 1996
    Journal Journal of General Internal Medicine
    Title Judging Hospitals by Severity-adjusted Mortality Rates: the Case of Cabg Surgery.
    Date August 1996
    Journal Inquiry : a Journal of Medical Care Organization, Provision and Financing
    Excerpt

    In many health care marketplaces, outcomes assessment is central to monitoring quality while controlling costs. Comparing outcomes across providers generally requires adjustment for patient severity. For mortality rates and other adverse outcomes comparisons, severity adjustment ideally aims to control for patient characteristics prior to the health care intervention. A variety of severity methodologies, specifically for hospitalized patients, are commercially available. Some have been adopted by state or regional initiatives for publicly comparing hospital outcomes. We applied 14 common severity measures to the same data set to determine whether judgments about risk-adjusted hospital death rates are sensitive to the specific severity method. We examined 7,765 patients undergoing coronary artery bypass graft (CABG) surgery at 38 hospitals. Unadjusted death rates ranged from 0% to 11.2% across hospitals. Comparisons of relative hospital performance were relatively insensitive to the severity adjustment method.

    Title Severity Measurement Methods and Judging Hospital Death Rates for Pneumonia.
    Date February 1996
    Journal Medical Care
    Excerpt

    Payers and policymakers are increasingly examining hospital mortality rates as indicators of hospital quality. To be meaningful, these death rates must be adjusted for patient severity. This research examined whether judgments about an individual hospital's risk-adjusted mortality is affected by the severity adjustment method. Data came from 105 acute care hospitals nationwide that use the Medis-Groups severity measure. The study population was 18,016 adults hospitalized in 1991 for pneumonia. Multivariable logistic models to predict in-hospital death were computed separately for 14 severity methods, controlling for patient age, sex, and diagnosis-related group (DRG). For each hospital, observed-to-expected death rates and z scores were calculated for each severity method. The overall in-hospital death rate was 9.6%. Unadjusted mortality rates for the 105 hospitals ranged from 1.4% to 19.6%. After adjusting for age, sex, DRG, and severity, 73 facilities had observed mortality rates that did not differ significantly from expected rates according to all 14 severity methods; two had rates significantly higher than expected for all 14 severity methods. For 30 hospitals, observed mortality rates differed significantly from expected rates when judged by one or more but not all 14 severity methods. Kappa analysis showed fair to excellent agreement between severity methods. The 14 severity methods agreed about relative hospital performance more often than expected by chance, but perceptions of individual hospitals' mortality rates varied using different severity adjustment methods for almost one third of facilities. Judgments about individual hospital performance using different severity adjustment approaches may reach different conclusions.

    Title Predicting Who Dies Depends on How Severity is Measured: Implications for Evaluating Patient Outcomes.
    Date November 1995
    Journal Annals of Internal Medicine
    Excerpt

    To determine whether assessments of illness severity, defined as risk for in-hospital death, varied across four severity measures.

    Title Using Severity-adjusted Stroke Mortality Rates to Judge Hospitals.
    Date October 1995
    Journal International Journal for Quality in Health Care : Journal of the International Society for Quality in Health Care / Isqua
    Excerpt

    Mortality rates are commonly used to judge hospital performance. In comparing death rates across hospitals, it is important to control for differences in patient severity. Various severity tools are now actively marketed in the United States. This study asked whether one would identify different hospitals as having higher- or lower-than-expected death rates using different severity measures. We applied 11 widely-used severity measures to the same database containing 9407 medically-treated stroke patients from 94 hospitals, with 916 (9.7%) in-hospital deaths. Unadjusted hospital mortality rates ranged from 0 to 24.4%. For 27 hospitals, observed mortality rates differed significantly from expected rates when judged by one or more, but not all 11, severity methods. The agreement between pairs of severity methods for identifying the worst 10% or best 50% of hospitals was fair to good. Efforts to evaluate hospital performance based on severity-adjusted, in-hospital death rates for stroke patients are likely to be sensitive to how severity is measured.

