Above all 'do no harm'. How shall we avoid errors in medicine?
Explore the source record for details and available documents.
Drug Utilization↗
Biomedical subjects
K L Kahn
Publications and source records attributed to K L Kahn.
Reductions in cost and cesarean rate by routine use of external cephalic version: a decision analysis.
OBJECTIVE: To describe currently accepted methods for managing the term breech pregnancy, and to predict the delivery outcomes and costs of each method. METHODS: Literature review was used to derive four options for the peripartum management of the term breech pregnancy. Using decision-analysis techniques, we calculated the predicted delivery outcomes and costs associated with each option. RESULTS: Applying external cephalic version to all term breech pregnancies without contraindications to labor or version, and allowing a trial of labor for eligible women who fail version, results in a 25% cesarean rate, at a cost of $8071 per case. Delivering unsuccessful versions by scheduled cesarean results in a 32% cesarean rate, at a cost of $8276 per case. In contrast, a strategy not using external version but allowing a trial of labor for those mothers who meet eligibility criteria results in a 63% cesarean rate, at a cost of $8755 per case. Routinely scheduling a cesarean when a breech is identified at term results in an 89% cesarean rate, at a cost of $9544 per case. CONCLUSIONS: Although the liberal use of vaginal delivery for term breech pregnancies has been suggested as one way of lowering the cesarean rate, the addition of routine external cephalic version to the management strategy will result in more vaginal deliveries and lower costs than strategies that allow vaginal delivery but do not include an attempted cephalic version. Routine cesarean without attempted external cephalic version results in excessive operative deliveries.
Breech Presentation↗
Health care for black and poor hospitalized Medicare patients.
OBJECTIVE: To analyze whether elderly patients who are black or from poor neighborhoods receive worse hospital care than other patients, taking account of hospital effects and using validated measures of quality of care. DESIGN: We compare quality of care provided to insured, hospitalized Medicare patients who are black or live in poor neighborhoods as compared with others, using simple and multivariable comparisons of clinically detailed measures of sickness at admission, quality, and outcomes. SETTING: Two hundred ninety-seven acute care hospitals in 30 areas within five states. PATIENTS OR OTHER PARTICIPANTS: The sample includes a nationally representative sample of 9932 patients 65 years of age or older who lived at home prior to hospitalization for congestive heart failure, acute myocardial infarction, pneumonia, or stroke. INTERVENTIONS: This was an observational study. MAIN OUTCOME MEASURES: Processes of care, length of stay, instability at discharge, discharge destination, and mortality. RESULTS: Within rural, urban nonteaching, and urban teaching hospitals, patients who are black or from poor neighborhoods have worse processes of care and greater instability at discharge than other patients (P < .05). However, this worse quality is offset by patients who are black or from poor neighborhoods being 1.8 times more likely to receive care in urban teaching hospitals that have been shown to provide better quality of care (P < .001). Because these patients receive more of their care in better-quality hospitals, there are no overall differences in quality by race and poverty status. Death rates did not vary by race or poverty status. CONCLUSIONS: Quality of hospital care for insured Medicare patients in influenced both by the patient's race and financial characteristics and by the hospital type in which the patient receives care.
Black or African American↗
Effect of epidural analgesia for labor on the cesarean delivery rate.
OBJECTIVE: To use meta-analysis to evaluate the effect of epidural analgesia on the cesarean delivery rate. DATA SOURCES: The MEDLINE data base was searched for articles published in English between January 1981 and April 1992. We also interviewed experts and conducted a bibliographic follow-up and manual review of recent journals published from April to July 1992. METHODS OF STUDY SELECTION: We excluded articles with irrelevant titles, and those case studies, book chapters, or articles that did not provide primary and relevant data. Two hundred thirty articles were read, including articles that reported on women of standard obstetric risk and on cesarean delivery rates for an epidural group and for a concurrent no-epidural group. These criteria yielded six studies for a primary analysis and two others for a secondary analysis. DATA EXTRACTION AND SYNTHESIS: The sample size of the epidural and no-epidural groups and the number of cesareans within each group were extracted. Tests of homogeneity were conducted. The pooled cesarean delivery risk difference as a result of epidural analgesia was estimated. The cesarean rate for women undergoing epidural analgesia was ten percentage points greater than for no-epidural women (P < .05). More than a nine percentage point increase was shown for cesarean deliveries for dystocia (P < .05), when pooling either all studies or only randomized studies. CONCLUSIONS: The results of this meta-analysis strongly support an increase in cesarean delivery associated with epidural analgesia. Further research should evaluate the balance between analgesia associated with the use of epidurals, and postpartum morbidity and costs associated with cesarean deliveries.
Analgesia, Epidural↗
Why do sicker patients cost more? A charge-based analysis of patients undergoing prostatectomy.
