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Biomedical subjects

L F McMahon

Publications and source records attributed to L F McMahon.

At least 37 records · Page 2Linked to original sources
PubMed1991

Measuring outcomes of hospital care using multiple risk-adjusted indexes.

Using existing data sources, we developed three risk-adjusted measures of hospital quality: the risk-adjusted mortality index (RAMI), the risk-adjusted readmissions index (RARI), and the risk-adjusted complication index (RACI). We describe the construction and validation of each of these indexes. After these measures were developed, we tested the relationships among the three indexes using a sample of 300 hospitals. Actual numbers of adverse events were observed for each hospital and compared to the number predicted by the RAMI, RARI, and RACI models. Then each hospital was ranked on each index. Our results showed that no relationship existed between a hospital's ranking on any one of these indexes and its ranking on the other two indexes. This result provides some evidence that no measure of quality should be used by itself to represent different aspects of the quality of hospital care. Adequate overall measures of hospital quality will need to include multiple measures in order to be credible and to reflect the complexity of hospital care. The findings suggest that consumers, payers, and policymakers cannot simply choose one hospitalwide measure, such as the mortality rate, to validly represent a hospital's performance: those hospitals with high rankings on their mortality rates do not necessarily rank high on their readmission rates or complication rates.

Abstracting and Indexing↗
PubMed1990

An integrated inpatient management model.

The academic health center has emerged as the cornerstone of the American health care system. To assess the vulnerability of the academic medical center to the new competitive forces that exist today, a prototype project has been developed that attempts to address the issue of competition in clinical activity, while at the same time enhancing the academic health center's education and research roles.

Academic Medical Centers↗
PubMed1990

Small-area analysis of gastrointestinal disease hospital discharge variation: are the poor at risk?

Capitation plans may place their enrollees at risk of rationed services if they do not adjust for underlying patient characteristics that dictate differing levels of care. To assess the degree to which population-based socioeconomic characteristics are associated with hospital use, this study explored small-area variation in hospital discharges for gastrointestinal and liver (GI) Diagnosis Related Groups (DRGs). Utilizing a 1980 Michigan database of 1.5 million discharges, we constructed age-adjusted, population-based discharge rates for the GI DRGs. We then evaluated the effect of poverty, defined by the percent of households in a hospital market community below the poverty line. Using regression techniques, we found that poverty explained 27.5% of the variation in GI hospital discharges, with the poor admitted more often (p less than 0.0001). Using cost weighted discharge rates as the dependent variable, we found that poverty explained 20.3% (p = 0.0003) of the variation in cost weighted discharges. These results suggest that poverty explains a significant amount of variation in hospital discharges and has a significant effect on associated small-area hospitalization costs in GI diseases. Practicing gastroenterologists and surgeons need to be aware of factors that influence patients utilizing their services in order to retain their role as patient advocates as changes in payment systems are suggested.

Capitation Fee↗
PubMed1990

A critique of the Harvard Resource-Based Relative Value Scale.

Physician payment reform has assumed a prominent place in the national health policy debate. A key component in this debate is the Harvard Resource-Based Relative Value Scale (RBRVS). The Harvard research effort relied upon several necessary methodologic assumptions and compromises that must be understood to appreciate the RBRVS's strengths and weaknesses. For example, the Harvard group surveyed too few cases to cover the range of clinical practice in a specialty, had too little input in the selection of cases that were judged to be the same or equivalent between specialties, and used an unproven extrapolation methodology to assign final values for total work to non-surveyed physician services. This methodology led to a number of anomalies in the final RBRVS, such as values for comprehensive services for some specialties that were lower for new than for established patients, and total work values for many new patient office services that were lower for Internal Medicine than for Family Practice, a finding inconsistent with empiric evidence. The Harvard RBRVS represents a significant contribution that increases our understanding of physician practice. The system should not be viewed as a finished product. Further investigation and explanation of the assumptions and anomalies are needed to construct a system that reflects adequately the complexity in physician work.

Economics, Medical↗
PubMed1990

Measuring hospital performance. The development and validation of risk-adjusted indexes of mortality, readmissions, and complications.

In this study we used information from discharge abstracts to develop three different risk-adjusted measures of hospital performance: a Risk-Adjusted Mortality Index, a Risk-Adjusted Readmissions Index, and a Risk-Adjusted Complications Index. The adjustments have face validity, and appear to account for much of the variation across hospitals in the rates of these adverse events. The indexes are stable over time, and are not biased with respect to hospital size, ownership, or teaching status. All three indexes appear to have construct validity when tested against the changes in hospital care that occurred when PPS was introduced.

