Maryland Hospital Research Articles

The Use of Angioplasty, Bypass Surgery, and Amputation in the Management of Peripheral Vascular Disease

Percutaneous transluminal angioplasty has been adopted widely as a treatment for patients with peripheral vascular disease of the lower extremities. However, the effect of this procedure on the overall management of peripheral vascular disease and on the outcomes of patients has not been clearly delineated. In particular, it is not known whether angioplasty has replaced other treatments for peripheral vascular disease. To assess the extent to which angioplasty is used and the associated changes in the surgical management of peripheral vascular disease of the lower extremities, we used data on hospital discharges in Maryland to identify all angioplasty procedures, peripheral bypass operations, and lower-extremity amputations performed for peripheral vascular disease in Maryland hospitals between 1979 and 1989. We estimated that from 1979 to 1989 the annual rate of percutaneous transluminal angioplasty for peripheral vascular disease of the lower extremities, adjusted for age and sex, rose from 1 to 24 per 100,000 Maryland residents (P less than 0.0001 by linear regression). Despite this increase in the use of angioplasty, the adjusted annual rate of peripheral bypass surgery also rose substantially, from 32 to 65 per 100,000 (P less than 0.001), whereas the adjusted annual rate of lower-extremity amputation remained stable at about 30 per 100,000. Total charges for hospitalizations during which a peripheral revascularization procedure was performed increased from $14.7 million in 1979 (in 1989 dollars) to $30.5 million in 1989. In Maryland, the adoption of percutaneous transluminal angioplasty for peripheral vascular disease of the lower extremities has been associated with an increase in the use of peripheral bypass surgery and with no decline in lower-extremity amputations. These results could be due to increased diagnosis of peripheral vascular disease, expanded indications for procedural interventions, or an increased number of repeat procedures performed in patients with peripheral vascular disease of the lower extremities.

White-Black Differences in Cardiovascular Malformations in Infancy and Socioeconomic Factors

Cardiovascular malformations were examined for white/black variation in the Baltimore-Washington Infant Study. In this population-based case-control study, cases (n = 2,087) were live births with cardiovascular malformations ascertained through pediatric cardiology centers and 53 hospitals in Maryland, the District of Columbia, and northern Virginia between 1981 and 1987. Controls (n = 2,721) were a random sample of infants from the live-birth cohort that gave rise to the cases. The proportion of infants that were white was similar for all cases as a group and controls (0.68 and 0.67, respectively). Subgroup analysis, however, revealed an excess of white infants among cases with Ebstein's anomaly (odds ratio (OR) = 3.7, 95% confidence interval (Cl) 1.1-12.5), aortic stenosis (OR = 3.6, 95% Cl 1.7-7.6), pulmonary atresia (OR = 2.5, 95% Cl 1.0-6.1), coarctation of the aorta (OR = 2.2, 95% Cl 1.4-3.5), and D-transposition of the great arteries (OR = 1.6, 95% Cl 1.1-2.5), and a deficit of white infants among cases with pulmonary stenosis (OR = 0.6, 95% Cl 0.4-0.8) and heterotaxia (OR = 0.4, 95% Cl 0.3-0.8). These associations remained when cases were stratified by infant's age or by method of diagnosis. Controlling for socioeconomic factors attenuated the white excess for Ebstein's anomaly (OR = 3.0, 95% Cl 0.9-10.5), disclosed a white excess among cases of L-transposition of the great arteries (OR = 2.8, 95% Cl 1.0-8.0), and revealed that the white excess for aortic stenosis was limited to low and middle socioeconomic strata. These results highlight racial variations in cardiovascular malformations, suggest that socioeconomic factors account for some of this variation, and identify malformation subgroups for which further evaluation of sociocultural, environmental, and familial factors is needed.

Reducing High Blood Cholesterol Levels With Drugs

To the Editor. — The treacherous nature and potential pitfalls of cost-effectiveness analysis are illustrated in part in the recent article by Schulman et al. 1 Costs are notoriously difficult to identify and define. Misidentifying can warp results. The authors based laboratory on the workload recording manual of The College of American Pathologists 2 (which they referred to as a value scale), adjusted by Maryland hospital costs per work unit. The College of American Pathologists' workload method is not a relative value scale. It is solely a standardized method of evaluating the time required of medical technologists to perform a test. It cannot accurately be converted into total costs, since all of the other laboratory are not linearly correlated with personnel costs. The manual cited was even 8 years out of date. For the purpose of assessing of lipid-lowering regimens, independent laboratory are more

The Supply of Charity Services by Nonprofit Hospitals: Motives and Market Structure

This article studies provision of charity care by private, nonprofit hospitals. We demonstrate that in the absence of large positive income effects on charity care supply, convex preferences for the nonprofit hospital imply crowding out by other private or government hospitals. Extending our model to include impure altruism (rivalry) provides a possible explanation for the previously reported empirical result that both crowding out and income effects on indigent care supply are often weak or insignificant. Empirical analysis of data for hospitals in Maryland provides evidence of rivalry on the supply of charity care.

