Impact of a function-based payment model on the financial performance of acute inpatient medical rehabilitation providers: a simulation analysis

OBJECTIVES

To operationalize research findings about a medical rehabilitation classification and payment model by building a prototype of a prospective payment system, and to determine whether this prototype model promotes payment equity. This latter objective is accomplished by identifying whether any facility or payment model characteristics are systematically associated with financial performance.

DESIGN

This study was conducted in two phases. In Phase 1 the components of a diagnosis-related group (DRG)-like payment system, including a base rate, function-related group (FRG) weights, and adjusters, were identified and estimated using hospital cost functions. Phase 2 consisted of a simulation analysis in which each facility's financial performance was modeled, based on its 1990-1991 case mix. A multivariate regression equation was conducted to assess the extent to which characteristics of 42 rehabilitation facilities contribute toward determining financial performance under the present Medicare payment system as well as under the hypothetical model developed.

PARTICIPANTS

Phase 1 (model development) included 61 rehabilitation hospitals. Approximately 59% were rehabilitation units within a general hospital and 48% were teaching facilities. The number of rehabilitation beds averaged 52. Phase 2 of the stimulation analysis included 42 rehabilitation facilities, subscribers to UDS in 1990-1991. Of these, 69% were rehabilitation units and 52% were teaching facilities. The number of rehabilitation beds averaged 48.

MAIN OUTCOME MEASURE

Financial performance, as measured by the ratio of reimbursement to average costs.

RESULTS

Case-mix index is the primary determinant of financial performance under the present Medicare payment system. None of the facility characteristics included in this analysis were associated with financial performance under the hypothetical FRG payment model.

CONCLUSIONS

The most notable impact of an FRG-based payment model would be to create a stronger link between resource intensity and level of reimbursement, resulting in greater equity in the reimbursement of inpatient medical rehabilitation hospitals.

Mutation and downregulation of the transforming growth factor beta type II receptor gene in primary squamous cell carcinomas of the head and neck

In the present study, we analyzed 28 squamous cell carcinomas of the head and neck (SCCHN) for mutations in the coding region of TbetaR-II using 'Cold' SSCP and automatic DNA sequencing analyses. Twenty-one percent (6/28) of the SCCHN examined contained TbetaR-II mutations compared with patient-matched normal tissues. These alterations included five missense mutations (A:T-->G:C transitions in codons 250, 401, 448 and 488, and a G:C-->T:A transversion in codon 373), and a 38-bp deletion between nucleotides 1825 to 1862. In addition to these code-altering mutations, one case exhibited a silent mutation (A:T-->G:C transition in codon 451) and three cases contained one of two potential population polymorphisms (codons 354 and 389). In contrast to colon and gastric cancers exhibiting microsatellite instability (MI) or replication errors (RER+), no 'indirect' frameshift mutations were identified within a 10-bp polyadenine repeat present in the TbetaR-II coding sequence. All of the mutations in the present study occurred within the highly conserved serine/threonine kinase domain and represent the first report of such 'direct' TbetaR-II mutations in primary human tumors. In addition, we analyzed a subset of SCCHN and corresponding normal samples for TbetaR-II mRNA expression using semi-quantitative multiplex RT-PCR. Expression of TbetaR-II was decreased by 24% to 74% in 20 of 23 SCCHN (87%) compared with patient-matched normal tissues. Taken together, the results from this study suggest that alterations in the nucleic acid sequence and mRNA expression of TbetaR-II are prevalent events in the development of SCCHN, which may deregulate cell cycle control.

[The effects of Gu Chi Gao on IL-8 in GCF of periodontitis]

In order to find a new treatment of periodontitis, this paper studied the effects of Gu Chi Gao on IL-8 in gingival crevicular fluid (GCF) of periodontitis. One tooth was selected from every patient in 24 patients with adult periodontitis. After supragingival scaling, the patients were divided into two groups randomly. One group was treated with Gu Chi Gao, while the other group was untreated as control group. All patients were examined after one month. GCF samples were collected with 2 mm x 20 mm Whatman I filter paper stripes and IL-8 in the GCF samples were detected by the method of ELISA. The result demonstrated that the levels of GCF and IL-8 in the treated group were lower than that of control group (P < 0.01), it suggests that Gu Chi Gao may inhibit the production of IL-8 and GCF.