Hospitals are reimbursed a greater amount for Medicare patients undergoing prostate surgery who have comorbid and complicating conditions than for patients without these conditions, since the former have been shown to have higher hospital costs and charges. We attempted to determine whether the higher hospital charges are due to duration of hospital stay and/or intensity of services. We analyzed hospital discharge data from 799 patients undergoing radical or transurethral prostatectomy during a 3-year period (1988 to 1991) at 2 major teaching hospitals by examining length of stay (duration), charges per hospital day (intensity) and total charges per stay. Mean lengths of stay were significantly longer for sicker versus healthier patients undergoing radical prostatectomy (7.4 versus 6.8 days at hospital 1 and 8.9 versus 7.8 days at hospital 2, p < 0.05) and transurethral prostatectomy (3.5 versus 2.8 days at hospital 1 and 3.5 versus 2.5 days at hospital 2, p < 0.05). Total hospital charges were significantly higher for sicker versus healthier patients undergoing radical prostatectomy ($14,557 versus $13,357 at hospital 1 and $17,864 versus $16,080 at hospital 2, p < 0.05) and transurethral prostatectomy ($6,446 versus $5,012 at hospital 1 and $5,468 versus $3,710 at hospital 2, p < 0.05). However, sicker and healthier patients had similar charges per day for radical prostatectomy ($1,959 versus $1,961 at hospital 1 and $2,006 versus $2,073 at hospital 2, p not significant) and for transurethral prostatectomy ($1.839 versus $1,800 at hospital 1 and $1.544 versus $1,488 at hospital 2, p not significant). On specified hospital days the charges per day for room/nursing, medical/surgical supplies, laboratory services and pharmacy services were similar for patients with and without comorbid conditions. Patients who are more ill at admission remain hospitalized longer after prostatectomy. However, they do not receive more intense care during their stays. For these procedures duration and not intensity appears to be the primary determinant of higher hospital charges for sicker patients.
Comorbidity↗
Narratives of birth and the postpartum: analysis of the focus group responses of new mothers.
Focus groups were conducted to encourage and examine women's frank discussions of the events surrounding their experiences of labor, birth, and the postpartum period. Transcripts of the tape-recorded narratives of 41 new mothers were analyzed and five themes were identified: loss of autonomy and control; unexpected physical pain of childbirth; unexpected emotional reactions; financial pressures; and the effects of support during labor and birth. Participants' perceptions shed light on and supplemented previous questionnaire and interview research on these topics. The survey results suggest ways to help improve women's birth experiences.
Adult↗
Differences in quality of care for hospitalized elderly men and women.
OBJECTIVE: To analyze whether important gender differences exist in the quality of hospital care provided to patients with four major medical conditions. DESIGN: Bivariate and multivariate comparisons of clinically detailed sickness at admission, quality, utilization, and outcome measures. SETTING: Acute care hospitals located in five states. PATIENTS OR OTHER PARTICIPANTS: A total of 11,242 patients 65 years or older who were hospitalized with one of four diseases: congestive heart failure, acute myocardial infarction, pneumonia, and cerebrovascular accident. We derived our data from the nationally representative sample used to study the quality of hospital care for Medicare patients before and after the implementation of the prospective payment system. A hierarchical (nested) cluster sampling design was used to draw disease-specific samples of patients hospitalized in 1981, 1982, 1985, or 1986 in one of 297 hospitals located in 30 areas within five states. INTERVENTIONS: This was an observational study. MAIN OUTCOME MEASURES: Sickness at admission, process, use rates, length of stay, discharge status, discharge destination, and mortality. RESULTS: Sex differences in sickness at admission varied by disease. There was some evidence that women received worse process of care, but the difference was very small. We found many similarities in the process and outcomes of care for male and female patients. CONCLUSIONS: After controlling for sickness at admission, age, and other important covariates, the in-hospital experiences of elderly men and women showed greater similarities than differences. The concern that sex bias enters into clinical decision making during hospitalization is eased, although not entirely eliminated.
Aged↗
Hospital characteristics and quality of care.
OBJECTIVE: To compare quality of care measured by explicit criteria, implicit review, and sickness-adjusted outcomes at different types of hospitals. DESIGN: Further analysis of data retrospectively abstracted from medical records to evaluate the effects of prospective payment on quality of care for hospitalized Medicare patients. SETTING: Hospitals in five states were sampled to represent the national Medicare admissions along many dimensions. PATIENTS: A total of 14,008 elderly patients with one of the following five diseases: congestive heart failure, acute myocardial infarction, pneumonia, stroke, or hip fracture. These patients were randomly sampled from those with these diseases in 297 hospitals in two time periods, 1981 to 1982 and 1985 to 1986. OUTCOME MEASURES: Explicit criteria, implicit review, and mortality within 30 days of admission adjusted for sickness at admission. RESULTS: Quality of care ratings for hospital types are similar using explicit criteria, implicit review, and outcomes adjusted for sickness at admission. Quality differences between types of hospitals were large, with the lowest group estimated to have four percentage points higher mortality than major teaching hospitals in a cohort of patients with average mortality of 16%. Quality varies from state to state, but teaching, larger, and more urban hospitals have better quality in general than nonteaching, small, and rural hospitals. Hospital quality persists over time, but small nonteaching hospitals narrowed the gap with better quality hospitals between 1981 and 1986. CONCLUSIONS: The different measures led to consistent and plausible relationships between quality and hospital characteristics. Thus, valid information about hospital quality can be obtained. We need to develop ways to use such information to improve care.
