NIA's Intervention Testing Program at 10 years of age

The previous 20 years of basic research on aging has identified a large number of genes and gene products whose expression can be manipulated in a variety of ways to increase the healthy life span of animal models such as yeast, nematodes, fruit flies, and mice. In an overt attempt to capitalize on this information, the National Institute on Aging (NIA) began a program in 2003 to identify nutritional and pharmaceutical interventions that could be safely employed to extend the healthy life span of mice. This program is called the Intervention Testing Program (ITP), and this article briefly describes the development of this initiative and some of the early success achieved during its first 10 years (2004-2014) of operation.

Nordihydroguaiaretic acid and aspirin increase lifespan of genetically heterogeneous male mice

The National Institute on Aging's Interventions Testing Program was established to evaluate agents that are purported to increase lifespan and delay the appearance of age-related disease in genetically heterogeneous mice. Up to five compounds are added to the study each year and each compound is tested at three test sites (The Jackson Laboratory, University of Michigan, and University of Texas Health Science Center at San Antonio). Mice in the first cohort were exposed to one of four agents: aspirin, nitroflurbiprofen, 4-OH-alpha-phenyl-N-tert-butyl nitrone, or nordihydroguaiaretic acid (NDGA). Sample size was sufficient to detect a 10% difference in lifespan in either sex,with 80% power, using data from two of the three sites. Pooling data from all three sites, a log-rank test showed that both NDGA (p=0.0006) and aspirin (p=0.01) led to increased lifespan of male mice. Comparison of the proportion of live mice at the age of 90% mortality was used as a surrogate for measurement of maximum lifespan;neither NDGA (p=0.12) nor aspirin (p=0.16) had a significant effect in this test. Measures of blood levels of NDGA or aspirin and its salicylic acid metabolite suggest that the observed lack of effects of NDGA or aspirin on life span in females could be related to gender differences in drug disposition or metabolism. Further studies are warranted to find whether NDGA or aspirin, over a range of doses,might prove to postpone death and various age-related outcomes reproducibly in mice.

A frame-based representation for a bedside ventilator weaning protocol

We describe the use of a frame-based knowledge representation to construct an adequately-explicit bedside clinical decision support application for ventilator weaning. The application consists of a data entry form, a knowledge base, an inference engine, and a patient database. The knowledge base contains database queries, a data dictionary, and decision frames. A frame consists of a title, a list of findings necessary to make a decision or carry out an action, and a logic or mathematical statement to determine its output. Frames for knowledge representation are advantageous because they can be created, visualized, and conceptualized as self-contained entities that correspond to accepted medical constructs. They facilitate knowledge engineering and provide understandable explanations of protocol outputs for clinicians. Our frames are elements of a hierarchical decision process. In addition to running diagnostic and therapeutic logic, frames can run database queries, make changes to the user interface, and modify computer variables.

2006 Kent award lecture: is cell death and replacement a factor in aging?

This article briefly summarizes the Kent Award Lecture I gave at the annual meeting of The Gerontological Society of America held in Dallas, Texas, in November 2006. Cell death is a normal response of cells to cytotoxic damage due to both internal and external threats, and this cell loss is normally countered by proliferation of neighboring cells and/or replacement of these cells from progenitor cell pools. Maintaining tissue homeostasis is a critical challenge during aging, and this article describes a few aspects of the dynamic cell turnover that occurs continuously in vivo, with particular reference to the adverse effects of mutations that accelerate cell death through dysfunctional DNA metabolism, and how these events might contribute to aging in general.

Time, damage, and aging: what really matters?

This presentation was one of three short talks in the introductory session at the 2007 Edmonton Aging Symposium titled "The Damage of Aging: Present and Future Therapies." This title implies that if we can document what biological damage occurs with increasing age, then by either preventing, reducing or repairing this damage, we could intervene to delay the onset and severity of the adverse age-related phenotypes that accompany aging, and perhaps increase life span as well. While this assumption seems quite reasonable, some recent results suggest that this approach is not as straightforward as it might seem.