[Evaluation of emergency surgery in gestational trophoblastic tumours]

We retrospectively analyzed 27 cases of gestational trophoblastic neoplasia treated by emergency surgery from 1985-1996 at PUMC hospital. Seventeen cases were diagnosed of choriocarcinoma and 10 were invasive mole. Sixteen out of 27 patients were subjected to hysterectomy because of uterine perforation or severe uterine bleeding; 4 cases received unilateral oophorectomy because of torsion of theca lutein cyst. Emergency open surgery and excision of the metastatic brain tumour were undertaken in 3 patients with elevated intracranial pressure caused by brain edema and haemorrhage; 2 patients showed lifethreatening haemorrhage from vaginal metastatic tumour and were managed by operative intervention. Partial jejunectomy was performed in 2 patients due to rupture of jejunal metastatic mass. Of these 27 cases, 17 hadn't been treated with chemical reagents and 6 cases had received one course of chemotherapy before surgical procedures. After multiple courses of combined chemotherapy postoperatively, 23 patients had achieved complete remission. It is concluded that surgical intervention plays an important role in patients with trophoblastic disease when emergency situations (e.g. life-threatening haemorrhages) occur; early diagnosis and prompt initiation of chemotherapy might have rendered surgery unnecessary.

Cerebrospinal fluid apo E and apo A-I concentrations in early- and late-onset Alzheimer's disease

We compared cerebrospinal fluid (CSF) apolipoprotein (apo) A-I and apo E concentrations in early- and late-onset Alzheimer's disease (EOAD (n = 11), LOAD (n = 15), respectively) with those in control subjects (n = 23). CSF apo A-I levels in both EOAD and LOAD were consistent with control subjects. However, CSF apo E levels were significantly lower in EOAD group (mean +/- SD; 2.65 +/- 1.69 mg/l, P < 0.05) and higher in LOAD group (5.90 +/- 1.94 mg/l, P < 0.01) than those in control group (4.16 +/- 1.69 mg/l). In addition, the epsilon4 allele frequency was not different between EOAD and LOAD groups. Although the reason for the difference in CSF apo E concentrations between two groups is unknown, CSF apo E concentration seems to be associated with the pathogenesis of EOAD and LOAD. The rate of apo E production and/or catabolism in the brain may be different between them.

Evidence for K+ channels involvement in capillary sensing and for bidirectionality in capillary communication

Although the capillary sensing and communication phenomenon has been characterized, its mechanism is not clear. It has been hypothesized that capillary sensing involves a membrane potential change in the capillary endothelium and/or pericyte and that communication represents an electrotonic spread of this change along the capillary. The goal of the present study was to address this hypothesis by examining the presence of K+ channels on the capillary and by determining bidirectionality of communication. Using intravital microscopy, we locally applied K+ (100 mM), acetylcholine (ACh; 3 mM), and norepinephrine (NE; 0.3 mM) on capillaries, 400-500 microns downstream from the arteriole, at the surface of the sartorius muscle in anesthetized frogs. Responses were measured in terms of red blood cell velocity (VRBC) changes in the stimulated capillary (control prestimulation VRBC ranged from 110 to 770 microns/sec). K+ and ACh caused significant 19 and 38% increases in VRBC, while NE caused a -46% decrease, respectively. The K+ response was blocked by local pretreatment with K+ channel blocker BaCl2 (1 microM) and by pretreatment with tetraethyl ammonium chloride (TEA; 5 mM). Responses to ACh and NE were attenuated by pretreatment with 1 microM BaCl2 (to 1%) and with 50 mM TEA (to -25%), respectively. In a separate experiment, NE (3 mM) application on the capillary 500 microns away from the draining venule (capillary occluded) caused a 19% venular constriction (i.e., similar to a reported 21% arteriolar constriction caused by the NE stimulus). We concluded that (i) K+ channels were present on the capillary and (ii) capillary communication was bidirectional. We interpreted these results to be consistent with the above hypothesis of membrane potential change and electrotonic spread.

Expression of a putative vesicular acetylcholine transporter facilitates quantal transmitter packaging

A putative vesicular acetylcholine transporter (VAChT) was overexpressed in developing Xenopus spinal neurons by injection of rat VAChT cDNA or synthetic mRNA into Xenopus embryos. This resulted in a marked increase in the amplitude and frequency of miniature excitatory postsynaptic currents at neuromuscular synapses, reflecting an over 10-fold increase in the vesicular packaging of acetylcholine (ACh). The effect appeared in developing neurons even before synaptogenesis and was blocked by L-vesamicol, a specific blocker of ACh uptake into synaptic vesicles. Mutational studies showed that two highly conserved aspartate residues within putative transmembrane domains 4 and 10 are essential for the transport activity. These results provide direct evidence for the physiological function of a putative VAChT and demonstrate that quantal size can be regulated by changes in vesicular transporter activity.