Algorithms↗
Assessing clinical instability at discharge. The clinician's responsibility.
Explore the source record for details and available documents.
Diagnosis-Related Groups↗
Watching the doctor-watchers. How well do peer review organization methods detect hospital care quality problems?
OBJECTIVE: To determine how well one state's peer review organization (PRO) judged the quality of hospital care compared with an independent, credible judgment of quality of care. DESIGN: Retrospective study comparing a PRO's review, including initial screening, physician review, and final judgments, with an independent "study judgment" based on blinded, structured, implicit reviews of hospital records. SETTING: One state's medical and surgical Medicare hospitalizations during 1985 through 1987 audited randomly by the state's PRO. SAMPLE: Stratified random sampling of records: 62 records that passed the PRO initial screening process and were not referred for PRO physician review; 50 records that failed the PRO screen and then were confirmed by PRO physicians to be "quality problems." INTERVENTION: None. MAIN OUTCOME MEASURE: A study judgment of below standard or standard or above based on the mean of overall ratings by five internists for records in medical diagnosis related groups (DRGs) and by five internists and five surgeons for surgical DRGs. Each step in the PRO review was evaluated for how many records passing or failing that step were judged standard or above or below standard in the study (positive and negative predictive value) and how well that step classified records that the study judged below standard or standard or above (sensitivity and specificity). RESULTS: An estimated 18% of records reviewed by the PRO were below standard according to the study judgment, compared with 6.3% quality problems according to the PRO's final judgment (difference, 12%; 95% confidence interval, 1 to 23). The PRO's initial screening process failed to detect and refer for PRO physician review two of three records that the study judged below standard. In addition, only one of three of the records that PRO physicians judged to be quality problems were judged below standard by the study judgment. Therefore, the PRO's final quality of care judgment and the study judgment agreed little more than expected by chance, especially about poor quality of care. Although the PRO correctly classified 95% of the records that the study judged standard or above, it detected only 11% of records judged below standard by the study. CONCLUSIONS: Most of all, this PRO review process would be improved by additional preliminary screens to identify the 67% of records that the study judged below standard but that passed its initial screening. The screening process also must be more accurate in order to be cost-effective, as it was only slightly better than random sampling at correctly identifying below standard care. More reproducible physician review is also needed and might be accomplished through improved reviewer selection and training, a structured review method, and more physician reviewers per record.
Hospital Records↗
How well does the patient's burden of illness explain differences in outcome?
Explore the source record for details and available documents.
Hospitalization↗
Assigning appropriateness ratings for diagnostic upper gastrointestinal endoscopy using two different approaches.
Methods that combine information in the medical literature with expert clinical judgment are needed to determine the appropriateness of use of a procedure. The purpose of this study is to better understand the reliability and construct validity of this process by comparing ratings of appropriateness for diagnostic upper gastrointestinal endoscopy that were developed using different approaches by two independent groups. Both the RAND/UCLA Health Services Utilization Study (HSUS) and the American Society for Gastrointestinal Endoscopy (ASGE) combined scientific data with expert physician judgment to rate the appropriateness of specific clinical indications for the use of upper gastrointestinal endoscopy. This study applies the ratings developed by each group to a nationally representative sample of 1,585 endoscopies performed on people 65 years of age and older in 1981. HSUS developed indications that could be used to rate all 1,585 procedures; ASGE indications were less comprehensive and applied to 70% (n = 1,115) of procedures. Of those rated by both groups, appropriateness category ratings agreed for 94% of the procedures. However, the procedures not rated by ASGE were unevenly distributed across HSUS appropriateness ratings. Twelve percent of procedures rated as appropriate by HSUS were not rated by ASGE, but 80% of procedures rated as equivocal by HSUS and 73% rated as inappropriate by HSUS were not rated by ASGE, for those procedures rated by both approaches there was good agreement; however, a more explicit and comprehensive method may be required if equivocal and inappropriate use of a procedure is to be identified.
Aged↗
HMO vs fee-for-service care of older persons with acute myocardial infarction.
OBJECTIVES: Health maintenance organizations (HMOs) continue to grow in number and in their enrollment of Medicare recipients. They are also increasingly viewed as organizational structures that might contribute to control of health care costs. Yet little is known about the quality of care that elderly HMO enrollees receive. METHODS: We compared patients from three HMOs to a fee-for-service (FFS) sample that was national in scope. Sickness at admission, the quality of process of care, and mortality were assessed for patients aged 65 years and older who had been hospitalized with a diagnosis of acute myocardial infarction. RESULTS: After adjustment for sickness at admission, there were no significant mortality differences between the HMO and FFS groups at either 30 (23.2% vs 23.5%) or 180 days (34.4% vs 34.5%) after admission. Compliance with process criteria was higher for the HMO group as a whole (P < .05). The HMOs had greater compliance with three of five scales measuring different aspects of care for patients with acute myocardial infarction. CONCLUSIONS: We conclude that older patients from our participating HMOs who were hospitalized for acute myocardial infarction received hospital care that was generally better in terms of process than that received by patients in a national FFS sample.
Age Factors↗
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↗