Clinical performance and quality health care最新文献

{"title":"Primary-care--physician supply: policy analysis on the state level.","authors":"V Olchanski,&nbsp;D W Marsland,&nbsp;L F Rossiter,&nbsp;R E Johnson","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>To describe a method for policy analysis on the state level for understanding frequently overlooked determinants of the current status and dynamics of primary-care-physician supply.</p><p><strong>Design: </strong>The method used is systems analysis. The approach takes account of the changing interstate migration, tracking the professional origins of physicians, their uneven age distribution, and the considerable time delays in the system. The forecasting mathematical model consists of the physician-aging submodel, the undergraduate and graduate medical education submodel, and the migration subsystem.</p><p><strong>Setting: </strong>The necessary data were restored fully from the Virginia Board of Medicine archive database.</p><p><strong>Results: </strong>The analysis shows the outstanding importance of out-of-state migration for the state of Virginia: approximately two thirds of primary-care physicians are out-of-state medical graduates. In the next decade, the attrition of primary-care physicians will start to increase steadily because of the prominent bulge in the physician age distribution. Similar bulges were observed in the age distributions for some other states.</p><p><strong>Conclusions: </strong>The method reveals the underlying mechanisms and principles of physician work-force reproduction. It may show which goals are feasible, and it may be used in any state for the research necessary for rational policy formulation.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 3","pages":"129-37"},"PeriodicalIF":0.0,"publicationDate":"1998-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21054092","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":"Achieving JCAHO accreditation in a university student health center.","authors":"B A Johnson,&nbsp;B Reppert","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Of the approximately 1,500 colleges and universities in the United States, only approximately 100 university student health centers are accredited by either of the two major ambulatory healthcare accreditation agencies. The accreditation process can be daunting. We found few examples in the accreditation literature that assisted us in our endeavor. This article is designed as a primer to assist college health center administrators in achieving accreditation by the Joint Commission on Accreditation of Healthcare Organizations.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 3","pages":"114-28"},"PeriodicalIF":0.0,"publicationDate":"1998-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21054229","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":"Evolution and factors associated with biological-risk accidents reported in a university hospital in Spain, 1989 to 1995.","authors":"I Failde,&nbsp;F J López,&nbsp;J A Córdoba,&nbsp;M Zarzuela,&nbsp;E Benítez,&nbsp;V Senabre","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Background: </strong>The objective of this study was to describe the profile and evolution of accidents involving risk of transmission of hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) reported in a large Spanish hospital, together with the preventive measures administered and the factors associated with high-risk accidents.</p><p><strong>Methods: </strong>Data used were the accidents recorded in the hospital during the period from January 1989 to December 1995. A logistic model, using age, gender, service, occupation, and year of accident as independent variables was constructed to study the factors associated with these accidents.</p><p><strong>Results: </strong>The study included 1,009 accidents. Accidents were more common among nurses, female doctors, younger workers, and persons who worked in surgical settings. Of the total sources of infection studied, 11.6% were positive for HBV, 28.2% for HCV, and 24.4% for HIV. No seroconversions were detected in the partial follow-ups conducted. The factors associated with high-risk accidents were gender (relative risk [RR], 2.01; 95% confidence interval [CI95], 1.24-3.60); occupation as physician (RR, 2.57; CI95, 1.54-4.29) or as nursing staff (RR, 1.80; CI95, 1.12-2.89); and working in a surgical service (RR, 2.01; CI95, 1.27-3.18). Younger workers had more accidents overall, but older workers were more likely to have high-risk exposure. In the multivariate analysis, the occupation (physician and nursing staff) was the most important variable when adjusted by the other factors.</p><p><strong>Conclusions: </strong>Our results suggest that a greater effort still is required in the application and evaluation of preventive measures. New safety systems, with clearly proven cost-effectiveness, should be developed and applied.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 3","pages":"103-8"},"PeriodicalIF":0.0,"publicationDate":"1998-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21054228","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":"Variation in mortality among seven hemodialysis centers as a quality indicator.","authors":"B Mozes,&nbsp;E Shabtai,&nbsp;D Zucker","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objectives: </strong>To identify patient attributes that were associated with increased mortality; variables that were associated with process of care that were correlated with mortality; and outlier centers after adjustment for patient attributes.</p><p><strong>Design: </strong>Standard interviews were conducted by trained nurses with all patients. Detailed information regarding primary renal diagnosis, comorbidity, and results of laboratory tests were obtained from the medical charts. The vital status of the patients was obtained from the records of each of the centers. We used the Cox hazard method to identify variables that correlated with a 1-year mortality. Centers with observed mortality exceeding the 95% confidence interval (CI95) of the expected probability of death were marked as outliers.</p><p><strong>Setting: </strong>Seven dialysis centers located in large teaching hospitals in Israel.</p><p><strong>Patients: </strong>The current study included patients > 16 years of age who had undergone hemodialysis > 4 weeks prior to the day of data collection.