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Biomedical subjects

R H Brook

Publications and source records attributed to R H Brook.

At least 19 recordsLinked to original sources
PubMed1992

Differences in quality of care for hospitalized elderly men and women.

OBJECTIVE: To analyze whether important gender differences exist in the quality of hospital care provided to patients with four major medical conditions. DESIGN: Bivariate and multivariate comparisons of clinically detailed sickness at admission, quality, utilization, and outcome measures. SETTING: Acute care hospitals located in five states. PATIENTS OR OTHER PARTICIPANTS: A total of 11,242 patients 65 years or older who were hospitalized with one of four diseases: congestive heart failure, acute myocardial infarction, pneumonia, and cerebrovascular accident. We derived our data from the nationally representative sample used to study the quality of hospital care for Medicare patients before and after the implementation of the prospective payment system. A hierarchical (nested) cluster sampling design was used to draw disease-specific samples of patients hospitalized in 1981, 1982, 1985, or 1986 in one of 297 hospitals located in 30 areas within five states. INTERVENTIONS: This was an observational study. MAIN OUTCOME MEASURES: Sickness at admission, process, use rates, length of stay, discharge status, discharge destination, and mortality. RESULTS: Sex differences in sickness at admission varied by disease. There was some evidence that women received worse process of care, but the difference was very small. We found many similarities in the process and outcomes of care for male and female patients. CONCLUSIONS: After controlling for sickness at admission, age, and other important covariates, the in-hospital experiences of elderly men and women showed greater similarities than differences. The concern that sex bias enters into clinical decision making during hospitalization is eased, although not entirely eliminated.

Aged↗
PubMed1992

Hospital characteristics and quality of care.

OBJECTIVE: To compare quality of care measured by explicit criteria, implicit review, and sickness-adjusted outcomes at different types of hospitals. DESIGN: Further analysis of data retrospectively abstracted from medical records to evaluate the effects of prospective payment on quality of care for hospitalized Medicare patients. SETTING: Hospitals in five states were sampled to represent the national Medicare admissions along many dimensions. PATIENTS: A total of 14,008 elderly patients with one of the following five diseases: congestive heart failure, acute myocardial infarction, pneumonia, stroke, or hip fracture. These patients were randomly sampled from those with these diseases in 297 hospitals in two time periods, 1981 to 1982 and 1985 to 1986. OUTCOME MEASURES: Explicit criteria, implicit review, and mortality within 30 days of admission adjusted for sickness at admission. RESULTS: Quality of care ratings for hospital types are similar using explicit criteria, implicit review, and outcomes adjusted for sickness at admission. Quality differences between types of hospitals were large, with the lowest group estimated to have four percentage points higher mortality than major teaching hospitals in a cohort of patients with average mortality of 16%. Quality varies from state to state, but teaching, larger, and more urban hospitals have better quality in general than nonteaching, small, and rural hospitals. Hospital quality persists over time, but small nonteaching hospitals narrowed the gap with better quality hospitals between 1981 and 1986. CONCLUSIONS: The different measures led to consistent and plausible relationships between quality and hospital characteristics. Thus, valid information about hospital quality can be obtained. We need to develop ways to use such information to improve care.

Algorithms↗
PubMed1992

Spinal manipulation for low-back pain.

PURPOSE: To review the use, complications, and efficacy of spinal manipulation as a treatment for low-back pain. DATA IDENTIFICATION: Articles were identified through a MEDLINE search, review of articles' bibliographies, and advice from expert orthopedists and chiropractors. STUDY SELECTION: All studies reporting use and complications of spinal manipulation and all controlled trials of the efficacy of spinal manipulation were analyzed. Fifty-eight articles, including 25 controlled trials, were retrieved. DATA ANALYSIS: Data on the use and complications of spinal manipulation were summarized. Controlled trials of efficacy were critically appraised for study quality. Data from nine studies were combined using the confidence profile method of meta-analysis to estimate the effect of spinal manipulation on patients' pain and functional outcomes. RESULTS OF DATA SYNTHESIS: Chiropractors provide most of the manipulative therapy used in the United States for patients with low-back pain. Serious complications of lumbar manipulation, including paraplegia and death, have been reported. Although the occurrence rate of these complications is unknown, it is probably low. For patients with uncomplicated, acute low-back pain, the difference in probability of recovery at 3 weeks favoring treatment with spinal manipulation is 0.17 (for example, increase in recovery from 50% to 67%; 95% probability limits of estimate, 0.07 to 0.28). For patients with low-back pain and sciatic nerve irritation, the difference in probabilities of recovery at 4 weeks is 0.098 (probability limits, -0.016 to 0.209). CONCLUSIONS: Spinal manipulation is of short-term benefit in some patients, particularly those with uncomplicated, acute low-back pain. Data are insufficient concerning the efficacy of spinal manipulation for chronic low-back pain.

