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Biomedical subjects

L Wyszewianski

Publications and source records attributed to L Wyszewianski.

At least 19 recordsLinked to original sources
PubMed2000

Strategies for changing clinicians' practice patterns. A new perspective.

How can we persuade clinicians to adopt proven practices? Education, incentives, feedback, social marketing, and various other change strategies have inconsistent and unpredictable effects. We propose a theoretical framework that can provide a reliable basis for selecting effective change strategies. We divide clinicians into 4 categories on the basis of their responses to new information about the effectiveness of clinical strategies. We similarly divide the universe of practice change strategies into knowledge-oriented and behavior-oriented methods. We then show why specific combinations of these strategies are likely to be consistently effective for each of the 4 categories of clinicians.

Diffusion of Innovation↗
PubMed1997

Changing clinicians' behaviors in an academic medical center: does institutional commitment to total quality management matter?

The purpose of this project was to determine whether changing clinicians' behaviors to reduce costs in a large academic medical center is facilitated by the prior existence of a total quality management program. Ten teams, made up primarily of clinicians, were charged with devising strategies for altering specific clinical behaviors to reduce costs without detriment to quality of care. Half the teams followed the center's total quality management approach. Team success was assessed by how well three key tasks were completed: problem definition, design of plan of action, and plan implementation. Two teams achieved outright successes, three had outright failures, and five were in between. Adherence to a total quality management approach was not found to be associated with team success. A much better predictor of success was the level of involvement and support by clinicians and managers; because that factor is largely controlled by institutional incentives, those incentives may need to be realigned before the effectiveness of a total quality management approach can be properly evaluated.

Academic Medical Centers↗
PubMed1990

Quality of ambulatory care for the elderly: formulating evaluation criteria.

Efforts to assess the quality of ambulatory care services provided to Medicare beneficiaries cannot meaningfully proceed unless a concerted effort is made to develop criteria and standards for ambulatory care quality assessment that reflect the specific characteristics and needs of the elderly. In this article, we describe some of those characteristics and needs--such as physical and mental impairments and multiple coexisting conditions--and we show how they affect the care provided to the elderly and, therefore, the proper assessment of that care. We also outline an approach for the orderly development of the requisite criteria and standards.

Aged↗
PubMed1988

Quality of care: past achievements and future challenges.

The heightened attention currently given to quality of care offers a unique opportunity for major advances. But to make the most of it, the greater energy and resources now available have to build on what is already known about quality of care, rather than largely ignore and therefore rediscover what has been learned in the past about, for example: how quality can be defined and measured, the relation between outcomes and the process of care, and the distinction between quality assessment and determinations of efficacy. If future efforts are rooted in what is known about these and other aspects of quality of care, they can yield substantial insights into how to improve quality, rather than simply how to measure it, and how to do it for more than inpatient hospital care.

Cost Control↗
PubMed1988

The emphasis on measurement in quality assurance: reasons and implications.

Quality assurance initiatives and studies have focused more on the measurement of quality than on quality improvement and control. The bias toward measurement of current efforts is attributable to the marked preference for a competitive approach to quality assurance, in which measures play a central, triggering role. Reinforcing this bias is a long-standing belief that too little is known about measuring or even defining quality. This paper examines and evaluates these rationales. It concludes that a strong case can be made for pursuing a different overall strategy, one more balanced toward quality improvement and control and, within quality measurement itself, one less focused on the kinds of global outcome measures currently associated with the competitive approach to quality assurance.

Accreditation↗
PubMed1987

Case-based payment and the control of quality and efficiency in hospitals.

Case-based payment systems are rapidly becoming the dominant force in current efforts to control hospital inpatient expenditures. But as reliance on them grows, so does the fear that some, if not all, of the resulting reductions in costs will be achieved at the expense of lowering quality of care. In this paper we argue that such fears, while justified, may keep us from recognizing the positive effect that case-based payment systems can have on quality of care: These new payment systems are likely to foster controls that, to the extent they are successful in increasing efficiency, are also well suited to the control of quality of care. We discuss how and why hospitals can be expected to adopt control systems that are explicitly aimed at enhancing both efficiency and quality.

Attitude of Health Personnel↗
PubMed1987

The future of kidney transplantation. The effect of improvements in survival rate on the shortage of donated kidneys.

