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P Pronovost

Publications and source records attributed to P Pronovost.

13 recordsLinked to original sources
PubMed2001

Assessing the effectiveness of critical pathways on reducing resource utilization in the surgical intensive care unit.

OBJECTIVES: To evaluate the effectiveness of procedure-specific surgical critical pathways on reducing resource utilization in a university surgical intensive care unit (ICU). DESIGN AND SETTING: Prospective cohort study in a university surgical ICU. PATIENTS: 194 patients, accounting for 255 patient days, sampled on randomly selected days over a 12-month period of time. MEASUREMENTS AND RESULTS: The primary outcomes of this study were pathway eligibility and laboratory utilization. Patients were eligible for a procedure-specific pathway in 34% of patient days identified, and the patient's clinical course was "on" pathway in 22% of patient days. Of those "on" the pathway, 54% had a pathway present in the chart and 32% of these included documentation of the patient's clinical course. Thus in 78% of the patient days the patient was either not eligible for a critical pathway or the patient's clinical course was "off" pathway. In those patients "on" the pathway 46 % did not have a pathway present in the chart. Being on a critical pathway did not reduce laboratory utilization. Laboratory utilization did not vary between patients "on" and "off" the pathway (19.1 +/- 11.3 laboratory tests/patient day versus 20.4 +/- 5.7 laboratory tests/patient day). Predicted laboratory utilization by the pathway was 5.6 laboratory tests/patient day. By reducing actual laboratory utilization to that predicted by the critical pathway we would reduce laboratory utilization at our institution by $1.2 million per year. CONCLUSIONS: Procedure-specific surgical critical pathways are not an effective tool for reducing resource utilization in our ICU. Most of our patients were not eligible for an available pathway, and those who were eligible and were "on" the pathway did not appear to have laboratory utilization guided by the pathway. Future initiatives need to explore other means such as ICU-specific care processes to reduce resource utilization in the ICU.

Aged↗
PubMed2001

Variations in complication rates and opportunities for improvement in quality of care for patients having abdominal aortic surgery.

BACKGROUND: The purpose was to assess the current variation in complication rates and evaluate the association between specific types of complications and in-hospital mortality and total hospital charges for patients having abdominal aortic surgery. PATIENTS/METHODS: We studied 2987 patients for abdominal aortic surgery in Maryland from 1994 to 1996 and used discharge diagnoses and procedure codes to identify diagnoses that most likely represent major surgery complications. We evaluated how in-hospital mortality and total hospital charges related to specific complications, adjusting for patient demographics, severity of illness, comorbidity, and hospital and surgeon volumes. Discharge data was obtained from the hospital marketing departments. RESULTS: Complication rates varied widely among hospitals. Complications independently associated with increased risk of in-hospital death include cardiac arrest with an odds ratio (OR) of 90 and a 95% confidence interval (CI) of 32-251, septicemia (OR 6.1, CI 3.3-11.3), acute myocardial infarction (OR 5.7, CI 2.3-14.3), acute renal failure (OR 5.0, CI 2.3-11.0), surgical complications after a procedure (OR 3.1, CI 2.0-4.9), and reoperation for bleeding (OR 2.2, CI 1.1-4.8). The population-attributable risk for in-hospital mortality was 47% for cardiac arrest and 27% for acute renal failure. CONCLUSIONS: In abdominal aortic surgery on patients in Maryland, the rates of some complications vary widely and are independently associated with increased in-hospital mortality and hospital charges (charges differ from costs). Efforts to reduce these complications should help to decrease both levels.

Aortic Aneurysm, Abdominal↗
PubMed2001

The advantages and disadvantages of process-based measures of health care quality.

As consumers, payers, and regulatory agencies require evidence regarding health care qualities the demand for process of care measures will grow. Although outcome measures of quality represent the desired end results of health care, validated process of care measures provide an important additional element to quality improvement efforts, as they illuminate exactly which provider actions could be changed to improve patient outcomes. In this essay, we discuss the advantages and disadvantages of process measures of quality, and outline some practical strategies and issues in implementing them.

