PubMed Health⌕ Search

Biomedical subjects

D M Witter

Publications and source records attributed to D M Witter.

10 recordsLinked to original sources
PubMed2000

Quality of anticoagulation management among patients with atrial fibrillation: results of a review of medical records from 2 communities.

BACKGROUND: Most treatment of patients at risk for stroke is provided in the ambulatory setting. Although many studies have addressed the proportion of eligible patients with atrial fibrillation (AF) receiving warfarin sodium, few have addressed the quality of their anticoagulation management. OBJECTIVE: As a comprehensive assessment of quality, we analyzed the proportion of eligible patients receiving warfarin, the proportion of time their international normalized ratios (INRs) were within the target range, and, when an out-of-target range INR value occurred, the time until the next INR measurement was made. METHODS: Retrospective review of the medical records of 660 patients with AF managed by general internists and family practitioners in Rochester, NY, and the Research Triangle area of North Carolina. RESULTS: Only 34.7% of eligible patients with AF received warfarin. The INR values were out of the target range approximately half the time, and the response to these values was not always timely. For all the measures considered, both Rochester practices with access to an anticoagulation service had higher (albeit not ideal) quality of warfarin management than the remaining practices. CONCLUSIONS: We found significant deficiencies in the practice of warfarin management and suggestive evidence that anticoagulation services can partially ameliorate these deficiencies. More research is needed to describe the quality of anticoagulation management in typical practice and how this management can be improved.

Adult↗
PubMed1998

Carotid endarterectomy trends in the patterns and outcomes of care at academic medical centers, 1990 through 1995.

OBJECTIVE: To evaluate whether the patterns of inpatient care and patient characteristics have changed for patients undergoing a carotid endarterectomy across a group of academic medical centers from 1990 through 1995. If changes occurred, we investigated whether they had an impact on patient outcomes. DESIGN: Retrospective evaluation of patients undergoing a carotid endarterectomy using a hospital discharge data set compiled by the Academic Medical Center Consortium. SETTING: Ten academic medical centers. PATIENTS: A total of 7019 hospital admissions for patients who had 1 carotid endarterectomy performed as a principal procedure from January 1990 to December 1995. MAIN OUTCOME MEASURES: Trends in patient demographics, comorbidities, length of stay, days in the intensive care unit, and inpatient cerebral arteriogram use were determined. Patient outcomes included inpatient mortality, discharge to an institution, 30-day readmission rate, and selected diagnoses (postoperative hemorrhage, infection, or seizure; acute myocardial infarction; or cranial nerve palsy) and postprocedure diagnostic tests (computed tomography and magnetic resonance imaging of the head and electroencephalogram) indicative of complications. RESULTS: Over the 6-year study period, the number of carotid endarterectomies performed more than doubled and the percentage of hospital admissions for patients 65 years or older increased from 65% to 75%. The mean and median length of stay halved and the percentage of admissions with transfers to the intensive care unit decreased from 56% to 26% of cases. In addition, the percentage of cases with a cerebral arteriogram during the same admission but prior to the day of the carotid endarterectomy decreased from 52% to 27%. There were no trends in inpatient mortality, discharge to an institution, or 30-day readmission rate. There were no significant trends indicative of poorer quality of care as measured by the frequency of secondary diagnoses or postprocedure diagnostic test use. CONCLUSIONS: Despite dramatic changes that have occurred in patient characteristics and in hospital management practices for patients undergoing a carotid endarterectomy from 1990 to 1995, we were unable to detect any measurable impact on patient outcomes. These data have implications for monitoring and evaluating the impact of systemwide change on the overall quality of care for patients undergoing a carotid endarterectomy.

Academic Medical Centers↗
PubMed1997

Health status of individuals with mild stroke.

BACKGROUND AND PURPOSE: Diminished quality of life and limitations in higher levels of physical functioning are often underestimated in stroke and are not fully captured by measures such as the Barthel Index and the Rankin Outcome Scale. This study used additional measures to assess the health status of 304 persons with mild stroke and to compare these individuals with 184 persons with transient ischemic attack and 654 persons without history of stroke/transient ischemic attack but at elevated risk for stroke (asymptomatic group). METHODS: Subjects were recruited from the Academic Medical Center Consortium (inpatients), the Cardiovascular Health Study (population-based sample of community-dwelling persons 65 years and older), and United HealthCare (inpatients and outpatients typically younger than 65 years). Subjects were interviewed by telephone or in person to assess activities of daily living (Barthel Index), depression (Center for Epidemiological Studies Depression Scale), health status (MOS-36), and utility for current health state. RESULTS: Most respondents were independent on all Barthel items. The stroke group was more impaired on the MOS-36 than the asymptomatic group but similar to the group with transient ischemic attack. Health-related quality of life was lowest for persons with stroke. While symptom status and Barthel Index score were the strongest predictors of health status, the Barthel Index showed a consistent ceiling effect when compared with the physical function subscale of the MOS-36. CONCLUSIONS: The consequences of even mild stroke affect all dimensions of health except pain. Standardized assessment of persons with stroke must evaluate across the entire continuum of health-related functions.

