Misclassification of patients can affect group quality of care scores.
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Humans↗
Biomedical subjects
C M Ashton
Publications and source records attributed to C M Ashton.
Changes in VA hospital use 1980-1990.
During the 1980s several changes occurred within and outside the Veterans Affairs medical system which may have affected levels of Veterans Affairs (VA) hospital use. We performed a secondary analysis of the 1980-1990 national VA hospital discharge database and Veteran Population Files to examine trends in VA hospital use and to assess effects of the aging of the veteran population. Between 1980 and 1990 discharges increased by 7% despite a 6% drop in the number of veterans. Overall the crude discharge rate increased by 13% and the user rate by 1%. Most of the change was attributable to the fact that as the decade progressed, the veteran population was comprised of proportionately older veterans, who are higher users of hospital care than younger veterans. The 11% increase in the multiple stay ratio was not attributable to aging. Examination of age-specific utilization rates showed that veterans younger than age 45 had consistent increases in use, whereas use by older veterans declined. Our findings indicate that change in the age composition of the veteran population is responsible for some but not all of the increase in VA hospital use in the last decade. The increase in use by young veterans may reflect increasing barriers to access to non-VA care. Declines in use by older veterans may indicate that VA has been successful in shifting the locus of care from the hospital to the ambulatory and long-term care settings.
Age Distribution↗
A method of developing and weighting explicit process of care criteria for quality assessment.
The use of explicit criteria to evaluate how well processes of care conform to accepted standards is a key method of quality assessment. Synthesizing four decades of literature, we devised an inexpensive, 6-step method of developing reliable, content-valid, explicit process criteria. This paper describes the method using a set of congestive heart failure criteria. In step 1 of the Criteria Development Method, criteria are derived from state-of-the-art clinical literature. In step 2, criteria are refined by expert panels. In this study, panelists refined the items by mail in a three-round Delphi process. In step 3, decisions about unit-or differential item weighting are made; we derived differential item weights from the panelists' third-round ratings. Step 4 consists of flagging items which may yield little information, i.e., consensus items of low import, and nonconsensus items. Numeric flags were computed using third-round median ratings and their interquartile ranges. Selection of a scoring method to summarize scores and communicate results is done in step 5. In step 6, chart reviewers are trained, inter-rater reliability is measured, and items with poor reliability are culled. This straightforward developmental method can be used to devise explicit process criteria for use in ambulatory or hospital settings and to evaluate care delivered by different types of providers. The method yields reliable criteria representing accepted standards of current clinical practice. This high content validity is a sine qua non for convergent and predictive validity, both of which must be demonstrated in empirical studies in which the criteria are compared against external yardsticks.
Delphi Technique↗
Access of women veterans to Veterans Affairs hospitals.
Women veterans represent a rapidly growing segment of the veteran population. This study examines how the utilization of VA hospitals by women veterans has changed since 1980. Information on the use of VA hospitals was obtained from the discharge database for all VA hospitals. The demographics of the veteran population was compiled from the Veteran Population Files, which contain annual estimates of the number of veterans by age and sex. The VA hospital discharge rate for women increased nearly 29 percent during the 1980's while the VA user rate increased nearly 18.6 percent for women. The increase in the average number of VA stays per user was smaller for women than for men (8.4 percent versus 11 percent). Substantial increases in the utilization of VA hospitals by women veterans occurred during the 1980's. In most cases these increases were larger for women veterans than for men veterans. However, women veterans still use VA hospitals at about one-half the rate for men. Regardless, the VA system will continue to be an important source of health care for women.
Adult↗
The incidence of perioperative myocardial infarction in men undergoing noncardiac surgery.