Back Pain↗
PubMed1992

Watching the doctor-watchers. How well do peer review organization methods detect hospital care quality problems?

OBJECTIVE: To determine how well one state's peer review organization (PRO) judged the quality of hospital care compared with an independent, credible judgment of quality of care. DESIGN: Retrospective study comparing a PRO's review, including initial screening, physician review, and final judgments, with an independent "study judgment" based on blinded, structured, implicit reviews of hospital records. SETTING: One state's medical and surgical Medicare hospitalizations during 1985 through 1987 audited randomly by the state's PRO. SAMPLE: Stratified random sampling of records: 62 records that passed the PRO initial screening process and were not referred for PRO physician review; 50 records that failed the PRO screen and then were confirmed by PRO physicians to be "quality problems." INTERVENTION: None. MAIN OUTCOME MEASURE: A study judgment of below standard or standard or above based on the mean of overall ratings by five internists for records in medical diagnosis related groups (DRGs) and by five internists and five surgeons for surgical DRGs. Each step in the PRO review was evaluated for how many records passing or failing that step were judged standard or above or below standard in the study (positive and negative predictive value) and how well that step classified records that the study judged below standard or standard or above (sensitivity and specificity). RESULTS: An estimated 18% of records reviewed by the PRO were below standard according to the study judgment, compared with 6.3% quality problems according to the PRO's final judgment (difference, 12%; 95% confidence interval, 1 to 23). The PRO's initial screening process failed to detect and refer for PRO physician review two of three records that the study judged below standard. In addition, only one of three of the records that PRO physicians judged to be quality problems were judged below standard by the study judgment. Therefore, the PRO's final quality of care judgment and the study judgment agreed little more than expected by chance, especially about poor quality of care. Although the PRO correctly classified 95% of the records that the study judged standard or above, it detected only 11% of records judged below standard by the study. CONCLUSIONS: Most of all, this PRO review process would be improved by additional preliminary screens to identify the 67% of records that the study judged below standard but that passed its initial screening. The screening process also must be more accurate in order to be cost-effective, as it was only slightly better than random sampling at correctly identifying below standard care. More reproducible physician review is also needed and might be accomplished through improved reviewer selection and training, a structured review method, and more physician reviewers per record.

Hospital Records↗
PubMed1992

Cross-validation performance of mortality prediction models.

Mortality prediction models hold substantial promise as tools for patient management, quality assessment, and, perhaps, health care resource allocation planning. Yet relatively little is known about the predictive validity of these models. We report here a comparison of the cross-validation performance of seven statistical models of patient mortality: (1) ordinary-least-squares (OLS) regression predicting 0/1 death status six months after admission; (2) logistic regression; (3) Cox regression; (4-6) three unit-weight models derived from the logistic regression, and (7) a recursive partitioning classification technique (CART). We calculated the following performance statistics for each model in both a learning and test sample of patients, all of whom were drawn from a nationally representative sample of 2558 Medicare patients with acute myocardial infarction: overall accuracy in predicting six-month mortality, sensitivity and specificity rates, positive and negative predictive values, and per cent improvement in accuracy rates and error rates over model-free predictions (i.e., predictions that make no use of available independent variables). We developed ROC curves based on logistic regression, the best unit-weight model, the single best predictor variable, and a series of CART models generated by varying the misclassification cost specifications. In our sample, the models reduced model-free error rates at the patient level by 8-22 per cent in the test sample. We found that the performance of the logistic regression models was marginally superior to that of other models. The areas under the ROC curves for the best models ranged from 0.61 to 0.63. Overall predictive accuracy for the best models may be adequate to support activities such as quality assessment that involve aggregating over large groups of patients, but the extent to which these models may be appropriately applied to patient-level resource allocation planning is less clear.

