Assessing clinical instability at discharge. The clinician's responsibility.
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Diagnosis-Related Groups↗
Biomedical subjects
J Kosecoff
Publications and source records attributed to J Kosecoff.
Evaluating the treatment of sexually transmitted diseases at an urban public hospital outpatient clinic.
Sexually transmitted diseases occur disproportionately among the poor, are often treated in public hospitals and clinics, and have not been subjected to quality-of-care evaluation. We designed a medical record abstraction system using well-established, specific process-of-care criteria drawn from the medical literature and experts and grouped into three levels of quality: excellent, adequate, and minimal. One hundred seventy-six consecutive patients were identified from the clinic logbook and their medical records abstracted. Deficiencies in history taking, physical examination, laboratory testing, treatment, and public health reporting were identified.
Abstracting and Indexing↗
Failure of physicians to recognize functional disability in ambulatory patients.
OBJECTIVE: To assess the ability of internists to identify functional disabilities reported by their patients. DESIGN: Comparison of responses by physicians and a random sample of their patients to a 12-item questionnaire about physical and social function. SETTING: A hospital-based internal medicine group practice in Boston, Massachusetts, and selected office-based internal medicine practices in Los Angeles, California. SUBJECTS: Five staff physicians, three general internal medicine fellows, and 34 internal medicine residents in the hospital-based practice and 178 of their patients. Seventy-six physicians in the office-based practices and 230 of their patients. MEASUREMENTS AND MAIN RESULTS: Physicians underestimated or failed to recognize 66% of disabilities reported by patients. Patient-reported disabilities were underestimated or unrecognized more often in the hospital-based practice than in the office-based practices (75% compared with 60%, P less than 0.05). Physicians overstated functional impairment in 21% of paired responses in which patients reported no disability. CONCLUSIONS: Physicians often underestimate or fail to recognize functional disabilities that are reported by their patients. They overstate functional impairment to a lesser degree. Because these discrepancies may adversely affect patient care and well-being, medical educators and clinicians should pay more attention to the assessment of patient function.
Activities of Daily Living↗
Carotid endarterectomy for elderly patients: predicting complications.
OBJECTIVE: To determine whether the complication or death rate from carotid endarterectomy can be predicted from hospital and physician structural variables, such as the hospital's teaching status or the number of endarterectomies done by the surgeon per year. DESIGN: Survey of medical records. After controlling for the severity of the patient's condition on the basis of data in the medical record at the time of the endarterectomy, regression analyses were used to predict the postoperative stroke, heart attack, and 30-day death rate as a function of patient, physician, and hospital characteristics. SETTING: Three geographic areas (states or large parts of states; average population, 3 million) in the United States. PATIENTS: Random sample of 1302 patients 65 years of age or older having carotid endarterectomy in 1981. INTERVENTION: Carotid endarterectomy. MEASUREMENTS AND MAIN RESULTS: Of 1302 patients, 11.3% had a postoperative stroke or heart attack or died within 30 days of the operation. Patient age, race, income, and gender; physician volume, board certification status, and age; and hospital size, for-profit status, ownership, and teaching status were not significantly related to the postoperative complication or death rate. If the surgeon was a graduate of a foreign, but not a Western European or Canadian, medical school, however, the average complication or death rate rose from 10.4% to 19.6% (P less than 0.05). CONCLUSIONS: The effectiveness of carotid endarterectomy depends heavily on its complication rate. Because complications after surgery cannot, in general, be predicted from structural variables, referring physicians cannot rely solely on the surgeon's experience and qualifications when recommending a carotid endarterectomy. The surgeon's and the hospital's actual postoperative complication and death rate should be considered.
Age Factors↗
Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography.
BACKGROUND AND METHODS: In a nationally representative population 65 years of age or older, we have demonstrated that about one quarter of coronary angiographies and upper gastrointestinal endoscopies and two thirds of carotid endarterectomies were performed for reasons that were less than medically appropriate. In this paper we examine whether specific characteristics of patients (age, sex, and race), physicians (age, board-certification status, and experience with the procedure), or hospitals (teaching status, profit-making status, and size) predict whether a procedure will be performed appropriately. RESULTS: In general, we found that little of the variability in the appropriateness of care (4 percent or less) could be explained on the basis of standard, easily obtainable data about the patient, the physician, or the hospital. For all three procedures, however, performance in a teaching hospital increased the likelihood that the reasons would be medically appropriate (P = 0.09 for angiography, P = 0.30 for endoscopy, and P less than 0.01 for endarterectomy). In addition, angiographies were more often performed for appropriate reasons in older or more affluent patients (P less than 0.01 for both). Being treated by a surgeon who performed a high rather than a low number of procedures decreased the likelihood of an appropriate endarterectomy by one third, from 40 to 28 percent (P less than 0.01). CONCLUSIONS: Appropriateness of care cannot be closely predicted from many easily determined characteristics of patients, physicians, or hospitals. Thus, for the present, if appropriateness is to be improved it will have to be assessed directly at the level of each patient, hospital, and physician.