Abstracting and Indexing↗
PubMed1989

The integrated inpatient management model. A new approach to clinical practice.

The delivery and financing of health care have undergone a metamorphosis over the past 10 years. These changes have been particularly dramatic for hospital care. The new health care environment, with more prospective-payment and managed-care systems and less fee-for-service payment for both physicians and hospitals, has made physicians and hospitals mutually dependent. A hospital's long-term financial viability is now dependent largely on the practice style of its physicians. The Department of Internal Medicine at The University of Michigan has developed a new clinical management system called the Integrated Inpatient Management Model (IIMM). This new system includes a major revision of the hospital organization structure, new administrative information systems, and new clinical information systems. Physicians in the Department of Internal Medicine have assumed for the first time formal organizational responsibility for many aspects of the operations of the inpatient medical service. The IIMM represents a prototype of a system that we believe offers considerable promise for involving physicians to a much greater extent in the management of the nation's hospitals. We hope that describing the system in detail will facilitate the development of other systems for the management of the inpatient practice of internal medicine.

Diagnosis-Related Groups↗
PubMed1989

Small-area variation in hospital discharge rates. Do socioeconomic variables matter?

Although numerous studies have been made of the determinants of small-area variation in hospital discharge rates, there is still disagreement about the role of socioeconomic factors. The lack of consensus stems, in part, from the difficulty in comparing results across studies that use different units and methods of analysis. Many of the studies using well-defined hospital service areas did not have the data needed to conduct a controlled analysis of the determinants of hospital utilization. Most of the studies that have performed controlled analyses have relied on larger geopolitical areas, which are not believed to capture self-contained health care systems. The study described here used a consistent set of data, three methods of analysis, and two units of analysis to test the importance of socioeconomic characteristics in explaining the variation in medical and surgical discharge rates in Michigan. Socioeconomic factors are found to be statistically significant determinants of the variation in both medical and surgical discharge rates, whether the method of analysis is simple correlations or multiple regressions, and whether the unit of analysis is the county or a well-designed hospital service area. These results suggest that previous small-area variation studies may have incorrectly concluded that socioeconomic characteristics do not explain differences in utilization rates.

Hospitals↗
PubMed1989

Variation in hospital admissions among small areas. A comparison of Maine and Michigan.

Analysis of age-adjusted hospital admission profiles among small geographic areas has shown marked variation in hospital admissions for both surgical and medical cases in areas ranging from Maine to Manitoba. Much of the work has been led by John Wennberg and has focused on rural areas. This study examines the degree of variation in hospital admissions in small areas in the state of Michigan to determine whether those diseases that demonstrated high variation in Maine also demonstrated the same degree of variation in Michigan. The data on the degree of variation in 111 modified diagnosis-related groups (M-DRGs) from the state of Maine were supplied by Dr. Wennberg. Using the same M-DRGs, we defined age-adjusted, population-based hospital admission rates for the lower peninsula of Michigan for 1980 among 60 previously defined hospital marked communities. The observed hospital discharge counts in each of the M-DRGs were compared to the expected counts in each of the 60 communities, where the expected count was based on an indirect age adjustment. Both the Maine and Michigan small area data were expressed by the M-DRG's systematic standard deviation in which random variation has been accounted for via a Poisson probability model. It was found that the systematic standard deviations of the M-DRGs in Maine and the M-DRGs in Michigan strongly correlated with a Spearman correlation coefficient of 0.71 (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis-Related Groups↗
PubMed1989

Patterns of surgical and nonsurgical hospital use in Michigan communities from 1980 through 1984.

Hospital discharge rates vary substantially among 60 communities in Michigan. (R2 = 90 percent and R2 = 85 percent of the systematic variance is explained by community effects for nonsurgical and surgical discharges, respectively.) The ranking of communities by discharge rates is stable over a five-year period (Spearman rho = 0.78 for nonsurgical discharges and 0.72 for surgical discharges). Surgical discharge rates decreased substantially (4 percent per year) over this time period, while nonsurgical rates showed no consistent pattern. Communities with exceptional discharge rates showed no substantial or significant regression toward the mean through the five-year study.

Adolescent↗
PubMed1988

Prior hospitalization experience of DRG outliers versus inliers.

