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Biomedical subjects

J Feinglass

Publications and source records attributed to J Feinglass.

At least 55 records · Page 3Linked to original sources
PubMed1993

A quality-of-care analysis of cascade iatrogenesis in frail elderly hospital patients.

Cascade iatrogenesis is defined as a related sequence of adverse events that are triggered by an initial medical intervention. In an attempt to determine whether such a phenomenon is be associated with the quality of care provided, physician reviewers identified iatrogenic cascades and the rated quality of care given to a sample of long-stay teaching hospital patients. The care was rated with a structured implicit review instrument. Cascade iatrogenesis was found to occur most frequently among the oldest patients, the most functionally impaired, and those with a high severity of illness on admission. Closer examination of these findings suggests that there is significant potential for improving physicians' initial functional and diagnostic assessment skills when treating frail elderly patients.

Aged↗
PubMed1993

Use of the Rand Structured Implicit Review Instrument for Quality of Care Assessment.

The Rand Structured Implicit Review Instrument is a 27-item instrument that rates process quality of care for patients with five common illnesses. This study reports on the use of this instrument for hospitalized patients with long lengths of stay. A total of 120 medical records were reviewed by multiple physician reviewers for patients discharged with congestive heart failure, acute myocardial infarction, and pneumonia. Mean inter-rater reliability was assessed for a subsample of six records by kappa score. A multiple regression analysis was used to estimate the relationship between process ratings for the quality of documentation, assessment, monitoring, and therapy and overall quality of care scores, controlled for physician judgments about patients' prognosis and selected patient characteristics. Each reviewer also evaluated the instrument. Mean kappa for trichotomized ratings of quality of care was 0.50. The majority of all quality of care ratings were in the good or very good range (77.5%). The full regression model, including process subscale quality ratings, prognostic items, and patient characteristics, accounted for 38% of the total variance in the quality of care ratings. Items measuring the quality of assessment (p < 0.0001), therapy (p < 0.02) and monitoring (p < 0.01) were significant. Physicians accepted the use of such a form moderately well. The Rand quality of care form shows consistency in rating overall quality of care and individual dimensions of quality. Achieving a high level of inter-rater reliability is difficult with implicit review. By focusing on specific areas of potentially deficient care, structured review instruments can improve clinical quality improvement efforts.

Humans↗
PubMed1993

Aortic diameter as a function of age, gender, and body surface area.

BACKGROUND: An aortic aneurysm is defined as a 50% or greater increase in diameter compared with normal levels or the level of the left renal vein. However, normal diameters for many aortic segments are not known, and the aortic segment at the left renal vein may be enlarged. The purpose of this study was to determine normal diameters of the thoracic and abdominal aortas in relationship to age, gender, and body size. METHODS: Aortic diameters (ADs) were determined at four anatomic levels: thoracic aorta, abdominal aorta at the celiac axis, renal arteries, and midway between the renal arteries and the bifurcation. ADs were determined with the use of a video analyzer and an electronic caliper. Computed tomographic scans (n = 389) obtained for nonvascular diagnoses were analyzed according to gender, age, height, weight, and body surface area (BSA). RESULTS: At all levels and in each decade the AD is significantly greater in men than in women (p < 0.0001). BSA is a better predictor of size than height or weight. AD increased with age at all levels, and there was a positive correlation between the AD and BSA and gender. Expected ADs for each aortic segment may be calculated according to regression equations. Age-, gender-, and BSA-matched patients with abdominal aortic aneurysms revealed significant enlargements in all proximal aortic segments. CONCLUSIONS: AD at a given level is a function of gender, age, and BSA. When these variables are known, it is possible to calculate an expected AD. The AD is greater at all levels in patients with abdominal aortic aneurysms and in men compared with women.

Adolescent↗
PubMed1993

Prognosis after graft replacement operation for abdominal aortic aneurysm.

We analyze findings on the long-term survival of patients undergoing elective graft replacement operations for abdominal aortic aneurysm. We review the principal surgical case series published in peer-reviewed, English-language journals over the past 15 years. Preoperative mortality was 4.0%, and 5-year survival was 69% in 16 reviewed studies encompassing 4,288 patients. Articles on late survival have largely focused on the preoperative assessment of coronary artery disease in patients who are candidates for aortic resection. The influence of other recognized risk factors, such as advanced age, hypertension, cerebrovascular disease, congestive heart failure, diabetes mellitus, and multiple aneurysms, is often not well specified in these studies. As a greater number of older patients with abdominal aortic aneurysm are seen with serious associated disease, knowledge about the expected survival of patients with surgically treated aneurysms is becoming more important to both primary care physicians and vascular surgeons when eliciting patient preferences for surgical treatment.

Age Factors↗
PubMed1993

State experience with Medicare hospital mortality: how does New York State compare?