Discriminant Analysis↗
PubMed1992

Reliability and validity of the Katz Adjustment Scales in an epilepsy sample.

Development of quality of life measures de novo is time-consuming and expensive, and a number of instruments are already available for general use. Reevaluation and refinement of quality of life tools are needed to improve the existing pool of measures. In this study, data from a sample of 328 epilepsy patients were used to revise a measure of social adjustment and emotional status developed in the 1960s, the 127-item form R1 of the Katz Adjustment Scales (KAS-R1). Using a comprehensive item analysis procedure, we increased the number of items used in scoring the KAS-R1 from 76 to 113 and substantially improved the reliability of scales in both the original sample of 328 epilepsy patients and in a second administration to a 'cross-validation' sample of 193 epilepsy patients. Support for the validity of the revised KAS-R1 scoring system was obtained in a known groups analysis of patients who had previously undergone surgery for epilepsy: mean scores were significantly higher (p < 0.05) on 11 out of 14 scales in the revised KAS-R1 for patients who were completely seizure-free compared to patients who were having seizures with loss of consciousness, after adjusting for age, gender, and anticonvulsant medication use.

Adaptation, Psychological↗
PubMed1992

A health-related quality of life instrument for patients evaluated for epilepsy surgery.

The goals of surgery in treating intractable epilepsy are to eliminate seizures and improve quality of life. This report describes the development of the Epilepsy Surgery Inventory (ESI)-55, a 55-item measure of health-related quality of life for epilepsy patients. The ESI-55 includes the following scales (number of items in parentheses): health perceptions (9), energy/fatigue (4), overall quality of life (2), social function (2), emotional well-being (5), cognitive function (5), physical function (10), pain (2), and three separate scales of role limitations due to emotional, physical, or memory problems (5 items each). Also included is one change in health item. The ESI-55 was completed by 89% of 224 adults who had undergone a protocol evaluation for epilepsy surgery since 1974. Alpha internal consistency reliability coefficients ranged from 0.76 to 0.88 except for social function (alpha = 0.68). Multitrait scaling analyses supported item discrimination across scales. Factor analysis confirmed previously identified mental and physical health factors, and yielded a third factor defined by cognitive function and role limitations scales. Construct validity was supported by correlations of the ESI-55 with a mood profile instrument. Analysis of ESI-55 scale scores by seizure classification showed that the 44 patients who were seizure-free following surgery scored higher than did 55 patients who continued to have seizures (P less than 0.05 for all comparisons); 43 patients having seizures without loss of consciousness scored in between. Results of this study indicate that the ESI-55 is reliable, valid, and sensitive to differences in seizure status.

Adult↗
PubMed1992

Assigning appropriateness ratings for diagnostic upper gastrointestinal endoscopy using two different approaches.

Methods that combine information in the medical literature with expert clinical judgment are needed to determine the appropriateness of use of a procedure. The purpose of this study is to better understand the reliability and construct validity of this process by comparing ratings of appropriateness for diagnostic upper gastrointestinal endoscopy that were developed using different approaches by two independent groups. Both the RAND/UCLA Health Services Utilization Study (HSUS) and the American Society for Gastrointestinal Endoscopy (ASGE) combined scientific data with expert physician judgment to rate the appropriateness of specific clinical indications for the use of upper gastrointestinal endoscopy. This study applies the ratings developed by each group to a nationally representative sample of 1,585 endoscopies performed on people 65 years of age and older in 1981. HSUS developed indications that could be used to rate all 1,585 procedures; ASGE indications were less comprehensive and applied to 70% (n = 1,115) of procedures. Of those rated by both groups, appropriateness category ratings agreed for 94% of the procedures. However, the procedures not rated by ASGE were unevenly distributed across HSUS appropriateness ratings. Twelve percent of procedures rated as appropriate by HSUS were not rated by ASGE, but 80% of procedures rated as equivocal by HSUS and 73% rated as inappropriate by HSUS were not rated by ASGE, for those procedures rated by both approaches there was good agreement; however, a more explicit and comprehensive method may be required if equivocal and inappropriate use of a procedure is to be identified.