Humans↗
PubMed2001

From a process of care to a measure: the development and testing of a quality indicator.

This paper outlines the steps in developing and implementing process measures of quality. Developing a process measure includes defining the purpose of and audiences for the measures, choosing the clinical area to evaluate, organizing the assessment team, choosing the component of the process to measure, writing the indicator specifications, performing preliminary tests of feasibility, reliability and validity, and determining scoring and analytical specifications. Given the growing evidence in the literature regarding the impact of care, and an evolving understanding of how to develop and implement process of care measures as outlined here, the future should bring the development and implementation of quality indicators that are rigorously developed and that will provide insights into opportunities to improve the quality of care.

Humans↗
PubMed2001

Economics of end-of-life care in the intensive care unit.

End-of life care is in need of improvement, yet little is known about the effectiveness or cost of various end-of-life therapies. Economic analyses are used to help make decisions between two or more therapies when resources are constrained. In this chapter, we review the various types of economic analyses, the costs of dying, and how healthcare reform has impacted these costs. Finally, we discuss the unique issues associated with cost-effectiveness studies of palliative therapy, with emphasis on the problem of calculating a cost-effectiveness ratio when there is no good measurement for valuing the quality of death. It is likely that methods for conducting a cost-effectiveness analyses for end-of-life care will need to evolve or alternative strategies such as cost-benefit analysis or distributive justice will be needed to inform resource allocation decisions. As the national debate about healthcare costs, access, and quality continues, we will increasingly turn to economic analyses to help make resource allocation decisions. Cost-effectiveness analysis will continue to be the most popular form of economic analysis because it combines the results (effectiveness of treatment) with the costs of achieving the results. We must be aware of the limitations of cost-effectiveness analyses and the need for value judgments when using cost-effectiveness analyses to inform healthcare decisions.

Attitude to Death↗
PubMed2000

Survival and functional outcome after prolonged intensive care unit stay.

OBJECTIVE: To examine the functional outcome and costs of a prolonged illness requiring a stay in the surgical intensive care unit (SICU) of 7 of more days. SUMMARY BACKGROUND DATA: The long-term benefits and costs after a prolonged SICU stay have not been well studied. METHODS: All patients with an SICU length of stay of 7 or more days from July 1, 1996, to June 30, 1997, were enrolled. One hundred twenty-eight patients met the entry criteria, and mortality status was known in 127. Functional outcome was determined at baseline and at 1, 3, 6, and 12 months using the Sickness Impact Profile score, which ranges from 0 to 100, with a score of 30 being severely disabled. Hospital costs for the index admission and for all readmissions to Johns Hopkins Hospital were obtained. All data are reported as median values. RESULTS: For the index admission, age was 57 and APACHE II score was 23. The initial length of stay in the ICU was 11 days; the hospital length of stay was 31 days. The Sickness Impact Profile score was 20.2 at baseline, 42.9 at 1 month, 36.2 at 3 months, and 20.3 at 6 months, and was lower than baseline at 1 year. The actual 1-year survival rate was 45.3%. The index admission median cost was $85,806, with 65 total subsequent admissions to this facility. The cost for a single 1-year survivor was $282,618 (1996). CONCLUSIONS: An acute surgical illness that results in a prolonged SICU stay has a substantial in-hospital death rate and is costly, but the functional outcome from both a physical and physiologic standpoint is compatible with a good quality of life.

APACHE↗
PubMed2000

Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care.