1987 Medicare hospital mortality statistics for 255 New York hospitals (including 57 hospitals in New York City) were compared with 4,617 hospitals located in other states. An analysis of covariance examined how overall Medicare hospital mortality rates differed across states; these rates were adjusted for expected mortality, hospital bed size, and major teaching status. This study tested for the hypothesis that New York State had an average 30-day post-admission Medicare mortality rate significantly different from the mean hospital mortality rate for all states. The results indicated that New York State was -0.43 percentage points below the average risk-adjusted mortality rate of the other states (p < 0.0001). Although it remains speculative to what extent differences in adjusted Medicare hospital mortality are a function of quality of care, these results indicate that New York's historically high level of hospital regulation has not resulted in inferior patient outcomes.

Hospital Mortality↗
PubMed1992

Iatrogenic complications in high-risk, elderly patients.

BACKGROUND: This study explores the quality improvement potential of reviewing care for long-stay, elderly medicine service patients hospitalized for congestive heart failure, acute myocardial infarction, or pneumonia at a large Midwestern teaching hospital. METHODS: Medical records were reviewed for 120 patients aged 65 years or older who were discharged between January 1987 and June 1989, with hospital stays of 15 days or longer. Patients' severity of illness on admission was rated using the Medicare Mortality Predictor System; process quality of care was rated using a structured implicit review form for judging several dimensions of clinical assessment and decision making. Serious complications were coded by etiology and type and judged as possibly or probably preventable. Logistic regression was used to identify risk factors for iatrogenic events; multiple regression was used to assess potential outcome bias in ratings of overall quality of care. RESULTS: Of 120 medical records reviewed, 70 (58.3%) suffered at least one iatrogenic complication. Forty-three patients (35.8%) suffered an iatrogenic complication rated as potentially preventable. Significant predictors of all iatrogenic complications were quality ratings of initial physician assessment, patients' inability to walk unassisted, and low Glasgow Coma Score. For potentially preventable complications, quality ratings for physician documentation of functional status were also significant. Ratings for overall quality of care were not significantly influenced by the mere presence of death or complications. CONCLUSIONS: Iatrogenic complications are likely to be an extremely common experience for elderly medicine service patients with long lengths of stay. A significant portion of these complications may be potentially preventable with closer attention to initial assessment and documentation of patients' functional status.

Aged↗
PubMed1992

Regional variation in Medicare hospital mortality.

This study examines variation in severity-adjusted Medicare hospital mortality rates across nine U.S. census regions. The extent to which regional variation is reduced by controlling for differences in hospital resources and structure, county-level population characteristics, and the level of federal SuperPRO-identified hospital quality problems is estimated. Hospital resources, population characteristics, and SuperPro process quality scores are significant predictors of hospital mortality rates, but they do not explain the important, highly significant regional differences observed after controlling for hospital case-mix severity.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1991

The relationship of residents' autonomy and use of a teaching hospital's resources.

This 1990 study examines the relationship between the degree of use of patient care resources and the degree of supervision of residents by attending physicians (as perceived by residents) at a large midwestern teaching hospital. Ratings of the degree of clinical autonomy allowed residents by 65 attending physicians--each of whom had a general internal medicine practice with a significant hospital component--were provided by 23 former internal medicine chief residents and 17 internal medicine residents who were in their third year at the time of the study. A regression model was used to test the association between hospital resource use (as shown by total hospital charges to patients and their lengths of stay) and the residents' mean ratings of the degrees of autonomy the attending physicians permitted residents, for 7,169 of these physicians' patients discharged between 1986 and 1989 in 28 diagnosis-related groups. The analysis was controlled for patients' insurance status and chronic disease comorbidities. The patients whose attending physicians were rated as allowing substantial clinical autonomy had significantly lower total charges and lengths of stay (p less than .0001). These results suggest that internal medicine residents have an inherently conservative practice style that values low-intensity workups and rapid discharge of patients.

Aged↗
PubMed1991

The financial effect of physician practice style on hospital resource use.

Several specifications of a statistical model were used to measure the effect that internal medicine attending physicians had on inpatient charges and length of stay at a large urban teaching hospital. The study was based on a sample of 1,458 patients discharged during 1985-1987 with 12 common principal diagnosis clusters. The relationship between 31 physicians' clinical decisions and hospital charges and length of stay was analyzed controlling for patients' health status, as measured by demographic characteristics, diagnostic group, and ratings for the Severity of Illness Index (SOII). Results indicated that attending physicians were statistically significant predictors of the log of total charges (p = .0030) and the log of length of stay (p less than .0001), and not as significant predictors of untransformed total charges (p = .1255). Equivalent results were obtained when overall SOII ratings were replaced by SOII subscale ratings for the presenting stage of the principal diagnosis on admission. Examination of individual physician regression coefficients revealed that physicians varied within a 40 percent range of generated per patient charges. No significant differences in mortality, early readmissions or residual impairment on discharge were found between the ten highest and ten lowest resource use physicians. The conservatively estimated range of attending physician practice variations observed in this study has serious financial implications for hospitals operating under incentives to minimize operating costs, particularly for teaching hospitals facing reductions in subsidies for graduate medical education.