Do Trauma Centers Improve Outcome over Non-Trauma Centers

Development of regional medical care systems to treat patients who sustain major accidental injuries (trauma victims) has been based on autopsy studies which demonstrate that hospitals that meet certain accepted criteria of readiness (trauma centers) can prevent needless deaths of trauma victims. However, since only autopsy data have been available from non-trauma centers, it has not previously been possible to compare morbidity data between trauma centers and non-trauma hospitals. This study examines discharge abstract data and a new patient classification system called patient management categories (PMC) which are generated from this abstract data to evaluate length of stay (LOS), complications, and death to compare morbidity and mortality data from trauma centers and non-trauma centers. Discharge abstracts for 1,332 patients with the PMC of femoral shaft fracture with operation were obtained from all hospitals in Western Pennsylvania and Maryland for 1 year. Data from trauma centers were identified and compared to non-trauma centers using the following criteria: time to OR (less than or equal to 2 days vs. greater than 2 days), age (0-12, 13-55, greater than 55 years), associated injuries, and development of complications and death. Patients treated in trauma centers had significantly fewer complications (21% vs. 33%; p less than 0.001) and lower mortality rates (p less than 0.05) than those treated in non-trauma centers. Associated injuries, age, complications, and/or delay in time to OR significantly increased intensity and length of stay in both trauma and non-trauma centers. This significantly increased the cost of care provided to these patients in both types of centers.(ABSTRACT TRUNCATED AT 250 WORDS)

Coding external causes of injury (E-codes) in Maryland hospital discharges 1979-88: a statewide study to explore the uncoded population.

We examined the trends in hospital discharge E-coding in Maryland over a 10-year period. The overall proportion of E-coded discharges has increased from 40 percent in 1979 to 55 percent in 1988. E-coding was lower in the severely injured, the elderly, and patients with long hospital stays. Our findings demonstrate that E-code reporting varies because of the limited number of data fields available for coding of discharge diagnoses. Universal, systematic reporting of E-codes in hospital discharge data is essential if these data are to provide critically needed information about nonfatal injuries. Hospital discharge data formats should contain separate fields for E-codes and the use of these codes, we believe, should be mandated.

It's Not OK to Get Sick in July

<h3>To the Editor.—</h3> I would like to note some findings from a study of mortality following unscheduled surgery in Maryland hospitals that I believe are pertinent to the recent editorial by Dr Perry¹and the related article by Rich et al.²In the Maryland study, my colleagues and I made case-specific adjustments in risk using procedures performed, diagnoses present on admission, age, sex, and preoperative stay. The Table summarizes the findings for patients admitted in July 1984 (these data are described elsewhere in more detail³). The difference between the observed-to-expected ratio of deaths at teaching hospitals and other hospitalshad a χ²value of 5.3 (<i>P</i>&lt;.025, 1<i>df</i>).⁴Teaching hospitals were not adverse for patients admitted in all other months together, excluding July. There are several limitations in the study by Rich et al that reduced their prospect of detecting any possible association of house officer experience with risk-adjusted mortality in July. They did not specifically test for July house officer status as a predictor of mortality. Two continuous variables in their logistic regression model were both related

Outpatient Hemorrhoidectomy

Fifty-three patients underwent closed hemorrhoidectomies on an outpatient basis at the Naval Hospital Bethesda, Bethesda, Maryland, and George Washington University Hospital, Washington, DC. Our goal was to show that closed hemorrhoidectomies could be tolerated well in an outpatient setting. We found that patients tolerated this surgery well, and there was no progression of complications due to the out-of-hospital setting. An additional benefit is the cost savings to the patient who does not require an overnight hospitalization. Outpatient hemorrhoidectomy is a technique that can be effectively used in an ambulatory surgical setting with good patient tolerance and acceptance.

