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PubMed1993

Effect of prospective reimbursement on nursing home costs.

OBJECTIVE: This study evaluates the effect of Maine's Medicaid nursing home prospective payment system on nursing home costs and access to care for public patients. DATA SOURCES/STUDY SETTING: The implementation of a facility-specific prospective payment system for nursing homes provided the opportunity for longitudinal study of the effect of that system. Data sources included audited Medicaid nursing home cost reports, quality-of-care data from state facility survey and licensure files, and facility case-mix information from random, stratified samples of homes and residents. Data were obtained for six years (1979-1985) covering the three-year period before and after implementation of the prospective payment system. STUDY DESIGN: This study used a pre-post, longitudinal analytical design in which interrupted, time-series regression models were estimated to test the effects of prospective payment and other factors, e.g., facility characteristics, nursing home market factors, facility case mix, and quality of care, on nursing home costs. PRINCIPAL FINDINGS: Prospective payment contributed to an estimated $3.03 decrease in total variable costs in the third year from what would have been expected under the previous retrospective cost-based payment system. Responsiveness to payment system efficiency incentives declined over the study period, however, indicating a growing problem in achieving further cost reductions. Some evidence suggested that cost reductions might have reduced access for public patients. CONCLUSIONS: Study findings are consistent with the results of other studies that have demonstrated the effectiveness of prospective payment systems in restraining nursing home costs. Potential policy trade-offs among cost containment, access, and quality assurance deserve further consideration, particularly by researchers and policymakers designing the new generation of case mix-based and other nursing home payment systems.

Cost Control↗
PubMed2006

Data feedback for quality improvement of stroke care: CAPTURE Stroke experience.

BACKGROUND: Feedback on "quality indicators" collected from chart audit is a widely used quality-improvement strategy. Skeptics argue that temporal change in practice patterns or improvement of documentation as a result of implementation of chart audit can affect change in quality indicators rather than change in practice due to feedback. This study compared the effectiveness in quality improvement for stroke care of chart audit and feedback versus chart audit only. METHODS: Data were examined on quality indicators constructed from the performance measures abstracted from chart audit for 1953 stroke patients admitted to 13 hospitals. Seven of the 13 hospitals were provided with feedback on quality indicators from baseline audit, and 6 hospitals had chart audit only. RESULTS: Least-squares estimation was used to estimate the adjusted mean change in quality indicators between follow-up and baseline audits and differences in mean change between feedback and nonfeedback groups. Differences in adjusted mean change (with 90% confidence interval) were: deep vein thrombosis prophylaxis, 8.46 (-9.46 to 26.38); dysphagia screening, -3.78 (-21.37 to 13.81); antithrombotic therapy within 48 hours of hospitalization, 3.63 (-6.59 to 13.84); discharged on antithrombotic, -0.31 (-6.26 to 5.63); patients with atrial fibrillation discharged on warfarin/coumadin, 44.73 (-13.14 to 102.60); lipid screening, 19.93 (2.99 to 36.86); and smoking counseling, 17.47 (-12.13 to 47.08). CONCLUSIONS: Although not statistically significant, results suggest a potential for improvement with data feedback. There is a need for evaluation of the effectiveness of a multifaceted approach in a community setting.

Acute Disease↗
PubMed2001

Assessment of blood administration procedures: problems identified by direct observation and administrative incident reporting.