An Aging Interventions Testing Program: study design and interim report

The National Institute on Aging's Interventions Testing Program (ITP) has developed a plan to evaluate agents that are considered plausible candidates for delaying rates of aging. Key features include: (i) use of genetically heterogeneous mice (a standardized four-way cross), (ii) replication at three test sites (the Jackson Laboratory, TJL; University of Michigan, UM; and University of Texas, UT), (iii) sufficient statistical power to detect 10% changes in lifespan, (iv) tests for age-dependent changes in T cell subsets and physical activity, and (v) an annual solicitation for collaborators who wish to suggest new interventions for evaluation. Mice in the first cohort were exposed to one of four agents: aspirin, nitroflurbiprofen (NFP), 4-OH-alpha-phenyl-N-tert-butyl nitrone (4-OH-PBN), or nordihydroguiaretic acid (NDGA). An interim analysis was conducted using survival data available on the date at which at least 50% of the male control mice had died at each test site. Survival of control males was significantly higher, at the interim time-point, at UM than at UT or TJL; all three sites had similar survival of control females. Males in the NDGA group had significantly improved survival (P = 0.0004), with significant effects noted at TJL (P < 0.01) and UT (P < 0.04). None of the other agents altered survival, although there was a suggestion (P = 0.07) of a beneficial effect of aspirin in males. More data will be needed to determine if any of these compounds can extend maximal lifespan, but the current data show that NDGA reduces early life mortality risks in genetically heterogeneous mice at multiple test sites.

Is cell death and replacement a factor in aging?

The central theme of the 3rd International Conference on Functional Genomics of Ageing was tissue regeneration as a remedial strategy to address age-related cellular damage and the pathology that ensues. The conference included sessions on maintaining genome integrity and the potential of stem cells to restore function to damaged tissues. In addition to several human syndromes that appear to reflect accelerated ageing, there are now a number of mouse models that prematurely display phenotypes associated with ageing. The intent of this summary presented at the end of the conference was to: (1) discuss various human syndromes and mouse models of accelerated ageing; (2) evaluate whether the phenotypes displayed might result from an elevated rate of cell death coupled with an inability to adequately maintain cell number in various tissues with increasing age; and (3) discuss whether similar events may be occurring during normal ageing, albeit much more slowly.

Scientific and Ethical Concerns Regarding Engineering Human Longevity

The goal of biogerontological research is to elucidate the biological factors underlying adverse age-related changes in structure and function of molecules, cells, tissues, and organisms. In spite of the considerable progress achieved so far, it is still too early to predict what strategies will be both safe and effective at preventing, delaying, or reversing these changes in humans, and whether such strategies will also increase longevity.

Twenty years of progress in biogerontology research

The first 10 years of NIA's existence were characterized by funding for descriptive and discovery research, as the field had not yet come of age. As Couzin expressed it in the July 1, 2005 issue of Science, "Just 2 or 3 decades ago, research on aging was a backwater" (Couzin J 2005 How much can human life span be extended. Science 309: 83). With the isolation of long-lived animal mutants and the application of the tools of molecular biology and transgenic technology to biogerontology research, the situation has changed dramatically since then, and aging research has become increasingly mechanistic and respectable. This transition has been aided by some well-thought out research initiatives by the NIA, and the purpose of this article is to provide a brief summary of the progress made in the past 20 years, and describe the part that NIA initiatives and funding have played in this transition.

Developing a Research Agenda in Biogerontology: Basic Mechanisms

The National Institute on Aging (NIA) began operation in 1975, splitting off from the National Institute of Child Health and Human Development. The first 10 years of NIA's existence were characterized by funding descriptive and discovery research, as the field by then had not come of age. With the isolation of long-lived animal mutants and the application of the tools of molecular biology (including whole-genome sequencing) and transgenic technology to biogerontology research, the situation has changed dramatically since then, and aging-related research has become increasingly mechanistic and respectable. This transition has been aided by research initiatives implemented by NIA staff, and the goal of this article is to describe how NIA develops such research initiatives using research progress made in biogerontology over the past 20 years as the basis for the discussion.

Longevity genes: from primitive organisms to humans

Recent results indicate that the longevity of both invertebrates and vertebrates can be altered through genetic manipulation and pharmacological intervention. Most of these interventions involve alterations of one or more of the following: insulin/IGF-I signaling pathway, caloric intake, stress resistance and nuclear structure. How longevity regulation relates to aging per se is less clear, but longevity increases are usually accompanied by extended periods of good health. How these results will translate to primate aging and longevity remains to be shown.

