Clinical performance and quality health care最新文献

{"title":"Counterpoint: public disclosure of process and outcome measures.","authors":"W E Scheckler","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Bad data is a toxic substance. In the release of process and outcome measures in the field of health care, numerous examples exist of published bad data. In 1986, the Healthcare Financing Administration released 14 volumes of data concerning Medicare mortality rates which, on analysis, were misleading and unrelated to quality of care. Good data on outcome measures need to follow accepted, rational, and scientific procedures. Such procedures include appropriate definitions of the process or outcome to be measured and careful description of the population being observed, risk adjusted for severity of illness. When this is done, the data can be published with some confidence that it will have value.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"7 1","pages":"41-2"},"PeriodicalIF":0.0,"publicationDate":"1999-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21220005","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Red blood cell transfusions for elective hip and knee arthroplasty: opportunity to improve quality of care and documentation.","authors":"S S Cook,&nbsp;C B Cangialose,&nbsp;D M Sieburg,&nbsp;S M Kieszak,&nbsp;R Boudreau,&nbsp;L H Hoffman,&nbsp;K S Elward,&nbsp;D J Ballard","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objectives: </strong>To assess current practice for red blood cell transfusion relative to the American College of Physicians guideline for red blood cell transfusion; to determine comparative rates and relative appropriateness of autologous versus allogeneic blood use; and, to assess cost implications of current transfusion practices.</p><p><strong>Design: </strong>Computerized quality-of-care algorithm applied retrospectively to medical-record and blood-bank data.</p><p><strong>Setting: </strong>Twenty-six hospitals in Colorado, Connecticut, Georgia, Oklahoma, and Virginia.</p><p><strong>Patients: </strong>Medicare beneficiaries (2,137) who were hospitalized in 1993 for two elective surgical procedures: total hip arthroplasty and total knee arthroplasty. Of the 1,195 patients who received a preoperative or postoperative transfusion, 728 were excluded from the analysis because the hospital medical record did not contain the clinical documentation necessary to apply the American College of Physicians guideline to each unit transfused. The remaining 467 patients comprised the sample.</p><p><strong>Results: </strong>For 467 patients who underwent these two procedures and received a total of 651 units of preoperative or postoperative blood, there were 256 excess units transfused. Two hundred four of these units were autologous, and 52 were allogeneic. These excess units accounted for $48,200 of the total $121,000 direct cost of transfused units.</p><p><strong>Conclusions: </strong>These findings demonstrate that current medical records lack the documentation necessary to evaluate transfusion practice for the majority of Medicare beneficiaries undergoing elective hip and knee arthroplasty. The direct costs of preoperative and postoperative blood transfusion for these two procedures could be reduced by nearly 40% through adherence to the American College of Physicians guideline. The majority of this cost saving would be realized through reduction in unnecessary collection and use of autologous blood.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"7 1","pages":"5-16"},"PeriodicalIF":0.0,"publicationDate":"1999-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21220003","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Inappropriateness of cataract extraction: an analysis in two Israeli hospital settings.","authors":"M Leshno,&nbsp;H Reuveni","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>To assess and compare the appropriateness of cataract extraction in two Israeli regional hospitals.</p><p><strong>Settings: </strong>Two Israeli hospitals located in different geographic areas.</p><p><strong>Design: </strong>A randomized sample of 150 patients was drawn from a list of all patients who underwent cataract surgery at the two study hospitals during 1995. Detailed extraction of hospital medical records was performed. The appropriateness of cataract surgery was assessed using the Medical Review System, an interactive expert system that assesses the appropriateness of selected medical and surgical procedures.</p><p><strong>Results: </strong>The rates of cataract surgery in the two hospitals were 0.54 and 0.59 operations per 1,000 population, respectively, and the age-adjusted rates per 1,000 population were 5.7 and 6.2, respectively. The percentage of patients with only light perception or hand-motion perception in the operated eye before the operation was 62.2%, with no difference in the two hospitals. There was not a significant difference in the distribution of visual acuity before the operation; however, there was a significant difference in the distribution of visual acuity after the surgery. Rates of inappropriate surgeries in the two hospitals were found to be similar to the inappropriate rate in the United States (1.3%). The preoperative visual acuity of patients undergoing cataract surgery in Israel was inferior to the visual acuity of patients undergoing cataract surgery in the United States.</p><p><strong>Conclusion: </strong>To increase quality and cost-effectiveness in the Israeli medical system, future studies of this type are warranted in connection with surgical procedures.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"7 1","pages":"23-7"},"PeriodicalIF":0.0,"publicationDate":"1999-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21220094","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The challenges of automating a real-time clinical practice guideline.","authors":"Y Sun,&nbsp;F J van Wingerde,&nbsp;I S Kohane,&nbsp;O Harary,&nbsp;K D Mandl,&nbsp;S R Salem-Schatz,&nbsp;C J Homer","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>To elucidate the types of problems encountered during implementation of a World Wide Web-based clinical practice guideline to manage hyperbilirubinemia in newborn infants.