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Biomedical subjects

J W Peabody

Publications and source records attributed to J W Peabody.

At least 19 recordsLinked to original sources
PubMed2006

Tuberculosis control in Bolivia, Chile, Colombia and Peru: why does incidence vary so much between neighbors?

SETTING: In 2003, Peru and Bolivia reported the highest annual tuberculosis (TB) incidence rates in the Americas. Neighboring Colombia and Chile had lower annual incidence rates despite their proximity. OBJECTIVE: To determine what factors contribute to differences in TB incidence rates among Chile, Colombia, Bolivia and Peru. DESIGN: Multiple sources of literature dating between 1990 and 2005 were used and World Health Organization TB control guidelines were consulted for policy level comparisons. RESULTS: Comprehensive implementation of the DOTS strategy is the main factor explaining the differences in TB incidence rates, even after considering socio-economic factors. CONCLUSION: Cross-national comparisons suggest ways to improve regional DOTS implementation.

Bolivia↗
PubMed2002

The ethical problem of false positives: a prospective evaluation of physician reporting in the medical record.

OBJECTIVE: To determine if the medical record might overestimate the quality of care through false, and potentially unethical, documentation by physicians. DESIGN: Prospective trial comparing two methods for measuring the quality of care for four common outpatient conditions: (1) structured reports by standardised patients (SPs) who presented unannounced to the physicians' clinics, and (2) abstraction of the medical records generated during these visits. SETTING: The general medicine clinics of two veterans affairs medical centres. PARTICIPANTS: Twenty randomly selected physicians (10 at each site) from among eligible second and third year internal medicine residents and attending physicians. MAIN MEASUREMENTS: Explicit criteria were used to score the medical records of physicians and the reports of SPs generated during 160 visits (8 cases x 20 physicians). Individual scoring items were categorised into four domains of clinical performance: history, physical examination, treatment, and diagnosis. To determine the false positive rate, physician entries were classified as false positive (documented in the record but not reported by the SP), false negative, true positive, and true negative. RESULTS: False positives were identified in the medical record for 6.4% of measured items. The false positive rate was higher for physical examination (0.330) and diagnosis (0.304) than for history (0.166) and treatment (0.082). For individual physician subjects, the false positive rate ranged from 0.098 to 0.397. CONCLUSIONS: These data indicate that the medical record falsely overestimates the quality of important dimensions of care such as the physical examination. Though it is doubtful that most subjects in our study participated in regular, intentional falsification, we cannot exclude the possibility that false positives were in some instances intentional, and therefore fraudulent, misrepresentations. Further research is needed to explore the questions raised but incompletely answered by this research.

Benchmarking↗
PubMed2000

How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record.

PURPOSE: Despite widespread reliance on chart abstraction for quality measurement, concerns persist about its reliability and validity. We prospectively evaluated the validity of chart abstraction by directly comparing it with the gold standard of reports by standardized patients. SUBJECTS AND METHODS: Twenty randomly selected general internal medicine residents and attending faculty physicians at the primary care clinics of two Veterans Affairs Medical Centers blindly evaluated and treated actor-patients (standardized patients) who had one of four common diseases: diabetes, chronic obstructive pulmonary disease, coronary artery disease, or low back pain. Charts from the visits were abstracted using explicit quality criteria; standardized patients completed a checklist containing the same criteria. For each physician, quality was measured for two different cases of the four conditions (a total of 160 physician-patient encounters). We compared chart abstraction with standardized-patient reports for four aspects of the encounter: taking the history, examining the patient, making the diagnosis, and prescribing appropriate treatment. The sensitivity and specificity of chart abstraction were calculated. RESULTS: The mean (+/- SD) chart abstraction score was 54% +/- 9%, substantially less than the mean score on the standardized-patient checklist of 68% +/- 9% (P <0.001). This finding was similar for all four conditions and at both sites. "False positives"-chart-recorded necessary care actions not reported by the standardized patients-resulted in a specificity of only 81%. The overall sensitivity of chart abstraction for necessary care was only 70%. CONCLUSIONS: Chart abstraction underestimates the quality of care for common outpatient general medical conditions when compared with standardized-patient reports. The medical record is neither sensitive nor specific. Quality measurements derived from chart abstraction may have important shortcomings, particularly as the basis for drawing policy conclusions or making management decisions.

