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PubMed1989

Race and diagnostic related group prospective hospital payment for medical patients.

The diagnostic related group (DRG) prospective hospital payment system has been on line for five years with no major changes implemented by the federal government. Data suggest that the DRG system may be inequitable to patients of lower socioeconomic status. We studied the consumption of hospital resources by race (ie, white vs black) for hospitalized medical patients using the DRG prospective payment system. All adult medical admissions (N = 30,097) were analyzed for a three-year period at a large academic medical center using the DRG "all payor" classification scheme in effect for New York State. We found that black patients (N = 3,373) had a significantly greater (P less than .0001) mean length of hospital stay and cost per patient (adjusted for DRG weight index) compared with white patients (N = 26,724). Black patients also exposed the medical center to greater (P less than .0001) financial risk compared with white patients, as measured by outliers and losses under DRGs. Black patients (P less than .0001) had a significantly higher proportion of emergency admissions to the hospital, a greater severity of illness (as measured by total International Classification of Diseases-9-Clinical Modification codes) (P less than .0001), and higher diagnostic costs (P less than .0001) for each episode of illness. These data suggest that at our medical center black medical patients may consume more hospital resources (adjusted for DRG case mix) compared with whites. It is important that methods to modify DRG prospective hospital payment for medical diseases be considered to provide more equitable DRG reimbursement for black Americans in the future.

Black or African American↗
PubMed1986

Thoracic and cardiovascular operations in the United States, 1979 to 1984.

Using data from the National Center for Health Statistics, I conducted an in-depth analysis of numbers of thoracic and cardiovascular operations from 1979 to 1984. This is the first full 5 year period since the inception of International Classification of Diseases, Ninth Revision, Clinical Modification codes, and the findings delineate the present status of thoracic and cardiovascular surgery in the United States. During the study period there was a 34% increase in total numbers of thoracic and cardiovascular operations. Since 1970 there has been a total increase in numbers of thoracic and cardiovascular operations of 150%. In 1983 thoracic and cardiovascular surgeons performed 191,000 coronary artery bypasses. This operation is the most common thoracic and cardiovascular procedure and has become the nineteenth most common operation now performed in this country. Pacemaker placement, revision, or removal (190,000) is the second most common thoracic and cardiovascular operation and the country's twentieth. The twenty most common thoracic and cardiovascular operations constitute 87% of all thoracic and cardiovascular operations. In 1983 thoracic and cardiovascular operations represented 3% of all operations completed in this country. These figures represent the dynamics of thoracic and cardiovascular surgical practice. They demonstrate that numbers of thoracic and cardiovascular operations have consistently increased over the past 15 years. However, this increase is almost entirely due to the advent of coronary artery bypass.

Cardiac Surgical Procedures↗
PubMed1987

Serial determinations of the amino-terminal peptide of type III procollagen in severe chronic active hepatitis.

To evaluate the diagnostic significance of the amino-terminal propeptide of procollagen type III (P-III-P) in monitoring chronic liver disease, serum P-III-P concentrations were measured in 46 patients with severe chronic active hepatitis (CAH) at entry and at remission during a therapeutic clinical trial. Coded sera were analyzed for P-III-P concentrations by both a standard radioimmunoassay and a recently developed and potentially more precise radioimmunoassay that uses Fab fragments rather than intact antibodies for binding antigen. As compared with conditions in 22 normal controls, P-III-P concentrations were elevated in 98% and 72% of patients with CAH by use of the standard and Fab radioimmunoassays, respectively. With treatment, P-III-P levels fell at remission to levels that were not significantly different from control values, as measured by both assays. The Fab radioimmunoassay, either alone or combined with the standard radioimmunoassay, provided no advantage over the standard radioimmunoassay alone. Serum P-III-P levels, as measured by either assay, correlated poorly or not at all with standard liver function tests and with histologic grade of disease. These data suggest that P-III-P serum levels are abnormal in severe CAH but normalize when remission of disease has been achieved. Consequently, serum P-III-P levels may be a diagnostic aid in the sequential evaluation of patients with severe CAH requiring treatment, and this test deserves further investigation. In this regard, the standard P-III-P assay has greater diagnostic accuracy than the Fab assay.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs.

OBJECTIVE: To examine whether blacks admitted to Veterans Affairs Medical Centers (VAMCs) with an acute myocardial infarction (AMI) are less likely than whites to undergo cardiac catheterization or coronary revascularization procedures and to determine the impact of these differences on patient survival. DESIGN: A retrospective observational study of inpatient discharge abstracts from the Veterans Health Administration (VHA). SETTING: All one hundred fifty-eight acute care hospitals in the VHA. PATIENT POPULATION: Male veterans (n = 33,641) discharge from VAMCs with an International Classification of Diseases, Ninth Revision, Clinical Modification code for AMI from January 1, 1988, to December 31, 1990. INTERVENTION: None. MAIN OUTCOME MEASURES: The use of cardiac catheterization, coronary angioplasty, and/or bypass surgery in the 90 days after admission for AMI, and survival at 30 days, 1 year, and 2 years. MAIN RESULTS: Adjusting for patient and hospital characteristics, blacks with an AMI were 33% less likely than whites to undergo cardiac catheterization, 42% less likely to receive coronary angioplasty, and 54% less likely to receive coronary bypass surgery. Among patients who underwent catheterization, blacks were also less likely than whites to have a subsequent cardiac revascularization procedure. Adjusted 30-day survival for blacks was significantly greater than for whites. One- and 2-year survival rates after AMI were not significantly different between blacks and whites. CONCLUSIONS: In a health care system designed to provide equivalent availability of care to all eligible patients, blacks received substantially fewer cardiac procedures after AMI than whites. Despite undergoing fewer interventional procedures, blacks had better short-term and equivalent intermediate survival rates compared with whites.