    Title Diagnosis-related Group Refinement with Diagnosis- and Procedure-specific Comorbidities and Complications.
    Date September 1995
    Journal Medical Care
    Excerpt

    Diagnosis-related groups have been revised through more refined uses of secondary diagnoses. Under the refined diagnosis-related groups, patients are distinguished with respect to classes of secondary diagnoses that are disease- and procedure-specific. Each class represents a different level of utilization for a given principal diagnosis or surgical procedure. The refined system was evaluated with national data from the Medicare program. Estimates of hospital costs and utilization based on refined diagnosis-related groups were more precise than those based on unrefined diagnosis-related groups. This approach to diagnosis-related group refinement does not represent a radical departure from the current diagnosis-related group framework and does not require new data collection efforts. Moreover, a payment system based on the refined model is less affected by the ordering of the diagnoses than under the existing diagnosis-related group system. How the refined diagnosis-related group framework can accommodate future refinements at all levels of the classification scheme is also discussed.

    Title Distal Clavicular Excision: a Detailed Functional Assessment.
    Date May 1995
    Journal The Australian and New Zealand Journal of Surgery
    Excerpt

    Distal clavicular excision is commonly performed for a number of clinical conditions. The results of the procedure are not well described. Using the Constant, American Shoulder and Elbow Surgeons (ASES), University of California at Los Angeles (UCLA) and Neer scoring systems, the medium term results of distal clavicular excision were assessed. Over an 8 year period, 39 patients underwent distal clavicular excision for conditions other than acromioclavicular instability (subluxation or dislocation). A single technique was employed. A retrospective study was performed of all 18 patients who could be contacted. In those cases patient satisfaction was universal. Pre-operative pain was severe in 16 patients (89%) and moderate in two (11%). Following surgery, five (28%) were free from pain, 10 (55%) had only mild or occasional pain, and three (17%) reported moderate pain. The difference between pre-operative and postoperative levels of pain was highly significant (P < 0.001). However, continuing difficulties with work (59%), sleeping (55%) and activities of daily living (59%) were reported. Ten of 14 (71%) wishing to return to sporting activities were able to do so without restriction. Neither shoulder strength nor range of movement was fully restored following surgery, which relieved pain but did not restore normality. This series may facilitate subsequent assessment of arthroscopic distal clavicular excision.

    Title Identifying Complications of Care Using Administrative Data.
    Date August 1994
    Journal Medical Care
    Excerpt

    The Complications Screening Program (CSP) is a method using standard hospital discharge abstract data to identify 27 potentially preventable in-hospital complications, such as post-operative pneumonia, hemorrhage, medication incidents, and wound infection. The CSP was applied to over 1.9 million adult medical/surgical cases using 1988 California discharge abstract data. Cases with complications were significantly older and more likely to die, and they had much higher average total charges and lengths of stay than other cases (P < 0.0001). For most case types, 13 chronic conditions, defined using diagnosis codes, increased the relative risks of having a complication after adjusting for patient age. Cases at larger hospitals and teaching facilities generally had higher complication rates. Logistic regression models to predict complications using demographic, administrative, clinical, and hospital characteristics variables, had modest power (C statistics = 0.64 to 0.70). The CSP requires further evaluation before using it for purposes other than research.

    Title Using Administrative Data to Screen Hospitals for High Complication Rates.
    Date May 1994
    Journal Inquiry : a Journal of Medical Care Organization, Provision and Financing
    Excerpt

    Medicare's Peer Review Organizations (PROs) now are required to work with hospitals to improve patient outcomes. Which hospitals should be targeted? We used 1988 California discharge data to identify hospitals with higher-than-expected rates of complications in six adult, medical-surgical patient populations. Relative hospital complication rates generally were correlated across clinical areas, although correlations were lower between medical and surgical case types. Higher relative rates of complications were associated with larger size, major teaching facilities, and provision of open heart surgery, as well as with coding more diagnoses per case. Complication rates generally were not related significantly to hospital mortality rates as calculated by the Health Care Financing Administration. Different hospitals may be chosen for quality review depending on the method used to identify poor outcomes.

