A real-time audit of radiation therapy in a regional cancer center.

PURPOSE: To report the development, structure, and implementation of a real-time clinical radiotherapy audit of the practice of radiation oncology in a regional cancer center. METHODS AND MATERIALS: Radiotherapy treatment plans were audited by a real-time peer-review process over an 8-year period (1989-1996). The overall goal of the audit was to establish a process for quality assurance (QA) of radiotherapy planning and prescription for individual patients. A parallel process was developed to audit the implementation of intervention-specific radiotherapy treatment policies. RESULTS: A total of 3052 treatment plans were audited. Of these, 124 (4.1%) were not approved by the audit due to apparent errors in radiation planning. The majority of the nonapproved plans (79%) were modified prior to initiating treatment; the audit provided important clinical feedback about individual patient care in these instances. Most of the remaining nonapproved plans were deviations from normal practice due to patient-specific considerations. A further 110 (3.6% of all audited plans) were not approved by the audit due to deviations from radiotherapy treatment policy. A minority of these plans (22%) were modified prior to initiating treatment and the remainder provided important feedback for continuous quality improvement of treatment policies. CONCLUSION: A real-time audit of radiotherapy practice in a regional cancer center setting proved feasible and provided important direct and indirect patient benefits.

Considerations in predicting mental health care use: implications for managed care plans.

Managed care plans and other health care providers face a difficult task in predicting outpatient mental health services use. Existing research offers some guidance, but our knowledge of which factors influence use is confounded by methodological problems and sampling constraints. Consequently, available findings are insufficient for developing accurate predictions, which managed care plans need in order to formulate fiscally responsible service delivery contracts. This article reviews the primary data sources and research on ambulatory mental health services. On the basis of this review, the probability and intensity of outpatient visits are estimated. The primary predictors of use are also examined because they may help managed care plans forecast use by a given population or group of enrollees. Gender, age, race, education, health status, and insurance coverage are several variables surfacing as statistically significant predictors of use. The implications for planning capitated mental health services are discussed.

Assessing hospital administrators' responses to prospective payment. A case study in New Mexico.

Few studies have assessed the relationship between hospital administrators' efforts at planning and subsequent performance of health care organizations. Nonetheless, planning is viewed as an important mechanism for aligning health services delivery efforts with community needs and operating constraints. When prospective payment (PPS) was first introduced, hospital administrators had little choice other than to plan how they would respond to the new reimbursement policies. However, it is unclear whether they actively undertook planning in an effort to address prospective payment and related pressures. This article presents a case study of rural New Mexico hospital administrators' efforts to respond to prospective payment. Two dimensions of planning effort by administrators--intensity and formality--are analyzed within rural hospitals during the PPS transition (i.e., 1983 to 1987) and after its full implementation (i.e., since 1988). The findings suggest that planning intensity during the PPS transition is associated with higher performance; notably, higher net patient care revenues, lower costs per patient day, higher operating margins, higher net income, and higher planning effectiveness. However, the strength of these associations weakened as PPS was fully implemented. Given the exploratory nature of this evaluative case study, the results should be viewed as preliminary until confirmed by larger studies. The implications for research that evaluates planning-performance relationships in the health care field are discussed.

Watch for pitfalls of discounted cash flow techniques.

Discounted cash flow (DCF) techniques can enhance the effectiveness of a healthcare organization's capital budgeting decisions. But a financial manager unaware of common misapplications of DCF techniques may make capital decisions with a hidden bias against long-term projects, an inaccurate evaluation of options, or inappropriate estimations of expected inflation and risk. Social and psychological factors also can impede effective decisions on projects already introduced.

Purification and characterization of recombinant human interleukin 4. Biological activities, receptor binding and the generation of monoclonal antibodies.

A synthetic gene coding for human interleukin 4 (IL-4) was cloned and expressed in Saccharomyces cerevisiae (baker's yeast) as a C-terminal fusion protein with the yeast prepro alpha-mating factor sequence, resulting in secretion of mature IL-4 into the culture medium (0.6-0.8 micrograms/ml). A protocol was developed for purification of this protein. Crude cell-free conditioned medium was passed over a concanavalin A-Sepharose affinity column; bound proteins were eluted and further purified by S-Sepharose Fast Flow cation exchange and C18 reverse-phase h.p.l.c. Highly purified IL-4 was obtained by this method (0.3-0.4 mg per litre of culture) with a recovery of 51%. Thermospray liquid chromatography-mass spectrometry showed the C-terminal N-glycosylation site to be largely unmodified, and also showed that the N-terminus of the purified recombinant IL-4 (rIL-4) was authentic. Thiol titration revealed no free cysteine residues, implying that there are three disulphide groups, the positions of which remain to be determined. We have characterized the biological activities of the purified rIL-4. This material is active in B-cell co-stimulator assays, T-cell proliferation assays and in the induction of cell-surface expression of CD23 (the low-affinity receptor for IgE) on tonsillar B-cells. Half-maximal biological activity of the rIL-4 was achieved at a concentration of 120 pM. We have radioiodinated rIL-4 without loss of biological activity and performed equilibrium binding studies on Raji cells, a human B-cell line. The 125I-rIL-4 bound specifically to a single class of binding studies on Raji cells, a human B-cell line. The 125I-rIL-4 bound specifically to a single class of binding site with high affinity (Kd = 100 pM) and revealed 1100 receptors per cell. Receptor-ligand cross-linking studies demonstrated a single cell-surface receptor with an apparent molecular mass of 124 kDa. Two monoclonal antibodies have been raised to the human rIL-4, one of which blocks both the biological activity of rIL-4 and binding to its receptor.

Functional and phenotypic properties of T-cell clones which regulate IgE synthesis.

We have generated a panel of T-lymphocyte clones from a patient suffering from the hyper IgE syndrome, and have attempted to correlate the ability of each to help IgE responses in vitro with the profile of lymphokines secreted after mitogenic stimulation. Clones which showed positive IgE helper activity released larger amounts of interleukin-4 (IL-4) than the non-helpers, which tended to release more interleukin-2 (IL-2). Surprisingly, all clones released moderate amounts of gamma interferon (IFN), which has been shown to inhibit the action of IL-4 on B cells. The clones were analysed by indirect immunofluorescence using monoclonal antibodies to CDw29 and CD45R (4B4 and 2H4 respectively). Those T cells which could provide strong helper activity for all isotypes, expressed high levels of CDw29 and low CD45R. These data suggest that these CD4-positive T cells expressing surface antigen of the 'memory' subset i.e. CDw29, are involved in IgE isotype regulation by virtue of their ability to secrete IL-4 upon antigenic stimulation.