OBJECTIVES: To determine the incidence of and risk factors for perioperative myocardial infarction with noncardiac surgery and to test the accuracy of a risk stratification system. DESIGN: Prospective cohort study. SETTING: A large urban Veterans Affairs hospital. PARTICIPANTS: A total of 1487 men older than 40 years undergoing major, nonemergent, noncardiac operations. MEASUREMENTS: Infarction was established by at least two of the following: development of new Q waves, typical change in creatine kinase MB, and positive technetium pyrophosphate scintigraphy. Patients were stratified preoperatively into high-, intermediate-, low-, and negligible-risk strata based on clinical markers corresponding to different levels of coronary artery disease prevalence. MAIN RESULTS: Patients with coronary disease (high-risk stratum) had a 4.1% incidence of infarction (13 of 319; 95% CI, 1.8% to 6.4%); patients with peripheral vascular disease but no evidence of coronary disease (intermediate-risk stratum) had a 0.8% incidence (2 of 260, upper bound of CI, 2.0%); patients with high atherogenic risk factor profiles but no clinical atherosclerosis (low-risk stratum) had a 0% incidence (0 of 256, upper bound of CI, 1.2%). No cardiac deaths occurred in 652 men who had no atherosclerosis and low atherogenic risk factor profiles (the negligible-risk stratum). Factors independently associated with infarction included age more than 75 years (adjusted odds ratio, 4.77; CI, 1.17 to 19.41), signs of heart failure on the preoperative examination (adjusted odds ratio, 3.31; CI, 0.96 to 11.38), coronary disease (adjusted odds ratio, 10.39; CI, 2.27 to 47.46), and a planned vascular operation (adjusted odds ratio, 3.72; CI, 1.12 to 12.37). CONCLUSIONS: Coronary artery disease is the major risk factor for perioperative infarction. The stratification scheme identifies subsets of patients with different risks, and finer within-stratum distinctions can be made using additional variables.
Adult↗
"Invisible" doctors: making a case for involving medical residents in hospital quality improvement programs.
The author maintains that residents should be as actively engaged in the evaluation and improvement of the inpatient and ambulatory care they deliver as staff physicians are, and that to exclude them from their departments' formal quality assessment and assurance program wastes valuable opportunities to train them and to improve patient care. For example, residents can benefit from process-of-care reviews, which help teach them the standards of adequate medical care and motivate them to improve the care they give. Residents can also benefit from participating in the quality assessment process itself; this will help develop their clinical and analytic skills, hone their skills in searching and critiquing the medical literature, and help them understand the links between the processes and outcomes of care. In addition, systematic, criteria-based reviews of residents' clinical competence in the diagnosis and treatment of common medical conditions can help attending physicians and residency directors evaluate the residents' abilities. And finally, hospitals benefit from the involvement of housestaff in the quality improvement program, since housestaff often have more insight than staff physicians or administrators into aspects of the physical plant or organizational structure that impair clinicians' ability to provide good care. The author gives examples for each of the preceding statements, and concludes by saying that when residents are treated as if they are "invisible" in quality assessment programs, the program staff is in some measure abdicating its responsibility for the residents' education and for the well-being of the program's current and the residents' future patients.
Clinical Competence↗
Forecasting areawide hospital utilization: a comparison of five univariate time series techniques.
Time series analysis is one of the methods health services researchers, managers and planners have to examine and predict utilization over time. The focus of this study is univariate time series techniques, which model the change in a dependent variable over time, using time as the only independent variable. These techniques can be used with administrative healthcare databases, which typically contain reliable, time-specific utilization variables, but may lack adequate numbers of variables needed for behavioral or economic modeling. The inpatient discharge database of the Department of Veterans Affairs, the Patient Treatment File, was used to calculate monthly time series over a six-year period for the nation and across US Census Bureau regions for three hospital utilization indicators: average length of stay, discharge rate, and multiple stay ratio, a measure of readmissions. The first purpose of this study was to determine the accuracy of forecasting these indicators 24 months into the future using five univariate time series techniques. In almost all cases, techniques were able to forecast the magnitude and direction of future utilization within a 10% mean monthly error. The second purpose of the study was to describe time series of the three hospital utilization indicators. This approach raised several questions concerning Department of Veterans Affairs hospital utilization.