[Nucleotide sequence of gltB gene encoding the large subunit of Rhodobacter sphaeroides glutamate synthase]

The complete nucleotide sequence of a 5.4-kb chromosomal EcoRI-SalI fragment was determined, which contains the structural gene (gltB) for the large subunit of Rhodobacter sphaeroides glutamate synthase, as well as the 5'- and 3'- flanking regions. A open reading frame of 4636 base pairs was identified as R. sphaeroides gltB gene. The MW of the large subunit, as deduced from the nucleotide sequence, was estimated as 164kD. Comparision of the nucleotide sequences revealed a high similarity among gltB genes of R. sphaeroides, Azospirillum brasilense and Escherichia coli. The deduced amino acid sequence of R. sphaeroides GltB showed a high similarity with that of A. brasilense GltB.

[Effect of Yang-warming and Qi-tonifying natural products on neuroendocrine of deficiency-cold rats]

The rat fed with the compound drug Zhi Mu and Shi Gao was made into an animal model of deficiency cold syndrome. The deficiency cold state was kept for more than 7 days after stopping the drug. So the animal model is good for studing the therapeutic effect of products of heat nature. After 3 therapeutic days with Fu Jiang and Shen Qi compounds, the D beta H activity in serum, cortisone in adrenal gland and NE, DA amount in brain were increased, but serotonin was decreased, and after 7 days the effect was increased significantly. Both compounds could excite the sympathetic nerve and endocrine system in the peripheral and central nervous systems. Shen Qi compound acts quickly, but does not last as long as Fu Jiang. The effect will be better if the two compounds are used together.

[Preparation and characterization of recombinant retroviral vector containing t-PA cDNA]

A recombinant retroviral vector containing tissue-type plasminogen activator (t-PA) cDNA was constructed and transfected into PA317 viral packaging cells, forming intact virus particles. Under electron microscope the recombinant retroviral particles were composed of envelope, capsid and core. These viral particles were spherical with a diameter of 90-180nm, and spread dispersely in the cells. NIH3T3 cell infected by retrovirus particles were screened with G418. The virus titer of 6 x 10(8) CFU/L was verified by counting the positive clones two weeks after screening. The expression of t-PA was demonstrated in the NIH3T3 cells infected with the recombinant virus.

[The expression of IL-1 alpha gene in gingival tissue]

IL-1 is secreted by a variety of cells and plays an important role in the network of cytokines. In this study, the expression of IL-1 alpha in gingival tissue was determined with reverse transcription-polymerase chain reaction (RT-PCR). The PCR-product was confirmed by DNA sequencing. The results showed that IL-1 alpha transcription was detected in all 5 inflammatory gingival tissue samples, but it was not delected in the normal gingival tissue samples and in the samples after treatment. These findings suggested that IL-1 alpha may be a specific indicator of periodontal disease, and a potential mediator in pathogenesis of periodontitis.

In vitro motility of AtKCBP, a calmodulin-binding kinesin protein of Arabidopsis

AtKCBP is a calcium-dependent calmodulin-binding protein from Arabidopsis that contains a conserved kinesin microtubule motor domain. Calmodulin has been shown previously to bind to heavy chains of the unconventional myosins, where it is required for in vitro motility of brush border myosin I, but AtKCBP is the first kinesin-related heavy chain reported to be capable of binding specifically to calmodulin. Other kinesin proteins have been identified in Arabidopsis, but none of these binds to calmodulin, and none has been demonstrated to be a microtubule motor. We have tested bacterially expressed AtKCBP for the ability to bind microtubules to a glass surface and induce gliding of microtubules across the glass surface. We find that AtKCBP is a microtubule motor protein that moves on microtubules toward the minus ends, with the opposite polarity as kinesin. In the presence of calcium and calmodulin, AtKCBP no longer binds microtubules to the coverslip surface. This contrasts strikingly with the requirement of calmodulin for in vitro motility of brush border myosin I. Calmodulin could regulate AtKCBP binding to microtubules in the cell by inhibiting the binding of the motor to microtubules. The ability to bind to calmodulin provides an evolutionary link between the kinesin and myosin motor proteins, but our results indicate that the mechanisms of interaction and regulation of kinesin and myosin heavy chains by calmodulin are likely to differ significantly.

Failure of insulin-like growth factor type I to suppress HIV type 1 in adult or umbilical cord mononuclear blood cells

Insulin-like growth factor type I (IGF-I) has been used as a treatment for cachexia in adults with AIDS and has been reported to show inhibitory activity against HIV-1IIIB in cord blood mononuclear cells (CBMCs) in vitro at low-concentration (1%) fetal bovine serum (FCS). We evaluated the effect of IGF-I on MN, IIIB, and BaL strains, as well as on a patient isolate of HIV-1 in CBMCs and adult peripheral blood mononuclear cells (PBMCs). IGF-I failed to show any inhibitory effect on HIV replication in CBMCs or adult PBMCs under various culture conditions. In contrast to an earlier report of an antiviral effect, IGF-I augmented HIV-1 replication in PHA-stimulated PBMCs maintained in a low concentration of FCS.