New drugs and other medical advances in organ transplantation are expected to increase the rate of retention of transplanted kidneys, or grafts, and therefore also raise patient survival rates. In particular, the immunosuppressive drug cyclosporine has been found to reduce the likelihood of rejection of a transplanted kidney by the immune system of the transplant recipient. A critical issue is the effect changes in the graft and patient survival rates will have on the current shortage of donated kidneys. On one hand, higher survival rates may decrease the demand for transplants, as fewer people require a second or third transplant following the failure of a previous one. On the other hand, however, demand for first-time transplants may increase as more end-stage renal disease (ESRD) patients perceive transplantation as a more successful, and therefore more desirable, procedure. We used a simulation model to estimate the net effect of these changes. The results show that, all else being held constant, the increase in the survival rate resulting from medical advances could alleviate the current kidney shortage. However, if higher survival rates lead to an increased demand for transplants, the net effect would be a substantial aggravation of the current shortage of donated kidneys. That would force regional organ procurement agencies and other concerned organizations to attempt unprecedented increases in kidney donations ranging from 50% to 300% over the current rate.

Forecasting↗
PubMed1986

Financially catastrophic and high-cost cases: definitions, distinctions, and their implications for policy formulation.

To facilitate discourse and improve the formulation of policy, a clear distinction should be made between financially catastrophic and high-cost health care expenditures. I propose that "financially catastrophic" be used to describe cases whose expenditures are large relative to ability to pay (e.g., when out-of-pocket medical expenditures exceed 15% of annual family income) and that "high cost" describe cases whose total expenditures exceed a set amount (e.g., $10,000 in a year's time) regardless of source of payment or ability to pay. Using these distinctions, I show how third-party coverage and other resources determine whether a high-cost case or illness is also financially catastrophic. I illustrate the usefulness of the proposed categorization by applying it to several current policy issues.

Acquired Immunodeficiency Syndrome↗
PubMed1986

Families with catastrophic health care expenditures.

This article describes the characteristics of families with catastrophic health care expenditures. Based on data from a national sample, three overlapping groups of families are considered: those incurring annual out-of-pocket expenditures that exceed, respectively, 5, 10, and 20 percent of the family's income. Such families represent a small percentage of all families, but they account for a disproportionally large share of total health care expenditures. Nevertheless, the actual amounts spent out of pocket by most of these families are relatively small. Modest sums are financially burdensome to these families because they are more likely to be low-income and to be headed by someone who is not employed. Families with catastrophic expenditures are also more likely to be headed by someone 65 or older and, consistent with that, a greater share of their total expenditures is covered by Medicare. However, all other third-party payers cover a relatively smaller share of total expenditures for these families than they do for all families, reflecting the generally worse third-party coverage of families with catastrophic health expenditures. The implications of these findings for several current issues are discussed, including catastrophic coverage proposals for Medicare and proposed programs to help the medically indigent and the uninsured.

Adolescent↗
PubMed1985

Health insurance coverage of the unemployed.

Of 1,332 unemployed individuals in the Detroit area interviewed in late 1983, 51% did not have health insurance. Lack of insurance was directly related to length of unemployment. Of those unemployed 3 months or less, 31% had no insurance, as compared with 56% of those unemployed more than 3 years. For the most part, these were not the chronically uninsured: 78% of them were insured when they were employed. Three fourths of those without insurance were not covered by Medicaid either. These findings suggest that during the latest economic recession, the problem of health insurance loss due to losing one's job was more severe than had been assumed by most policymakers.

Adult↗
PubMed1985

High-volume and low-volume users of health services: United States, 1980.