The Future of Aging Therapies

Advances in understanding aging processes and their consequences are leading to the development of therapies to slow or reverse adverse changes formerly considered to be "normal" aging and processes that underlie multiple age-related conditions. Estimating the effectiveness of candidate aging therapies, whose effects on human aging may require many years to determine, is a particular challenge. Strategies for identifying candidate interventions can be developed through multiple approaches, including the screening of molecular targets and pathways in vitro and in animal models, informed as well by evidence from human genetic and epidemiologic data. A number of recently established programs and networks can serve as resources for such research. For all these research approaches, from in vitro molecular studies to clinical trials, contributions of cell and molecular biology are crucial and offer the prospect of therapeutic advances that address fundamental biological processes as well as the clinically important challenges of aging.

The Future of Aging Interventions: Current Status of Efforts to Measure and Modulate the Biological Rate of Aging

Biomarkers of aging would be highly desirable, but so far, a definitive panel of biomarkers to predict mortality risk has not been obtained, even though many traits that vary with age have been identified. This lack hinders the search for interventions that may retard the rate of aging in mammals. The recent discovery and characterization of many longevity genes in animal model systems, such as nematodes, fruit flies, and mice, are providing new targets for research by providing insight into mechanisms of longevity regulation in these model systems. It is hoped that this will ultimately lead to interventions to delay the development of age-related pathology in humans.

Models of accelerated ageing can be informative about the molecular mechanisms of ageing and/or age-related pathology

During the past ten years considerable progress has been made in discovering genes that regulate longevity by identifying single gene mutations that lead to increased longevity. The initial success in nematodes was quickly followed by comparable success in fruit flies and mice. In contrast, mutations that cause a decrease in longevity have been largely discounted as unlikely to be informative about aging mechanisms. However, the recent creation of several mutant mouse models that develop a variety of aging-like phenotypes and die prematurely, suggests that such models may be useful in understanding aging mechanisms, particularly as they relate to progressive tissue and organ dysfunction. A possible common feature of these models may be an imbalance between loss of cells by apoptosis and subsequent cell replacement, leading gradually to a net loss of cells in multiple tissues.

Subfield history: use of model organisms in the search for human aging genes

The National Institute on Aging (NIA) started a program in 1993 to identify genes involved in the regulation of longevity in a variety of species, including yeast, nematodes, fruit flies, and mice. The initial success of this program has attracted the interest of many investigators working with these organisms. Of primary interest are single-gene mutants that have identified genes and processes involved in longevity regulation across species. These processes include the insulin-like signaling pathway, stress resistance, and most recently, chromosome and nuclear architecture. Mutations in genes that regulate these processes indirectly are also being identified in this program. The ultimate goal of this program is to extend these results to humans to identify the major biological risk factors for age-related decline of function in human physiological systems.

Recent progress in understanding the relationships among aging, replicative senescence, cell turnover and cancer

The link between aging and cancer is more than just the increasing accumulation of mutations with time. Recent research provides evidence that senescent cells are not merely passive bystanders, but may promote cancer through degradation of the tissue microenvironment. Another critical factor in the relationship between aging and cancer is p53 function; its activity level is apparently finely tuned to suppress cancer while regulating both apoptosis and the replacement of damaged cells through stem cell proliferation. The deacetylase activity of the sir2 gene product plays a role in longevity regulation in invertebrates, and also regulates p53 function in mammals, implying yet another link between aging and cancer in mammals.

Is there an antiaging medicine?

In spite of considerable hype to the contrary, there is no convincing evidence that currently existing so-called "antiaging" remedies promoted by a variety of companies and other organizations can slow aging or increase longevity in humans. Nevertheless, a variety of experiments with laboratory animals indicate that aging rates and life expectancy can be altered. Research going back to the 1930s has shown that caloric restriction (also called dietary restriction) extends life expectancy by 30-40% in experimental animals, presumably at least partially by delaying the occurrence of age-dependent diseases. Mutations that decrease production of insulin growth factor I in laboratory mammals, and those that decrease insulin-like signaling in nematodes and fruit flies, have increased life expectancy as well. Other general strategies that appear promising include interventions that reduce oxidative stress and/or increase resistance to stress; hormone and cell replacement therapies may also have value in dealing with specific age-related pathologies. This article reports the findings of a consensus workshop that discussed what is known about existing and future interventions to slow, stop, or reverse aging in animals, and how these might be applied to humans through future research.