Analysis of Variance↗
The frequency and significance of ECG changes after transurethral prostate resection.
Although many clinicians routinely recommend a base-line preoperative electrocardiogram (ECG) and obtain frequent postoperative ECGs to screen for myocardial infarction or ischemia, the diagnostic utility of screening perioperative ECGs is unknown. The present analysis evaluates the sensitivity and specificity of the perioperative ECG and examines its value as a predictor of early postoperative cardiac events and outcomes during the postoperative year. ECGs obtained preoperatively and on the first 3 postoperative days in 206 men undergoing transurethral prostate resection were analyzed using the Minnesota Code. The occurrence of cardiac events during the operative stay was assessed by measurement of the cardiospecific MB creatine kinase isoenzyme on the first 3 postoperative days and review of the entire clinical course. Twenty-one percent of patients developed postoperative ECG changes, mostly involving the T wave; none had cardiac symptoms or sustained creatine kinase MB elevation. Changes were not significantly more common in men known to have coronary disease. The single patient who had a perioperative myocardial infarction confirmed by enzymes had no codable ECG changes. The specificity of any ECG change for perioperative infarction was 78%; of ST segment changes only, 95%. Only one of the patients (2%) who had postoperative ECG changes had a cardiac event in the year after surgery. Routine perioperative ECGs is of little diagnostic/predictive utility in situations in which the incidence of perioperative myocardial infarction is low.
Aged↗
Severe heat stroke in an experienced athlete.
A 28-year-old experienced athlete suffered severe heat stroke after running competitively in hot, humid conditions. He developed disseminated rhabdomyolysis and acute renal failure. His course was complicated by multiple system organ failure and bismuth iodide (BIPP) toxicity. After almost five months in intensive care he recovered sufficiently to be transferred to the ward and subsequently to a rehabilitation hospital and was eventually able to return to work. Heat stroke can be prevented and this case provides several lessons for the running fraternity and the medical profession.
Acute Kidney Injury↗
The incidence of perioperative myocardial infarction with transurethral resection of the prostate.
We performed a prospective study of 250 men undergoing transurethral resection of the prostate to determine the incidence of perioperative myocardial infarction. The prevalence of coronary artery disease in the study group was 27%. Patients had measurement of total creatine kinase and its MB isoenzyme and electrocardiography preoperatively and on the first three postoperative days. Only one myocardial infarction was diagnosed, an incidence rate of 0.4%. The overall rate of serious post-operative complications was 3.6%. No deaths occurred during the operative hospitalization. We conclude that with transurethral resection perioperative myocardial infarction is a rare event despite the high prevalence of coronary artery disease in this surgical population. Routine postoperative surveillance with electrocardiograms and creatine kinase determinations in asymptomatic patients is not warranted.
Aged↗
Characteristics of the recurrently hospitalized adult. An information synthesis.
Hospital use in the US is concentrated in the approximately 2% of the population that is repeatedly hospitalized. Using the research integration technique of information synthesis, empirical studies of readmission were assembled and analyzed to determine the demographic and clinical characteristics of the repeatedly hospitalized adult. The authors' synthesis of articles that met preset criteria of relevance and validity indicated that clinical variables show a more consistent association with readmission than demographic variables. Diagnosis, prior use, and disability appear to be strong predictors of an individual's level of hospital use. Demographic variables with consistent positive associations with readmission include being widowed, living with relatives other than a spouse, decreasing income, living in the South, and living in an urban area, but available work does not indicate whether these demographic variables are independent predictors of readmission or merely markers of an increased prevalence of chronic disease. Findings indicate that future investigations of the predictors of this costly pattern of hospital use will be most illuminating if illness-related factors such as diagnosis, disease severity, functional status, and usage history are carefully specified and examined.
Adolescent↗
Predicting readmission in veterans with chronic disease. Development and validation of discharge criteria.
