An evaluation of the centers for Medicare & Medicaid Services' Hospital Acquired Conditions and Present on Admission Indicator Reporting program

Objective: This dissertation evaluated three aspects of the Centers for Medicare and Medicaid Services' Hospital Acquired Conditions and Present on Admission Indicator Reporting program (HACPOA program) to produce three journal articles for publication. ^ Methods: All payer admission records from state inpatient databases from Arizona, New Jersey and Washington states were analyzed for the year 2008. However some analyses required a sample of adult only Medicare patients in the first two studies. California's inpatient data (2004 – 2010) was also analyzed in the third study to examine the reporting and non-payment program elements' impact on the incidence of hospital acquired conditions. ^ Results: Majority diagnoses reported in inpatient prospective payment systems hospitals were present on admission. However, some diagnoses are still coded as "not present on admission" and "insufficient documentation to determine whether or not conditions are present on admission or not". This is important because it reveals that hospital complications still occur in hospitals. Hospital fall and trauma injuries were the most common hospital acquired conditions observed in this study. Predictors of hospital fall injuries include age, gender, number of diagnoses, number of procedures, number of chronic conditions while predictors of hospital trauma injuries include number of e-codes, number of diagnoses and the presence of chronic conditions on a patient's admission records. Finally, the implementation of the present on admission reporting requirement increased reports of certain hospital acquired conditions while the non-payment policy element in the Hospital Acquired Conditions program reduced the incidence of hospital fall and trauma injuries in particular. ^ Conclusion: The implementation of the Hospital Acquired Conditions and Present on Admission Indicator Reporting program has made the state inpatient database a more useful source of data capable of now identifying hospital complications. The reporting and nonpayment program elements in the HACPOA program have also impacted the incidence of hospital acquired conditions. ^

Cost-effectiveness of intensified interventions to control healthcare-associated MRSA infections -- A systematic literature review

Methicillin Resistant Staphylococcus aureus healthcare-associated infections (MRSA HAIs) are a major cause of morbidity in hospitalized patients. They pose great economic burden to hospitals caring for these patients. Intensified Interventions aim to control MRSA HAIs. Cost-effectiveness of Intensified Interventions is largely unclear. We performed a review of cost-effectiveness literature on Intensified Interventions , and provide a summary of study findings, the status of economic research in the area, and information that will help decision-makers at regional level and guide future research.^ We conducted literature search using electronic database PubMed, EBSCO, and The Cochrane Library. We limited our search to English articles published after 1999. We reviewed a total of 1,356 titles, and after applying our inclusion and exclusion criteria selected seven articles for our final review. We modified the Economic Evaluation Abstraction Form provided by CDC, and used this form to abstract data from studies.^ Of the seven selected articles two were cohort studies and the remaining five were modeling studies. They were done in various countries, in different study settings, and with different variations of the Intensified Intervention . Overall, six of the seven studies reported that Intensified Interventions were dominant or at least cost-effective in their study setting. This effect persisted on sensitivity testing.^ We identified many gaps in research in this field. The cost-effectiveness research in the field is mostly composed of modeling studies. The studies do not always clearly describe the intervention. The intervention and infection costs and the sources for these costs are not always explicit or are missing. In modeling studies, there is uncertainty associated with some key model inputs, but these inputs are not always identified. The models utilized in the modeling studies are not always tested for internal consistency or validity. Studies usually test the short term cost-effectiveness of Intensified Interventions but not the long results.^ Our study limitation was the inability to adjust for differences in study settings, intervention costs, disease costs, or effectiveness measures. Our study strength is the presentation of a focused literature review of Intensified Interventions in hospital settings. Through this study we provide information that will help decision makers at regional level, help guide future research, and might change clinical care and policies. ^

Mechanisms of multidrug resistance: Differences between natural and acquired adriamycin -resistant human colon carcinoma cells

Mechanisms of multidrug resistance (MDR) were studied in two independent MDR sublines (AdR1.2 and SRA1.2) derived from the established human colon carcinoma cell line LoVo. AdR1.2 was developed by long-term continuous exposure of the cells to adriamycin (AdR) in stepwise increments of concentration, while SRA1.2 was selected by repetitive pulse treatments with AdR at a single concentration. In this dissertation, the hypothesis that the mechanism of drug resistance in SRA1.2 is different than that in AdR1.2 is tested. While SRA1.2 demonstrated similar biological characteristics when compared to the parental LoVo, AdR1.2 exhibited remarkable alterations in biological properties. The resistance phenotype of AdR1.2 was reversible when the cells were grown in the drug-free medium whereas SRA1.2 maintained its resistance for at least 10 months under similar conditions. Km and Vmax of carrier-mediated facilitated diffusion AdR transport were similar among the three lines. However, both resistant sublines exhibited an energy-dependent drug efflux. AdR1.2 appeared to possess an activated efflux pump, and a decreased nucleus-binding of AdR, whereas SRA1.2 showed merely a lower affinity in binding of AdR to the nuclei. Southern blot analysis showed no amplification of the MDR1 gene in either of the two resistant subclones. However, Western blot analysis using the C219 monoclonal antibody against P170 glycoprotein detected a Mr 150-kDa plasma protein (P150) in AdR1.2 but not in SRA1.2 or in the parental LoVo. In vitro phosphorylation studies revealed that P150 was a phosphoprotein; its phosphorylation was Mg$\sp{2+}$-dependent and could be enhanced by verapamil, an agent capable of increasing intracellular AdR accumulation in AdR1.2 cells. The phosphorylation studies also revealed elevated phosphorylation of a Mr 66-kDa plasma membrane protein that was detectable in the AdR1.2 revertant and in AdR1.2 when verapamil was present, suggesting that hyperphosphorylation of the Mr 66-kDa protein may be related to the reversal of MDR. SDS-PAGE of the plasma membrane protein demonstrated overproduction of a Mr 130-kDa, MDR-related protein in both the resistant sublines. The Mr 130-kDa, MDR-related protein in both the resistant sublines. The Mr 130-kDa protein was not immunoreactive with C219, but its absence in the AdR1.2 revertant and the parental LoVo suggests that it is an MDR-related plasma membrane protein. In conclusion, the results from this study support the author's hypothesis that the mechanisms responsible for "Acquired" and "Natural" MDR are not identical. ^