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Biomedical subjects

W H Rogers

Publications and source records attributed to W H Rogers.

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

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↗
PubMed1990

The effects of the DRG-based prospective payment system on quality of care for hospitalized Medicare patients. An introduction to the series.

In 1985, we began a 4-year evaluation of the effects of the diagnosis related groups-based prospective payment system on quality of care for hospitalized Medicare patients. This article provides an overview of the study's background, aims, design, and methods. We used a clinically detailed review of the medical record supplemented by data on postdischarge outcomes drawn from the files of the Health Care Financing Administration and fiscal intermediaries to (1) compare outcomes of care after adjustment for sickness at admission, (2) assess the process of in-hospital care and relationships between processes and outcomes, and (3) assess status at discharge for a nationally representative sample of patients hospitalized before and after prospective payment was implemented.

Diagnosis-Related Groups↗
PubMed1990

Studying the effects of the DRG-based prospective payment system on quality of care. Design, sampling, and fieldwork.

We have conducted a nationally representative before-after study of the effects of the diagnosis related groups-based prospective payment system (PPS) on quality of in-hospital care for aged Medicare patients. We used a pre-post design with multiple time points in both the pre-PPS (calendar years 1981 and 1982) and post-PPS (July 1985 through June 1986) periods. We gathered clinically detailed data from medical records of patients with one of six diseases and supplemented these data with postdischarge information from Health Care Financing Administration files. We used a stratified multistage cluster sampling design with data gathered on 16,758 patients chosen from 297 hospitals in 30 areas in five states. Our hospital participation rate was 97%; we successfully accessed 96% of the medical records we requested; and our mean item-level reliability score was 0.80. Our sample matches the nation closely on hospital urbanicity, size, teaching status, ownership, and percentages of Medicare and Medicaid patients, and patient demographics and mortality.

Cross-Sectional Studies↗
PubMed1990

Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system.

We developed explicit process criteria and scales for Medicare patients hospitalized with congestive heart failure, myocardial infarction, pneumonia, cerebrovascular accident, and hip fracture. We applied the process scales to a nationally representative sample of 14,012 patients hospitalized before and after the implementation of the diagnosis related group-based prospective payment system. For the four medical diseases, a better process of care resulted in lower mortality rates 30 days after admission. Patients in the upper quartile of process scores had a 30-day mortality rate 5% lower than that of patients in the lower quartile. The process of care improved after the introduction of the prospective payment system; eg, better nursing care after the introduction of the prospective payment system was associated with an expected decrease in 30-day mortality rates in pneumonia patients of 0.8 percentage points, and better physician cognitive performance was associated with an expected decrease in 30-day mortality rates of 0.4 percentage points. Overall, process improvements across all four medical conditions were associated with a 1 percentage point reduction in 30-day mortality rates after the introduction of the prospective payment system.

Aged↗
PubMed1990

Comparing outcomes of care before and after implementation of the DRG-based prospective payment system.

We compared patient outcomes before and after the introduction of the diagnosis related groups (DRG)-based prospective payment system (PPS) in a nationally representative sample of 14,012 Medicare patients hospitalized in 1981 through 1982 and 1985 through 1986 with one of five diseases. For the five diseases combined; length of stay dropped 24% and in-hospital mortality declined from 16.1% to 12.6% after the PPS was introduced (P less than .05). Thirty-day mortality adjusted for sickness at admission was 1.1% lower than before (16.5% pre-PPS, 15.4% post-PPS; P less than .05), and 180-day adjusted mortality was essentially unchanged at 29.6% pre-vs 29.0% post-PPS (P less than .05). For patients admitted to the hospital from home, 4% more patients were not discharged home post-PPS than pre-PPS (P less than .05), and an additional 1% of patients had prolonged nursing home stays (P less than .05). The introduction of the PPS was not associated with a worsening of outcome for hospitalized Medicare patients. However, because our post-PPS data are from 1985 and 1986, we recommend that clinical monitoring be maintained to ensure that changes in prospective payment do not negatively affect patient outcome.