Ambulatory Care↗
PubMed2000

Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality.

CONTEXT: Better health care quality is a universal goal, yet measuring quality has proven to be difficult and problematic. A central problem has been isolating physician practices from other effects of the health care system. OBJECTIVE: To validate clinical vignettes as a method for measuring the competence of physicians and the quality of their actual practice. DESIGN: Prospective trial conducted in 1997 comparing 3 methods for measuring the quality of care for 4 common outpatient conditions: (1) structured reports by standardized patients (SPs), trained actors who presented unannounced to physicians' clinics (the gold standard); (2) abstraction of medical records for those same visits; and (3) physicians' responses to clinical vignettes that exactly corresponded to the SPs' presentations. Setting Outpatient primary care clinics at 2 Veterans Affairs medical centers. PARTICIPANTS: Ninety-eight (97%) of 101 general internal medicine staff physicians, faculty, and second- and third-year residents consented to be randomized for the study. From this group, 10 physicians at each site were randomly selected for inclusion. MAIN OUTCOME MEASURES: A total of 160 quality scores (8 cases x 20 physicians) were generated for each method using identical explicit criteria based on national guidelines and local expert panels. Scores were defined as the percentage of process criteria correctly met and were compared among the 3 methods. RESULTS: The quality of care, as measured by all 3 methods, ranged from 76.2% (SPs) to 71.0% (vignettes) to 65.6% (chart abstraction). Measuring quality using vignettes consistently produced scores closer to the gold standard of SP scores than using chart abstraction. This pattern was robust when the scores were disaggregated by the 4 conditions (P<.001 to <.05), by case complexity (P<.001), by site (P<.001), and by level of physician training (P values from <.001 to <.05). The pattern persisted, although less dominantly, when we assessed the component domains of the clinical encounter--history, physical examination, diagnosis, and treatment. Vignettes were responsive to expected directions of variation in quality between sites and levels of training. The vignette responses did not appear to be sensitive to physicians' having seen an SP presenting with the same case. CONCLUSIONS: Our data indicate that quality of health care can be measured in an outpatient setting by using clinical vignettes. Vignettes appear to be a valid and comprehensive method that directly focuses on the process of care provided in actual clinical practice. Vignettes show promise as an inexpensive case-mix adjusted method for measuring the quality of care provided by a group of physicians.

Ambulatory Care↗
PubMed2000

Using standardized patients to measure quality: evidence from the literature and a prospective study.

BACKGROUND: Use of standardized patients for evaluating the clinical skills of medical students and medical trainees is commonplace. This has encouraged the use of standardized patients to evaluate the quality of physician practice in outpatient settings. However, there may be substantive differences between observing student performance and evaluating whether the provision of care meets defined quality criteria. OBJECTIVES: This study had two primary objectives: (1) to review studies that use standardized patients to evaluate physician performance and (2) to ascertain directly whether standardized patients could be useful in assessing quality of outpatient care. METHODS: A comprehensive literature review of studies that used standardized patients to assess physician performance was conducted. A prospective study that included 20 physicians at two outpatient settings and 27 actor patients assessed quality of care using eight clinical cases divided into five clinical domains, each of which had explicit criteria checklists based on widely accepted guidelines. RESULTS: The literature review identified five important issues: developing scenarios, selecting explicit criteria, standardizing standardized patient training, creating subterfuges, and ensuring reliability and validity of measures. In the study, trained standardized patients were able to assess physician practice accurately for common medical conditions, using proven criteria linked to health outcomes. The detection rate was 3%. There was no performance variation between actors for seven of the eight cases. CONCLUSIONS: Using standardized patients to measure the quality of care is practical and feasible. The major methodological challenge is incorporating observable evidence-based criteria into realistic scripts and objective checklists. The major logistical challenge is obtaining and maintaining undetected entry into physicians' offices.

Clinical Competence↗
PubMed2000

Measuring compliance with preventive care guidelines: standardized patients, clinical vignettes, and the medical record.