Black or African American↗
PubMed1993

The health care status of the diabetic population as reflected by physician claims to a major insurer.

BACKGROUND: Conventional epidemiologic data suggest that diabetic patients use more health care resources than nondiabetic patients, yet overall health care use by diabetic individuals has never been fully quantitated. We took a new approach to this issue based on the actual economics of the provision of health care to diabetic insured individuals. METHODS: The claims records in the Mutual of Omaha Current Trends database, which contains information on more than 400,000 individuals, were surveyed to identify patients with diabetes and create the contrast population of nondiabetic patients by exclusion. International Classification of Diseases, Ninth Revision, Clinical Modification, codes and Physicians' Current Procedural Terminology, Fourth Edition, codes were used to determine all diagnoses recorded and all physician services rendered to the contrast populations. Age- and sex-adjusted comparisons were performed using Mantel-Haenszel procedures to determine an adjusted odds ratio (AOR). RESULTS: A total of 13,304 diabetic individuals and 388,053 nondiabetic individuals who received health care services from January 1, 1988, to January 1, 1989, were identified. Diabetic insured individuals constituted 3.1% of the overall insured population yet accounted for 8.3% of the charges (P < .01). Inpatient charges accounted for 81% of total diabetic charges but only 61.5% of total nondiabetic charges (P < .001). Diabetic insured individuals had twice as many physician office visits (AOR = 1.87; 95% confidence interval [CI], 1.79 to 1.96), with 2.5 times more physician hospital visits [AOR = 2.50; 95% CI, 2.27 to 2.75). However, the increases in physician care were not uniformly distributed across the diagnostic spectrum. The frequencies of well-established complications of diabetes, such as ischemic heart disease (AOR = 3.32; 95% CI, 3.12 to 3.53), peripheral vascular disease (AOR = 3.14; 95% CI, 2.79 to 3.53), and eye disease (AOR = 3.10; 95% CI, 2.94 to 3.27), were threefold higher in the diabetic group, with parallel increases in related medical services, such as cardiac catheterization (AOR = 3.02; 95% CI, 2.27 to 4.0), vascular surgery (AOR = 2.94; 95% CI, 2.64 to 3.27), and ophthalmologic procedures (AOR = 2.94; 95% CI, 2.72 to 3.18). In contrast, most diagnostic categories showed little or no increase. For example, the frequency of neoplasms (AOR = 1.11; 95% CI, 1.03 to 1.19) was minimally increased, and the associated procedural concomitants of therapeutic radiology (AOR = 0.81; 95% CI, 0.47 to 1.39) and chemotherapy (AOR = 0.98; 95% CI, 0.60 to 1.60) were not increased in the diabetic group. CONCLUSIONS: Our most important new finding is that diabetic patients have neither an elevated risk for a wide spectrum of diseases nor an increase in the receipt of physician services for diagnostic categories without increased risk, despite more frequent physician encounters. We provide real-world risk estimates that help in calculating the effect of offering specific insurance to diabetic individuals or including them in group health plans. The techniques we have developed to analyze computerized claims databases in this way may serve to better quantify the true impact of chronic diseases on the health care system.

Adult↗
PubMed1984

Who should code cause of death in a clinical trial?

Clinical trials of intervention in chronic disease often use cause-specific mortality as a principal outcome variable. Surprisingly, there has been little standardization of the approach to determining cause of death. Some studies use standard nosological coding based on the International Statistical Classification of Diseases while others rely on panels of physicians. Some studies utilize autopsy findings; others do not. There is a clear need for standardization, and a unified approach is suggested. In this approach, panels of physicians prepare death certificates and are trained and standardized to generate reproducible information. A system for adjudication of differences is a part of the trial's design. Death certificates are then transmitted to panels of nosologists who assign cause of death. Again, the nosologists are standardized, and an adjudication system for resolving differences is developed. This two-stage system takes advantage of strengths of the two types of cause of death coding now in use in clinical trials and should produce results permitting cross-trial and cross-time comparisons.

Adult↗
PubMed1995

Transcranial color-coded sonography in normal Chinese adults and its clinical applications.