BACKGROUND: Adverse events in blood administration frequently involve the identification of transfusion recipients or components. This report details the results of an investigation of the efficacy of direct observation and that of a hospital-wide incident-reporting system in detecting standard operating procedures (SOPs) for deviations in blood administration. STUDY DESIGN AND METHODS: A process-driven audit form targeting 19 blood administration steps was developed for direct observation monitoring of blood administration. Over 18 months, 202 transfusions were observed in selected hospital locations. Data from this audit were compared with data collected from the incident reporting system. RESULTS: Through direct observation, 334 events were identified for a rate of 1.65 SOP deviations per transfusion. The incident reporting system identified 52 adverse events. Deviations were categorized as being related to the patient or component information, transfusion, patient monitoring, record documentation, and ordering or delivery of the component. Fifty-five percent of the events detected with direct observation related to identification of the patient or component, compared with 17 percent of incident reports. Using direct observation, 9 percent of transfused patients had wristband identification deviations. Such SOP deviations were not detected with the incident reporting system. Transfusion SOP deviations represented 15 percent of direct observation reports and 38 percent of incident reports. Direct observation identified deviations in monitoring practices and record documentation not detected by incident reporting. CONCLUSION: Direct observation appears to be an effective means for identifying deviations related to patient identification, patient monitoring, and record documentation.

Blood Transfusion↗
PubMed2003

General practitioners' uptake of clinical practice guidelines: a qualitative study.

OBJECTIVE: To explain recent rapid audited change in the uptake of locally implemented, evidence-based clinical guidelines for asthma and angina in primary care. METHODS: A case study of primary care in two matched, adjacent districts in Northern England, focusing on a stratified random sample of 49 general practitioners (GPs) from eight primary care groups. Data were collected from three cycles of mainly qualitative interviews carried out at six-monthly intervals, before and after the dissemination of local guidelines and after audit data were gathered. Interviews examined attitudes, awareness and impact of locally disseminated asthma and angina guidelines and the subsequent audit. Audit data on guideline uptake were also available from a parallel study. RESULTS: The rapid increase in guideline uptake observed in both intervention and control groups was not explained by individual practitioners or practice factors. The findings are attributed to GPs' awareness of policies for evidence-based medicine, of new health service institutions and of the clinical governance activities of primary care groups. Behaviour change reflects GPs' decisions about what to record in case notes as well as their clinical decisions, so that findings may reflect changing perceptions about accountability rather than about preferred treatment regimes. CONCLUSIONS: Guideline production and dissemination is best seen in the broader context of policy change. Studies of guideline implementation should report before and after data and incorporate significant qualitative components in order to identify important contextual factors.

Angina Pectoris↗
PubMed2003

[Neuro-link, an Italian traumatic coma data bank: what did we learn from the first 1000 patients and how can we do better? ].

To understand the complex physiopathology of post-traumatic brain damage is important to have data on epidemiology, clinical course, monitoring, effect of therapy and outcomes. In 1997 3 neuro-intensive care units in the Milan metropolitan area developed a computer assisted database named Neuro-Link (NL) for collection of information on head injury. All head injured patients requiring intensive care during the first 24 hours post-trauma were eligible. The data collection form was designed for use with a computer interface to cover: 1) general, previous and admission data; 2) secondary insults and complication; 3) CT scan and monitoring data; 4) outcome data. Two different data collections were performed: 1) NL domestic (data from 3 centres from 1997); 2) NL 18 centres (3 month survey of Italian centres with interest in neurotrauma care). An audit of the data was performed. NL domestic included 1 085 patients from 1997 to 2002. NL 18 centres included 282 patients in the 3 month period. Audit is performed on 35 000 data per year.A large number of good quality information on head injury patients is now available. The database is useful for: 1) production of information; 2) base for prospective studies.

Coma↗
PubMed1986

NTP Toxicology and Carcinogenesis Studies of Commercial Grade 2,4 (80%)- and 2,6 (20%)- Toluene Diisocyanate (CAS No. 26471-62-5) in F344/N Rats and B6C3F1 Mice (Gavage Studies).