</p><p><strong>Results: </strong>The study included 564 patients. Significant differences were found in patient demographics and process variables among the centers. The following variables correlated with mortality; diabetes (odds ratio [OR], 2.03; CI95, 1.28-3.21); ischemic heart disease (OR, 2.2; CI95, 1.39-3.49); each year of age (OR, 1.04; CI95, 1.02-1.06); each 1 g% of albumin (OR, 0.51; CI95, 0.30-0.86). The average observed mortality in all centers was 17.4%. After adjustment for casemix, one center showed excess mortality (24% observed compared to 15% expected after adjustment for patient attributes; CI95, 6.2-23.7).</p><p><strong>Conclusions: </strong>The ability to compare mortality rates among dialysis centers to detect possible quality outliers depends on thorough consideration of patient attributes and random variation.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 2","pages":"73-8"},"PeriodicalIF":0.0,"publicationDate":"1998-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21051001","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":"Phlebotomy teams reduce blood-culture contamination rate and save money.","authors":"S Surdulescu,&nbsp;D Utamsingh,&nbsp;R Shekar","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>To determine the extent of resource utilization due to contaminated blood cultures.</p><p><strong>Design: </strong>Case-control retrospective analysis. Twenty-three patients who had contaminated blood cultures were matched by age, underlying diseases, and discharge diagnoses with 23 patients who had negative blood cultures.</p><p><strong>Setting: </strong>St Luke's Medical Center, a community teaching hospital in Cleveland, Ohio. The phlebotomy team was eliminated in November 1993 to reduce the costs.</p><p><strong>Results: </strong>Blood cultures drawn by the phlebotomy team had a lower contamination rate compared with those drawn by nonphlebotomists (2.6% vs 5.6%). Patients with contaminated blood cultures were compared to those with negative blood cultures. The following parameters were found to be statistically significant: total hospital length of stay (LOS; 13.9 vs 5.5 days; P = .002), postculture LOS (8.9 vs 4.6; P = .01), postculture number of days on antibiotics (5.9 vs 2.9; P = .03), vancomycin use (9 vs 2 patients; P = .03), postculture cost of antibiotics ($762 vs $121; P = .004), and postculture hospital cost per patient ($10,515 vs $4,213; P = .001).</p><p><strong>Conclusions: </strong>This study demonstrated a substantial increase in resource utilization in our hospital due to contaminated blood cultures. The reinstitution of a phlebotomy team could be a cost-effective solution with savings between $950,000 and $1.5 million per year for our hospital.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 2","pages":"60-2"},"PeriodicalIF":0.0,"publicationDate":"1998-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21052220","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":"Assessing quality in home-care programs.","authors":"L Abbey","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>As the chronically homebound population increases, more primary-care individuals and groups will be providing care in the home. Assessing and improving the care of this population involves developing strategies to monitor the quality of care provided (for example, using clinical practice guidelines), assessing the efficacy of plans to help prevent decline, and identifying unavoidable negative outcomes. Outcome indicators for this group must be able to discriminate between expected decline and decline that could have been modified by medical intervention. Because of multiple variables not present in institutional settings, in-home care presents a somewhat different situation than care of nursing home residents.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 2","pages":"84-7"},"PeriodicalIF":0.0,"publicationDate":"1998-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21050996","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 use of a quality-improvement approach to reduce needlestick injuries in a Saudi Arabian hospital.","authors":"M Kennedy,&nbsp;D O'Reilly,&nbsp;M W Mah","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective/design: </strong>An increase was noted in the incidence of needlestick injuries in our institution. A retrospective study was carried out analyzing the accident reports and medical records of needle-stick injuries from January 1995 to July 1996. Study variables included monthly incidence; location; injury site; mechanism; staff vocational status; source virological status; staff immunity; and serological conversion to hepatitis B and C viruses and the human immunodeficiency virus (HIV).</p><p><strong>Setting: </strong>350-bed general hospital in Western Saudi Arabia employing 2,083 employees of many different nationalities.</p><p><strong>Results: </strong>126 injuries were identified. Thirty percent of injuries occurred in the operating room and 28% on general wards. Twenty-five injuries occurred during a surgical procedure in the operating room, 22 injuries were caused by undisposed sharps, 11 occurred during suturing, 11 occurred during injection, and 10 occurred while disposing of refuse. At least 38% of the injuries were avoidable. Sixty percent of those injured were nurses, 30% were medical staff, and 6% were housekeeping staff. Nine of the identifiable sources were hepatitis B surface antigen-positive, nine were hepatitis C antibody-positive, and none were anti-HIV positive. Eighty-nine percent of injuries involved the hands. None of our injured employees had seroconverted at 3, 6, or 9 months follow-up to HIV, hepatitis C, or hepatitis B. Eighty-four percent of injured staff were hepatitis B immune.</p><p><strong>Conclusion: </strong>Steps taken to reduce the future incidence of injuries included the provision of readily accessible sharps boxes, a hospitalwide education program focusing on safe handling and disposal of sharps, and the development of clear policies and procedures for dealing with sharps injuries. A further study will be conducted 12 months after the introduction of these measures.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 2","pages":"79-83"},"PeriodicalIF":0.0,"publicationDate":"1998-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21052222","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":"Handwashing practices in a tertiary-care, pediatric hospital and the effect on an educational program.","authors":"M L Avila-Agüero,&nbsp;M A Umaña,&nbsp;A L Jiménez,&nbsp;I Faingezicht,&nbsp;M M París","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>To study the frequency of handwashing and the effects of an educational program.