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N Wintfeld

Publications and source records attributed to N Wintfeld.

12 recordsLinked to original sources
PubMed1997

In search of America's best hospitals. The promise and reality of quality assessment.

"America's Best Hospitals," by US News & World Report, is a sophisticated and influential appraisal of hospital care. Using measures of health care structure, process, and outcome, the report identifies outstanding hospitals in 16 medical specialties through an overall "index of hospital quality." This strong conceptual design, however, has not been adequately implemented because national data sources for all 3 components are severely limited. Most importantly, since there are no national data on process of care, a reputation survey has been used to measure this component of quality. One consequence of reliance on reputation is that a small group of prominent hospitals in each specialty receives such high scores that they automatically rise to the top of the rankings, regardless of structure or outcome score. "America's Best Hospitals" identifies America's best regarded hospitals, but provides limited additional insight into quality. Adequate surveillance and protection of quality in an era of managed care requires measurement systems beyond the scope of existing data and methods.

American Hospital Association↗
PubMed1994

The $147,000 misunderstanding: repercussions of overestimating the cost of AIDS.

The increasing incidence of AIDS in the 1980s prompted inquiry into the resources required to meet projected needs. In the first economic study to appear on the illness, the Centers for Disease Control (CDC) estimated that the costs of inpatient care were $147,000 per AIDS patient, heightening concern that the health care system would be overwhelmed by the epidemic. However, every study published subsequently has produced much lower cost estimates. As a result, many have concluded that treatment costs declined due to improved delivery of AIDS care. We offer an alternative interpretation, based on evidence demonstrating that the CDC's methods and assumptions yielded a figure about three times too high. The CDC's erroneous estimate had significant policy repercussions. Using the $147,000 figure, the health insurance industry lobbied successfully for the right to screen applicants for HIV. Next, when a study of San Francisco AIDS patients found local hospital costs per case to be $27,571, many concluded that billions of dollars could be saved if the "San Francisco model" of care (emphasizing home and community-based services and case management) were universalized. Since then, most programs for AIDS services have provided funds for community care. While such programs improve access to vital services, they are unlikely to guarantee "better care for less money." A more informed understanding of the cost of AIDS should lead to programs that also strengthen inpatient care.

AIDS Serodiagnosis↗
PubMed1993

How accurate are hospital discharge data for evaluating effectiveness of care?

Demand for quality of care data has led to publication of adjusted mortality rates of hospitals and physicians. Yet the accuracy of databases used for this purpose is questionable, raising the possibility that consumer-oriented profiles of providers could be misleading. A stratified random sample of discharge abstract records of Medicare-aged patients hospitalized in California were audited by the state's health data agency. The results of the audit were analyzed to determine the effect that coding errors have on expected death rates assigned to hospitals as risk-adjustment measures in the annual Medicare hospital mortality report. Discharge abstracts of Medicare-aged patients contained many errors among coded risk factors used to calculate expected death rates. Comorbidities and transfers from nursing homes were seriously underreported and 'urgency of admission' was often miscoded. Hospitals differed with respect to error rates (P < .0001); these varying levels of miscoding caused measurement errors that ranged in size from 0.2 to 2.2 expected 30-day deaths per 100 admissions (10th vs. 90th percentile). Detailed knowledge of the limitations of claims data can help analysts minimize the impact of coding error. Beyond this, quality control of data used for outcomes research needs strengthening.

Abstracting and Indexing↗
PubMed1991

Analyzing hospital mortality. The consequences of diversity in patient mix.

Consumers and payers increasingly demand data with which to evaluate health care providers. While publication of risk-adjusted hospital-specific death rates is one response, debate continues over whether higher than predicted mortality is a warning about quality of care or rather a reflection of a hospital's atypical patient population. To help inform this debate, we compared the characteristics of Medicare patients discharged from 187 hospitals that the Health Care Financing Administration (HCFA) had labeled "high-mortality outliers" with those of Medicare patients from 5373 hospitals not so designated. Hospitals were most likely to be flagged as high-mortality outliers by HCFA when they had large shares of very elderly patients (age greater than or equal to 85 years), patients with high-risk diagnoses, or patients requiring nursing home care. After adjustments were made to compensate for these biases, nearly half the hospitals flagged as outliers by HCFA were no longer so designated. Statistics purporting to measure effectiveness of care from hospital death rates should be modified to account for diversity in patient mix.

Aged↗
PubMed1990

The importance of severity of illness in assessing hospital mortality.

Each year, the Health Care Financing Administration (HCFA) releases a report comparing hospital mortality rates with predicted rates. Some argue that the HCFA's prediction model does not adequately account for patient severity. We tested this hypothesis by comparing the HCFA's model (replicated as closely as we could) to a second that added a severity measure (the Stage of Principal Diagnosis at Admission, a subscale of the Severity of Illness Index). In our simulation, the HCFA's model had very limited capacity to predict mortality (average R2, 2.5%). Patients grouped according to admission severity had markedly different mortality rates, which the HCFA's model's predictions could not differentiate. The HCFA model also failed to predict large differences in mortality between hospitals with low- and high-severity admissions. Adding severity to the HCFA's model yielded more than an eightfold increase in the R2, to 21.5%, and reduced instances of higher than expected hospital mortality to chance levels. These findings suggest that the HCFA's mortality release needs to be made much more sensitive to admission severity before it can be used to make valid inferences about the quality or effectiveness of hospital care.

Centers for Medicare and Medicaid Services, U.S.↗