    Title "country Boys Make the Best Nurses": Nursing the Insane in Alabama, 1861-1910.
    Date May 1994
    Journal Journal of the History of Medicine and Allied Sciences
    Title Posterior Internal Compression Arthrodesis of the Ankle.
    Date October 1992
    Journal The Journal of Bone and Joint Surgery. British Volume
    Excerpt

    We have reviewed the results of 19 ankle arthrodeses in 18 patients by a new technique of posterior internal compression. Sixteen of the ankles fused at a mean time of 14 weeks and the other three after reoperation. Complications included one case each of infection, Sudeck's atrophy and non-fatal pulmonary embolism. Clinical assessment using Mazur's ankle score showed excellent or good results in nine ankles and three painfree ankles in patients who were wheelchair-bound for other reasons. The mean position of fusion was in 1.7 degrees equinus and 0.8 degrees varus, and the mean range of midtarsal movements was 15.8 degrees. Twelve patients showed radiographic signs of talonavicular or subtalar osteoarthritis.

    Title The Strength of Surgical Repairs of the Rotator Cuff. A Biomechanical Study on Cadavers.
    Date August 1992
    Journal The Journal of Bone and Joint Surgery. British Volume
    Excerpt

    Using 26 cadaver shoulders, we produced a standard defect in the supraspinatus tendon and performed one of three types of repair. Their strength was found by testing in tension the force required to produce a gap of 3 mm, then 6 mm, and finally total disruption of the repair. The use of a polyethylene patch to spread the forces over the lateral bone surface and of extra sutures to grasp the tendon end raised by 2.6 times the load at which a 3 mm gap in the repair occurred and by 1.7 times the load to failure.

    Title The Economic Consequences of the Osha Cotton Dust Standards: an Analysis of Stock Price Behavior.
    Date October 1991
    Journal The Journal of Law & Economics
    Title How Well Has Canada Contained the Costs of Doctoring?
    Date May 1991
    Journal Jama : the Journal of the American Medical Association
    Excerpt

    Canada's provinces have had varying success at containing the costs of physician services through the use of fee schedules and expenditure targets. This article examines the wide variation in the increases in the costs of physician services among Ontario, Quebec, and British Columbia between 1975 and 1987. Cost increases during that time resulted from various combinations of increases in prices (fees) and utilization, stimulated by an increased supply of physicians. Differences among the three provinces resulted from differences in the aggressiveness of fee schedule controls and whether expenditure targets were imposed. Regardless of the degree of expenditure increases, utilization increased steadily in all three provinces and was associated most consistently with growth in the supply of physicians. This was most dramatically illustrated in Quebec, which noted the most rapid rise in physician-to-population ratio. Cost containment may ultimately require constraints on the number of new physicians in addition to controls on fees and utilization.

    Title Procedure Codes: Potential Modifiers of Diagnosis-related Groups.
    Date February 1991
    Journal Health Care Financing Review
    Excerpt

    Proposals to make complexity-of-illness adjustments to the diagnosis-related group system have relied on secondary diagnosis codes and additional clinical information obtained from the hospital record. Another potential mechanism for modifying diagnosis-related groups involves the use of non-operating room procedure codes. The use of these codes has the advantage of reliably identifying costly subgroups of patients and thus the potential to provide for fairer compensation to hospitals caring for the sickest patients. There are a number of disadvantages, however, and therefore the criteria with which to evaluate procedures as potential modifiers are suggested.