Aged↗
The effects of the DRG-based prospective payment system on quality of care for hospitalized Medicare patients. An introduction to the series.
In 1985, we began a 4-year evaluation of the effects of the diagnosis related groups-based prospective payment system on quality of care for hospitalized Medicare patients. This article provides an overview of the study's background, aims, design, and methods. We used a clinically detailed review of the medical record supplemented by data on postdischarge outcomes drawn from the files of the Health Care Financing Administration and fiscal intermediaries to (1) compare outcomes of care after adjustment for sickness at admission, (2) assess the process of in-hospital care and relationships between processes and outcomes, and (3) assess status at discharge for a nationally representative sample of patients hospitalized before and after prospective payment was implemented.
Diagnosis-Related Groups↗
Studying the effects of the DRG-based prospective payment system on quality of care. Design, sampling, and fieldwork.
We have conducted a nationally representative before-after study of the effects of the diagnosis related groups-based prospective payment system (PPS) on quality of in-hospital care for aged Medicare patients. We used a pre-post design with multiple time points in both the pre-PPS (calendar years 1981 and 1982) and post-PPS (July 1985 through June 1986) periods. We gathered clinically detailed data from medical records of patients with one of six diseases and supplemented these data with postdischarge information from Health Care Financing Administration files. We used a stratified multistage cluster sampling design with data gathered on 16,758 patients chosen from 297 hospitals in 30 areas in five states. Our hospital participation rate was 97%; we successfully accessed 96% of the medical records we requested; and our mean item-level reliability score was 0.80. Our sample matches the nation closely on hospital urbanicity, size, teaching status, ownership, and percentages of Medicare and Medicaid patients, and patient demographics and mortality.
Cross-Sectional Studies↗
Changes in sickness at admission following the introduction of the prospective payment system.
We developed disease-specific measures of sickness at admission based on medical record data to study mortality of Medicare patients with one of five conditions (congestive heart failure, acute myocardial infarction, cerebrovascular accident, pneumonia, and hip fracture). We collected an average of 73 sickness variables per disease, but our final sickness-at-admission scales use, on average, 19 variables. These scales are publicly available, and explain 25% of the variance in 30-day postadmission mortality for patients with acute myocardial infarction, pneumonia, or cerebrovascular accident. Sickness at admission increased following the introduction of the prospective payment system (PPS). For our five diseases combined, the 30-day mortality to be expected because of sickness at admission was 1.0% higher in the 1985-1986 period than in the 1981-1982 period (16.4% vs 15.4%), and the expected 180-day mortality was 1.6% higher (30.1% vs 28.5%). Studies of the effects of PPS on mortality must take this increase in sickness at admission into account.
Aged↗
Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system.
We developed explicit process criteria and scales for Medicare patients hospitalized with congestive heart failure, myocardial infarction, pneumonia, cerebrovascular accident, and hip fracture. We applied the process scales to a nationally representative sample of 14,012 patients hospitalized before and after the implementation of the diagnosis related group-based prospective payment system. For the four medical diseases, a better process of care resulted in lower mortality rates 30 days after admission. Patients in the upper quartile of process scores had a 30-day mortality rate 5% lower than that of patients in the lower quartile. The process of care improved after the introduction of the prospective payment system; eg, better nursing care after the introduction of the prospective payment system was associated with an expected decrease in 30-day mortality rates in pneumonia patients of 0.8 percentage points, and better physician cognitive performance was associated with an expected decrease in 30-day mortality rates of 0.4 percentage points. Overall, process improvements across all four medical conditions were associated with a 1 percentage point reduction in 30-day mortality rates after the introduction of the prospective payment system.
Aged↗
Comparing outcomes of care before and after implementation of the DRG-based prospective payment system.
