Characteristics and financial performance of a pediatric faculty inpatient attending service: a resource-based relative value scale analysis.

OBJECTIVES: In many children's hospitals, inpatient attending physician services are provided by academic faculty who function as part-time inpatient specialists or hospitalists. Although some have claimed that hospitalist care can reduce length of stay and total hospital resource use and expenses, there are few benchmarks or data regarding physician productivity or the characteristics and financial performance of these programs. The resource-based relative value scale (RBRVS) is a valuable tool for developing national benchmarks and comparing the financial performance of inpatient programs at varying daily census and reimbursement levels. The objectives of this study were to 1) describe physician productivity on an inpatient service as measured by total relative value units (TRVUs) and professional charges, 2) determine whether inpatient collections were adequate to support faculty salaries for the time spent attending, and 3) develop a model to evaluate financial performance of inpatient programs at varying census and TRVU reimbursement levels. METHODS: A retrospective review of hospital discharge and faculty practice billing data between June 1997 and July 1998 was conducted in a general medical service in a regional, 208-bed, university-affiliated children's hospital in the Pacific Northwest. RESULTS: Of 4113 patients who were admitted to the children's hospital general medical service during a 12-month period, faculty part-time hospitalists (N = 28) served as the attending physician for 1738 (42%). On an annual basis, faculty attended for an average of 29.1 days (median: 21.0; range: 7.0-97.0), with an average daily patient census (ADC) of 7.2 (median: 6.5; range: 2.8-12.0). Inpatient attendings billed for 1738 initial visits and 3957 subsequent visits. Total physician productivity for the inpatient attending group during 1 year included 12 085 TRVUs and gross professional charges of $777 743. The average payment, or conversion factor (CF), was $24.46/TRVU (71% of Medicare CF). The cash collection rate was 38%, reflecting a payor mix that included 54% Medicaid, 28% commercial payors, 12% health maintenance organization, and 6% other payors. On a weekly basis, physicians generated an average of 109 TRVUs and collected $2665 in cash. The average salary cost per RVU was $23.40, and weekly faculty salary and benefit expenses were $2550. After operating expenses and academic taxes totaling 24% were deducted ($5.87/TRVU), RBRVS-based payments and cash collections covered 79% of average faculty weekly salaries. Financial modeling showed that either an average CF of $31/TRVU or an ADC of 9 patients per day on the inpatient service would be required to generate sufficient revenue to support physician salaries and operating expenses. CONCLUSIONS: For a faculty inpatient attending service in a children's hospital with an ADC of 7, a $24.46 RBRVS-based CF payment is inadequate to support faculty salaries and operating expenses for the time spent attending. Inpatient services in similar payor environments with comparable expenses and staffed by faculty who care for fewer than 9 patients per day will not cover typical faculty salary costs and operating expenses.

Cisapride: a survey of the frequency of use and adverse events in premature newborns.

OBJECTIVE: This survey estimated the frequency of use and adverse events associated with cisapride treatment of premature newborns in intensive care units. It was initiated in response to a warning issued in Canada cautioning against cisapride treatment of premature infants of <36 weeks' gestation and <3 months of age. METHODOLOGY: Surveys were mailed to 105 neonatology training program directors to obtain the total number of neonatal intensive care unit (NICU) admissions, the number of admissions of infants of <36 weeks' gestation, the number of years that cisapride had been used, the estimated percent/number of premature patients treated with cisapride per year, and the frequency and nature of arrhythmias or other adverse events associated with cisapride treatment. Of 105 programs, 46 responded to a single mailing of the first survey. A second survey mailed to the 45 respondents to the first survey sought to determine the indications, diagnostic tests, and dosages used with cisapride treatment of premature newborns. Of the 45 programs, 26 responded to the second survey. RESULTS: More than 58 000 premature newborns of <36 weeks' gestation were admitted to the NICUs we surveyed, and approximately 19% were treated with cisapride. No deaths attributable to cisapride were reported among >11 000 preterm newborns treated. Three nonfatal arrhythmias were reported; two associated with 10-fold dosing errors and one with co-treatment with erythromycin, a macrolide antibiotic that reduces the metabolism of cisapride. Diarrhea was reported in 12 patients, and reversible liver enzyme changes were noted in one patient. Typically, cisapride treatment was started in dosages of 0.1 to 0.2 mg/kg/dose, repeated every 6 to 8 hours. Treatment usually was begun empirically, without a preceding study to document gastroesophageal reflux. The most frequent indications for cisapride treatment were choking or gagging, with associated apnea, bradycardia, and desaturation. Approximately 50% of patients had discontinued cisapride treatment before discharge. Eighty-four percent of clinicians judged cisapride to be effective for the problems being treated. CONCLUSIONS: Cisapride treatment of premature infants of <36 weeks' gestation and <3 months of age in NICUs appears to be widespread in the United States. Complications and adverse events were seen when cisapride was administered in excessive dosages or in combination with a drug that inhibits its metabolism and leads to increased serum concentrations. Severe toxicities such as arrhythmias were reported with a frequency of <1/11 000 NICU admissions. However, in a retrospective survey, episodes of toxicity, including mortality, attributable to cisapride may not have been recognized or reported.