Toluene diisocyanate (TDI) is commercially produced as an approximate 80:20 mixture of the 2,4- and 2,6-isomers. In 1980, 580,000 pounds of this chemical were produced in the United States, primarily for use in the manufacture of flexible polyurethane foams. These foam elastomers are found in furniture and automobile cushions, carpet underlays, pillow filling, mattresses, insulation, shoes, purses, and toys. TDI is also used to produce polyurethane coatings for lacquers and wood finishes. Groups of 50 female F344/N rats and 50 B6C3F1 mice were administered commercial grade toluene diisocyanate (80% 2,4- and 20% 2,6-) in corn oil by gavage at doses of 60 or 120 mg/kg body weight, 5 days per week for 105 or 106 weeks. Groups of 50 male F344/N rats received 30 or 60 mg/kg and groups of 50 male B6C3F1 mice received 120 or 240 mg/kg on the same schedule. Dosage analyses of toluene diisocyanate indicated that the chemical had reacted in the corn oil vehicle, resulting in actual gavage concentrations 77% to 90% of theoretical values. Groups of 50 rats and 50 mice of each sex received corn oil only and served as vehicle controls. Survival in all groups of dosed rats in the 2-year studies were shorter (P</=0.005) than that of the controls; depressions of the mean body weight gain relative to controls were greater than 10% in all dosed rat groups throughout most of the study. A dose-dependent pattern of cumulative toxicity began at 70 weeks and culminated in excessive mortality, indicating the estimated tolerated dose had been exceeded for rats. Acute bronchopneumonia occurred at increased incidences in groups of dosed male and female rats (males: control, 2/50; low dose, 6/50; high dose, 14/50; females: 1/50, 10/50, 25/49). Subcutaneous tissue fibromas or fibrosarcomas (combined) in male rats occurred with a positive trend (P<0.01; 3/50, 6/50, 12/50). The incidence in the high dose group was higher than that in the controls (P</=0.01). The same tumor comparisons were significant (P<0.001) in female rats by the life table analysis. Mammary gland fibroadenomas in female rats occurred with a positive trend (P<0.001), and the incidences in low and high dose groups were significantly higher than that in controls (P</=0.01). Pancreatic acinar cell adenomas in male rats occurred with a positive trend (P<0.05; 1/47, 3/47, 7/49). The incidence in the high dose group was higher than that in the controls (P<0.05). The incidences of pancreatic islet cell adenomas in female rats were higher by the incidental tumor test (P</=0.01) in low dose (6/49) and high dose (2/47) groups than in controls (0/50). An islet cell carcinoma was also observed in a low dose female rat. The incidences of female rats with neoplastic nodules in the liver occurred with a positive trend (P<0.05; 3/50, 8/50, 8/48), and the incidence in the high dose group was higher (P<0.05) than that in the controls. Survival of high dose male mice in the 2-year study was significantly shorter than that of the controls (P<0.001). During the second year of the study, mean body weight gains of high dose male mice were less than those of the controls. Cytomegaly of kidney tubular epithelium was found in 45/48 (94%) low dose male mice and 41/50 (82%) high dose male mice but not in any of the controls. Hemangiomas or hemangiosarcomas (combined) of the circulatory system in female mice occurred with a positive trend (P</=0.01; control, 0/50; low dose, 1/50; high dose, 5/50). The incidence in the high dose group was significantly higher than that in the controls (P<0.05). Hepatocellular adenomas in female mice occurred with a positive trend (P</=0.001; 2/50, 3/50, 12/50), and the incidence in the high dose group was higher than that in the controls (P<0.01). Toluene diisocyanate was mutagenic in Salmonella typhimurium strains TA98 and TA100 in the presence (but not the absence) of Aroclor 1254-induced male Sprague-Dawley rat or male Syrian hamster liver S9; it was not mutagenic in strains TA 1535 or 1537. An audit of the experimental data for these 2-year toxicological and carcinogenicity An audit of the experimental data for these 2-year toxicological and carcinogenicity studies on commercial grade 2,4- and 2,6-toluene diisocyanate was conducted. There were no data discrepancies that influenced the final interpretations. Under the conditions of these gavage studies, commercial grade toluene diisocyanate in corn oil was carcinogenic for F344/N rats, causing subcutaneous fibromas and fibrosarcomas (combined) in males and females, pancreatic acinar cell adenomas in males, and pancreatic islet cell adenomas, neoplastic nodules of the liver, and mammary gland fibroadenomas in females. Toluene diisocyanate was not carcinogenic for male B6C3F1 mice. TDI was carcinogenic for female B6C3F1 mice, causing hemangiomas or hemangiosarcomas (combined), as well as hepatocellular adenomas. Levels of Evidence of Carcinogenicity: Male Rats: Positive Female Rats: Positive Male Mice: Negative Female Mice: Positive Synonym: TDI

Journal Article↗
PubMed2002

Treatment-related morbidity and hospital league tables: experience from a national audit of radiotherapy-induced morbidity in cervical carcinoma.

