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Biomedical subjects

M R Chassin

Publications and source records attributed to M R Chassin.

At least 19 recordsLinked to original sources
PubMed2000

Determining the quality of breast cancer care: do tumor registries measure up?

BACKGROUND: Hospital tumor registries, which provide data that inform health services research and cancer control policies, may be a source of information about quality of cancer care. However, the accuracy of data from such registries is unknown. OBJECTIVE: To determine the accuracy of tumor registry data by comparing it with data collected from numerous sources for a breast cancer quality improvement project. DESIGN: Retrospective cohort study. SETTING: Three teaching hospitals with tumor registries in the New York metropolitan area that had participated in the quality improvement project. PATIENTS: All women with newly diagnosed primary breast cancer (stage I or stage II) who were surgically treated at the study hospitals between 1 November 1994 and 31 August 1996. MEASUREMENTS: Sensitivity and specificity were calculated, and data from the quality improvement project were used as the gold standard. RESULTS: The tumor registries and the quality improvement project had similar information on tumor stage and surgery type. Sensitivity ranged from 0.91 to 0.96, and specificity ranged from 0.93 to 0.97. When both sources were used to calculate quality measures, the overall rate of radiation therapy after breast-conserving surgery was 80% in the quality improvement project and 48% in the tumor registries (sensitivity, 0.58; specificity, 0.94). For receipt of adjuvant systemic treatment, the rate was 78% in the quality improvement project and 22% in the tumor registries (sensitivity, 0.27; specificity, 0.97). CONCLUSIONS: Data from tumor registries provide accurate measures for hospital-based surgical treatments but not for outpatient treatments. Unverified tumor registry data should not be used to measure quality of care.

Ambulatory Care↗
PubMed2000

The quality of early-stage breast cancer care.

OBJECTIVE: To assess whether recent practice has improved, the authors created detailed, evidence-based guidelines and assessed the quality of early-stage breast cancer care at four hospitals in the metropolitan New York area. SUMMARY BACKGROUND DATA: Adjuvant treatments for early-stage breast cancer have been shown to improve health and longevity. However, reports from the 1980s showed marked underuse of these therapies. METHODS: All 723 women with early-stage breast cancer who had a definitive surgical procedure at four participating hospitals in the Mount Sinai-NYU Health System between April 1994 and August 1996 were included. Inpatient and outpatient records were abstracted. RESULTS: Fifty-nine percent of women underwent breast-conserving surgery, of whom 81% received radiation therapy. Hospital-specific radiation therapy rates varied from 69% to 87%. Seventy-eight percent of women with stage 1B or greater cancer received systemic treatment, with hospital-specific rates varying from 71% to 86%. Between 18% and 33% of women who could have benefited from local or systemic adjuvant treatments did not receive them. The risk of not getting a beneficial adjuvant treatment varied more than twofold by the hospital where the breast cancer surgery was performed. CONCLUSIONS: The hospital where breast cancer surgery is performed is associated with the likelihood that women receive effective local and systemic adjuvant treatments. Surgeons and members of hospital quality improvement programs should encourage multidisciplinary approaches to breast cancer care.

Adult↗
PubMed1998

The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality.

OBJECTIVE: To identify issues related to the quality of health care in the United States, including its measurement, assessment, and improvement, requiring action by health care professionals or other constituencies in the public or private sectors. PARTICIPANTS: The National Roundtable on Health Care Quality, convened by the Institute of Medicine, a component of the National Academy of Sciences, comprised 20 representatives of the private and public sectors, practicing medicine and nursing, representing academia, business, consumer advocacy, and the health media, and including the heads of federal health programs. The roundtable met 6 times between February 1996 and January 1998. It explored ongoing, rapid changes in health care and the implications of these changes for the quality of health and health care in the United States. EVIDENCE: Roundtable members held discussions with a wide variety of experts, convened conferences, commissioned papers, and drew on their individual professional experience. CONSENSUS PROCESS: At the end of its deliberations, roundtable members reached consensus on the conclusions described in this article by a series of discussions at committee meetings and reviews of successive draft documents, the first of which was created by the listed authors and the Institute of Medicine project director. The drafts were revised following these discussions, and the final document was approved according to the formal report review procedures of the National Research Council of the National Academy of Sciences. CONCLUSIONS: The quality of health care can be precisely defined and measured with a degree of scientific accuracy comparable with that of most measures used in clinical medicine. Serious and widespread quality problems exist throughout American medicine. These problems, which may be classified as underuse, overuse, or misuse, occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care. Very large numbers of Americans are harmed as a direct result. Quality of care is the problem, not managed care. Current efforts to improve will not succeed unless we undertake a major, systematic effort to overhaul how we deliver health care services, educate and train clinicians, and assess and improve quality.

Health Services Misuse↗
PubMed1998

The medical consultant's role in caring for patients with hip fracture.