OBJECTIVE: Intensive care units (ICUs) account for an increasing percentage of hospital admissions and resource consumption. Adverse events are common in ICU patients and contribute to high mortality rates and costs. Although evidence demonstrates reduced complications and mortality when intensivists manage ICU patients, a dramatic national shortage of these specialists precludes most hospitals from implementing an around-the-clock, on-site intensivist care model. Alternate strategies are needed to bring expertise and proactive, continuous care to the critically ill. We evaluated the feasibility of using telemedicine as a means of achieving 24-hr intensivist oversight and improved clinical outcomes. DESIGN: Observational time series triple cohort study. SETTING: A ten-bed surgical ICU in an academic-affiliated community hospital. PATIENTS: All patients whose entire ICU stay occurred within the study periods. INTERVENTIONS: A 16-wk program of continuous intensivist oversight was instituted in a surgical ICU, where before the intervention, intensivist consultation was available but there were no on-site intensivists. Intensivists provided management during the intervention using remote monitoring methodologies (video conferencing and computer-based data transmission) to obtain clinical information and to communicate with on-site personnel. To assess the benefit of the remote management program, clinical and economic performance during the intervention were compared with two 16-wk periods within the year before the intervention. MEASUREMENTS AND MAIN RESULTS: ICU and hospital mortality (observed and Acute Physiology and Chronic Health Evaluation III, severity-adjusted), ICU complications, ICU and hospital length-of-stay, and ICU and hospital costs were measured during the 3 study periods. Severity-adjusted ICU mortality decreased during the intervention period by 68% and 46%, compared with baseline periods one and two, respectively. Severity-adjusted hospital mortality decreased by 33% and 30%, and the incidence of ICU complications was decreased by 44% and 50%. ICU length of stay decreased by 34% and 30%, and ICU costs decreased by 33% and 36%, respectively. The cost savings were associated with a lower incidence of complications. CONCLUSIONS: Technology-enabled remote care can be used to provide continuous ICU patient management and to achieve improved clinical and economic outcomes. This intervention's success suggests that remote care programs may provide a means of improving quality of care and reducing costs when on-site intensivist coverage is not available.

APACHE↗
PubMed1999

Using large-scale databases to measure outcomes in critical care.

The major intent of this article is to describe the availability and potential use of large-scale databases; however, it is first essential to know and understand the basic principles involved in the conduct and interpretation of observational outcomes studies. In this article, the authors briefly overview the design of observational outcomes studies as applied to critical care medicine. Then, criteria for evaluating data sources and for in-depth reviewing of the available data sources from which these observational studies can be conducted are discussed.

Critical Care↗
PubMed1999

The association between preoperative patient characteristics and both clinical and economic outcomes after abdominal aortic surgery.

OBJECTIVE: To evaluate the association between patient characteristics and both clinical and economic outcomes in patients having abdominal aortic surgery in Maryland between 1994 and 1996. DESIGN: Retrospective study using an administrative data set. SETTING: All Maryland hospitals that performed abdominal aortic surgery from 1994 through 1996 (n = 46). PARTICIPANTS: All patients who had abdominal aortic surgery in Maryland from 1994 through 1996 (n = 2,987). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors obtained discharge abstracts from the Maryland Health Services Cost Review Commission for patients with a primary procedure code for abdominal aortic surgery. Primary outcome variables were in-hospital mortality, hospital length of stay, and intensive care unit (ICU) days. The authors evaluated the following groups of independent variables: demographic characteristics, severity of illness, comorbid disease, and preoperative admission days. In multivariate analysis, independent predictors of in-hospital mortality were age 61 to 70 years (odds ratio [OR], 3.1; confidence interval [CI], 1.4 to 6.9), age 71 to 84 years (OR, 7.2; CI, 3.7 to 14.1), age 85 years or older (OR, 9.3; CI, 3.9 to 21.9), ruptured aneurysm (OR, 5.3; CI, 3.5 to 8.2), urgent operation (OR, 2.3; CI, 1.1 to 5.2), emergent operation (OR, 3.0; CI, 1.9 to 4.7), mild liver disease (OR, 4.6; CI, 2.0 to 10.9), and chronic renal disease (OR, 6.9; CI, 3.9 to 12.1). Hospital admission 1 to 2 days preoperatively was not associated with a difference in in-hospital mortality but was associated with a 31% increase in hospital days (CI, 23% to 40%) and a 38% increase in ICU days (CI, 19% to 60%). CONCLUSION: In patients having aortic surgery, several patient characteristics such as mild liver disease and chronic renal failure, were associated with increased in-hospital mortality and length of stay. The practice of admitting patients to the hospital 1 to 2 days before surgery should be reevaluated because this was not associated with reduced in-hospital mortality but was associated with increased hospital and ICU stay.

Aged↗