The Diagnosis-Related Group (DRG)-based Medicare Prospective Payment System has raised a number of concerns. One major concern has centered on both the definition of outlier patients and how hospitals are to be paid for their care. The epidemiology of outlier patients, however, has received relatively little attention. Using a retrospective database, we constructed a case control study in which the cases were DRG outliers and the control patients were DRG-matched inlier patients. We then examined both the prior hospitalization experience of outlier patients and inlier controls, and the prior outlier experience of the attending physicians of outlier patients and inlier control patients. We demonstrated that DRG-based outlier patients were more likely to have had prior admissions to the hospital as compared with DRG-matched inlier control patients. Moreover, DRG-matched outlier cases were more likely to have had prior outlier admissions as compared to controls--an effect that was more pronounced when only the subset of patients who actually had a prior admission was evaluated. Finally, physicians of the DRG outlier patients were more likely to have had previous outlier patients than physicians of the DRG-matched inlier control patients. In summary, we were able to demonstrate that DRG-based outlier patients have a different prior admission and outlier experience than DRG-matched inlier control patients. However, because we showed the same relationship when we evaluated the outlier experience of physicians of outlier patients as compared to physicians of DRG-matched inlier controls, we were unable to determine if the effect was patient- or physician-based.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis-Related Groups↗
PubMed1988

The Risk-Adjusted Mortality Index. A new measure of hospital performance.

The Commission on Professional and Hospital Activities (CPHA) developed the Risk-Adjusted Mortality Index (RAMI), a method for comparing hospital death rates using existing abstract or billing data. The method is comprehensive insofar as it includes all payers and all types of cases except neonates. RAMI was designed to differentiate among admissions on the basis of the patient characteristics that increase or reduce the risk of dying in the hospital. Using a large national data base, risk factors were determined empirically within each of 310 clusters based on diagnosis-related groups (DRGs). The model was very effective at predicting risk-adjusted outcomes, with a correlation of 0.98 between actual and predicted deaths in a sample of 300 hospitals. RAMI appears to be a powerful tool for using existing data to monitor changes over time in hospital death rates.

Adult↗
PubMed1987

Prediction rules for patients with suspected myocardial infarction. Applying guidelines in community hospitals.

Several clinical prediction rules have been developed to assist physicians in managing intensive care resources for patients with suspected myocardial infarction. These guidelines, developed in university settings, attempt to identify patients at high or low risk for developing life-threatening complications or death. Since some prediction rules have not performed well when applied to different patient populations, we applied these rules to 397 patients with suspected myocardial infarction who were admitted to community hospital coronary care units. The relative risk of dying associated with an abnormal initial electrocardiogram declined from 17 in the academic center to 2.9 in the community hospital. In contrast, a guideline that uses data available after 24 hours of observation did segregate patients at higher and lower risk in both the community and academic hospitals. This study shows that clinical prediction rules that were developed in academic medical centers should be validated before applying them in community hospital settings.

Coronary Care Units↗
PubMed1986

Gastrointestinal bleeding in competitive runners.

Competitive runners have been shown to develop previously undescribed clinical conditions, including "runner's anemia." This has been shown to be an iron-deficiency anemia of several etiologies including gastrointestinal bleeding. Although 8-23% of runners have been shown to have guaiac-positive stools after a marathon, the incidence of significant and prolonged bleeding is unknown. We report four cases of competitive runners with iron-deficiency anemia, gastrointestinal bleeding coinciding with running, and no definitive gastrointestinal pathology despite extensive evaluation.

Adult↗
PubMed1986

Variation in resource use within diagnosis-related groups. The effect of severity of illness and physician practice.

The diagnosis-related group (DRG)-based Medicare prospective payment system pays hospitals a fixed amount for the care of similar patients. The DRG definitions serve as the modifier of payment for Medicare patients. The dependence on these patient definitions raises many questions, among them the reason(s) for observed resource variability within a DRG. Various severity-of-illness measures have been shown to account for some of the resource variability noted within the DRGs. Most severity-of-illness studies to date, however, have not attempted to assess the effect of other known sources of resource variation, such as differing physician practice patterns. The authors examined the ability of severity of illness, as defined by disease staging, and physician practice variation to explain residual intra-DRG variability in length of stay. They demonstrate that physician practice variation accounts for more variance reduction than does severity of illness.

Diagnosis-Related Groups↗