The case for supporting basic research in gerontology

Basic research on aging has moved well beyond describing the aging of physiological systems and developing theories of aging, to the pursuit of mechanistic answers to questions such as: Why do we age? Why do individuals within a population age differently? Why do different species have such different life spans? How do aging changes increase the risk of developing age-related disease? and Can we develop safe and effective interventions to reduce age-related disability? Two general areas of research promise to provide answers to these questions. One is the attempt to understand the mechanisms by which caloric restriction extends longevity and delays the onset of age-related disease. The other is the identification of genes which strongly influence the rate of aging in various animal model systems. Recent results in the latter area of research are providing new insights into the answers to these central aging questions and may help us understand how caloric restriction retards aging.

Support for basic gerontological research in the USA

Support for research in basic gerontology in the United States of America is briefly described. The support mechanisms, how to apply for a grant, and priority areas of research are outlined, and recent progress in a few of these priority areas is discussed. In general, government support for biogerontology research has been generous, and as a result considerable progress has been made in understanding the molecular mechanisms of aging in animal model systems. Translation of these findings to humans, and development of interventions to promote healthy aging in humans remain an unfulfilled priority, but new knowledge and development of better technologies and model systems suggest an optimistic future.

Program for testing biological interventions to promote healthy aging

The National Institute on Aging (NIA) sponsored a workshop on September, 1999 to discuss the feasibility of establishing a program to evaluate potential intervention strategies to decelerate the rate of aging in mammals. The ultimate goal is to identify promising interventions in animals that might lead to clinical trials in humans. The participants discussed various animal models, biological endpoints and possible structure of such a program. The ability to implement such a program will require a decision by NIA staff about whether the anticipated benefits to be derived from identification of effective interventions under well controlled conditions in an animal model, in this case the mouse, would justify the anticipated cost of the testing program.

Apoptosis: a two-edged sword in aging

Here we summarize briefly what is known about both the positive and negative impacts of apoptosis during aging in mammalian systems and also update an earlier review. It is important to understand both of these impacts to devise useful interventions. Such interventions include both physiological and molecular approaches, including transgenic interventions. The critical roles of the mitochondria in both generating reactive oxygen species, and in initiating apoptosis are recognized, suggesting that maintaining mitochondrial function could be an important therapeutic goal, especially in post-mitotic tissues. In contrast, the ability to eliminate unwanted, damaged and dysfunctional cells through apoptosis has anti-aging implications in mitotic tissues.

Apoptosis: a two-edged sword in aging

It is now recognized that apoptosis plays an important role in many physiological processes, including aging and age-related diseases. Apoptosis plays both positive and negative roles in aging, and some of these roles are reviewed here. Of particular importance are the roles of apoptosis in reducing cancer incidence, and in promoting neurodegenerative disease. Therefore, the regulation of apoptosis is an inviting target for therapeutic interventions in aging and age-related disease.

The HELP hospital information system: update 1998

The HELP hospital information system has been operational at LDS Hospital since 1967. The system initially supported a heart catheterization laboratory and a post open heart Intensive Care Unit. Since the initial installation the system has been expanded to become an integrated hospital information system providing services with sophisticated clinical decision-support capabilities to a wide variety of clinical areas such as laboratory, nurse charting, radiology, pharmacy, etc. The HELP system is currently operational in multiple hospitals of LDS Hospital's parent health care enterprise--Intermountain Health Care (IHC). The HELP system has also been integrated into the daily operations of several other hospitals in addition to those at IHC. Evaluations of the system have shown: (1) it to be widely accepted by clinical staff; (2) computerized clinical decision-support is feasible; (3) the system provides improvements in patient care; and (4) the system has aided in providing more cost-effective patient care. Plans for making the transition from the 'function rich' HELP system to more modern hardware and software platforms are also discussed.