Diagnosis-Related Groups↗
PubMed1990

Quality of care before and after implementation of the DRG-based prospective payment system. A summary of effects.

In this series we have described changes in the quality of care that have occurred in the treatment of hospitalized elderly Medicare patients with one of five conditions between 1981-1982 and 1985-1986. In this article we report on a mortality analysis, patient and hospital subgroup comparisons, and time series studies we have conducted in an attempt to determine whether changes in quality of care can be linked causally to the introduction of the prospective payment system. Based on these analyses we conclude that (1) mortality following hospitalization has been unaffected by the introduction of the prospective payment system, and improvements in in-hospital processes of care that began prior to the prospective payment system have continued after its introduction, but (2) the prospective payment system has increased the likelihood that a patient will be discharged home in an unstable condition. We recommend that efforts to correct this problem be intensified and that clinical monitoring of the impact of the prospective payment system continue as hospital cost-containment pressures intensify.

Continuity of Patient Care↗
PubMed1990

Changes in quality of care for five diseases measured by implicit review, 1981 to 1986.

We measured quality of care before and after implementation of the prospective payment system. We developed a structured implicit review form and applied it to a sample of 1366 Medicare patients with congestive heart failure, acute myocardial infarction, pneumonia, cerebrovascular accident, or hip fracture who were hospitalized in 1981-1982 or 1985-1986. Very poor quality of care was associated with increased death rates 30 days after admission (17% with very good care died vs 30% with very poor care). The quality of medical care improved between 1981-1982 and 1985-1986 (from 25% receiving poor or very poor care to 12%), although more patients were judged to have been discharged too soon and in unstable condition (7% vs 4%). Except for discharge planning processes, the quality of hospital care has continued to improve for Medicare patients despite, or because of, the introduction of the prospective payment system with its accompanying professional review organization review.

Aged↗
PubMed1990

Prospective payment system and impairment at discharge. The 'quicker-and-sicker' story revisited.

Since the introduction of the prospective payment system (PPS), anecdotal evidence has accumulated that patients are leaving the hospital "quicker and sicker." We developed valid measures of discharge impairment and measured these levels in a nationally representative sample of patients with one of five conditions prior to and following the PPS implementation. Instability at discharge (important clinical problems usually first occurring prior to discharge) predicted the likelihood of postdischarge deaths. At 90 days postdischarge, 16% of patients discharged unstable were dead vs 10% of patients discharged stable. After the PPS introduction, instability increased primarily among patients discharged home. Prior to the PPS, 10% of patients discharged home were unstable; after the PPS was implemented, 15% were discharged unstable, a 43% relative change. Efforts to monitor the effect of this increase in discharge instability on health should be implemented.

Aged↗
PubMed1990

Explaining variations in hospital death rates. Randomness, severity of illness, quality of care.

We used administrative (Part A Medicare) data to identify a representative sample of 1126 patients with congestive heart failure and 1150 with acute myocardial infarction in hospitals with significant unexpectedly high inpatient, age-sex-race-disease-specific death rates ("targeted") vs all other ("untargeted") hospitals in four states. Although death rates in targeted hospitals were 5.0 to 10.9 higher per 100 admissions than in untargeted hospitals, 56% to 82% of the excess could result from purely random variation. Differences in the quality of the process of care (based on a medical record review) could not explain the remaining statistically significant differences in mortality. Comparing targeted hospitals with subsets of untargeted ones, eg, those with lower than expected death rates, did not affect this conclusion. Severity of illness explained up to 2.8 excess deaths per 100 admissions for patients with myocardial infarction. Identifying hospitals that provide poor-quality care based on administrative data and single-year death rates is unlikely; targeting based on time periods greater than 1 year may be better.

Aged↗
PubMed1989

Functional status and well-being of patients with chronic conditions. Results from the Medical Outcomes Study.