Data are now available from a U.K. audit of survival and late morbidity following curative radiotherapy for cancer of the cervix treated in 1993. The complication rate per centre ranges from 0 to 67%. Although the frequency of complications following curative radiotherapy for cancer of the cervix might be considered to be an indicator of clinical performance, variation in treatment outcomes can be explained by sampling variability rather than real differences in quality of care. In the present study we have asked the question: could the disparity in complication rates between centres be no more or less than would be expected by chance? Our analysis suggests that this is the case, and for this reason it would be premature to use such outcome data to produce league tables or to assess institutional differences. Thus, ranking centres according to complication rate would not be valid, as the differences in rates observed are probably not significantly different from the national average. It is important that audit data are not used inappropriately and this analysis further highlights the need for reliable prospective collection of clinical information and the importance of considering sampling variability in interpreting the results of such studies.

Female↗
PubMed1975

Data retrieval in the coronary care unit: prospective vs. retrospective.

A standardized system for recording patient care data for medical audit was developed and implemented in six community hospitals' coronary care units. It utilized the principles of predefining the data base and having both nurses and physicians participate. This system was compared with conventional retrospective record abstraction as a source of information for medical audit. The results suggest that the proposed system produces slightly more clinical data relevant to diagnostic impressions. Accuracy is comparable to that achieved by standard computerized abstraction procedures. Such an approach is readily adaptable for implementing medical audit to meet the requirements currently imposed upon community hospitals.

Coronary Care Units↗
PubMed1994

Quality assurance audits of community screening mammography practices: availability of active follow-up for data collection and outcome assessment.

OBJECTIVE: Routine and periodic mammography audit studies, the systematic evaluation of clinical follow-up procedures and outcomes subsequent to screening mammography reports of abnormal findings, have been advocated as an important component of quality assurance in screening mammography. This study assessed the degree to which mammography facilities in community practice maintain reporting and record-keeping systems and ascertain sufficient clinical follow-up data to facilitate the practice of mammography audit studies. MATERIALS AND METHODS: As part of a national survey of 1057 mammography facilities, data were collected from a stratified subsample of 50 facilities on facility information systems, and facility records were systematically abstracted to determine the degree of completeness of clinical follow-up data to screening mammography examinations with abnormal findings. Facilities were assisted in obtaining additional information through active data follow-up, and this information also was entered into the study's database. RESULTS: The nature of mammography information systems and the degree of data completeness varied widely. Computerized systems were used at relatively few facilities (12%). The organization of records and data varied widely and was generally not designed to accommodate routine systematic analysis. Screening examinations could be identified without reading the actual text of the mammography report at 94% of the facilities, but reports had to be read at the majority of facilities to identify examinations with abnormal findings (70%). Before active data follow-up, records were incomplete in about 40% of all cases. After active data follow-up, this decreased to 16%. Forty-two facilities achieved an average completeness of more than 90%, whereas the remaining eight lagged significantly behind this level. CONCLUSION: At the time of this study (late 1992 to early 1993), only about 20% of the facilities surveyed had informational systems and sufficient ascertainment of data to support the practice of mammography audit studies. After active data follow-up, more than 80% of the facilities were willing and able to achieve a high degree of data completeness with the assistance of our data abstracters. The results of this study suggest that, with the advent of standardized mammography data collection and analysis systems and increased emphasis on clinical outcomes assessment as a standard of care, the practice of performing mammography audits, although not currently widespread, is feasible for most facilities.