Aged↗
PubMed1992

HMO vs fee-for-service care of older persons with acute myocardial infarction.

OBJECTIVES: Health maintenance organizations (HMOs) continue to grow in number and in their enrollment of Medicare recipients. They are also increasingly viewed as organizational structures that might contribute to control of health care costs. Yet little is known about the quality of care that elderly HMO enrollees receive. METHODS: We compared patients from three HMOs to a fee-for-service (FFS) sample that was national in scope. Sickness at admission, the quality of process of care, and mortality were assessed for patients aged 65 years and older who had been hospitalized with a diagnosis of acute myocardial infarction. RESULTS: After adjustment for sickness at admission, there were no significant mortality differences between the HMO and FFS groups at either 30 (23.2% vs 23.5%) or 180 days (34.4% vs 34.5%) after admission. Compliance with process criteria was higher for the HMO group as a whole (P < .05). The HMOs had greater compliance with three of five scales measuring different aspects of care for patients with acute myocardial infarction. CONCLUSIONS: We conclude that older patients from our participating HMOs who were hospitalized for acute myocardial infarction received hospital care that was generally better in terms of process than that received by patients in a national FFS sample.

Age Factors↗
PubMed1992

Group judgments of appropriateness: the effect of panel composition.

The current interest in the development of practice guidelines raises an important question about the effect of expert panel composition on the outcome of the guideline development process. We compared the ratings of appropriateness of indications for carotid endarterectomy produced by two panels: an all-surgical panel and a "balanced" panel composed of four surgeons, two neurologists, and one specialist each from family practice, internal medicine, and radiology. We then compared the effect of the two sets of ratings when used to evaluate 1302 patients who had undergone carotid endarterectomy. The all-surgical panel found more indications "appropriate" (24 versus 14%) and fewer indications "inappropriate" (61 versus 70%) than the balanced panel (p less than 0.01). The all-surgical panel also more often reached agreement. When ratings were applied to patients, 70% were appropriate by the all-surgical criteria versus 38% by the balanced panel, while 19% of the operations were inappropriate by all-surgical criteria, versus 31% by the balanced panel ratings. However, the percentage of procedures judged "inappropriate with agreement" was 15% for all-surgical and 16% for the balanced panel. We conclude that the all-surgical panel was more likely to favor operative treatment for carotid disease than the multispecialty panel, but that concensus judgments of inappropriateness by the two panels were very similar.

Arteriosclerosis↗
PubMed1992

Relation between hospital experience and in-hospital mortality for patients with AIDS-related Pneumocystis carinii pneumonia: experience from 3,126 cases in New York City in 1987.

There is marked debate about whether outcomes of care, particularly mortality, vary as a function of hospital and physician experience with a disease. This issue is especially important with respect to AIDS because greater than 200,000 individuals have now been diagnosed with this disease. We analyzed discharge data for 3,126 persons with AIDS who had Pneumocystis carinii pneumonia and who were treated at one of 73 New York City hospitals in 1987. In-hospital mortality was 25%. Factors associated with higher chances of short-term death were older age, being black, not having private health insurance, and being severely ill. A logistic regression model indicated that after controlling for differences in patient and hospital characteristics, the chances of death decreased when care was given at hospitals with higher caseloads of patients with Pneumocystis carinii pneumonia. Our findings suggest that hospital experience may decrease mortality in this subset of patients with human immunodeficiency virus disease, although it is unknown whether this is due to differences in quality of care.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Appropriateness of care. A comparison of global and outcome methods to set standards.