    Title Occupational Exposure and the Central Index of Dose Information.
    Date February 1991
    Journal The British Journal of Radiology
    Title Improving Drgs. Use of Procedure Codes for Assisted Respiration to Adjust for Complexity of Illness.
    Date August 1989
    Journal Medical Care
    Excerpt

    Medicare's diagnosis related groups (DRGs) payment system has been criticized for not making adequate allowances for severity of illness differences within DRGs. The respiratory diseases major diagnostic category (MDC) has been a particular target; therefore, ability of several procedure codes that identify patients with assisted respiration (temporary tracheostomy, endotracheal intubation, and mechanical respiratory assistance) to identify high-cost patients in that MDC was examined. Total charges were used as the dependent variable in a 10% sample of Medicare hospital discharges from 1985. A consistent and strong association was found between the procedures and total charges for both Medicare "outliers" and "nonoutliers." Patients requiring either intubation or mechanical respiratory assistance had average charges two to three times higher, and patients with tracheostomy four to five times higher than charges for patients without assisted respiration. Patients with assisted respiration tended to resemble each other more than they resembled the other patients in their respective DRGs without assisted respiration. These findings provide the basis for recent revisions in Medicare's classification scheme for the respiratory diseases MDC.

    Title Medical Art and Medical Science: an Exhortation to Students on Primary Care.
    Date March 1989
    Journal Journal of General Internal Medicine
    Title Psychophysiologic Stress Testing As a Predictor of Mean Daily Blood Pressure.
    Date August 1988
    Journal American Heart Journal
    Excerpt

    This study describes correlations between the mean daily blood pressures determined by ambulatory blood pressure monitoring and those obtained during psychophysiologic stress testing. Seven normotensive and 21 hypertensive persons were monitored for hemodynamic changes in the laboratory while undergoing various standardized, low-challenge psychophysiologic tests. The same persons then had their blood pressure monitored with an ambulatory unit for the rest of the day. The laboratory "resting" pressure used was derived by averaging measurements for mean blood pressure obtained in three positions: standing, sitting, and supine. The "stress" pressure used was the mean blood pressure obtained by averaging three readings taken during videogame playing. A good correlation (r = 0.78) between work-time blood pressure and the laboratory stress pressure was noted. The correlation was improved (r = 0.8) when the averages of laboratory resting and stress values were used. A relationship was also noted between peak pressures obtained during the laboratory testing and those obtained during work-time by ambulatory monitoring.

    Title Isaac Ray's "project of a Law" and the 19th Century Debate over Involuntary Commitment.
    Date March 1987
    Journal International Journal of Law and Psychiatry
    Title Spinal Cord Decompression Sickness After Standard U.s. Navy Air Decompression.
    Date May 1986
    Journal Military Medicine
    Title Hematologic and Hemostatic Changes with Repetitive Air Diving.
    Date September 1984
    Journal Aviation, Space, and Environmental Medicine
    Excerpt

    In order to determine the effects of repetitive compression-decompression cycles on hematologic and hemostatic factors in humans, 14 subjects were exposed to 150 ft sea water gauge (fswg) for 30 min with standard U.S. Navy decompression on each of 12 consecutive days. Red blood cell number, volume, and size distribution; hemoglobin concentration; hematocrit; white blood cell number and differential counts; platelet number and volume; prothrombin and partial thromboplastin times; and fibrinogen and fibrin/fibrinogen degradation products were measured in venous blood samples collected before the first and after alternate dives. Subjects in the study had no symptoms other than pruritus and occasional fatigue following the exposures. More than 60% had venous gas emboli detectable by precordial doppler monitoring which generally persisted for 3-5 h after surfacing. Results show a small decrease in red cell mass, with an increase in size distribution and no change in mean corpuscular volume. No change in total white cell number was noted, but the basophilic granulocytes and atypical lymphocytes were elevated at the end of the series. A biphasic change was noted in monocyte number, and immature neutrophilic granulocytes were reduced. No change in platelet number or volume, or in the prothrombin/partial thromboplastine time, was apparent. Although fibrinogen concentration significantly decreased during the exposures, fibrin/fibrinogen degradation products remained undetectable. All changes remained in a clinically acceptable range.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Occupational Exposure in Medicine--a Review of Radiation Doses to Hospital Staff in North-west England.
    Date November 1983
    Journal The British Journal of Radiology
    Excerpt

    The personal monitoring service operated by the Regional Physics Department at the Christie Hospital and Holt Radium Institute, Manchester, monitors staff involved with the uses of ionising radiations at all hospitals and clinics administered by the North Western Region Health Authority in England. Monitoring results relating principally to exposure during 1981 have been collated and examined. The analysis indicates that the doses received by staff are for the most part very low and provide little reason for concern. The only area of work in which worthwhile and cost-effective dose reductions could probably be achieved is that involving the use of pre-loaded applicators in gynaecological intra-cavitary therapy. Some relatively high staff exposures result from the use of this technique, and very significant reductions in these doses are confidently expected from a programme which has now commenced for the increasing use of remotely-controlled after-loading equipment housed in shielded treatment rooms.