Clinical event management using push technology--implementation and evaluation at two health care centers

For two years, beginning in 1995, we developed and implemented a novel method for delivering patient information directly to clinicians. Using rules based logic to scan data bound for an electronic medical record, messages were automatically written that alert care providers to important patient information. These messages were transmitted electronically to either existing email accounts or to wide-screen pagers, or to both. This system now is operational at two medical centers. We describe the model and methods that led to its successful implementation and compare it to other ways of delivering patient information.

What does cell death have to do with aging?

When Lockshin and Zakeri discussed the relevance of apoptosis to aging 7 years ago, the common view was that apoptosis would have primarily a negative impact on aging by destroying essential and often irreplaceable cells. That view has now changed to one that acknowledges that there are two general ways in which apoptosis can play a role in aging: (1) elimination of damaged and presumably dysfunctional cells (e.g., fibroblasts, hepatocytes), which can then be replaced by cell proliferation, thereby maintaining homeostasis, and (2) elimination of essential post-mitotic cells (e.g., neurons, cardiac myocytes), which cannot be replaced, thereby leading to pathology. Evidence exists in two systems (fibroblasts and thymocytes/lymphocytes) that there are age-related decreases in the potential for apoptosis, although the molecular bases for the decreases in these two systems appear to differ. Upon becoming senescent, fibroblasts lose the ability to down-regulate expression of the bcl-2 gene in response to an apoptotic signal; thus, apoptosis is blocked even though an initiating signal has been received. In contrast, thymocytes/lymphocytes lack the ability to initiate the signal because of down-regulation of the cell surface receptor Fas. There is limited information available for other tissue types, and nothing is known about why and how age-related changes occur. An interesting observation is that the frequency of up-regulation of the bcl-2 gene as a result of chromosome translocation in otherwise normal B cells increases with age; the functional consequences of this phenomenon during aging are not known. The role of apoptosis in regulating cell number is also a promising area of research. The studies on liver damage and neoplastic lesions suggest an extremely important role for apoptosis in controlling cancer. This may be particularly important in the prostate where hypertrophy and/or cancer are a virtual certainty with ever-increasing age. It is not known whether the ability to undergo apoptosis declines in the prostate with increasing age, but it appears possible that it may, thus explaining the loss of control over cell number in this tissue. A particularly important area of research is whether apoptosis plays a role in the changing balance between bone formation and resorption observed during osteoporosis. Monica Driscoll has already pointed out that, "regulation and execution of cell death is an absolutely critical process that interfaces with nearly every aspect of life. Future investigation of the links of cell death to cellular aging and the aging of organisms should be an exciting enterprise." The results currently available do suggest that apoptosis is a process that may be important in aging, at least in some tissues, and the mechanism of its regulation, in particular, needs to be understood. Several tumor suppressor gene and oncogene products are involved in signal transduction associated with apoptosis, but it remains to be shown which of these, if any, are actually involved in "on-off" switches for apoptosis. Where great progress has been made is in understanding the events occurring after binding of either Fas ligand or tumor necrosis factor to their respective receptors. However, one area about which little is known is the identity of the signals that initiate this process in response to intracellular damage. Through continuing research on cell death mechanisms, funded by the NIA, we hope to provide answers to such fundamental questions as: 1. Are there age-related changes in apoptosis, and what role, if any, do these have in the aging process? 2. If age-related changes in apoptosis do occur, what molecular mechanisms are altered to produce these changes? 3. Can approaches be developed to improve the detection and elimination of damaged cells in vivo in tissues where cell replacement is possible? 4. Can death of damaged cells be attenuated or delayed in nonrenewable tissues, and, if so, is it advantageous to the org

Subtotal hysterectomy in modern gynecology: a decision analysis

OBJECTIVE

Our purpose was to compare the risks and benefits of subtotal (supracervical) hysterectomy with those of total hysterectomy in women at low risk for cervical cancer.

STUDY DESIGN

A decision analysis was performed. Baseline probabilities for operative and postoperative morbidity, mortality, and long-term quality of life were established for subtotal and total hysterectomy.

RESULTS

Operative complication rates and ranges for total abdominal hysterectomy were infection 3.0% (3.0% to 20.0%), hemorrhage 2.0% (2.0% to 15.4%), and adjacent organ injury 1.0% (0.7% to 2.0%). Those for subtotal hysterectomy were infection 1.4% (1.0% to 5.0%), hemorrhage 2.0% (0.7% to 4.0%), and adjacent organ injury 0.7% (0.6% to 1.0%). Operative mortality, the risk for development of cervicovaginal cancer, and long-term adverse effects on sexual or vesicourethral function were low in both groups.