Laser angioplasty in the lower extremities: An early surgical experience

From July 1988 through December 1988 laser “hot tip” angioplasties coupled with balloon dilations were performed on 95 patients at the Union Memorial and University of Maryland hospitals. The patients ranged in age from 42 to 84 years (mean, 66.4 years), and there were 61 men and 34 women in the study. Indications for the procedure included claudication in 70 (74%) and severe ischemia in 25 (26%). Noninvasive studies were performed on all patients before and after the procedure. One hundred seventeen segments were treated in 28 iliac arteries and 89 superficial femoral/popliteal arteries. No tibial arteries were treated. Fifty-two stenoses and 65 occlusions occurred. The procedures were performed percutaneously in 52 patients (55%), and open surgical technique was used in 43 patients (45%). Nine immediate failures (9.5%) and 86 successes (90.5%) were noted within 24 hours of the procedure. Follow-up ranged from 1 to 6 months with a mean of 3.2 months. Late failures within this time period occurred in 21 patients (22%). The total failure rate was 3095 or 31.5%. Only one of the patients was made worse by a failed laser-assisted balloon angioplasty. Immediate complications consisted of formation of subcutaneous hematoma in 20 of the 52 patients having percutaneous procedures (38%) and healing difficulty in 3 of the 43 patients having open surgical procedures (7%). Hospital stay was usually 1 day longer in the latter group. No patient required surgical intervention for bleeding as a result of a vessel perforation. However, this phenomenon was noted during the course of three superficial femoral artery laser-assisted balloon angioplasties. No limb loss or patient death occurred in this series. In conclusion, laser-assisted balloon angioplasty appears to be a safe procedure with a low morbidity. However, it does have a high degree of early hemodynamic failure, which may be reduced in the future with better patient selection.

Laser angioplasty in the lower extremities: An early surgical experience

From July 1988 through December 1988 laser "hot tip" angioplasties coupled with balloon dilations were performed on 95 patients at the Union Memorial and University of Maryland hospitals. The patients ranged in age from 42 to 84 years (mean, 66.4 years), and there were 61 men and 34 women in the study. Indications for the procedure included claudication in 70 (74%) and severe ischemia in 25 (26%). Noninvasive studies were performed on all patients before and after the procedure. One hundred seventeen segments were treated in 28 iliac arteries and 89 superficial femoral/popliteal arteries. No tibial arteries were treated. Fifty-two stenoses and 65 occlusions occurred. The procedures were performed percutaneously in 52 patients (55%), and open surgical technique was used in 43 patients (45%). Nine immediate failures (9.5%) and 86 successes (90.5%) were noted within 24 hours of the procedure. Follow-up ranged from 1 to 6 months with a mean of 3.2 months. Late failures within this time period occurred in 21 patients (22%). The total failure rate was 30/95 or 31.5%. Only one of the patients was made worse by a failed laser-assisted balloon angioplasty. Immediate complications consisted of formation of subcutaneous hematoma in 20 of the 52 patients having percutaneous procedures (38%) and healing difficulty in 3 of the 43 patients having open surgical procedures (7%). Hospital stay was usually 1 day longer in the latter group. No patient required surgical intervention for bleeding as a result of a vessel perforation. However, this phenomenon was noted during the course of three superficial femoral artery laser-assisted balloon angioplasties.(ABSTRACT TRUNCATED AT 250 WORDS)

Cesarean Section Guidelines: The Maryland Experience

To the Editor.— The Maryland Hospital Association convened a statewide group of obstetricians in June 1988 to develop guidelines for cesarean section. Representing community and teaching hospitals, low- and high-rate cesarean section hospitals, and rural and urban hospitals, this panel of nine exerts first identified the necessary information that should be recorded in both the mother's and the child's medical records. The panel's initial conclusion was that only a fraction of this information could be gleaned from patient records. As a result, the panel devised a set of indications that should be recorded for each episode of cesarean section. By providing a more complete description of the labor management, these indicators would assist physicians in reconstructing the obstetrician's decision-making process. Six Maryland hospitals tested the protocol. Preliminary analysis of 260 cesarean section records indicates that the variation in the rate of this procedure may be attributable more to differences

Trends in hospitalized discharge rates for head injury in Maryland, 1979-86.

Hospital discharge data from all acute care hospitals in Maryland were used to examine trends in hospitalized head injury incidence and outcome by severity. From 1979 to 1986, discharge rates increased by 3.4/100,000 per year; the largest percent increase was for more severe injuries. Discharge rates increased the most for adults ages 15-24 and ages 75+ but declined for children ages 0-4. Coinciding with the increase in head injury discharges was a decrease in the hospital case-fatality rate across all severity groups.

Determinants of Hospital Charges and Length of Stay for Ocular Trauma

Ocular trauma is an important cause of blindness and visual impairment in the United States. This study examined the economic effect of ocular trauma by evaluating hospital length of stay and charges for 4406 discharges from Maryland hospitals from 1979 to 1986. Length of stay declined on average 6.1 % per year during this period. Length of stay was positively associated with age which could not be accounted for by the severity of the trauma or the presence of secondary trauma diagnoses. Other factors associated with length of stay included race, principal diagnosis, secondary trauma, and characteristics of the hospital. National projections estimate greater than 227,000 hospital days and $175 to $200 million in hospital charges alone are due to ocular injuries every year.