Age Distribution↗
PubMed1997

Inaccuracy of the International Classification of Diseases (ICD-9-CM) in identifying the diagnosis of ischemic cerebrovascular disease.

In administrative databases the International Classification of Diseases, Version 9, Clinical Modification (ICD-9-CM) is often used to identify patients with specific diagnoses. However, certain conditions may not be accurately reflected by the ICD-9 codes. We assessed the accuracy of ICD-9 coding for cerebrovascular disease by comparing ICD-9 codes in an administrative database with clinical findings ascertained from medical record abstractions. We selected patients with ICD-9 diagnostic codes of 433 through 436 (in either the primary or secondary positions) from an administrative database of patients hospitalized in five academic medical centers in 1992. Medical records of the selected patients were reviewed by trained medical abstractors, and the patients' clinical conditions during the admission (stroke, TIA, asymptomatic) were recorded, as well as any history of cerebrovascular symptoms. Results of the medical record review were compared with the ICD-9 codes from the administrative database. More than 85% of those patients with the ICD-9 code 433 were asymptomatic for the index admission. More than one-third of these asymptomatic patients did not undergo either cerebral angiography or carotid endarterectomy. For ICD-9 code 434, 85% of patients were classified as having a stroke and for ICD-9 code 435, 77% had TIAs. For code 436, 77% of patients were classified as having strokes. Limiting the identifying ICD-9 code to the primary position increased the likelihood of agreement with the medical record review. The ICD-9 coding scheme may be inaccurate in the classification of patients with ischemic cerebrovascular disease. Its limitations must be recognized in the analyses of administrative databases selected by using ICD-9 codes 433 through 436.

Arterial Occlusive Diseases↗
PubMed1996

The appropriateness of coronary artery bypass graft surgery in academic medical centers. Working Group of the Appropriateness Project of the Academic Medical Center Consortium.

OBJECTIVE: To compare the appropriateness of use of coronary artery bypass graft (CABG) surgery in Academic Medical Center Consortium hospitals as judged 1) according to criteria developed by an expert panel, 2) according to revisions of those criteria made by cardiac surgeons from the Academic Medical Center Consortium, and 3) by review of cases by the surgeons responsible for those cases. DESIGN: Retrospective, randomized medical record review. SETTING: 12 Academic Medical Center Consortium hospitals. PATIENTS: Random sample of 1156 patients who had had isolated CABG surgery in 1990. MAIN OUTCOME MEASURES: 1) Percentage of patients with indications for which CABG surgery was classified as appropriate, Inappropriate, or of uncertain appropriateness and 2) percentage of cases in which CABG surgery was judged inappropriate or uncertain for which ratings changed after local case review. RESULTS: Data were retrieved from medical records by trained abstractors using an explicit data collection instrument. Cases in which CABG surgery was judged to be inappropriate or uncertain were individually reviewed by the responsible surgeons. According to the expert panel ratings, 83% of the CABG operations (95% CI, 81% to 85%) were necessary, 9% (CI, 8% to 10%) were appropriate, 7% (CI, 5% to 8%) were uncertain, and 1.6% (CI, 0.6% to 2.5%) were inappropriate. These rates are almost identical to those found in a previous study that was done in New York State and that used the same criteria (in that study, 91% of operations were classified as necessary or appropriate, 7% were classified as uncertain, and 2.4% were classified as inappropriate). Rates of inappropriate procedures varied from 0% to 5% among the 12 member hospitals (P = 0.02). The Academic Medical Center Consortium cardiac surgeons revised 568 (24%) of the indications used by the expert panel. However, because those revisions altered the appropriateness ratings in both directions and affected only 50 cases (4%), the net effect of the revisions was slight: The rate of inappropriate CABG surgery increased from 1.6% to 1.9%. Local review found that data collection errors had caused erroneous ratings in 12.5% of 64 cases in which surgery had been classified as inappropriate or uncertain. CONCLUSIONS: The Academic Medical Center Consortium hospitals had low rates of inappropriate and uncertain use of CABG surgery, regardless of the criteria used for assessment. Even though surgeons from the Consortium revised the appropriateness ratings extensively, their revisions had a negligible effect on the overall assessment of appropriateness. However, because of potential data collection errors, appropriateness criteria should be used for individual case audits only if supplemented by subsequent physician review.