We compared patient outcomes before and after the introduction of the diagnosis related groups (DRG)-based prospective payment system (PPS) in a nationally representative sample of 14,012 Medicare patients hospitalized in 1981 through 1982 and 1985 through 1986 with one of five diseases. For the five diseases combined; length of stay dropped 24% and in-hospital mortality declined from 16.1% to 12.6% after the PPS was introduced (P less than .05). Thirty-day mortality adjusted for sickness at admission was 1.1% lower than before (16.5% pre-PPS, 15.4% post-PPS; P less than .05), and 180-day adjusted mortality was essentially unchanged at 29.6% pre-vs 29.0% post-PPS (P less than .05). For patients admitted to the hospital from home, 4% more patients were not discharged home post-PPS than pre-PPS (P less than .05), and an additional 1% of patients had prolonged nursing home stays (P less than .05). The introduction of the PPS was not associated with a worsening of outcome for hospitalized Medicare patients. However, because our post-PPS data are from 1985 and 1986, we recommend that clinical monitoring be maintained to ensure that changes in prospective payment do not negatively affect patient outcome.
Diagnosis-Related Groups↗
Quality of care before and after implementation of the DRG-based prospective payment system. A summary of effects.
In this series we have described changes in the quality of care that have occurred in the treatment of hospitalized elderly Medicare patients with one of five conditions between 1981-1982 and 1985-1986. In this article we report on a mortality analysis, patient and hospital subgroup comparisons, and time series studies we have conducted in an attempt to determine whether changes in quality of care can be linked causally to the introduction of the prospective payment system. Based on these analyses we conclude that (1) mortality following hospitalization has been unaffected by the introduction of the prospective payment system, and improvements in in-hospital processes of care that began prior to the prospective payment system have continued after its introduction, but (2) the prospective payment system has increased the likelihood that a patient will be discharged home in an unstable condition. We recommend that efforts to correct this problem be intensified and that clinical monitoring of the impact of the prospective payment system continue as hospital cost-containment pressures intensify.
Continuity of Patient Care↗
Prospective payment system and impairment at discharge. The 'quicker-and-sicker' story revisited.
Since the introduction of the prospective payment system (PPS), anecdotal evidence has accumulated that patients are leaving the hospital "quicker and sicker." We developed valid measures of discharge impairment and measured these levels in a nationally representative sample of patients with one of five conditions prior to and following the PPS implementation. Instability at discharge (important clinical problems usually first occurring prior to discharge) predicted the likelihood of postdischarge deaths. At 90 days postdischarge, 16% of patients discharged unstable were dead vs 10% of patients discharged stable. After the PPS introduction, instability increased primarily among patients discharged home. Prior to the PPS, 10% of patients discharged home were unstable; after the PPS was implemented, 15% were discharged unstable, a 43% relative change. Efforts to monitor the effect of this increase in discharge instability on health should be implemented.
Aged↗
Explaining variations in hospital death rates. Randomness, severity of illness, quality of care.
We used administrative (Part A Medicare) data to identify a representative sample of 1126 patients with congestive heart failure and 1150 with acute myocardial infarction in hospitals with significant unexpectedly high inpatient, age-sex-race-disease-specific death rates ("targeted") vs all other ("untargeted") hospitals in four states. Although death rates in targeted hospitals were 5.0 to 10.9 higher per 100 admissions than in untargeted hospitals, 56% to 82% of the excess could result from purely random variation. Differences in the quality of the process of care (based on a medical record review) could not explain the remaining statistically significant differences in mortality. Comparing targeted hospitals with subsets of untargeted ones, eg, those with lower than expected death rates, did not affect this conclusion. Severity of illness explained up to 2.8 excess deaths per 100 admissions for patients with myocardial infarction. Identifying hospitals that provide poor-quality care based on administrative data and single-year death rates is unlikely; targeting based on time periods greater than 1 year may be better.
Aged↗
Audit of coronary angiography and bypass surgery.
The appropriateness of coronary angiography and coronary artery bypass surgery in the Trent regional health authority was assessed by comparison with predetermined consensus criteria. 49% of coronary angiographies were considered to be entirely appropriate in relation to the patient's clinical condition, but 21% were deemed inappropriate. Coronary artery bypass surgery was considered appropriate in 55% of patients, but inappropriate in 16%. Audit by "appropriateness" scores may help to determine which patients should first be investigated and treated when resources are limited and waiting lists are long.
Adult↗
Does inappropriate use explain small-area variations in the use of health care services?