    Title Toxicity of N,n-dimethylformamide Used As a Solvent in Toxicity Tests with the Green Alga, Selenastrum Capricornutum.
    Date October 1983
    Journal Bulletin of Environmental Contamination and Toxicology
    Title Duration of Blood Pressure Elevation in Accurately Predicting Surgical Cure of Renovascular Hypertension.
    Date May 1981
    Journal American Heart Journal
    Excerpt

    Among 110 patients who underwent corrective surgery for unilateral renovascular hypertension, we found that a preoperative of hypertension was a highly important predictor of postoperative achievement of normotension. Those with less than a 5-year history of hypertension experienced 78% incidence of successful outcome, compared to such a salutary frequency of only 25% in patients with longer hypertension duration. Although the best renal vein renin (RVR) boundary ratio (1.4) was less predictive of overall surgical success in the population studied, the prognostic value of this test improved considerably when analysis of RVR ratio results were confined to patients not receiving renin-suppressing agents during RVR sampling and who had technically satisfactory operations. Highest surgical benefit rate occurred in the group of patient with both short duration of hypertension and high RVR ratio. Conversely, patients with long hypertension duration and low RVR ratio exhibited lowest surgical success frequency. Therefore, duration of hypertension is hereby shown to be an important factor in the preoperative evaluation of appropriate management of patients with renovascular hypertension.

    Title Patterns of Patient Utilization in a Volunteer Medical Clinic.
    Date August 1972
    Journal North Carolina Medical Journal
    Title An Appraisal of the Continuing Practice of Prescribing Tranquillizing Drugs for Long-stay Psychiatric Patients.
    Date December 1967
    Journal The British Journal of Psychiatry : the Journal of Mental Science
    Title Ecology and the Evolution of Biphasic Life Cycles.
    Date
    Journal The American Naturalist
    Excerpt

    Sexual eukaryotes undergo an alternation between haploid and diploid nuclear phases. In some organisms, both the haploid and diploid phases undergo somatic development and exist as independent entities. Despite recent attention, the mechanisms by which such biphasic life cycles evolve and persist remain obscure. One explanation that has received little theoretical attention is that haploid-diploid organisms may exploit their environments more efficiently through niche differentiation of the two ploidy phases. Even in isomorphic species, in which adults are morphologically similar, slight differences in the adult phase or among juveniles may play an important ecological role and help maintain haploid-diploidy. We develop a genetic model for the evolution of life cycles that incorporates density-dependent growth. We find that ecological differences between haploid and diploid phases can lead to the evolution and maintenance of biphasic life cycles under a broad range of conditions. Parameter estimates derived from demographic data on a population of Gracilaria gracilis, a haploid-diploid red alga with an isomorphic alternation of generations, are used to demonstrate that an ecological explanation for haploid-diploidy is plausible even when there are only slight morphological differences among adults.

    Title Inferences About Character and Motive Influence Intentionality Attributions About Side Effects.
    Date
    Journal The British Journal of Social Psychology / the British Psychological Society
    Excerpt

    In two studies, we predicted and found that inferences about motive and character influence intentionality attributions about foreseeable consequences of action (i.e., side effects). First, we show that inferences about intentionality are greater for good side effects than bad side effects when a target person's character is described positively. In Study 2, we manipulated information about a target person and found that inferences about intentionality were greater when side effects were consistent with a target person's character and motives. Overall, our data cast doubt on the generality of the side-effect effect. We discuss our findings and their implications for future research on intentionality and social perception.


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