The RAND-UCLA Health Services Utilization Study previously analyzed the appropriateness of use of carotid endarterectomy based on a literature review and global expert judgments. In this study, for 45 of the same clinical indications used in the RAND-UCLA Study, the authors compare the appropriateness judgments based on the global judgment method to appropriateness ratings based on probability estimates of specific outcomes that were provided by the same panel of experts. The authors asked these experts to estimate, for each clinical indication, the likelihood of important medical outcomes (i.e. stroke within a year) in the presence and absence of endarterectomy. Using decision analysis, the appropriateness of endarterectomy for these 45 indications was then calculated. For only two of the eight physicians were the Spearman rank-order correlations between these two methods of judging appropriateness significant and positive. (Correlations for the eight physicians ranged from 0.45 to -0.38). This result was produced by: 1) the tendency of the experts to estimate relatively poor outcomes for seriously ill patients whether or not endarterectomy was performed; and 2) a far less consistent effect of clinical factors on outcome estimates than on global judgments. Better methods for incorporating probability estimates into a global rating process must be developed. The authors found excellent agreement between the panelists' relative outcome estimates for common endarterectomy indications and the observed stroke rate for these same indications, suggesting that one promising method is to use specific outcome data to "anchor" expert judgments.

Aged↗
PubMed1991

The health care resource allocation debate. Defining our terms.

The problem of health care distribution in the United States demands immediate action. Many different solutions have been proposed to slow rising health care costs and to improve access to care for the poor and uninsured. Debate among proponents of these various proposals might be advanced if a common language were adopted with regard to certain key terms instead of the various meanings currently assigned to these terms. For this reason, we propose and defend the following three definitions: (1) rationing is the societal toleration of inequitable access to health services acknowledged to be necessary by reference to necessary-care guidelines; (2) health care needs are desires for services that have been reasonably well demonstrated to provide significant net benefit for patients with specified clinical conditions; and (3) basic benefit plans are insurance packages that provide for all and only acknowledged health care needs, again by reference to appropriate clinical guidelines.

Comprehensive Health Care↗
PubMed1991

Quality of care: do we care?

The quality of U.S. health care must improve. Practicing physicians need to become involved in generating new knowledge about what does and does not work in medical practice. Physicians might, for example, participate in building national databases on chronic and acute conditions using data from their patients or might help to enroll patients in cohort studies or experimental trials. Furthermore, our knowledge is now sufficient to support a substantial investment of funds in improving what physicians now do in medical practice and in developing publicly available standards of medical practice. Such standards or guidelines could be used by both physicians and patients as part of an explicit process to assess the medical appropriateness of expensive or dangerous procedures before they are done. In addition, the competence with which care is delivered also needs to be measured. Both of these assessments should be used prospectively by physicians to help patients choose the referral source that will maximize their preferences.

Clinical Protocols↗
PubMed1991

Patients who leave a public hospital emergency department without being seen by a physician. Causes and consequences.

OBJECTIVE: To determine whether patients who sought care at a public hospital emergency department and left without being seen by a physician needed immediate medical attention and whether they obtained care after leaving. DESIGN: Follow-up study of patients who left without being seen and of patients who waited to be seen by a physician. SETTING: A public hospital's emergency department in Torrance, Calif. PATIENTS: All patients who registered for care and left without being seen (n = 186) and a 20% random sample of patients who waited until they were seen (n = 211) in a 2-week period during spring 1990. MAIN OUTCOME MEASURES: At time of presentation: triage nurse urgency assessment, clinical acuity rating, and self-reported health status. At follow-up: hospitalization rates. RESULTS: Patients who left reported that they had waited 6.4 hours before leaving; those who stayed reported a 6.2-hour wait before being seen. There were no differences between those who left and those who stayed in chief complaint, triage nurse assessment, acuity ratings, or self-reported health status. Forty-six percent of those who left were judged to need immediate medical attention, and 29% needed care within 24 to 48 hours. Eleven percent of those who left were hospitalized within the next week, and three patients required emergency surgery. Nine percent of those who waited to be seen were hospitalized. Forty-nine percent of patients who left did not see a physician during the 1-week follow-up period. CONCLUSION: Overcrowding in this public hospital's emergency department restricts access to needed ambulatory medical care for the poor and uninsured.

Acute Disease↗