Marked increases in concentrations of apolipoprotein in the cerebrospinal fluid of poliovirus-infected macaques: relations between apolipoprotein concentrations and severity of brain injury

Apolipoproteins in cerebrospinal fluid (CSF) might have important functional roles in the pathophysiology of brain and lipid metabolism in the vascular component. The present study examined apolipoprotein A-I (apo-A-I) and apolipoprotein E (apo-E) levels in CSF and serum from poliovirus-infected macaques. Poliovirus-infected macaques developed motor deficits and were classified into three groups: (1) muscle weakness in one or both legs; (2) partial paralysis in one or both legs; (3) complete paralysis in one or both legs. No motor deficits were evident in the control or sham-treated macaques. Apo-A-I concentrations in CSF were markedly elevated in poliovirus-infected macaques with weakness, partial or complete paralysis, in comparison with either control or sham-treated animals, and were proportional to the severity of motor impairment. Apo-E concentrations in CSF were also significantly elevated in poliovirus-infected macaques with complete paralysis. The magnitude of increase in CSF apo-A-I or apo-E concentrations was also closely associated with the degree of histologic neurological damage and inflammation (lesion scores). However, no changes in serum apo-A-I and apo-E concentrations were observed in the poliovirus-infected macaques compared with control macaques. Furthermore there were no significant correlations apo-A-I or apo-E concentrations between serum and CSF. We hypothesize that the elevation of apo-A-I and apo-E concentrations after poliovirus infection is caused by immune stimulation within the central nervous system (CNS). Measures of CSF apo-A-I and apo-E levels might serve as a useful marker for the severity and/or the range of CNS injury.

[Clinical significance of changes of fibrillation potential amplitude following denervation of human skeletal muscle]

To evaluate the value of clinical application of examination of fibrillation potential amplitude, 110 patients, 97 males and 13 females, were examined and only the maximum fibrillation potential amplitudes were recorded in 420 muscles. The results showed that there was no significant difference between sexes, ages and sides. However, significant difference was evident between the groups of different frequency (1+ to 4+). The fibrillation potential amplitude was maximum at 3 to 4 months after denervation and still remained at relatively high level for years in certain patients. No significant difference was showed between the time groups in incomplete nerve injuries. Surgery did not affect the course of fibrillation potential amplitude change. It was suggested that the muscle cells sustained their property for years after denervation in some patients, thus it might explain that satisfactory result could be obtained from operative repair in some late cases. The changes of fibrillation potential amplitude might indicate that the changes from muscle denervation was still reversible and might be more accurate than traditional method of examination.

Fibroblast growth factor 2 can replace ectodermal signaling for feather development

The initiation and morphogenesis of cutaneous appendages depend on a series of reciprocal signaling events between the epithelium and mesenchyme of the embryonic skin. In the development of feather germs, early dermal signals induce the formation of epidermal placodes that in turn signal the mesoderm to form dermal condensations immediately beneath them. We find a spatially and temporally restricted pattern of transcription for the genes that encode fibroblast growth factor (FGF) 2 and FGF receptor (FGFR) 1 in developing feather germs of the chicken embryo. FGF-2 expression is restricted to the epidermal placodes, whereas FGFR-1 expression is limited to the dermal condensations. Transcription of these genes could not be detected in skins of scaleless (sc/sc) embryos that fail to develop feathers as a result of an ectodermal defect. Treatment of sc/sc skins with FGF-2 results in the formation of feathers at the site of application of the growth factor and the induced feathers express FGFR-1 in their dermal condensations. Thus, we have established FGF-2 as an epidermal signal in early feather germ formation. The observation that FGF-2 can rescue the mutant phenotype of sc/sc embryos suggests that FGF-2 either is, or is downstream from, the signal that the sc/sc mutant ectoderm fails to generate.

The spatial relationship between infant mortality and birth defect rates in a U.S. city

The spatial patterns of infant mortality and birth defect rates in the Des Moines, Iowa, urban region are described as a contoured surface based on the punctual kriging of address-matched vital statistics records from The Iowa Department of Public Health. Areas defined as having high rates are shown to be sensitive to the size of the spatial filtering units. There is no correlation between infant mortality and birth defect rates in the region. The significance of areas with high rates is determined by a Monte Carlo simulation procedure. One area of high infant mortality is found in the region, which contrasts with many smaller areas with high birth defect rates in the region. The observed birth defect rate pattern is consistent with the hypothesis that each birth was equally likely to result in a birth defect, while the infant mortality pattern is unlikely to be the result of such an equal likelihood process.

