Biomedical subjects
Publications and source records attributed to John E Brush.
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BACKGROUND: Continuous quality improvement (CQI) is widely used in other industries and has been promoted as a method for quality control in medicine. The national databases developed by the American College of Cardiology and the Society of Thoracic Surgeons have greatly facilitated data collection for CQI. Hospitals can encounter barriers to CQI, however, which include creating the proper organizational infrastructure and engaging physicians and hospital administrators in the process. These barriers are particularly evident in large community hospitals. METHODS: We describe the organizational infrastructure for CQI, including committee structure, methods of repeated data collection and feedback, and maintenance of data integrity and confidentiality. We report demographic data and clinical outcomes for patients undergoing percutaneous coronary intervention and coronary artery bypass surgery before and after implementation of our CQI program. RESULTS: Since 1995, we have maintained a CQI process driven by repeated collection of valid, confidential, operator-specific data. We have observed sustained physician and administration participation and buy-in. During the follow-up period, patient complexity increased and observed outcomes improved, although the improvement was clearly multifactorial. CONCLUSIONS: We describe the organization of a CQI program at a large complex community hospital. Our CQI program was successfully implemented, has been sustained, and is associated in observed improvement in patient outcomes. The program described here may be a useful model for other similar hospitals that are attempting to create a program to address quality improvement.
With the proliferation of efforts to report publicly the outcomes of healthcare providers and institutions, there is a growing need to define standards for the methods that are being employed. An interdisciplinary writing group identified 7 preferred attributes of statistical models used for publicly reported outcomes. These attributes include (1) clear and explicit definition of an appropriate patient sample, (2) clinical coherence of model variables, (3) sufficiently high-quality and timely data, (4) designation of an appropriate reference time before which covariates are derived and after which outcomes are measured, (5) use of an appropriate outcome and a standardized period of outcome assessment, (6) application of an analytical approach that takes into account the multilevel organization of data, and (7) disclosure of the methods used to compare outcomes, including disclosure of performance of risk-adjustment methodology in derivation and validation samples.
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BACKGROUND: Short- and long-term comparative follow-up studies of patients receiving primary angioplasty or thrombolytic therapy for acute myocardial infarction show higher 30-day survival, and sustained benefits in mortality, reinfarction and ejection fraction in patients treated with primary angioplasty. Long-term benefits of primary angioplasty on cardiac function performed in community hospitals without surgical back-up have not been fully assessed. METHODS: Sixty-one patients who underwent primary angioplasty were compared with patients receiving thrombolytic therapy who were matched for age, gender and location of acute myocardial infarction. Clinical information, reviewed through August 2000, was provided by retrospective analysis of healthcare databases and office and hospital charts. Mortality data were confirmed by the social security death index. RESULTS: Of the original 61 primary angioplasty patients, two died during initial hospitalization. Of the 59 surviving patients, fifty-four (92%) had complete follow-up averaging 57 months. Of the original 61 thrombolytic therapy patients, three died during initial hospitalization. Of the 58 surviving patients, fifty-two (90%) had complete follow-up averaging 46 months. At follow-up, averaging 57 months, ejection fraction was significantly higher in the primary angioplasty group, as compared with the thrombolytic therapy group (51.4% versus 45.8%, respectively; p = 0.038). There was no statistical difference between the two groups regarding reinfarction, revascularization at > or = 6 months after the initial presentation or cardiac death. CONCLUSIONS: Primary angioplasty performed in a community hospital without surgical back-up results in improved cardiac function when compared to thrombolytic therapy. These results are similar to those reported from large tertiary centers with on-site surgical back-up, and provide an explanation for the improved long-term outcome that is observed in patients with acute myocardial infarction treated with primary angioplasty.