OBJECTIVE: To determine how accurately preventive care reported in the medical record reflects actual physician practice or competence. DESIGN: Scoring criteria based on national guidelines were developed for 7 separate items of preventive care. The preventive care provided by randomly selected physicians was measured prospectively for each of the 7 items. Three measurement methods were used for comparison: (1) the abstracted medical record from a standardized patient (SP) visit; (2) explicit reports of physician practice during those visits from the SPs, who were actors trained to present undetected as patients; and (3) physician responses to written case scenarios (vignettes) identical to the SP presentations. SETTING: The general medicine primary care clinics of two university-afflliated VA medical centers. PARTICIPANTS: Twenty randomly selected physicians (10 at each site) from among eligible second- and third-year general internal medicine residents and attending physicians. MEASUREMENTS AND MAIN RESULTS: Physicians saw 160 SPs (8 cases x 20 physicians). We calculated the percentage of visits in which each prevention item was recorded in the chart, determined the marginal percentage improvement of SP checklists and vignettes over chart abstraction alone, and compared the three methods using an analysis-of-variance model. We found that chart abstraction underestimated overall prevention compliance by 16% (P < .01) compared with SP checklists. Chart abstraction scores were lower than SP checklists for all seven items and lower than vignettes for four items. The marginal percentage improvement of SP checklists and vignettes to performance as measured by chart abstraction was significant for all seven prevention items and raised the overall prevention scores from 46% to 72% (P < .0001). CONCLUSIONS: These data indicate that physicians perform more preventive care than they report in the medical record. Thus, benchmarks of preventive care by individual physicians and institutions that rely solely on the medical record may be misleading, at best.

Adult↗
PubMed2000

Improving the public sector: can reengineering identify how to boost efficiency and effectiveness at a VA medical center?

Reengineering is a widespread management technique, but few evaluations of its application in health care, especially in public sector organizations, have been reported. We conducted a reengineering analysis to determine if the method could identify how to improve the efficiency and effectiveness of a VA medical center's primary care delivery system. We found that the reengineering method appears applicable in the institutional context of a public sector teaching hospital.

Benchmarking↗
PubMed1999

Measuring the social responsiveness of medical schools: setting the standards.

This article calls for medical schools to use a new set of standards to gauge how well they contribute to social welfare. Because medical schools receive public funding and are given the authority to certify that providers are sufficiently trained, they incur an obligation to be socially responsible. In addition to setting and using higher standards, medical schools should call on their credibility and use their scientific expertise to find new policies that promote social welfare. In particular, they should do research on socially oriented policies and participate more actively in debates about health sector reform. Although societies vary and have different values, most countries and peoples probably share the following social objectives: They want to use limited public and private resources rationally to produce the best possible health, they do not want individuals or groups to suffer, and they want to protect people against catastrophic illness and associated financial losses. Although new standards are needed, medical schools should be encouraged to continue producing technically sophisticated providers and conducting high-level basic and clinical research. Available evidence suggests that medical schools can further contribute to the three social objectives noted above by increasing the intensity and relevancy of primary care training, expanding the curriculum beyond its biomedical focus, encouraging research in health services, and assessing the effectiveness of social policy in improving the health of the population.

Curriculum↗
PubMed1998

How far down the managed care road? A comparison of primary care outpatient services in a Veterans Affairs medical center and a capitated multispecialty group practice.

BACKGROUND: Under increasing pressure to provide more efficient, higher-quality care, the Department of Veterans Affairs (VA) is expanding primary care and implementing other managed care techniques. To assess the magnitude of performance improvement possible in the VA and to investigate potential barriers to implementation of new techniques, we compared a VA facility with similar managed care organizations on specific managed care performance benchmarks. METHODS AND DATA COLLECTION: Detailed case studies of a large VA medical center and a large capitated multispecialty group practice in the same region were carried out. Various qualitative and quantitative data were collected between October 1, 1994, and September 30, 1997. Unstructured and semistructured interviews, participant and direct observations, document review, electronic data abstractions, and patient surveys were used to collect the data. RESULTS: Patients in the VA medical center were poorer (average income, $13300 per year), older (36.5% aged 65 years and older), and more likely to be homeless (10.5%). The VA patients saw more specialists and made more emergency department visits than managed care patients. Although the VA had better electronic information flows, its providers saw fewer patients, had more unscheduled visits, and received fewer consultant reports, and its patients waited longer. Inpatient utilization was also higher (length of stay averaged 8 days) among VA primary care patients. CONCLUSIONS: On many dimensions the VA did not compare favorably with the efficiency or lower utilization of the capitated managed care practice. Part of the reason must be attributed to the VA's multiple missions, which include teaching and research; another reason is the VA's role to be a service provider to all eligible veterans regardless of sociodemographic or health characteristics. Whether these differences are also caused by different case mix, or differences in socioeconomic status of patients, surprisingly is not well understood. This hampers future efforts to use managed care techniques to improve the operation of the VA.