Developing models for pediatric residency training in managed care settings.

The preparation of pediatric residents to function optimally in managed care environments challenges educators to create a new set of educational objectives and competencies and to incorporate these into curricula that are already full. Many of the skills needed to practice managed care are those that have been required for the practice of pediatrics in any setting. Nevertheless, the emergence of managed care requires the identification of new knowledge to be acquired and new skills and attitudes to be incorporated into daily practice. These competencies can be identified most thoroughly through collaboration among physicians, educators, and leaders of managed care organizations. This joint effort should also serve to establish a foundation on which collaborative, mutually beneficial learning environments can be created. The development of curricula that provide the opportunities needed to attain managed care proficiencies requires an individualized approach for each program that takes into account the degree of managed care penetration in each training environment. Programs in which a managed care approach to patient care predominates will be able to promote most easily their trainees' incorporation of these principles into routine practice. Those with less regular exposure will be forced either to promote managed care principles in an environment in which they may not be accepted or practiced, or to join in partnership with managed care organizations (MCOs) to train residents. Regardless of the setting, evaluation methodologies must be developed to ensure that each of the core competencies has been learned, can be applied to clinical situations, and is retained throughout the training period. These efforts require the development of faculty who understand and can model a managed care approach to patient management. The ongoing evolution of managed care systems encourages the development of new, creative strategies to train faculty, who may find themselves learning about this emerging environment at the same time as are their trainees.

Cholelithiasis in infants receiving furosemide: a prospective study of the incidence and one-year follow-up.

Cholelithiasis has been reported to occur rarely in infants. To determine the incidence of cholelithiasis in infants receiving furosemide, we prospectively performed ultrasonograms on 86 patients. We studied 42 patients receiving furosemide (subjects) and 44 patients not receiving furosemide (controls). There was a significantly higher incidence of gallstones in subjects (21%) than in controls (2%) (P less than .05). When followed over 1 year, the gallstones did not resolve. There were no significant differences in the dosage of furosemide, gestational age, placement of umbilical venous catheters, or amount of total parenteral nutrition (TPN) between subjects with and without gallstones. However, subjects received more days of TPN (16.7 +/- 15.1) than controls (8.4 +/- 13.2) (P less than .05). These data show that the incidence of cholelithiasis is higher than previously suspected in infants receiving furosemide. Thus, furosemide, either independently or in conjunction with the use of TPN, predisposes infants to the development of cholelithiasis.

Prevention of perinatal transmission of hepatitis B virus: the sensitivity, specificity, and predictive value of the recommended screening questions to detect high-risk women in an obstetric population.

The Advisory Committee on Immunization Practices recommends that all pregnant women be questioned concerning risk factors for hepatitis B virus infection and that those giving positive responses be serotested. The sensitivity, specificity, and predictive value of those recommended questions among 692 parturient women were determined. A total of 59 currently or previously infected women (hepatitis B surface antigen (HBsAg), antibody to hepatitis B surface antigen (anti-HBs), or antibody to hepatitis B core antigen (anti-HBc) seropositive) were compared with the 633 seronegative women. Among nonwhite women, the sensitivity of a positive response to any one of the recommended questions was 60%. Specificity and positive predictive value were 71% and 19%, respectively. Among white women, the sensitivity, specificity, and positive predictive value were 56%, 75%, and 11%, respectively. To increase such unacceptably low sensitivity, the authors included two additional questions: single marital status and Medicaid/medical assistance payer status. Sensitivity increased to 96% among nonwhite women and 84% among white women. However, a positive response to at least one of the recommended questions or to additional questions was elicited from 78% of all women (92% nonwhite and 64% white). The authors conclude that to prevent perinatal transmission of hepatitis B, we must serotest all women in our obstetric population.

Intrauterine intestinal volvulus with hemoperitoneum presenting as fetal distress at 34 weeks' gestation.

A case of intrauterine intestinal volvulus and hemoperitoneum with symptoms of fetal distress at 34 weeks' gestation is presented. The mechanism of production of late decelerations in this setting is discussed.

Sclerema neonatorum and joint contractures at birth as a potential complication of chronic in utero hypoxia.

Three term neonates presented with an unusual combination of skin changes (sclerema) and joint contractures at birth. In each case a prolonged period of fetal hyporeactivity was reported by the mother. Each child demonstrated a number of clinical findings consistent with chronic fetal hypoxia. Each child recovered with normal joint function. We postulate that sclerema neonatorum and joint contractures are another, though poorly recognized sequela of chronic in utero hypoxia and are preceded by a prolonged period of diminished fetal activity.

