Biomedical subjects

Mark R Chassin

Publications and source records attributed to Mark R Chassin.

6 recordsLinked to original sources

PubMed2003

Revisiting the appropriateness of carotid endarterectomy.

BACKGROUND AND PURPOSE: In the 1980s, carotid endarterectomy was controversial because proof of efficacy was lacking, complication rates were high, and one third of cases were reported to be inappropriate. Since publication of several randomized controlled trials (RCTs), rates of carotid endarterectomy have doubled nationwide. This study assesses the appropriateness and use of carotid endarterectomy since publication of the RCTs. METHODS: Using the literature, we developed a list of 1557 mutually exclusive indications for carotid endarterectomy and asked a panel of national experts to rate the appropriateness of each indication using the RAND methodology. We used these ratings to assess appropriateness in a sample of 2124 patients who underwent the procedure in 1997 to 1998 in 6 hospitals. We also analyzed the reasons for the procedure and rates of death, stroke, and myocardial infarction within 30 days of surgery. RESULTS: Overall, 84.9% of operations were done for appropriate reasons, 4.5% for uncertain reasons, and 10.6% for inappropriate reasons. Among procedures considered inappropriate, the most common reasons were high comorbidity (46.6%) and minimal stenosis (27.1%). Overall, 72.5% were asymptomatic, 17.4% had a carotid transient ischemic attack, and 10.1% had a stroke. The 30-day rate of death or stroke was 5.47% for symptomatic patients and 2.26% for asymptomatic patients. Among patients having combined carotid and coronary artery bypass graft surgery, the rate was 10.32%. The complication rate in asymptomatic patients with high comorbidity was 5.56%. CONCLUSIONS: Since the RCTs, rates of overuse appear to have fallen considerably, although they are still significant. A major shift has occurred toward operating on asymptomatic patients. Although overall complication rates were low, rates among asymptomatic patients with high comorbidity exceeded recommended thresholds.

Aged↗

PubMed2002

Improving the quality of pneumonia care that patients experience.

PURPOSE: Although many hospitals have reported attempts to reduce length of stay for patients hospitalized with community-acquired pneumonia, few have included efforts to educate patients to prepare them for earlier discharges. We aimed to improve patients' knowledge about pneumonia and their experiences with inpatient care as part of a multifaceted intervention that included attempts to reduce unnecessary time on intravenous antibiotics and length of hospital stay. METHODS: We developed guidelines for the appropriate duration of intravenous antibiotics in patients with community-acquired pneumonia and collected baseline data retrospectively on patients discharged from October 1996 through April 1997. We surveyed these patients to assess knowledge and experience with care. Beginning in July 1997, we conducted a series of physician and nurse educational interventions (lectures, feedback of performance data, one-on-one education by peers). Patients received education about pneumonia from their nurses and a specially developed educational brochure. Following the interventions, we collected clinical and survey data on patients with pneumonia discharged from October 1997 through April 1998. RESULTS: Among patients who responded to the survey (163 in the preintervention period; 114 in the postintervention period), fewer reported that no one went out of the way to help them (preintervention, 37% [n = 60]; postintervention, 6% [n = 7]; P = 0.001), more reported that they received all the information they needed to recover (75% [n = 122] vs. 94% [n = 107], P = 0.02), and more reported that they were told about danger signals of relapse (46% [n = 75] vs. 60% [n = 68], P = 0.03). Mean (+/- SD) time on intravenous antibiotics decreased from 5.0 +/- 3.7 days to 4.3 +/- 3.3 days (P = 0.04). CONCLUSION: The interventions improved patients' knowledge and experiences with care, while decreasing time on intravenous antibiotics.

Adult↗

PubMed2002

Is volume related to outcome in health care? A systematic review and methodologic critique of the literature.