Age Factors↗
PubMed1998

The policy implications of better structure and process on birth outcomes in Jamaica.

BACKGROUND: We investigated if better structural and process elements of prenatal care relate to higher birth weights in the Jamaican population. METHODS: We used data from two surveys: (1) a national sample of randomly selected households; and (2) a concurrent facility survey of the public health clinics in Jamaica. In the household survey, all women aged 14-50, who had a pregnancy lasting 7 months during the previous 5 years (n = 913) were interviewed. From the household survey, we gathered information on the maternal, clinical and socioeconomic risk factors and on the newborns birth weight (the outcome measure). The facility survey collected data from all public primary care clinics in the country (n = 366). This gave us information on the quality of care (structure and process measures) provided in the clinics. FINDINGS: Prenatal care in Jamaica, while generally available, provides care to many women who are at particular risk because of parity, age and poverty. Structural measures of the facilities show that clinics are in general disrepair, have only 70% of the basic equipment and are insufficiently stocked with supplies or medication. Many facilities had poor process of care, as measured by assessing the clinical examination and counseling. The average birth weight was 3232 g and 9.8% weighed < 2500 g. The relationships between birth weight and the quality of care were estimated using multiple regression. The biologic and socioeconomic risk factors related to birth weight in the expected direction. None of the structural quality measures were statistically significant. Among the process measures, women who had access to a more complete examination, had infants that weighed an average of 128 g more at birth. INTERPRETATION: Better quality of care, provided by a more thorough clinical evaluation, has a more powerful effect on birth weight in the population than upgraded facilities or equipment. In developed or developing countries, where resources are limited, policy should focus on education and training to improve birth outcomes.

Adolescent↗
PubMed1997

The role of medical necessity and cost-effectiveness in making medical decisions.

The term "medical necessity" is used ubiquitously in health care, but its meaning and implementation vary substantially among providers, payers, and patients. This ambiguity has led some to suggest that cost-effectiveness be used as a basis for decision rules. This paper presents an analytical framework that is familiar to clinicians and shows that medical necessity and cost-effectiveness do not provide deterministic rules for clinical decision making. First, 2 x 2 tables are used to show the tradeoff between the sensitivity and specificity of decision rules. Then, the example of asymptomatic abdominal aortic aneurysm is used to show that these tradeoffs can be seen as a continuum of decision rules on a receiver-operating characteristic curve. Society can therefore choose a decision threshold on the basis of medical necessity that optimizes the number of lives saved or any other desired outcome, but the tradeoff between sensitivity and specificity cannot be avoided. Applying cost-effectiveness criteria may change the decision threshold because cost-effectiveness itself involves inherent tradeoffs that create additional ambiguity for clinical decisions. The conclusion is that decision rules based on medical necessity or cost-effectiveness should not be considered deterministic. Rather, decision rules are useful when they make assumptions explicit and specify tradeoffs so that clinicians, patients, and payers can make better decisions.

Cost-Benefit Analysis↗
PubMed1997

Are clinical criteria just proxies for socioeconomic status? A study of low birth weight in Jamaica.