Development and severity of palatal grooves in orally intubated newborns. Effect of 'soft' endotracheal tubes.

A prospective, blinded study of neonates orally intubated with either standard or "soft" endotracheal tubes included 57 infants in the standard "hard" tube group and 46 infants in the soft tube group. Infants were further divided by birth weights above and below 1,000 g. Palatal grooves were seen to develop regularly after seven days in infants weighing less than 1,000 g. Neither the incidence nor the severity of palatal groove formation was influenced by the use of the soft tube. However, in three cases the soft tube had to be abandoned due to technical difficulties with intubation.

The effect of insulin on ovine fetal oxygen extraction.

Infusion of exogenous insulin (54 +/- 19 mU/kg/hr) to seven fetal lambs caused hyperinsulinism and arterial hypoxemia but not hypoglycemia. We measured the relationship between fetal oxygen delivery and oxygen use for a better understanding of the cause of the observed hypoxemia. Oxygen delivered to the fetus is the product of fetal umbilical venous oxygen content and umbilical blood flow. Both of these quantities decreased as fetal insulin concentration rose. The fall in umbilical blood flow was due to a change in the distribution of cardiac output. Cardiac output rose, but placental perfusion decreased while blood flow to the fetal carcass increased. Oxygen consumption by the ovine fetus increased as insulin concentration rose. Since the delivery of oxygen to the fetus did not increase when its use was rising, fetal extraction of available oxygen increased. Fetal arterial hypoxemia is the result of this increased extraction of available oxygen.

Placental growth and fetal/placental weight (F/P) ratios throughout gestation--their relationship to patterns of fetal growth.

Available data would indicate that patterns of growth and velocity of growth in the placenta and fetus may be determined early in gestation, at or shortly after implantation. Such early growth characterization may be mediated through regulation of DNA synthesis, thereby limiting potential cell number in the developing placenta. If this assumption were true, many casualties would be possible: (1) chromosomal or genetic, (2) implantation abnormalities, (3) early acquisition of congenital viral disease, (4) radiation or toxin exposure, or (5) maternal autoimmune attack on the placental/fetal unit. Once the placenta's maximal cell number has been established, well defined placental and fetal growth velocities are predictable in the majority of gestations. However, within each growth category (AGA, SGA, LGA) a wide range of "normal" placental weights (and F/P ratios) are available and compatible with normal growth. When each growth category is considered separately, eventual placenta size (and therefore fetal size) may rely more directly on total protein accretion reflected in cell size. At this point in growth, other factors such as inadequate maternal nutrition, high altitude, maternal smoking, intrinsic maternal vascular disease, or yet later factors such as preeclampsia may be responsible for placental growth limitations. Such factors, many as yet undefined, would account for the wide variability of F/P ratios within the AGA, SGA, and LGA groups. Since mean F/P ratios vary little between such groups, the placenta appears to select an ideal fetal growth rate independent of predetermined growth category. Both AGA and LGA infants demonstrate a consistent increase in placental size until 42 wk of gestation.(ABSTRACT TRUNCATED AT 250 WORDS)

Response of cerebral blood flow to changes in PCO2 in fetal, newborn, and adult sheep.

Developmental effects on the response of cerebral blood flow (Qc) and cerebral O2 consumption (CMRO2) to changes in CO2 tension were assessed in unanesthetized fetal, newborn, and adult sheep. Blood flow was measured using the radioactive microsphere technique. CMRO2 was calculated as the product of Qc and the difference in O2 content between arterial and sagittal sinus blood (CaO2 -- CVO2). The response of Qc to changes in arterial CO2 tension increased from fetus [3.53 +/- 0.56 ml.100 g-1.min-1.mmHg PaCO2(-1) (SE)] to newborn (5.16 +/- 0.59) to adult (6.20 +/- 0.63). Only the fetal-adult difference was significant (P less than 0.05). It has been suggested that developmental differences in CO2 responsiveness of cerebral blood flow are the result of differences in CMRO2. We corrected for differences in CMRO2 by looking at the response to CO2 of the variable 1/(CaO2--CVO2). According to the Fick principle 1/(CaO2--CVO2) = Qc/CMRO2, i.e., blood flow per unit O2 consumption. The fetal response was not significantly different from the newborn, but the adult was significantly different from both (P less than 0.05). Thus the difference in CO2 response of cerebral blood flow between fetus and adult cannot be explained by differences in CMRO2.

Oxygen delivery to the brain before and after birth.