We studied the relationship of the appropriateness of the use of coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy to their rates of use in 23 adjacent counties in one state. We measured appropriateness by means of a detailed review of the medical records of Medicare beneficiaries who had the procedures performed in 1981, using present criteria derived by an expert panel. Use rates per 10,000 Medicare enrollees in a county varied from 13 to 158 for coronary angiography, 5 to 41 for carotid endarterectomy, and 42 to 164 for upper gastrointestinal tract endoscopy. Inappropriate use varied by county from 8% to 75% for coronary angiography, from 0% to 67% for carotid endarterectomy, and from 0% to 25% for endoscopy. For coronary angiography, inappropriate use accounted for 28% of the variance in the county rate. For the other two procedures, no significant correlations were found between inappropriateness of use and rate of use. We conclude that little of the variation in the rates of use of these procedures can be explained by inappropriate use.
Aged↗
Format and conduct of consensus development conferences. Multi-nation comparison.
The consensus development conference method developed by the National Institutes of Health in the United States has been adopted and modified by a number of countries. Based on published articles and communication with representatives from each country, we examined whether the organization and conduct of these conferences in nine countries (United States, Canada, Denmark, Finland, the Netherlands, Norway, Sweden, Switzerland, and the United Kingdom) enhanced or detracted from achieving the stated conference goals and objectives. We conclude that improvements in the process by which consensus conferences are conducted may be warranted. More scientific methods for synthesizing literature, such as meta-analysis, should be used in developing inputs for the conference panel. Formalizing the decision-making processes through polling or other methods that allow for structured disagreement with parts of a consensus statement would potentially expand the range and type of issues that can be addressed in such conferences. Finally, countries should consider having the consensus statement written over a longer period of time than the traditional overnight session, which seems unlikely to promote clear thinking.
Consensus Statements as Topic↗
Changing practice patterns in the management of primary breast cancer: Consensus Development Program.
In the last decade, new knowledge has emerged concerning the efficacy of treatment for breast cancer. For that reason, the National Institutes of Health devoted a consensus conference to this topic. To determine whether the consensus conference had influenced practice patterns, and to evaluate the level of quality of care given to women with breast cancer, the medical records of 573 patients treated in ten hospitals throughout the state of Washington were abstracted and analyzed. Results showed no changes with respect to the consensus conference's recommendations for use of a total mastectomy with axillary dissection or the use of a two-step procedure in which the biopsy is performed first and therapeutic options are discussed before a definitive surgery is undertaken. Analyses of quality of care issues not addressed by the consensus conference revealed that 4 percent of the sample were explicitly staged preoperatively and 29 percent postoperatively and that little changed over time in the use of sentinel laboratory tests. These results also show that consensus recommendations will not necessarily change physicians' behavior even where change is possible, and that quality of care in diagnosis and treatment of breast cancer still needs to be addressed.
Adult↗
Improving patient function: a randomized trial of functional disability screening.
STUDY OBJECTIVES: To test whether a 34-item functional status questionnaire measuring physical, psychological, and social function can be used by physicians in practice to help improve their patients' outcomes. DESIGN: Prospective randomized trial. SETTING: Community internal medicine practices. PATIENTS: Five hundred and ten continuing patients with functional disabilities who saw their physicians at least four times a year. PHYSICIANS: Seventy-six UCLA clinical volunteer faculty who are internists in community office practices. INTERVENTIONS: Physicians and their patients were randomly assigned to the experimental or the control group. Experimental group physicians attended a 2-hour multimedia educational session and received four functional status reports on each of their study patients over a 1-year period. Control group physicians received no education and no functional status feedback. Control group and experimental group patients were tested for functional status with the functional status questionnaire every 4 months for 1 year. Both groups also completed monthly diaries that measured use of health services. Experimental group physicians answered an anonymous evaluation questionnaire at 6 months after study entry. MEASUREMENTS AND MAIN RESULTS: Forty-three percent of experimental group physicians reported that they had used the functional status questionnaire to change therapy. Ninety-five percent reported that it was useful and accurate. Patient diaries did not show any difference between experimental group patients and control group patients in number of medications used, visits to physicians or other health professionals, equipment purchased, diet, or exercise programs. There were no significant differences between experimental and control group patients at exit from the study on any functional status or health outcome measure. CONCLUSION: A more powerful intervention than a 2-hour educational session and the regular provision of functional status information is needed to help office-based internists improve patient outcomes.
Activities of Daily Living↗