CONCLUSIONS

Recently proposed benefits from subtotal hysterectomy are not well proven. Total hysterectomy remains the procedure of choice for most women.

Aging and regulation of apoptosis

When Lockshin and Zakeri discussed the relevance of apoptosis to aging, the common view was that apoptosis had primarily a negative impact on aging by destroying essential and often irreplaceable cells. That view has now changed to one that acknowledges that there are two general ways in which apoptosis can play a role in aging: (1) elimination of damaged and presumably dysfunctional cells (e.g., fibroblasts, hepatocytes) which can then be replaced by cell proliferation, thereby maintaining homeostasis and elimination of essential postmitotic cells (e.g., neurons) which cannot be replaced, thereby leading to pathology. Evidence exists in two systems (fibroblasts and thymocytes/lymphocytes) that there are age-related decreases in the potential for apoptosis, although the molecular bases for these decreases appear to differ (Table II). Fibroblasts (and neurons?) lose the ability to downregulate bcl-2 in response to an apoptotic signal; thus, apoptosis is blocked even though an initiating signal has been received. In contrast, thymocytes/lymphocytes lack the ability to initiate the signal due to downregulation of the cell surface receptor Fas. There is limited information available for other tissue types, and nothing is known about why and how these age-related changes occur. An interesting observation, but not necessarily a critical one, is that the frequency of upregulation of the bcl-2 gene due to chromosome translocation increases with age. The role of apoptosis in regulating cell number is also a promising area of research. The studies on liver damage and neoplastic lesions suggest an extremely important role for apoptosis in controlling cancer. This may be particularly important in the prostate, where hypertrophy and cancer are a virtual certainty with ever-increasing age. It is not known whether the ability to undergo apoptosis declines in the prostate with increasing age, but it appears likely that it does. One problem in answering questions about the actual regulation of apoptosis is the lack of a quantitative assay. Apoptosis appears to be either "on" or "off" in cells, while the basic cell-killing machinery may often be present, but in an inactive form. Most assays for apoptosis are microscopic rather than kinetic, and the rate-limiting step may be at the level of the initiating signal. Thus, if CR, which extends the life span of rodents, does upregulate apoptosis, it is not clear how to quantify the magnitude of this effect or what should be quantified. The best one can do is to measure the frequency of occurrence of apoptotic bodies. This is essentially a pool size assay which provides little knowledge about how rapidly cells are leaving and entering the pool. Nevertheless, the results currently available do suggest that apoptosis is a process which may be important in aging, at least in some tissues, and the mechanism of its regulation needs to be understood. Although a variety of tumor suppressor gene and oncogene products are known to be involved in signal transduction associated with apoptosis, it remains to be shown which of these, if any, are actually involved in "on-off" switches for apoptosis and which might regulate the intrinsic rate of apoptosis. As Driscoll has already pointed out: "regulation and execution of cell death is an absolutely critical process that interfaces with nearly every aspect of life. Future investigation of the links of cell death to cellular aging and the aging of organisms should be an exciting enterprise."

Capturing clinical reports in a large academic medical center: feeding a central patient data repository

Clinical reports, notes, and other narratives are highly used components in the patient record. Unfortunately, the methods by which these reports are generated are as diverse as the fiscal autonomy of academic clinical departments in a university-based health science center. In this paper, we report on electronically capturing clinical reports, notes, and other text fragments from several hospital sources and many outpatient clinics. The purpose of the capture is to feed the ACIS (Advanced Clinical Information System) central patient data repository that is in use at the University of Utah Health Sciences Center (UUHSC). A survey conducted in early 1994 indicated that about 917,150 reports were generated per year at UUHSC representing about 1.2 million pieces of paper, occupying about 2.3 gigabytes of storage. The most crucial problem encountered in capturing the reports was linking them to the proper patient. Systems that had functioning and well-maintained admit-discharge-transfer (ADT) information performed well, but systems that relied on the human dictator to identify patients, produced patient linkage errors. In our open loop telephone dictation systems this error rate averaged between 6 and 10%. Subsequent to the wide-spread availability of clinical reports on ACIS, this error rate dropped to 3-5%, presumably due to increased demand for on-line availability of this information. From clinical secretaries who use their word processor to create the clinical reports, the linkage error rate was < 1% due to the use of our Advanced Text Upload (ATU) utility. The clinical text component in ACIS contributed significantly to the success of a JCAHO site visit in December 1995.