Breast Neoplasms↗
PubMed2006

Lack of ethnic disparities in adult immunization rates among underserved older patients in an urban public health system.

BACKGROUND: In some settings, immunization rates for ethnic minorities are less than those of non-Hispanic white populations. This study examines demographic differences in the rate of pneumococcal and influenza immunization in an ethnically diverse older patient population seeking care at an urban primary care clinic system. METHODS: The setting is an integrated system of 11 federally qualified community health centers serving approximately 100,000 unduplicated patients annually. We linked data from chart audits performed in 2001-2003 for quality assurance purposes with patient registration data to evaluate vaccination rates in 740 patients age 66 years and older who had at least 3 primary care visits in the previous 2 years. RESULTS: Factors significantly associated with receipt of pneumococcal vaccination in multivariable analysis were Hispanic ethnicity (odds ratio [OR] 1.66-1.77, P = 0.01), medical comorbidities (OR 1.48, P = 0.03), psychiatric comorbidities (OR 2.0, P = 0.001), use of a family medicine versus internal medicine clinic (OR 2.3, P < 0.001), and age (OR 1.04 for 1 year increase, P = 0.004). Factors significantly associated with influenza vaccination were having insurance (OR 2.25, P = 0.014), medical comorbidities (OR 1.71, P = 0.036), age (OR 1.03 for 1 year increase, P = 0.045), later year of audit (OR 1.68-1.73, P = 0.015), and a greater number of clinic visits (OR 1.69, P = 0.006). CONCLUSIONS: Among older regular users of our public community health centers, minority populations have equal or higher immunization rates compared with non-Hispanic whites.

Age Factors↗
PubMed2005

Stroke units: research and reality. Results from the National Sentinel Audit of Stroke.

OBJECTIVES: To use data from the 2001-2 National Stroke Audit to describe the organisation of stroke units in England, Wales and Northern Ireland, and to see if key characteristics deemed effective from the research literature were present. DESIGN: Data were collected as part of the National Sentinel Audit of Stroke in 2001, both on the organisation and structure of inpatient stroke care and the process of care to hospitals managing stroke patients. SETTING: 240 hospitals from England, Wales and Northern Ireland took part in the 2001-2 National Stroke Audit, a response rate of over 95%. These sites audited a total of 8200 patients. AUDIT TOOL: Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool. RESULTS: 73% of hospitals participating in the audit had a stroke unit but only 36% of stroke admissions spent any time on one. Only 46% of all units describing themselves as stroke units had all five organisational characteristics that previous research literature had identified as being key features, while 26% had four and 28% had three or less. Better organisation was associated with better process of care for patients, with patients managed on stroke units receiving better care than those managed in other settings. CONCLUSION: The National Service Framework for Older People set a target for all hospitals treating stroke patients to have a stroke unit by April 2004. This study suggests that in many hospitals this is being achieved without adequate resource and expertise.

Health Services Research↗
PubMed1999

ENVIRONMENTAL AUDITING: Use of Landsat Thematic Mapper Data to Assess Seasonal Rangeland Changes in the Southeast Kalahari, Botswana.

/ Management problems arise in semiarid rangeland that are characterized by marked wet and dry seasons because of forage deficiencies in the dry season. These natural vegetation rangelands can sustain livestock all year long when forage and senesced grass are available into the dry season. Seasonal range condition data are required to provide a basis for pasture management to help locate dry season cover and thereby minimize overstocking and degradation. The generation of seasonal data using Thematic Mapper (TM) imagery was undertaken to assess changes in natural vegetation cover in the southern Botswana Kalahari. Visual analysis of spectral reflectance curves, the development of spectral separability indexes, and conventional classification analysis techniques were used to identify and differentiate rangeland features. Results from reflectance curves indicated that most rangeland cover types could be preferentially distinguished using mainly wet season data, especially on the longer TM wavebands, and that range feature differentiation was more problematic on darker soils than on lighter soils. Spectral separability indexes (SSIs) confirmed that range feature separation varied considerably as a function of waveband and was more effective in the wet than the dry season. The SSIs also showed that range feature differentiation in both seasons was most effective using a combination of the chlorophyll absorpance band (TM3) and two mid-infrared bands (TM5 and TM7). Wet season data were more effectively classified in terms of range features than dry season data although some class similarity was inferred across the two classified data sets. The work shows that overall trends may be generated by comparing seasonal data sets, thereby providing an overall basis for dry season decision making. However, particular problems arise within the dry season data sets probably because of spectral similarities between shadow and darkened vegetation cover, thereby implying that further work is needed. KEY WORDS: Semiarid rangelands; Botswana; Kalahari; Spectral differentiation; Seasonal change; Darkened vegetation cover