</p><p><strong>Design: </strong>Formative assessment of an automated clinical-practice guideline in a large-scale implementation.</p><p><strong>Setting: </strong>Primary-care clinics and offices, inpatient clinics, and emergency department affiliated with an academic children's hospital.</p><p><strong>Participants: </strong>General pediatricians, neonatologists, pediatric nurses, and computer scientists.</p><p><strong>Results: </strong>Existing guidelines for hyperbilirubinemia management could not be translated directly into web pages. Modifications of the original guidelines were required to represent the clinical intent of the guidelines accurately. In addition, the automated guideline was augmented to incorporate a mechanism for generating clinical encounter forms in order for the system to be accepted into the clinical work flow. Other clinical considerations that influenced the final form of the automated guideline included limitations of computer resources and time constraints during patient encounters.</p><p><strong>Conclusions: </strong>Many existing guidelines are not amenable to straightforward implementation in automated systems. Strategies to increase the efficacy of the automated guidelines included guideline modifications, as well as careful consideration of the flow of clinical work. Repeated cycles of development and pilot testing are needed to design methods to accommodate the constraints imposed by clinical use.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"7 1","pages":"28-35"},"PeriodicalIF":0.0,"publicationDate":"1999-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21220096","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Public disclosure of process and outcome measures.","authors":"S Wolfe","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>There is a long history of resistance to public disclosure of data comparing the quality of doctors or hospitals. Examples of data ultimately disclosed are risk-adjusted cardiac bypass surgery mortality data, cesarean section rates, doctor immunization practices, and state medical board rates of serious disciplinary actions. Recent studies on postoperative infection rates in Veterans' Affairs hospitals show large differences even after risk adjustment. It is inevitable that more comparative quality data involving both the process and outcome of medical care will be made public after proper adjustment for risks.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"7 1","pages":"38-40"},"PeriodicalIF":0.0,"publicationDate":"1999-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21219998","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Costs of providing primary care: comparison of an academic general medicine practice with an MGMA benchmark.","authors":"R P Wenzel,&nbsp;J Girtman,&nbsp;D Costello,&nbsp;M D Nettleman","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Market-based healthcare reform has placed great financial pressures on academic departments of internal medicine. The current emphasis and increased recruiting for primary care have not been accompanied by a financially supportive institutional culture or favorable third-party reimbursement system for the generalist practitioners. In one department's analysis, there was a large difference in revenue (-$130,000) compared to a Medical Group Management Association (MGMA) standard, yet a reduced level of compensation for primary-care physicians, $61,000 less per full-time equivalent (FTE). Total overhead per FTE in our department was $80,000 greater than comparable practices of the MGMA standard. We have estimated the institutional strategic costs of having primary-care clinics in three separate locations in the city of Richmond ($74,000/FTE). No viable cost-cutting options placed the primary-care program in positive balance, but the analysis contributed to a creative institutional approach for a solution.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"7 1","pages":"43-7"},"PeriodicalIF":0.0,"publicationDate":"1999-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21219999","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Preadmission screening of patients scheduled for hip and knee replacement: impact on length of stay.","authors":"M Liebergall,&nbsp;V Soskolne,&nbsp;Y Mattan,&nbsp;N Feder,&nbsp;D Segal,&nbsp;S Spira,&nbsp;G Schneidman,&nbsp;Z Stern,&nbsp;A Israeli","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>An evaluation of the impact of a social work preadmission program on length of stay (LOS) of orthopedic patients undergoing elective total hip or total knee replacement surgeries (under diagnosis-related groups [DRGs]) at the Hadassah Ein-Kerem Hospital in Jerusalem is Israel.</p><p><strong>Intervention: </strong>The social work interventions included preadmission psychosocial evaluation and preliminary discharge planning, coordination of nursing and physiotherapy evaluations, ensuring completion of all medical tests prior to admission, and additional psychosocial follow-up during hospitalization to carry out the original discharge plan or prepare alternatives.</p><p><strong>Patients: </strong>The intervention patients were divided into two groups in order to see changes over time: May through December 1994 (n = 48), and January through December 1995 (n = 81). The comparison groups included patients operated on at the same hospital during 1993 (n = 51) and during January through April 1994 (n = 21) and at the Hadassah Mount Scopus Hospital during the same time periods. Patients in the comparison groups received usual social work intervention, as necessary, only after hospitalization.</p><p><strong>Results: </strong>Mean LOS was reduced significantly in the intervention patient groups, as compared to the preintervention patient groups in the same hospital, from 14.2 days (standard deviation [SD], 4.7) in 1993 and 14.7 (SD, 5.1) in January through April 1994 to 10.9 (SD, 3.0) in May through December 1994 and to 9.1 (SD, 2.8) in 1995 (P < .01). Length of stay also was reduced in the comparison hospital, but by 1995 was longer than in the intervention patients. No differences in LOS by gender, age, or marital status were found. Length of stay was significantly longer for those undergoing total hip replacement as compared to those undergoing total knee replacement in all the groups.