Quality assessment and patient participation in care by means of a touch-screen computer

Hospital characteristics vary greatly across a geographic area such as a state. Hospital peer groups internally exhibit similar characteristics and can be used as a basis for the analysis of data, the dissemination of information, and the adoption of continuous quality improvement project results. This paper reflects the efforts made toward the identification of hospital peer groups within the state of Michigan. Hospital characteristics data for fiscal year 1992 were obtained from the American Hospital Association's Annual Survey of Hospitals and the Health Care Financing Administration's MEDPRO database. Thirteen peer group clusters have been identified, reviewed, and commented on by the state's hospital association and have met general approval by hospital administrators across the state. The established peer groups are being used to identify the differences in patterns of care among hospitals in the state. The peer groups also are being used for the feedback of comparable data and the identification of hospitals for participation in continuous quality improvement projects. The next research objective is to experiment with other clustering techniques and other inpatient populations. The consistency of the peer groupings across all clustering techniques and across both Medicare and total inpatient populations will be studied.

Research review: a computer-based diagnostic model for individual case review

A previous study found that Iliad, a diagnostic expert system, detects diagnostic errors missed by peer review organization (PRO) review. That study used volunteer physicians from an institution as gold standard reviewers, however. The article discusses a second experiment employing Utah PRO (UPRO) review physicians as gold standards. Iliad was compared with the Unified Clinical Data Set used by the UPRO and was found to detect otherwise unsuspected diagnostic errors. The confirmation rate of Iliad flags was much higher in the earlier study, however. No agreement was found between institution and UPRO physicians, but there was agreement between a unique physician (who was both an institution and UPRO physician) and each of the two groups. Because Iliad screens for potential diagnostic errors to be confirmed or denied by gold standard physician review, the different types of physicians in the two experiments might have been the cause.

Enroute toward a computer based patient record: the ACIS project

The clinical arm of the University of Utah operates a 400 bed general hospital and 30 specialty and subspecialty clinics and with the advent of managed care will soon be linked to a much wider network of health care facilities throughout the state. Each of these patient care facilities maintains its own patient record. To provide common access to data on any patient needed to provide continuity to the care process where ever it occurs, the institution has embarked on the development of a completely electronic patient record. In this paper we will describe the route we have taken to achieve this goal in hopes of providing some sign posts along the way for others seeking the same destination.

Computerized practice guidelines for heart failure management: the HeartMan system

In this paper we discuss the initial stages of development and evaluation of the HeartMan system, a set of computerized practice guidelines for heart failure management. The concept of computerized guidelines as a hybrid of expert systems and practice guidelines methodologies and techniques is proposed. We show the results of the initial evaluation of the system, which are very promising, although the sample size is small, and the study is retrospective: Of 177 messages, 90% were considered appropriate, of which 97.5% would have been followed. Eight percent of the messages were classified as neutral, and 2% classified as inappropriate. The errors were correctable by changing the logic. The potential technical and sociological barriers to the complete development and clinical use of the system are discussed.

An event model of medical information representation

OBJECTIVE

Develop a model for structured and encoded representation of medical information that supports human review, decision support applications, ad hoc queries, statistical analysis, and natural-language processing.

DESIGN

A medical information representation model was developed from manual and semiautomated analysis of patient data. The key assumption of the model is that medical information can be represented as a series of linked events. The event representation has two main components. The first component is a frame or template definition that specifies the attributes of the event. The second component is a structured vocabulary, the terms of which are taken as the values of the slots in the event template structure. Individual event instances are linked by specific named relationships.

RESULTS

The proposed model was used to represent a chest-radiograph report.

CONCLUSIONS

The event model of medical information representation provides a mechanism for formal definition of the logical structure of medical data and allows explicit time-oriented and associative relationships between event instances.