Journal Article↗
PubMedDate not supplied

Observational precision in general practice data: a technique for analysis and audit.

Terminal digit preference is a well-known source of error in blood pressure measurements. This was demonstrated in general practice computer databases by conducting a routine search and constructing a frequency distribution of the 20 992 blood pressure readings using mathematical software for a personal computer. The charts produced have a practical application in providing an audit tool whereby nurses and doctors can be made aware of this source of error, providing an opportunity for improving measurement technique and developing more refined and realistic protocols for blood pressure management in general practice. The same principles may be applied to other measurements made in the GP consultation such as peak expiratory flow rate.

Blood Pressure Determination↗
PubMed1997

Smart cards--the key to trustworthy health information systems.

Some 20 years after they were first developed, "smart cards" are set to play a crucial part in healthcare systems. Last year about a billion were supplied, mainly for use in the financial sector, but their special features make them of particular strategic importance for the health sector, where they offer a ready made solution to some key problems of security and confidentiality. This article outlines what smart cards are and why they are so important in managing health information. I discuss some of the unique features of smart cards that are of special importance in the development of secure and trustworthy health information systems. Smart cards would enable individuals' identities to be authenticated and communications to be secured and would provide the mechanisms for implementing strong security, differential access to data, and definitive audit trails. Patient cards can also with complete security carry personal details, data on current health problems and medications, emergency care data, and pointers to where medical records for the patient can be found. Provider cards can in addition carry authorisations and information on computer set up.

Computer Security↗
PubMed2005

Assessing the financial effect of Medicare payment on rural hospitals: does the source of data change the results?

In this policy brief, we explore how predictions of changes in hospital financial performance as a result of change in Medicare payment differ when comparing results using data from the Medicare Cost Report (MCR) to results using data from the audited hospital financial statement (FS). The purpose of this exploratory research is to test the assumption that MCR data yield a valid indicator of changes in hospital financial well-being.

Data Collection↗
PubMed1999

Evaluation of audit-based performance measures for dental care plans.

OBJECTIVES: Although a set of clinical performance measures, i.e., a report card for dental plans, has been designed for use with administrative data, most plans do not have administrative data systems containing the data needed to calculate the measures. Therefore, we evaluated the use of a set of proxy clinical performance measures calculated from data obtained through chart audits. METHODS: Chart audits were conducted in seven dental programs--three public health clinics, two dental health maintenance organizations (DHMO), and two preferred provider organizations (PPO). In all instances audits were completed by clinical staff who had been trained using telephone consultation and a self-instructional audit manual. The performance measures were calculated for the seven programs, audit reliability was assessed in four programs, and for one program the audit-based proxy measures were compared to the measures calculated using administrative data. RESULTS: The audit-based measures were sensitive to known differences in program performance. The chart audit procedures yielded reasonably reliable data. However, missing data in patient charts rendered the calculation of some measures problematic--namely, caries and periodontal disease assessment and experience. Agreement between administrative and audit-based measures was good for most, but not all, measures in one program. CONCLUSIONS: The audit-based proxy measures represent a complex but feasible approach to the calculation of performance measures for those programs lacking robust administrative data systems. However, until charts contain more complete diagnostic information (i.e., periodontal charting and diagnostic codes or reason-for-treatment codes), accurate determination of these aspects of clinical performance will be difficult.

Adolescent↗