Aged↗
PubMed1990

The futures of physicians: agency and autonomy reconsidered.

The corporatization of U.S. health care has directed cost containment efforts toward scrutinizing the clinical decisions of physicians. This stimulated a variety of new utilization management interventions, particularly in hospital and managed care settings. Recent changes in fee-for-service medicine and physicians' traditional agency relationships with patients, purchasers, and insurers are examined here. New information systems monitoring of physician ordering behavior has already begun to impact on physician autonomy and the relationship of physicians to provider organizations in both for-profit and 'not-for-profit' sectors. As managed care practice settings proliferate, serious ethical questions will be raised about agency relationships with patients. This article examines health system dynamics altering the historical agency relationship between the physician and patient and eroding the tradiational autonomy of the medical profession in the United States. The corporatization of medicine and the accompanying information systems monitoring of physician productivity is seen to account of such change, now posing serious ethical dilemmas.

Cost Control↗
PubMed1990

Training house officers to be cost conscious. Effects of an educational intervention on charges and length of stay.

Two annual cost-containment educational programs, featuring involvement of respected senior physicians, lectures, comparative feedback, chart reviews, and small group discussions, were designed to reduce interns' generated costs in a private and a VA university hospital affiliated with Northwestern University Medical School. To evaluate the impact of this randomized educational intervention, hospital data on inpatient charges and length of stay (LOS) were collected for 12 common medical diagnoses and adjusted by the Severity of Illness Index. Interns who were randomized to the program were found to have significantly lower per patient costs and LOS than control group interns at both hospitals. These reductions in resource use and LOS were not associated with differences in patients' residual impairment on discharge, the incidence of inpatient complications, or the percentage of deaths and readmissions within 30 days. Our results suggest that the current hospital cost-containment environment may be far more conducive to physician cost-containment education than indicated by the earlier literature.

Chicago↗
PubMed1990

Corporatization of medicine: the use of medical management information systems to increase the clinical productivity of physicians.

Large corporate health care firms are seeking to reorganize the production of health services under growing cost-containment pressures from government and business payors. Medical management information systems (MMIS) applications are producing an increasing number of financially motivated utilization management interventions designed to constrain wide variations in the practice of medicine. In this article we examine how innovations in MMIS will be used to monitor practitioners' clinical decisions in order to improve the productivity of physicians and other health care personnel. As MMIS technology shifts power from previously autonomous physicians to corporate health care managers, the medical profession is likely to be subjected to far more administrative and bureaucratic controls than conceivable even a few years ago.

Cost Control↗
PubMed1989

Longer hospitalization at Veterans Administration hospitals than private hospitals. Verification and additional insights.

Utilizing 1,297 male patients under the primary care of an identical group of house officers and under treatment between 1985 and 1987 for ten common medical diagnoses, length of hospitalization was compared between a private sector (n = 481) and Veterans Administration (VA) (n = 816) facility, both affiliated with the same medical school. All patients were rated by the Horn Severity of Illness Index. After researchers controlled for diagnosis, severity of illness, age, race, and physician, results in this study indicate that an additional 3.2 days of hospitalization were associated with the VA facility. This finding is consistent with earlier reports of inappropriate hospitalization at the VA hospital and suggests that VA facility planners need to evaluate whether longer lengths of stay (LOS) are merited.

Adult↗
PubMed1989

A retrospective cost-effectiveness analysis of colorectal cancer screening in a public hospital. Savings from reduced hospitalization.

We compared the actual diagnosis and treatment costs for nine colon cancer and 19 polyp patients detected by occult blood screening with excess hospitalization costs incurred by a comparable group of traditionally detected patients. Program benefits were calculated from data on group differentials in surgical length of stay, readmissions in the year following surgery, and preventive polypectomies. A sensitivity analysis was performed to evaluate varying estimates of the percentage of polyps that may have become cancers, the urgency of presentation of clinically apparent cancer, and the inclusion or exclusion of the observed differences for hospitalization in the year after surgery. Two year program benefits varied from 59% to 185% of program costs. Adjusting estimates with DRG weightings for resource intensity produced considerably higher benefits. All estimates of program benefits are conservative because screened patients were compared with the 15-20% least severely ill, most favorably staged of all traditionally detected colon cancer patients admitted. Results indicate that occult blood screening programs may produce significant benefits derived from outpatient diagnosis, preventive polypectomies, coordination of care between medical and surgical services, and enhanced patient education.

Chicago↗
PubMed1988

Comparison of two systems to measure the severity of illness.

Using two systems of rating inpatient severity of illness, teaching hospital patients were classified into 15 common medical DRGs. The two systems were then analyzed and compared regarding conceptual differences, ability to predict costs within DRGs, and potential future resource usage with case-mix classifications.

Analysis of Variance↗