We studied the relationship between cerebral oxygen consumption and cerebral oxygen delivery (cerebral blood flow x arterial oxygen content) in fetal, newborn, and adult sheep, Relative to the amount of oxygen consumed, cerebral oxygen delivery in the fetus exceeds that in the lamb and adult by 70 percent. This may represent a protective advantage for the fetus or simply a necessary adaptation to the low arterial oxygen pressure in the intrauterine environment.

Ontogeny of erythrocyte insulin binding in the sheep.

The ontogeny of insulin binding in the sheep was studied using the erythrocytes (RBCs) of 31 fetuses, 10 lambs, and 5 adult animals. Six fetuses were studied on three occasions over a 2-week period from 120--135 days of gestation to provide longitudinal data on changes in insulin binding. Maximal percent binding of [125I]iodoinsulin and receptor concentration decreased significantly as the age of the animal increased (r = 0.76, P less than 0.001 and r = --0.49, P less than 0.001, respectively). Total loss of insulin binding to RBCs was estimated to occur in the second postnatal month, and the RBCs from the adult sheep showed no specific insulin binding. The osmotic fragility of RBCs in each developmental group of animals was also studied to assess possible differences in RBC membrane properties. RBC osmotic fragility was significantly lower in fetuses than in adult sheep (osmotic fragility 50 = 0.55% phosphate-buffered saline vs. 0.76% phosphate-buffered saline, respectively; P less than 0.001). The data suggest that fetal RBCs of lower osmotic fragility and high insulin binding capacity are progressively replaced during late prenatal and early postnatal life by adult-type RBCs of increased osmotic fragility and lacking binding capacity for insulin. The timing of the disappearance of insulin binding to RBCs coincides with the final transition in the animals from a monogastric to a ruminant metabolic state, and may reflect a change in the need for insulin with age.

Effects of changes in arterial O2 content on cerebral blood flow in the lamb.

The effect of variations in arterial O2 content (CaO2) on the cerebrovascular bed of seven unanesthetized newborn lambs was studied as the hematocrit and arterial PO2 (PaO2) were varied. Each subject was studied at a high hematocrit [44 +/- 3% (SD)] and a low hematocrit [24 +/- 3%]. At each hematocrit level the PaO2 was changed over a range of 30-150 mmHg. The relationship between cerebral blood flow and PO2 depended on hematocrit and vice versa. To the contrary, the relationship of blood flow to CaO2 was independent of hematocrit and/or PO/. As CaO2 fell, regardless of whether this was due to a fall in PO2 hematocrit or both, there was a reciprocal increase in cerebral blood flow such that cerebral O2 delivery (cerebral blood flow x CaO2) was constant. These data show that CaO2 is a variable of fundamental importance to the regulation of cerebral blood flow. Changes in CaO2 are accompanied by reciprocal changes in cerebral blood flow to maintain constant cerebral O2 delivery. Data among species with differing cerebral O2 consumption show that cerebral O2 delivery, in turn, is regulated according to cerebral O2 consumption.

Induction of fetal breathing by metabolic acidemia and its effect on blood flow to the respiratory muscles.

Sustained and vigorous fetal breathing activity was produced in a chronic fetal lamb preparation by infusion into the fetus of either NH4Cl or HCl. Over a 2 to 3 hour period, 20 to 25 mEq/kg were infused. All of the fetuses tolerated blood pH values of 6.7 to 6.8 and survived. The breathing activity began after the completion of the infusion, and consisted of regular 30 to 50 torr inspirations at a rate of 60 to 120 breaths/min. This activity was continuous for as much as 8 hours, and persisted with pauses and decreased amplitude for 24 to 36 hours. During fetal breathing, blood flow to the diaphragm and intercostal muscles increased approximately 12- and sixfold, respectively.

Relationship of fetal and placental weight in human beings: fetal/placental weight ratios at various gestational ages and birth weight distributions.

Two thousand consecutive deliveries occurring over an 11-month period were studied for fetal and placental (F/P) weight characteristics. Infant and placental weight pairs were analyzed according to their gestational ages and growth categories (AGA, SGA, LGA). Graphs were constructed to depict normal placental weight gain and F/P ratio changes over a wide range of gestational ages (23 to 43 weeks). Mean placental weights and F/P ratios continued to increase through 42 weeks' gestation in the AGA and LGA groups, though placental weight showed no change in the SGA group after 36 weeks. F/P ratio continued to increase in the SGA group and was indistinguishable from that of the other two groups. Fetal and placental weight were linearly related in the total sample as well as in the individual growth categories. However, when F/P ratio was plotted against placental weight, the infants were segregated into three completely distinct curves, depending upon their growth characteristics. A wide range of placental weight and f/p ratios existed within all three infant birth weight groups. When one-minute Apgar scores were considered, infants with F/P ratios of greater than 10.00 had significantly higher risks of an Apgar score of less than 6.