OBJECTIVE: To determine if the clinical risk factors for low birth weight are independent of socioeconomic risk factors in a population based sample from a developing country. DESIGN: Survey data from patient reported socioeconomic measures and their most recent pregnancy history. SETTING: A national sample of randomly selected households in Jamaica. SUBJECTS: All women aged 14-50 in the household who had a pregnancy lasting seven months in the past five years (n = 952). MAIN OUTCOME MEASURE: Birth weight. RESULTS: Clinical risk factors for low birth weight, such as parity age, are independent of socioeconomic determinants, such as consumption and where a mother lives. Women who are nulliparous, 35 or older, poor, or living in certain areas are more likely to have lower birth weight children than those that do not have these characteristics (t statistics > 2.0). The addition of socioeconomic factors to the multiple regression does not alter the estimates for the clinical risk factors for low birth weight. Thus, the effect of being nulliparous can be offset by being in the highest consumption quintile and, conversely, the risk of being older will be compounded if women are poor. CONCLUSIONS: Both clinical and socioeconomic risk factors should be used to target women at risk. In terms of the quality of care, this study links clinical and socioeconomic risk factors to poor outcomes. Further studies are needed, however, to link the quality of care at various locations to these outcomes.

Adolescent↗
PubMed1996

Translating clinical practice into health policy: an example from China.

Understanding a health problem and even having the technological capability to solve it are often not enough to lead to changes in health policy. To help accomplish such policy changes, we propose a five-step approach that involves (1) specifying the disciplines; (2) developing multidisciplinary hypotheses; (3) investigating the hypotheses; (4) developing a policy 'story'; and (5) advocating these solutions to policy makers. We use the example of neonatal hypothermia in Eastern China to illustrate this approach. We found that the approach both better informed policy and better motivated policy change. Using the approach extended our involvement from the hospital to a wider population; in addition our initial solutions expanded from clinical interventions to broader public health approaches that proved to be quite different from our original recommendations.

China↗
PubMed1996

Economic reform and health sector policy: lessons from structural adjustment programs.

From a purely economic perspective, structural adjustment programs (SAPs) and economic reform policies are viewed as short-term austerities that lead to long-term growth and development. These intertemporal trade-offs, however, are not always acceptable in health. Unique biologic events such as intrauterine development and neural development cannot be postponed even for a short period. Health policymakers need to understand the expected and unexpected impacts of economic reform on health outcomes in individuals and on the population. The interactions are complex, involve multiple sectors, and can be better understood by looking at the experience of developing countries over almost fifteen years of SAP experience. Health care budgets may be vulnerable to reduced government spending, quality of care deteriorates, nutrition will suffer more likely in urban areas, and cost-effective preventive programs may stop if labor and capital are not properly matched. Health outcomes overall do not appear to suffer but a more detailed look, with better data, shows that the incidence of preventable diseases rises and irreversible deterioration in health status does occur within countries. To prevent this from happening in the future, health policymakers need to take a multidisciplinary focus to first understand the effects of economic reform and then to plan a coordinated response. Better data, alternative financing, and strong political leadership are also important lessons.

Cost Control↗
PubMed1995

Health for all in the Republic of Korea: one country's experience with implementing universal health care.

Health care reforms in many countries face the twin challenges of providing universal coverage while controlling spiraling costs. Sixteen years ago the Republic of Korea had no national plan for health insurance, and only 8.8% of the population was covered. In 1975, health care accounted for 2.8% of GDP with government providing 12% of the finances. In 1977, Korea adopted a policy designed to achieve universal coverage while maintaining fee-for-service reimbursement. Korea incrementally established an employer based health care scheme by first mandating coverage for businesses, then government employees and teachers. Coverage was later extended to the poor, the self-employed, and residents of rural areas. Independent insurance societies manage each scheme, set premiums and co-payments, and are responsible for maintaining financial viability. By 1991, 30% of Korea's health care expenditures were from public funds, and health care costs had risen to 7.1% of GDP. Health care reform in Korea has been successful in achieving universal coverage, providing for a full range of services, and eliminating adverse selection. The system is financially solvent, costs are equitably distributed with the government providing subsidies when necessary, and small businesses have not been unduly burdened economically. Attempts to limit costs, however, have been unsuccessful. Patient demand for health care has remained surprisingly resistant to increasing co-payments. Providers have responded to lower physician and hospital fees by providing shorter, more frequent patient visits, relabeling services, and increasing hospital admissions. Competition between insurance societies has not materialized in a meaningful way to control costs.

Health Care Costs↗