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Chronic Disease↗
Characteristics of house staff work rounds on two academic general medicine services.
In this study, the authors determined how residents in internal medicine allotted their time during patient management rounds (work rounds). Fourteen house staff teams were observed for four days each, and the time spent on all activities was recorded. Of the 56 days studied, work rounds were not conducted on nine days. On the 47 days during which work rounds occurred, only 502 (76.4 percent) of a possible 657 visits to patients were made. Daily time spent on work rounds by each team averaged 49.4 minutes (range: 23.9 to 73.1), or 4.6 minutes (range: 2.3 to 6.6) per patient evaluated. Some part of a physical examination was performed on only 44 percent of the patients. For those patients examined, the average time of an examination was approximately one minute per patient. Vital signs sheets and medication sheets were reviewed infrequently. This study suggests that medical educators should be concerned about the thoroughness of house staff work rounds.
Appointments and Schedules↗
Use of porcine Factor VIII concentrate.
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Adult↗
Rates of health services utilization and survival in patients with heart failure in the Department of Veterans Affairs medical care system.
The objective of this study was to describe patterns of hospital and clinic use and survival for a large nationwide cohort of patients with heart failure. A retrospective cohort study of patients treated in the Veterans Affairs medical care system was conducted using linked administrative databases as data sources. In 1996, the average heart failure cohort member had 1-2 hospitalizations, 14 inpatient days, 6-7 visits with the primary physician, 15 other visits for consultations or tests, and 1-2 urgent care visits per 12 months. The overall risk-adjusted 5-year survival rate was 36%. Hospital use rates in the cohort fell dramatically between 1992 and 1996. One-year survival rates increased slightly over the period. Patients with heart failure are heavy users of services and have a very poor prognosis. Utilization and outcome data indicate the need for major efforts to assure quality of care and to devise innovative ways of delivering comprehensive services.
Adult↗
Trends in bacteremic infection due to Streptococcus pyogenes (group A streptococcus), 1986-1995.
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Bacteremia↗
Incentives for vertical integration in healthcare: the effect of reimbursement systems.
In the United States, many healthcare organizations are being transformed into large integrated delivery systems, even though currently available empirical evidence does not provide strong or unequivocal support for or against vertical integration. Unfortunately, the manager cannot delay organizational changes until further research has been completed, especially when further research is not likely to reveal a single, correct solution for the diverse healthcare systems in existence. Managers must therefore carefully evaluate the expected effects of integration on their individual organizations. Vertical integration may be appropriate if conditions facing the healthcare organization provide opportunities for efficiency gains through reorganization strategies. Managers must consider (1) how changes in the healthcare market have affected the dynamics of production efficiency and transaction costs; (2) the likelihood that integration strategies will achieve increases in efficiency or reductions in transaction costs; and (3) how vertical integration will affect other costs, and whether the benefits gained will outweigh additional costs and efficiency losses. This article presents reimbursement systems as an example of how recent changes in the industry may have changed the dynamics and efficiency of production. Evaluation of the effects of vertical integration should allow for reasonable adjustment time, but obviously unsuccessful strategies should not be followed or maintained.
Decision Making, Organizational↗
Evaluation of the VA mobile clinics demonstration project.
In 1988 the Veterans' Benefits and Services Act attempted to solve the problem of the lack of adequate VA healthcare facilities in rural areas by establishing a demonstration program using mobile clinics. Six clinics operated in areas that were at least 100 miles from a VA healthcare facility during the time period between October 1, 1992 and May 28, 1994. This article evaluated the effect of the mobile clinics' structural limitations on clinical care, the increased number of sites on VA usage, and cost. Limited space for storage of medical records and the unavailability of laboratory, electrocardiographic, or radiographic facilities significantly affected clinical practice. However, even with these space limitations, veterans' use of healthcare in the areas served by the mobile clinics increased significantly in comparison to reference areas. The direct costs per visit averaged more than three times what the VA would have reimbursed the private sector.
Demography↗