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Biomedical subjects

K N Lohr

Publications and source records attributed to K N Lohr.

At least 19 recordsLinked to original sources
PubMed1992

Medicare: a strategy for quality assurance, V: Quality of care in a changing health care environment.

This article, the fifth and final in a series, provides a retrospective wrap-up of an Institute of Medicine (IOM) study to develop a strategy for quality review and assurance in Medicare. Portions of that report were adapted for four articles in QRB in January, March, August, and October 1991. This final article reflects on selected developments in the period since the IOM report first appeared, particularly those involving other IOM activities, in the context of certain of the findings, conclusions, and recommendations of the IOM study committee on Medicare quality assurance.

Health Services Research↗
PubMed1992

Reasonable expectations: from the Institute of Medicine. Interview by Paul M. Schyve.

When the Omnibus Budget Reconciliation Act of 1989 created a new agency in the U.S. Public Health Service to foster the development of practice guidelines and outcomes and effectiveness research, the Institute of Medicine was engaged to develop the criteria for guideline development and medical review. The new agency--the Agency for Health Care Policy and Research (AHCPR)--has used those criteria to develop and disseminate its first three commissioned guidelines, released this spring. Those criteria are elaborated in the IOM's 1990 book. In a second book, released this summer, the IOM Committee on Clinical Practice Guidelines reviews the constructive expectations for guidelines and the conditions needed to ensure rigor in their development, application, evaluation, and revision to help realize these expectations. Key recommendations for action are development of an instrument to assess guidelines and establishment of an organization to carry out the assessment of guidelines. In an appendix, the report offers "A Provisional Instrument for Assessing Clinical Practice Guidelines." While asking that organizations undertake more field testing and revision of the instrument, the Committee on Clinical Practice Guidelines believes that the provisional instrument will be useful as an educational tool for those beginning to develop guidelines, a self-assessment tool that developers of guidelines can use to check their work, and a tool for external groups to use in judging whether a set of guidelines should or should not be recommended or adopted.

District of Columbia↗
PubMed1992

Applications of health status assessment measures in clinical practice. Overview of the third conference on advances in health status assessment.

To what purposes can the measurement of health status and health-related quality of life in clinical practice be put? What success might be expected from such endeavors? What obstacles lie in the way of that success? This monograph reports on the proceedings of a conference (the third in a series on advances in health status assessment) convened to address those questions. It presents two papers concerned with barriers to and benefits of health status and quality-of-life measurement in clinical practice and another two on strategies for overcoming those barriers and exploiting the benefits; also included are papers on historical forces motivating the use of these measures, one special address on ethical issues, eight presentations on empirical research in clinical settings, several panel discussions, and four methods roundtables. A broad conclusion to be drawn from the conference proceedings is that good methods and tools for health status assessment are here and are being used in many ways, but mostly for purposes other than routine patient care. Enthusiasm for fostering the diffusion of assessment instruments into practice settings is real, but so are the doubts, particularly for clinicians "in the trenches" of everyday practice, that widespread understanding and use can be achieved easily or quickly. The challenge for the field is to be aware of and sensitive to the uncertainties and misgivings of those in clinical practice, to address those apprehensions through both formal research and practical tests, and to maintain the momentum of communication and collaboration carried forward by this third conference.

Activities of Daily Living↗
PubMed1991

Medicare: a strategy for quality assurance, I: A recapitulation of the study and a definition of quality of care.

The first of a series of articles on the Institute of Medicine study on a quality review and assurance program for Medicare, this article reviews the findings, conclusions, and recommendations of the IOM study committee and discusses the quality-of-care definition, which became a focal point for the report. A QA system should achieve a balance among important dimensions of "quality of care;" several such dimensions were identified. Turning the definition into practical measurement and intervention approaches and implementing a QA strategy based on it remain significant challenges.

Medicare↗
PubMed1991

Medicare: a strategy for quality assurance, II: Site visits.

The second of a series of articles on the Institute of Medicine study on a quality review and assurance program for Medicare, this article recapitulates the findings of site visits conducted between October 1988 and May 1989. The issues and concerns raised by site visit hosts, as listed in the IOM report, are discussed in detail. For example, concerns about QA methods include those regarding the duplication of quality review and assurance efforts, the value of education and feedback of quality-of-care information, disclosure, dealing with the very poor practitioner, and improving average practice. Most problems of quality and QA identified by the organizations visited are those of "systems" rather than individual providers, which itself is an important finding.

Attitude of Health Personnel↗
PubMed1991

Medicare: a strategy for quality assurance, III: Beneficiary and physician focus groups.

The third of a series on the Institute of Medicine study on a quality review and assurance program for Medicare, this article describes findings on two separate series of focus groups held with Medicare beneficiaries and with physicians in private practice. The respondents' perceptions of quality of care, understanding of the Medicare program and QA activities, and recommendations for improvement are reported directly and examined for implications for designing a coherent QA strategy. A surprising finding is that both beneficiaries and physicians define quality of care in terms of the "art of care" as well as in technical and clinical terms.

Attitude of Health Personnel↗
PubMed1990

Use of insurance claims data in measuring quality of care.

This article discusses data that might be used for measuring quality of care, for health care administrative purposes, and for tracking the use of technologies. The advantages and limitations of administrative data banks for research purposes and some process-of-care and outcome analysis are noted. Three important obstacles to their use--reliability of diagnosis and service information, unique patient identifiers, and provider identifiers--are discussed briefly.

Health Services Research↗
PubMed1990

Quality of ambulatory care. Epidemiology and comparison by insurance status and income.