Data from the National Medical Care Utilization and Expenditure Survey of 1980 are used to examine the characteristics of high-volume users of health care services, contrasting them with low-volume users and those who used no services at all. The three major types of medical care services examined are hospital inpatient care, ambulatory visits, and prescribed medications. Low users were defined, respectively, as those who during the year had either one or two hospital days, one nondental visit to a physician or nonphysician, and one prescribed medicine acquisition. High users were those with, respectively, 17 or more hospital days, 20 or more visits, and 25 or more prescribed medicine acquisitions. A very small percent of the U.S. civilian noninstitutionalized population and of those who used services at all during the year consume a large percent of services in each of the three service types. High users of inpatient hospital care constitute 1.7 percent of the civilian noninstitutionalized population and 15 percent of persons hospitalized during the year, yet they used 54.4 percent of all hospital days used by the reference population. High users of ambulatory services constitute 4.5 percent of the reference population and only 5.7 percent of all users of ambulatory services, yet they accounted for 32.3 percent of all ambulatory visits. For prescribed medications, only 3.7 percent of the civilian noninstitutionalized population are high users, comprising 5.9 percent of all users, but they account for 32.9 percent of all prescription acquisitions. At the other extreme, low users of ambulatory care visits represent 17 percent of the reference population, and 21 percent of all users of such care, but only 3.3 percent of all visits. High users share certain characteristics. They are more likely than low users to be older and poorer, to have poorer health status and more medical conditions, and are more likely to have functional limitations. Both univariate and multivariable analyses show that the most important distinguishing characteristics of high users of any of the three medical services are poor health status, severe functional limitations, and the presence of multiple medical conditions--most importantly cancer, cardiac disorders, musculoskeletal diseases, respiratory diseases, and injuries and poisonings. Almost all high-volume users of every category of service (88 percent for hospital days, 89 percent for ambulatory visits, and 94 percent for prescribed medications) had at least three different diagnostic conditions reported during the year.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1983

Classification of hospitals based on measured output: the VA system.

Evaluation of hospital performance and improvement of resource allocation in hospital systems require a method for classifying hospitals on the basis of their output. Previous approaches to hospital classification relied largely on input characteristics. The authors propose and apply a procedure for classifying hospitals into groups where within-group hospitals are similar with respect to output. Direct measures of case-mix-adjusted discharges and outpatient visits are the principal measures of patient care output; other measures capture training and research functions. The component measures were weighted, and a composite output measure was calculated for each of the 162 hospitals in the Veterans Administration health care system. The output score then was used as the dependent variable in an Automatic Interaction Detector analysis, which partitioned the 162 hospitals into 10 groups, accounting for 85 per cent of the variance in the dependent variable. An extension of the output classification method is presented for illustration of how the difference between hospitals' actual operating costs and costs predicted on the basis of output can be used in defining isoefficiency groups.

Budgets↗
PubMed1983

Increasing Medicare enrollment in HMOs: the need for capitation rates adjusted for health status.

Although the federal government has sought to increase enrollment of Medicare beneficiaries in HMOs, at the end of 1981 less than 2% were HMO members. Of these, only two-tenths of 1% were enrolled under the type of risk-sharing contracts characteristic of HMOs. HMOs might have greater incentives to market to Medicare beneficiaries if a factor that adjusts for health status could be incorporated into the capitation formula. This paper develops such a factor using measures based on prior-year utilization, perceived health status, and functional health status.

Capitation Fee↗
PubMed1982

Quality, cost, and health: an integrative model.

This article presents an integrative model of the relations among health status, quality of care, and resource expenditure. It defines medical care quality in terms of outcomes, measured as the expected improvements in health status attributable to care. The consideration of how quality so defined is affected by the unconstrained, efficient use of resources for care leads to the specification of the absolutist definition of quality. Consideration of the incidence of individual and external costs and benefits of care provides the basis for distinguishing further between the individualized definition of quality, which depends upon individual preferences and ability to pay, and the social definition of quality, which includes consideration of external benefits, full social definition of quality, which includes consideration of external benefits, full social costs, and preferences for the distribution of welfare. An additional distinction is made between clinical efficiency and production efficiency. This article examines in detail the implications, for the selection of optimal strategies of care, of the three definitions of quality (absolutist, individualized, and social) and the two types of efficiency (clinical and production).

Attitude to Health↗
PubMed1981

Equity in the distribution of quality of care.

This article examines whether the quality of health care services in the United States is equitably distributed across all groups in the population, especially groups defined by age, race, sex, and income characteristics. The framework within which the question is answered draws distinctions among structural, process, and outcome inequities. The available evidence suggests that all three types of inequity are present, at least to some extent. However, there are too many gaps and weaknesses in what is known about this issue to reveal systematic patterns or to support broad generalizations. The need for additional research on this issue is discussed, as are the policy implications of what is already known about equity in the distribution of quality of care.

Age Factors↗