PURPOSE: To systematically review the methodologic rigor of the research on volume and outcomes and to summarize the magnitude and significance of the association between them. DATA SOURCES: The authors searched MEDLINE from January 1980 to December 2000 for English-language, population-based studies examining the independent relationship between hospital or physician volume and clinical outcomes. Bibliographies were reviewed to identify other articles of interest, and experts were contacted about missing or unpublished studies. STUDY SELECTION: Of 272 studies reviewed, 135 met inclusion criteria and covered 27 procedures and clinical conditions. DATA EXTRACTION: Two investigators independently reviewed each article, using a standard form to abstract information on key study characteristics and results. DATA SYNTHESIS: The methodologic rigor of the primary studies varied. Few studies used clinical data for risk adjustment or examined effects of hospital and physician volume simultaneously. Overall, 71% of all studies of hospital volume and 69% of studies of physician volume reported statistically significant associations between higher volume and better outcomes. The strongest associations were found for AIDS treatment and for surgery on pancreatic cancer, esophageal cancer, abdominal aortic aneurysms, and pediatric cardiac problems (a median of 3.3 to 13 excess deaths per 100 cases were attributed to low volume). Although statistically significant, the volume-outcome relationship for coronary artery bypass surgery, coronary angioplasty, carotid endarterectomy, other cancer surgery, and orthopedic procedures was of much smaller magnitude. Hospital volume-outcome studies that performed risk adjustment by using clinical data were less likely to report significant associations than were studies that adjusted for risk by using administrative data. CONCLUSIONS: High volume is associated with better outcomes across a wide range of procedures and conditions, but the magnitude of the association varies greatly. The clinical and policy significance of these findings is complicated by the methodologic shortcomings of many studies. Differences in case mix and processes of care between high- and low-volume providers may explain part of the observed relationship between volume and outcome.

Delivery of Health Care↗

PubMed2002

The wrong patient.

Among all types of medical errors, cases in which the wrong patient undergoes an invasive procedure are sufficiently distressing to warrant special attention. Nevertheless, institutions underreport such procedures, and the medical literature contains no discussions about them. This article examines the case of a patient who was mistakenly taken for another patient's invasive electrophysiology procedure. After reviewing the case and the results of the institution's "root-cause analysis," the discussants discovered at least 17 distinct errors, no single one of which could have caused this adverse event by itself. The discussants illustrate how these specific "active" errors interacted with a few underlying "latent conditions" (system weaknesses) to cause harm. The most remediable of these were absent or misused protocols for patient identification and informed consent, systematically faulty exchange of information among caregivers, and poorly functioning teams.

Aged↗

PubMed2002

Taking health care back: the physician's role in quality improvement.

Physicians now enjoy a moment of tactical advantage in the evolution of the struggle for control over health care in the United States. The most effective way to capitalize on this-perhaps fleeting-position and to more permanently alter the balance of power in their favor is for physicians to establish strong and visionary leadership in health care quality improvement. Such an undertaking, if successful, could place the very essence of health care-defining, measuring, and improving its quality-in the hands of physicians. To succeed requires understanding the relationships between the different kinds of quality problems that plague our health care system, the various kinds of errors that lead to them, and how amenable these different kinds of errors may be to different interventions. The authors delineate a conceptual framework that describes these relationships, as well as their implications for conducting effective and durable quality improvement. The authors then illustrate how physicians could engage in this activity in three different settings: a four-or-five-physician primary care practice, a 50-physician multispecialty group, and a 450-bed community hospital. Finally, the authors submit that now is an opportune time for physicians and the organizations they direct or guide to take the leadership role in conducting health care quality improvement. Realizing the opportunity will require dedicating significant resources and changing traditional approaches to quality, but in so doing, physicians can regain much of the autonomy over the practice of medicine previously lost to government and managed care.

Group Practice↗

PubMedDate not supplied

Achieving and sustaining improved quality: lessons from New York State and cardiac surgery.

Since 1989 the New York State Department of Health has published annual data on risk-adjusted mortality following coronary artery bypass graft surgery by hospital and surgeon. It was the first such program in the nation and is now the most long-lived. Many hospitals were prompted by the data to improve their cardiac surgery programs, and statewide mortality fell substantially as a result. This paper examines what physicians and hospitals did in response to the data, how the market reacted, and whether this approach to quality measurement and improvement could be used more widely.

Cardiology Service, Hospital↗