In this report the data from medical history questionnaires, screening examinations, insurance claims, and a face-to-face physician interview were used to examine the quality of ambulatory care received for 17 chronic conditions by a general population of 5986 adults (less than or equal to 65) and children (less than or equal to 14) enrolled in the RAND Health Insurance Experiment. Subjects in six U.S. sites were randomly assigned to insurance plans that were free or that required cost sharing, or in one site to an HMO. Quality-of-care criteria--both process (what was done to patients) and outcome (what happened to them)--were developed. Overall, 81% of outcome criteria and 62% of process criteria were met. Physicians interviewed patients with selected conditions at the Experiment's end to evaluate care. They suggested that approximately 70% of patients should have their current therapy changed, but only 30% of patients would obtain more than minor improvement from such a change. Clinically meaningful plan differences in quality of care were observed only for the process criteria dealing with the need for a visit (free plan compliance 59%; cost sharing compliance 52%). Quality of care for the poor was slightly worse than for the nonpoor and persons randomized to an HMO had slightly better overall quality of care than those in the fee-for-service system. Substantial improvements in the quality of the process of care could be made, but impact on outcome may be small. Results of the analysis suggest the need for development of clinical models to test the relationship between specific process criteria and improvements in outcome.

Adult↗
PubMed1989

Advances in health status assessment. Overview of the conference.

Although the art and science of health status measurement have a considerable history that is in some ways as old as the healing arts themselves, interest and developments in this field have accelerated in the last two decades. To take advantage of this encouraging environment, the Henry J. Kaiser Family Foundation sponsored its second conference on Advances in Health Status Assessment. It had two major goals: first, to let developers and potential users of health assessment tools explore further the conceptual and methodologic issues of particular concern to them; second, to highlight advances in applying these tools to clinical practice, clinical and biomedical research, and policy research. This monograph reports on the proceedings of that conference: three overviews and nine empirical reports in the above mentioned areas, one special report on health promotion, and four studies on particular methodologic issues: barriers to the use of health status assessment instruments; the advantages and limitations of generic and disease-specific measures; incorporating patient utilities into health status measures; and discounting. The conference highlighted both the considerable advances made in this field in the recent past and the numerous conceptual, methodologic, and practical problems yet to be resolved.

Health Services Research↗
PubMed1989

Differences among hospitals in Medicare patient mortality.

Using hospital discharge abstract data for fiscal year 1984 for all acute care hospitals treating Medicare patients (age greater than or equal to 65), we measured four mortality rates: inpatient deaths, deaths within 30 days after discharge, and deaths within two fixed periods following admission (30 days, and the 95th percentile length of stay for each condition). The metric of interest was the probability that a hospital would have as many deaths as it did (taking age, race, and sex into account). Differences among hospitals in inpatient death rates were large and significant (p less than .05) for 22 of 48 specific conditions studied and for all conditions together; among these 22 "high-variation" conditions, medical conditions accounted for far more deaths than did surgical conditions. We compared pairs of conditions in terms of hospital rankings by probability of observed numbers of inpatient deaths; we found relatively low correlations (Spearman correlation coefficients of 0.3 or lower) for most comparisons except between a few surgical conditions. When we compared different pairs of the four death measures on their rankings of hospitals by probabilities of the observed numbers of deaths, the correlations were moderate to high (Spearman correlation coefficients of 0.54 to 0.99). Hospitals with low probabilities of the number of observed deaths were not distributed randomly geographically; a small number of states had significantly more than their share of these hospitals (p less than .01). Information from hospital discharge abstract data is insufficient to determine the extent to which differences in severity of illness or quality of care account for this marked variability, so data on hospital death rates cannot now be used to draw inferences about quality of care. The magnitude of variability in death rates and the geographic clustering of facilities with low probabilities, however, both argue for further study of hospital death rates. These data may prove most useful as a screening mechanism to identify patterns of potentially poor quality of care. Careful choice of the mortality measure used is needed, however, to maximize the probability of identifying those hospitals, and only those hospitals, warranting more in-depth review.

Aged↗
PubMed1988

Outcome measurement: concepts and questions.

Outcome measurement-a central concept of quality of care-has both conceptual appeal and limitations as a practical assessment tool. The degree to which outcomes can be directly related to processes of care continues to be especially problematic. I view the continued debate about whether processes or outcomes are the preferable measure of quality as fundamentally unproductive, because both are needed. To strengthen our understanding of both measures in ascertaining quality of care, I suggest that work in four areas is needed: more definitive evidence of process and outcome linkages; stronger relationships between technology assessment and quality assessment; improved reliability and validity of outcome measures as screening tools; and continued development of health status measures.

Consumer Behavior↗
PubMed1987

The effect of cost sharing on the use of antibiotics in ambulatory care: results from a population-based randomized controlled trial.

Little is known about how generosity of insurance and population characteristics affect quantity or appropriateness of antibiotic use. Using insurance claims for antibiotics from 5765 non-elderly people who lived in six sites in the United States and were randomly assigned to insurance plans varying by level of cost-sharing, we describe how antibiotic use varies by insurance plan, diagnosis and health status, geographic area, and demographic characteristics. People with free medical care used 85% more antibiotics than those required to pay some portion of their medical bills (controlling for all other variables). Antibiotic use was significantly more common among women, the very young, patients with poorer health, and persons with higher income. Use of antibiotics for viral, viral-bacterial, and bacterial conditions did not differ between free and cost-sharing insurance plans, given antibiotics were the treatment of choice. Cost sharing reduced inappropriate and appropriate antibiotic use to a similar degree.

Adult↗