</p><p><strong>Design: </strong>A prospective study.</p><p><strong>Setting: </strong>A tertiary-care, pediatric hospital.</p><p><strong>Participants: </strong>Three divisions (two general pediatric wards and one infectious disease ward). The personnel observed included 60 medical staff (interns, residents, and attending, including consulting, physicians), 37 nurses, and 15 paramedical staff.</p><p><strong>Interventions: </strong>The study was carried out in 5 phases: (1) unobtrusive observation to obtain a baseline handwashing rate; (2) observation after written notification; (3) observation after providing motivating devices: movies, brochures, posters; (4) discontinuation of observation and motivation; (5) unobtrusive observation, to obtain a residual handwashing rate.</p><p><strong>Results: </strong>During this study, 1,123 patient contacts were observed. The baseline handwashing rates before and after patient contact were 52% and 49%, respectively. During phase 2, handwashing rates before and after patient contact increased slightly to 56% and 52%, respectively. During phase 3, rates increased to 74% and 69% (P < .01). However, rates fell during the final phases to 49% and 52%, respectively (P < .01). There were no significant differences among hospital staff in any phase of this study (P > .05).</p><p><strong>Conclusions: </strong>Constant motivation, using movies, brochures, and posters, transiently increased the frequency of handwashing among the house staff of a tertiary-care facility; however, to be effective, this motivation needs to be sustained.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 2","pages":"70-2"},"PeriodicalIF":0.0,"publicationDate":"1998-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21052218","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":"Linking claims and cancer registry data: is it worth the effort?","authors":"S T Fleming,&nbsp;F P Kohrs","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Insurance claims and cancer registries represent different sources of data, each with advantages and limitations insofar as describing severity of illness, cost, utilization, and outcome of care for cancer patients. Although registries typically are able to identify stage of disease and initial course of treatment, claims-based data include more detailed information on the cost and utilization of medical-care services. Moreover, claims data can provide critical information about the use and location of medical services prior to diagnosis of cancer. The purpose of this paper is to argue the advantages of merging claims with registry data by considering evidence and insights from the literature. We discuss the advantages and disadvantages of claims data, describe studies that compare claims and registry data, and highlight the advantages of linking both sources of data. The latter is accomplished by considering a major advantage of each source of data. Registry data contain useful measures of severity of illness (cancer stage, tumor size, and sites of metastasis), whereas claims data include a detailed history of the cost of medical service.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 2","pages":"88-96"},"PeriodicalIF":0.0,"publicationDate":"1998-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21051003","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":"Variation in the use of breast-conserving therapy for Medicare beneficiaries in Virginia: clinical, geographic, and hospital characteristics.","authors":"K S Elward,&nbsp;L T Penberthy,&nbsp;H Bear,&nbsp;D M Swartz,&nbsp;R M Boudreau,&nbsp;S S Cook","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Background: </strong>Treatment for early-stage breast cancer has evolved significantly in recent years. Breast-conserving therapy (BCT) has been shown to offer equivalent survival compared to traditional mastectomy. However, there is marked variation in the performance of BCT which may not reflect clinical appropriateness or patient preference. Little is known about the factors related to variation in BCT performance in older women with early-stage breast cancer.</p><p><strong>Methods: </strong>Retrospective claims analysis of 1,512 Medicare patients using part-A data for the years 1992 to 1993, with additional explicit chart review. A clinical algorithm was developed to categorize patients according to their candidacy for BCT and compare this to their treatment. Demographic, clinical, and geographic variables were included in the model.</p><p><strong>Results: </strong>The overall BCT rate in Virginia was 20%, with marked variation among providers of all types. BCT rates ranged from 0% to 44% among hospitals caring for more than 12 cases per year. Twenty-six percent of patients considered good candidates for BCT by current guidelines received this option. Large urban hospitals had significantly higher rates of BCT than smaller hospitals, regardless of the presence of radiation oncology capability. Distance from radiation oncology facilities was a factor in low BCT rates of rural populations, but low BCT rates also were present even in facilities with access to radiation oncology services.</p><p><strong>Conclusions: </strong>These data present a detailed analysis of the patterns of BCT for Virginia Medicare beneficiaries with early-stage breast cancer. Clinical contraindications to BCT for confirmed early-stage disease were uncommon. Despite similar patient profiles and hospital-reported range of cancer services, marked variation in BCT rates exists. A large number of patients chose traditional mastectomy over BCT due to fears of radiation, but few received radiation oncology consultation. BCT rates were highest in hospitals with radiation oncology facilities on grounds; hospitals with facilities nearby had rates similar to those without access to radiation facilities. Patient preferences are documented poorly. This study provides further evidence that many women are receiving BCT in patterns that may not reflect clinical appropriateness for BCT nor access to necessary facilities.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 2","pages":"63-9"},"PeriodicalIF":0.0,"publicationDate":"1998-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21052216","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}