</p><p><strong>Conclusions: </strong>Preadmission screening and case management by a social worker can contribute to the efforts to decrease LOS of orthopedic patients by early multidisciplinary evaluations, discharge planning, and coordination of services.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"7 1","pages":"17-22"},"PeriodicalIF":0.0,"publicationDate":"1999-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21220093","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Quality improvement in an integrated urban healthcare system: a necessary journey.","authors":"M P Earnest,&nbsp;S M Grimm,&nbsp;M A Malmgren,&nbsp;B A Martin,&nbsp;M Meehan,&nbsp;M B Potter,&nbsp;A W Steele,&nbsp;J R Zocholl","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Public hospitals and clinics in the United States provide health care for the needs of large numbers of people who are medically indigent, homeless, chronically mentally ill, and suffer medical and social disorders associated with poverty. These \"safety-net\" healthcare providers traditionally struggle with barriers to providing high-quality, patient-sensitive care, including decaying physical facilities, burdensome bureaucracies, underfunded capital equipment and construction programs, and complex, politically driven budgets and governance. However, these same institutions now must compete for their own Medicaid and Medicare clientele because the private sector is marketing to those patients. They also must continue to provide increasing services to growing numbers of uninsured patients. To accomplish this, these institutions must reinvent themselves as patient-focused, high-quality, cost-effective healthcare providers. The Denver Health system is the public safety-net provider for the city and county of Denver. This large public institution has instituted a multifaceted performance-improvement program. The program includes training employees for patient-focused service, implementing continuous quality-improvement practices, instituting clinical pathways, revising the preexisting ambulatory quality-management program, reengineering key aspects of ambulatory clinic services, and redesigning the hospital-based patient-care services. Major successes have been achieved in some initiatives, but not in all. Many key \"lessons learned\" may guide others.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 4","pages":"193-200"},"PeriodicalIF":0.0,"publicationDate":"1998-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21219522","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hospital credentialing for laparoscopic cholecystectomy: is stricter better?","authors":"C J Conover,&nbsp;F A Sloan,&nbsp;D Provenzale,&nbsp;E Oddone,&nbsp;P S Jowell,&nbsp;M L Mah","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>Hospital credentialing standards for laparoscopic cholecystectomy were established to improve surgical outcomes, but standards vary by hospital. We hypothesized that more stringent credentialing would result in better outcomes.</p><p><strong>Design: </strong>Univariate and multivariate logistic analyses were performed using a 1996 survey on hospital credentialing practices. Surgical-outcome data were obtained from statewide hospital discharge abstracts and hospital chart reviews. Multivariate logistic analysis was used to calculate the effects of hospital credentialing stringency and nine credentialing practices on operative and postoperative outcomes (including death), controlling for patient and hospital characteristics.</p><p><strong>Setting: </strong>Short-stay community hospitals performing laparoscopic cholecystectomy.</p><p><strong>Patients: </strong>Statewide hospital discharge data included 1995 inpatient discharges for laparoscopic cholecystectomy. Medical-records review included 843 laparoscopic cholecystectomy patients selected from 14 North Carolina hospitals with widely different credentialing practices.</p><p><strong>Results: </strong>Surgical complications from laparoscopic cholecystectomies appeared unrelated to stringency of the hospital credentialing environment. Important factors predicting complications included hospital volume and other hospital characteristics such as the number of registered nurses per patient day.</p><p><strong>Conclusions: </strong>Given current levels of training, performance, and credentialing standards, tightening of credentialing practices may not improve patient outcomes for laparoscopic cholecystectomy.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 4","pages":"155-62"},"PeriodicalIF":0.0,"publicationDate":"1998-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21220338","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Distance education and technology.","authors":"D Birnbaum","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>This first in a series of columns regarding distance education identifies existing offerings and introduces conceptual issues. Continuing professional education can be achieved through a variety of means, but university-based distance education degree programs offer particularly valuable attributes. Although a growing number of universities are offering such programs, few pertain specifically to infection control, hospital epidemiology, and health-service quality improvement. This first installment concludes by asking whether the Society for Healthcare Epidemiology of America should be partnering or otherwise collaborating with universities to maintain its leadership position in bringing high-quality educational opportunities to infection control practitioners and healthcare epidemiologists.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 4","pages":"190-2"},"PeriodicalIF":0.0,"publicationDate":"1998-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21219519","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}