Mandating Employer Coverage of Mental Health Care

Prologue: Roughly three-quarters of the estimated thirty-one million people who are uninsured in the United States work or are the dependents of employed persons. Given this and the fact that 64 percent of Americans currently receive their health insurance through their employer, the notion of requiring employers to provide insurance has become attractive to many policymakers. As legislators at the state and federal levels debate the benefits and problems of such a plan, one important aspect that bears discussing is the inclusion of mental health services. Here, economists Richard Frank and Thomas McGuire ask whether mental health care should be part of a broader health insurance mandate and look at the impact of such a requirement on the benefits and cost of coverage. Frank, who earned his doctorate in economics from Boston University, is an associate professor in the Department of Health Policy and Management at The Johns Hopkins University School of Hygiene and Public Health; a research associate at the National Bureau for Economic Research; and assistant director of the Johns Hopkins University-University of Maryland Center on Organization and Financing of Care for the Severely Mentally Ill. He also serves as a commissioner of the Maryland hospital rate-setting commission and is currently researching the public financing of mental health and the role of nonprofit organizations in funding care for the indigent. McGuire is a professor in the Department of Economics at Boston University. He received his doctorate in economics from Yale University. McGuire recently received a Research Scientist Award from the National Institute of Mental Health. His current research efforts include designing a model mental health benefits package and setting physician payment rates in psychiatry for a relative value scale.

Evaluating the Appropriateness of Care: A Study of Cesarean Section Rates

The Maryland Hospital Associations Quality Indicator Project was initiated in 1987 to evaluate ten inpatient care outcome indicators. One of these indicators, cesarean sections, has been a primary focus of the project's efforts thus far. Data on 270 C-sections performed in six Maryland hospitals were gathered and analyzed by a committee that included expert clinicians and representatives from medical societies. A protocol for C-sections was then developed listing the elements that required documentation in the records of patients having C-sections. For monitoring purposes, the protocol was converted into a data collection and evaluation form that was subsequently tested for its validity and practical value. The pilot test showed that the form was a viable tool for collecting information and that the direction and magnitude of association between data elements was as expected.

The economic impact of traumatic injuries: One-year treatment-related expenditures

Considerable attention has focused in recent years on developing estimates of the economic costs associated with illness and injury. Consistent throughout all of this work has been the finding that traumatic injuries rank among the most costly of conditions. This article provides detailed information on one-year charges related to the receipt of health care and rehabilitation services for a panel of 487 trauma patients aged 16 to 45 years who were injured severely enough to be initially hospitalized at one of two trauma centers. Per case one-year treatment charges ranged from an average of $8100 for those sustaining minor (Abbreviated Injury Scale severity score of 1 or 2) injuries to $105 350 for those with severe (Abbreviated Injury Scale severity score of 5) head or spinal cord injuries. When results were generalized to the population of all individuals aged 16 to 45 years who were hospitalized in Maryland hospitals in 1983 for treatment of an injury, total charges were estimated at $109 million, with 43% of the total incurred by individuals with a principal injury to one or more of the extremities. ( JAMA 1988;260:3290-3296)

Reflex Sympathetic Dystrophy Syndrome in Pregnancy

Department of Anesthesiology, University of Maryland Schools Medicine and Hospital, Baltimore, Maryland

Autopsy services for dementia patients.

Chiefs of Pathology of every nonfederal hospital in Maryland were surveyed to determine their hospitals' experience with autopsies of dementia patients. Few pathology services had extensive, ongoing experience with these postmortem examinations, and many hospitals lacked special histochemical techniques or a referral system to evaluate them. Problems exist in obtaining postmortem examinations for dementia patients, especially those who die outside facilities with Autopsy Services.

The Economic Impact of Traumatic Injuries

Considerable attention has focused in recent years on developing estimates of the economic costs associated with illness and injury. Consistent throughout all of this work has been the finding that traumatic injuries rank among the most costly of conditions. This article provides detailed information on one-year charges related to the receipt of health care and rehabilitation services for a panel of 487 trauma patients aged 16 to 45 years who were injured severely enough to be initially hospitalized at one of two trauma centers. Per case one-year treatment charges ranged from an average of $8100 for those sustaining minor (Abbreviated Injury Scale severity score of 1 or 2) injuries to $105,350 for those with severe (Abbreviated Injury Scale severity score of 5) head or spinal cord injuries. When results were generalized to the population of all individuals aged 16 to 45 years who were hospitalized in Maryland hospitals in 1983 for treatment of an injury, total charges were estimated at $109 million, with 43% of the total incurred by individuals with a principal injury to one or more of the extremities.

The effect of benzodiazepines and other GABA agonists on opioid antinociception : Stewart A. Bergman, DDS, MS, (Wynn, R.L., Williams, G.) University of Maryland Hospital, Div. of OMS, 22 S. Greene St., Baltimore, MD 21201

The effect of benzodiazepines and other GABA agonists on opioid antinociception : Stewart A. Bergman, DDS, MS, (Wynn, R.L., Williams, G.) University of Maryland Hospital, Div. of OMS, 22 S. Greene St., Baltimore, MD 21201