BACKGROUND: Hip fractures are an important cause of death and functional dependence in the United States. PURPOSE: To review the evidence for clinical decisions that medical consultants make for patients with hip fracture and to develop recommendations for care. DATA SOURCES: Published reports of clinical studies were found by searching MEDLINE and selected bibliographies. STUDY SELECTION: Studies were included if data were presented on clinical interventions to improve care of conditions typically encountered by medical consultants in the care of patients with hip fracture. Such conditions include timing of surgery, infection prophylaxis, thromboembolic prophylaxis, postoperative nutritional management, urinary tract management, prevention and management of delirium, application and timing of rehabilitation services, and prevention of subsequent falls. Meta-analyses; randomized, controlled trials; or other controlled studies were included if possible. If no such trials were identified, the best evidence from studies with other designs was included. DATA EXTRACTION: Interventions were selected on the basis of their efficacy or potential efficacy in improving functional outcome. Trials with positive and negative results were compared for differences in intervention and strength of study methods. DATA SYNTHESIS: Strong evidence supports medical recommendations for decisions about timing and duration of prophylactic antibiotics, selection of thromboembolic prophylaxis, urinary tract and nutritional management, and rehabilitative services. Many case series support early surgical repair, although patients who would benefit from delay and further medical work-up have not been well identified. Evidence for decisions about assessment of subsequent risk for fall and risk for and management of delirium is based largely on data from patients without hip fracture but is probably applicable. Future research should target optimal duration of thromboembolic prophylaxis, cost-effectiveness of low-molecular-weight heparin compared with that of other thromboembolic prophylactic regimens, management of delirium, rehabilitative services, and efficacy of assessment of risk for later falls. CONCLUSIONS: The data suggest that evidence-based medical care can improve hip fracture outcomes. The medical consultant has a key role in providing this care and managing the preoperative conditions and postoperative complications that may affect optimal functional recovery.

Accidental Falls↗
PubMed1998

Is health care ready for Six Sigma quality?

Serious, widespread problems exist in the quality of U.S. health care: too many patients are exposed to the risks of unnecessary services; opportunities to use effective care are missed; and preventable errors lead to injuries. Advanced practitioners of industrial quality management, like Motorola and General Electric, have committed themselves to reducing the frequency of defects in their business processes to fewer than 3.4 per million, a strategy known as Six Sigma Quality. In health care, quality problems frequently occur at rates of 20 to 50 percent, or 200,000 to 500,000 per million. In order to approach Six Sigma levels of quality, the health care sector must address the underlying causes of error and make important changes: adopting new educational models; devising strategies to increase consumer awareness; and encouraging public and private investment in quality improvement.

Delivery of Health Care↗
PubMed1997

Assessment of coronary artery bypass graft surgery performance in New York. Is there a bias against taking high-risk patients?

OBJECTIVES: The purpose of this study was to determine whether performing coronary artery bypass surgery on high-risk patients adversely affects the risk-adjusted mortality rates for patients of surgeons and hospitals in New York State compared with the impact of performing surgery on more routine patients. METHODS: Risk-adjusted mortality-rates were calculated for 31 hospitals and 87 surgeons for high-risk (a predicted mortality rate of at least 7.5%) and low-risk patients during the time period 1990 to 1992. RESULTS: The risk-adjusted mortality for all high-risk patients was lower (2.94%) than the risk-adjusted mortality for other patients (3.02%). Fifteen of the 31 hospitals had a lower risk-adjusted mortality for all patients than they did for low-risk patients only, and no differences in either direction were statistically significant. Forty-one of 87 surgeons (47%) had risk-adjusted mortality for all patients that was at least as low as the risk-adjusted mortality for low-risk patients. In general, hospitals and surgeons with the lowest risk-adjusted mortality for all cases also had the lowest risk-adjusted mortality for high-risk cases. CONCLUSIONS: The authors conclude that there is no systematic bias against operating on high-risk coronary artery bypass graft patients in the risk-adjusted performance system in New York.

Bias↗
PubMed1996

Academic quality improvement: new medicine in old bottles.

Academic medical centers and clinicians have been slow to embrace continuous quality improvement. The Mount Sinai Medical Center in New York has created a new Department of Health Policy that combines an academic research mission with an administrative mission to demonstrate improving quality of care. This article discusses the conceptual framework that undergirds this new effort, its organizational structure and initial agenda of activities, and why we believe it will succeed in engaging academic physicians in quality improvement.

Academic Medical Centers↗
PubMed1996

Quality improvement nearing the 21st century: prospects and perils.