Enhancing daily functioning and well-being is an increasingly advocated goal in the treatment of patients with chronic conditions. We evaluated the functioning and well-being of 9385 adults at the time of office visits to 362 physicians in three US cities, using brief surveys completed by both patients and physicians. For eight of nine common chronic medical conditions, patients with the condition showed markedly worse physical, role, and social functioning; mental health; health perceptions; and/or bodily pain compared with patients with no chronic conditions. Each condition had a unique profile among the various health components. Hypertension had the least overall impact; heart disease and patient-reported gastrointestinal disorders had the greatest impact. Patients with multiple conditions showed greater decrements in functioning and well-being than those with only one condition. Substantial variations in functioning and well-being within each chronic condition group remain to be explained.

Activities of Daily Living↗
PubMed1989

Prepaid group practice effects on the utilization of medical services and health outcomes for children: results from a controlled trial.

A total of 693 children between the ages of 0 and 13 years were randomly assigned to either a staff model HMO or to one of several fee-for-service insurance plans in Seattle to evaluate differences in medical expenditures and health outcomes. Although the fee-for-service plans varied the amount of cost sharing (0% to 95%), all children were covered for the same medical services, for either 3 or 5 years. No differences in imputed total expenditures were observed for children assigned to the HMO or any of the fee-for-service plans. Children with cost-sharing fee-for-service plans, however, had fewer medical contacts and received fewer preventive services than those assigned to the HMO. Nonetheless, children with the cost-sharing fee-for-service plans were perceived (by their mothers) to be in better health overall than those assigned to the HMO. No significant differences regarding physiological outcomes (eg, visual acuity, hemoglobin level) were observed between the two groups. The results of this experiment neither strongly support nor indict fee-for-service or prepaid care for children.

Adolescent↗
PubMed1989

Effect of brief, repeated hyperbaric exposures on susceptibility to nitrogen narcosis.

We investigated the effect of brief, repetitive exposures to 5.5 ATA (148 fsw) in a hyperbaric chamber on adaptation to nitrogen narcosis. A standing-steadiness task, which measures body sway, was administered to 2 groups of 3 chamber-qualified men at 5.5 ATA and 1.3 ATA [10 fsw (control)] on each of 12 successive days to determine if an initial performance decrement at 5.5 ATA would be ameliorated with time. Standing steadiness was significantly worse at 5.5 ATA than at 1.3 ATA across all 12 exposures. There were also changes in standing steadiness from day to day, but these changes occurred in both the test and control depths. There was no day-x-depth interaction that would have indicated that the initial performance decrement at 5.5 ATA was reduced with repetitive exposures. These results are taken as evidence that there is little or no behavioral adaptation to nitrogen narcosis in response to brief, repetitive exposures to narcosis-inducing hyperbaric air.

Adaptation, Physiological↗
PubMed1987

Hospital inpatient mortality. Is it a predictor of quality?

Various potential measures of quality of care are being used to differentiate hospitals. Last year, on the basis of diagnostic and demographic data, the Health Care Financing Administration identified hospitals in which the actual death rate differed from the predicted rate. We have developed a similar model. To understand why there are high-outlier hospitals (in which the actual death rate is above the predicted one) and low-outlier hospitals (in which the actual death rate is below the predicted one), we reviewed 378 medical records from 12 outlier hospitals treating patients with one of three conditions: cerebrovascular accident, myocardial infarction, and pneumonia. After adjustment for the severity of illness, the death rate in the high outliers exceeded that predicted from the severity of illness alone by 3 to 10 percent, and in the low outliers, the actual death rate fell short of the severity-adjusted predictions by 10 to 15 percent (P less than 0.01). Reviews of the process of care using 125 criteria revealed no differences between the high and low outliers. However, detailed reviews by physicians of the records of patients who died during hospitalization revealed a higher rate of preventable deaths in the high outliers than in the low outliers. For the three conditions studied, we project that 5.7 percent of a standard cohort of patients admitted to the high-outlier hospitals would have preventable deaths, as compared with 3.2 percent of patients admitted to the low-outlier hospitals (P less than 0.05). A meaningful comparison of hospital death rates requires adjustment for severity of illness. Our findings indicate that high-outlier hospitals care for sicker patients. However, these same hospitals or their medical staffs may also provide poorer care. Our results need confirmation before death-rate models can be used to screen hospitals.

Hospitals↗