[Curcuma longa L. tuber yield simulation model and its application under combined agronomic measures for good-quality, high-yield and obvious economic results]

A design of second order orthogonal rotative regression was developed and field tested, and the tuber models for yield, quality and benefit were simulated and built. The effect of agronomic measures on the tuber yield is plant density > phosphorus > sowing date > nitrogen > potassium. There is a clear interrelation effect among agronomic measures. The results of simulation experiment have shown that the optimal combination of farming practices can greatly increase the tuber yield, quality and benefit, and is adjusted according to climate, soil, ferilizer or manure sources, and so on.

A role of PDI in the reductive cleavage of mixed disulfides

We previously reported that protein disulfide isomerase (PDI) can dissociate the glutathione molecule in vitro from the mutant human lysozyme (hLZM) C77A-a, which is modified with glutathione at Cys95; however, it seems structurally difficult for PDI to attack either the disulfide bond or the side chain of the cysteine residue of a mixed disulfide. To investigate the function of PDI, we introduced several glutathione and cysteine derivatives at Cys95, instead of the glutathione of C77A-a. Using thiol compounds modified by 5,5'-dithiobis(2-nitrobenzoic acid) (DTNB), we could easily modify the free thiol group of C77A-b (C77A with no glutathionylation), without denaturation. For all of the modifications we tested, a negative correlation was found between the initial rate and the acceleration ratio of the reductive cleavage of mixed disulfides with PDI. A mutant PDI (hPDIM), which has no thiol-disulfide exchange activity, suppressed the reductive cleavage of the mixed disulfide of C77A-a with hPDI, suggesting that hPDI non-covalently interacted with the substrates. Taking account of the results of the structural analysis, we conclude that one of the functions of PDI in vivo lies in relaxing the structure around the disulfide bond, as well as in exchanging the thiol-disulfide bonds.

Binding sites on microtubules of kinesin motors of the same or opposite polarity

The kinesin motor proteins translocate toward either the plus or minus end of microtubules (MTs). Competitive microtubule binding assays were carried out with monomeric motor domains of the minus-end-directed nonclaret disjunctional (Ncd) and Kar3 and the plus-end-directed kinesin heavy chain (KHC) to determine whether motors of the same or opposite polarity compete for binding sites on MTs and to test the idea that motor polarity is determined by differences in binding sites on MTs of the motors. The stoichiometries of binding were approximately 1 motor:1 tubulin heterodimer for all three motors. Ncd and Kar3, both minus-end motors, severely inhibited the binding of one another to MTs, as predicted theoretically for binding of the two motors to the same site on MTs, indicating that the binding sites on MTs of Ncd and Kar3 are the same or overlap extensively. Motors of opposite polarity, KHC and Ncd or KHC and Kar3, showed partial or complete inhibition of binding to MTs under different experimental protocols. The differences in binding behavior could be due to experimental conditions or be inherent in the nature of motor binding to MTs. Alternatively, differences in KHC and Ncd or Kar3 binding sites on MTs may exist such that the motors bind to partially overlapping but nonidentical sites on MTs. These differences in binding sites may be related to the opposite polarity of translocation on MTs of the motors.

[Effects of blood pressure day-nocturnal rhythm and endothelin in patients of sleep apnea syndrome]

OBJECTIVE

To analyse the change of blood pressure and endothelin in sleep apnea syndrome.

METHODS

The ambulatory blood pressure, echocardiogram and plasma endothelin in 164 cases of hypertension and normal controls with or without sleep apnea syndrome (SAS) were examined. The patients were divided into four groups and 41 cases were in each group.

RESULTS

The results showed that in a number of the patients of sleep apnea with or without hypertension blood pressure day nocturnal rhythm disappeared and endothelin increased (18.2 +/- 5.7 ng/L and 13.2 +/- 4.4 ng/L) The difference of nocturnal blood pressure and endothelin between SAS groups and non-SAS groups (11.7 +/- 3.9 ng/L and 4.3 +/- 2.1 ng/L) were statistically significant (P < 0.05 and P < 0.01).

CONCLUSION

It was suggested that the SAS patients might be due to cyclical hypoxemia and nerve-endocrine abnormality activating endothelin, and other vasoactive peptides with increased blood pressure during sleep and enhance the damage to target organs.