Quality improvement is the key to providing universal access to affordable high quality health care to all Americans. By eliminating the major quality problems of overuse and misuse of health services, quality of care can be improved and costs reduced at the same time. Thus, resources can be made available to provide necessary and effective care to those currently left out of the system. Three strategies exist for improving quality: regulation, professionalism, and competition. Each has strengths and weaknesses. Achieving quality improvement for populations will require a blend of all three strategies. The New York State Department of Health uses such a blended strategy to improve quality of care for patients undergoing cardiac surgery. This program includes regulation that strictly limits the number of hospitals permitted to offer cardiac surgical services, a professionally driven effort to improve outcomes following coronary artery bypass surgery, and the competitive peer pressure generated by publishing hospital and surgeon-specific mortality data. During the first four years when all three components of the program were in effect (1989-1992), risk-adjusted operative mortality following CABG surgery fell by 41%.

Cardiac Surgical Procedures↗
PubMed1995

The decline in coronary artery bypass graft surgery mortality in New York State. The role of surgeon volume.

OBJECTIVE: To examine the longitudinal relationship between surgeon volume and in-hospital mortality for coronary artery bypass graft (CABG) surgery in New York State and to explain changes in mortality that occurred over time. DESIGN: Observation of clinically risk-adjusted operative mortality over time. SETTING: All 30 New York State hospitals in which CABG surgery was performed for 1989 through 1992. PATIENTS: All 57,187 patients undergoing isolated CABG surgery in New York State in 1989 through 1992 in the 30 hospitals. MAIN OUTCOME MEASURES: Actual, expected, and risk-adjusted mortality. RESULTS: Risk-adjusted in-hospital mortality decreased for all categories of surgeons. Low-volume surgeons (< or = 50 operations per year) experienced a 60% reduction in risk-adjusted mortality in the 4-year period, whereas the highest-volume surgeons (> 150 operations per year) experienced a 34% reduction. The percentage of patients undergoing CABG surgery by low-volume surgeons decreased from 7.6% in 1989 to 5.7% in 1992, a 25% decrease. CONCLUSIONS: The overall decline in risk-adjusted mortality could not be explained by shifts in patients away from low-volume surgeons to high-volume surgeons. The proportionately larger decrease in risk-adjusted mortality for low-volume surgeons could not be explained by changes in patient case mix or by improvements in the performance of surgeons with persistently low volumes. Part of the decrease was a result of the exodus of low-volume surgeons with high risk-adjusted mortality (in all years studied), the markedly better performance of surgeons who were new to the system (especially in 1991 and 1992), and the performance of surgeons who were not consistently low-volume surgeons (especially in 1992).

Clinical Competence↗
PubMed1994

Improving the outcomes of coronary artery bypass surgery in New York State.

OBJECTIVE: To assess changes in outcomes of coronary artery bypass graft (CABG) surgery in New York since 1989, when the State Department of Health began collecting, analyzing, and disseminating information regarding risk factors, mortality, and complications of CABG surgery. These new data stimulated specific quality improvement activities at hospitals throughout the state. DESIGN: A clinical database was used to identify significant independent risk factors and to assess risk-adjusted provider mortality rates. SETTING: All 30 hospitals performing CABG surgery in New York during the period 1989 through 1992. PATIENTS: All 57,187 patients undergoing isolated CABG surgery who were discharged from New York State hospitals in 1989 through 1992. MAIN OUTCOME MEASURES: Actual, expected (from a logistic regression model), and risk-adjusted in-hospital mortality. RESULTS: Actual mortality decreased from 3.52% in 1989 to 2.78% in 1992. Because average patient severity of illness increased, risk-adjusted mortality decreased even more--a decrease of 41% from 4.17% in 1989 to 2.45% in 1992. The risk-adjustment model performed well; there were no clinically or statistically significant differences between actual and predicted numbers of deaths at any of 10 levels of patient severity. CONCLUSIONS: We believe that this quality improvement program, based on the collection and dissemination of risk-adjusted mortality data for CABG surgery, played a significant role in the observed decline in the death rate from this procedure. Quality improvement programs based on similar principles for other procedures and conditions should be undertaken.

Actuarial Analysis↗
PubMed1994

New York State's Cardiac Surgery Reporting System: four years later.

This study examined changes in the risk-adjusted mortality associated with coronary artery bypass grafting procedures performed in New York State during the first 4 years of New York's Cardiac Surgery Reporting System (1989 to 1992). To track performance over time, surgeons and hospitals were subdivided into three groups on the basis of their performance in 1989. The risk-adjusted mortality for each of the three groups was computed for 1992 and compared with their 1989 mortality. The results indicate that all groups of providers exhibited large reductions in the risk-adjusted mortalities, with the groups that showed the highest initial mortalities manifesting the most improvement. However, the group rankings remained the same in 1992 as they were in 1989. For example, when the hospital groups were based on the terciles of risk-adjusted mortality observed in 1989, the risk-adjusted mortality decreased from 2.72% to 2.19% for group 1, from 4.24% to 2.51% for group 2, and from 7.12% to 2.77% for group 3. Notably, the risk-adjusted mortalities of the three groups were all significantly different from one another in 1989, but were not significantly different from one another in 1992. Another interesting finding was that the volume of operations performed by the various provider groups did not change substantially in the 4-year period.

Coronary Artery Bypass↗