Academic Medical Centers↗
PubMed1996

Transforming paradigms for provider information systems.

Developments in health care information systems are being driven by the changing health care market environment as well as the availability of enhanced communication and computer technologies. These developments represent basic shifts in traditional paradigms on which provider information systems are based. The ultimate success of providers will depend on their making fundamental changes in the use of information systems to support new and evolving incentive systems, organizational structures, and market expectations.

Capitation Fee↗
PubMed1996

Inpatient costs of specific cerebrovascular events at five academic medical centers.

We estimated the hospital costs for patients with different cerebrovascular events and applied patient and administrative variables to explain the variance of the cost estimates with particular attention to the relationship between patient age and cost. The study sample was drawn from an administrative data set of all hospital discharges from five academic medical centers for the 1992 calendar year. Using International Classification of Diseases (ICD-9-CM) primary diagnosis codes, cases were classified into cerebrovascular subgroups: subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), ischemic cerebral infarction (ICI), and transient ischemic attack (TIA). The ICD-9-driven data file was supplemented with billing data containing inpatient charges reported in UB-82 format. Costs were imputed by applying Medicare charge-to-cost ratios and regional wage adjustments to the billing data. We estimated relationships between inpatient costs and a number of demographic and administrative variables. A statistically significant difference was found between cerebrovascular subgroups for both the mean cost per discharge (p<0.01) and the mean cost of an inpatient day (p<0.01). The mean cost per discharge for each subgroup was as follows: SAH, $39,994 (n=218); ICH, $21,535 (n=258); ICI, $9,882 (n=908); TIA, $4,653 (n=303). Likewise, the mean cost per inpatient day was as follows: SAH, $2,215; ICH, $1,396; ICI, $1,036; TIA, $1,117. Length of stay as a measure of resource use was strongly predictive of inpatient cost, explaining 72 to 82% of the variation in cost. Demographic variables (i.e., age, gender, race, insurance status), however, revealed virtually no predictive power, accounting for less than 10% of the variance in each of the four subgroups. There are substantial differences in the patient-level cost of hospital services for stroke-related events. After controlling for the type of cerebrovascular event, basic demographic variables and insurance status (including Medicare) contribute little to the total cost of inpatient care. More important factor include stroke severity, social factors, and clinical practice variations.

Academic Medical Centers↗
PubMed1993

The Stroke Prevention Patient Outcomes Research Team. Goals and methods.

BACKGROUND AND PURPOSE: The aim of the present study, based at Duke University and involving 14 other institutions, is to identify the most appropriate and cost-effective clinical strategies for prevention of ischemic (thrombotic or embolic) stroke in high-risk individuals and to design and test an intervention to disseminate this information to providers and the public. METHODS: The study uses (1) secondary data from literature review, Medicare claims, and population-based data from three epidemiological studies and (2) primary data generated in national physician and patient surveys and in demonstration trials. Phases I through III involve data collection and analysis using a decision/cost-effectiveness model and consensus development methods. Phase IV includes intervention in physicians' practice patterns. Data is collected by literature survey and abstraction, review of medical records, claims analysis, and patient and physician surveys. CONCLUSIONS: A structured decision model and a well-defined clinical focus provide a successful organization for a PORT on stroke prevention.

Cerebrovascular Disorders↗
PubMed1990

A bereavement program: good care, quality assurance, and risk management.

Oregon Health Sciences University Hospital implemented a proactive bereavement program based on a faculty research project demonstrating poor sensitivity to the families of deceased patients, their subsequent postdeath adjustment, and feelings about interactions at the hospital. The program has improved support to families at the time of death and established a follow-up system that refers families with adjustment difficulties to an appropriate provider. Educational programs have improved the skills and sensitivity of trainees and staff in responding to stressful patient-family situations concerning death and bereavement. Beyond providing optimal care, a bereavement program benefits quality assurance, risk management, and the community image of any hospital.

Attitude to Death↗