We have performed transcranial color-coded sonography to 150 normal adults. Through the temporal, orbital and foraminal windows, by using a 2 MHz pulsed-wave transducer, we were able to directly insonate the brain parenchyma, and to obtain color-coded Doppler vascular imagings and flow velocities of the intracranial basal cerebral arteries. There was no significant difference of blood flow velocities and resistance index between the right and left hemispheres. The mean velocities was highest in the middle cerebral artery and lowest in the ophthalmic artery while which had the highest resistance index. Female had higher mean velocity in basilar artery. The mean velocity, peak systolic velocity, as well as end diastolic velocity decreased significantly with age in middle cerebral artery, anterior cerebral artery and basilar artery. Four illustrative cases with abnormal findings were presented to compare with normal control. Some pitfalls in ultrasonography were also described.

Adolescent↗
PubMedDate not supplied

Facilitating the nurse practitioner's research role: using a microcomputer for data entry in clinical settings.

Data coding and entry can be a tedious and error-prone component of research. Statistical packages for a microcomputer are now available that enable the researcher to create data entry forms in a spread sheet format. In this article the use of software that can be used for data entry, manipulation, and analysis is discussed. In a practice setting these features are particularly useful, because the nurse practitioner can take the microcomputer to the clinical facility and enter data directly from client-provider interactions or from records. In clinical settings where client data are entered directly into a computer database as part of assessment and care giving, data can be downloaded onto this or similar programs for manipulation and analysis.

Humans↗
PubMed2006

Evaluation of a nurse consultant's clinical activities and the search for patient outcomes in critical care.

AIMS: To describe the actual clinical activities undertaken by a critical care nurse consultant in an eight-bedded adult surgical high dependency unit within a large NHS Teaching Hospitals NHS Trust. BACKGROUND: In the United Kingdom, the first critical care nurse consultants were approved in 2000 following the Department of Health's (1999) revised career structure for nurses. Expert practice is a core function of the role although the nature of expert practice in the context of critical care is unclear. Expert practice is often deemed to be a feature of advanced practice and although a number of studies have investigated this in context of critical care, there is little insight into the nature of advanced practitioners' clinical practice and how it might influence patient outcome. DESIGN METHODS: A diary was used by a critical care nurse consultant to record activity during scheduled clinical sessions. Data were collected for four months: 39 sessions were evaluated. Qualitative data were content analysed and coded into categories. Clinical activities were coded, categorized and analysed using SPSS 11.0 for windows (SPSS Inc., Chicago, IL, USA). FINDINGS: Clinical activities included direct care activities, clinical leadership, education and training. Two main themes emerged from the qualitative data and were categorized as clinical reasoning and clinical instruction. Clinical activities arising from clinical reasoning and clinical instruction were aimed at minimizing risk and the provision of quality care. In doing this, one of the outcomes was the detection and resolution of untoward clinical occurrences. CONCLUSION: The level of achievement--or end point--of clinical activities was that the patient was established in 'a state free from risk or harm that optimises rehabilitation'. 'A state free from risk or harm that optimizes rehabilitation' might be one outcome reflecting the needs of individual critically ill patients that is sensitive to individual nursing contribution. RELEVANCE TO CLINICAL PRACTICE: There is increasing pressure on health-care professionals to identify and measure their individual impact on the outcome of patients. This study adds further insight into the complexities associated with evaluating the influence of individual contribution on patient outcome, especially when it is characterized by complex processes involving clinical judgement and decision-making.

Adult↗
PubMed2003

The diagnosis related groups enhanced electronic medical record.

PROBLEM: The introduction of Diagnosis Related Groups as a basis for hospital payment in Germany announced essential changes in the hospital reimbursement practice. A hospital's economical survival will depend vitally on the accuracy and completeness of the documentation of DRG relevant data like diagnosis and procedure codes. In order to enhance physicians' coding compliance, an easy-to-use interface integrating coding tasks seamlessly into clinical routine had to be developed. A generic approach should access coding and clinical guidelines from different information sources. METHODS: Within the Electronic Medical Record (EMR) a user interface ('DRG Control Center') for all DRG relevant clinical and administrative data has been built. A comprehensive DRG-related web site gives online access to DRG grouping software and an electronic coding expert. Both components are linked together using an application supporting bi-directional communication. Other web based services like a guideline search engine can be integrated as well. RESULTS: With the proposed method, the clinician gains quick access to context sensitive clinical guidelines for appropriate treatment of his/her patient and administrative guidelines for the adequate coding of the diagnoses and procedures. This paper describes the design and current implementation and discusses our experiences.

Diagnosis-Related Groups↗
PubMed1996

Weightings of items on the Code-Müller Protocols: the effects of clinical experience of aphasia therapy.

One hundred and twenty-two professionals engaged in aphasia therapy (graduates and undergraduates) ranked and weighted the relevance of the items of the Code-Müller Protocols (CMP) for assessing perceptions of psychosocial adjustment to aphasia using the multiattribute utility technique (MAUT). The degree of clinical experience with aphasia had a significant influence on participants' weightings of the items 'ability to follow interests and hobbies' and 'receiving speech therapy'.

Adaptation, Psychological↗
PubMed1995

[Computer-assisted classification of ICD-9/10 and IKPM in compliance with the new federal health care regulation--practice-oriented solution for trauma surgery and orthopedics].

From the beginning of 1995, the German law on the health system structure prescribes that in all clinics the four-digit ICD code be supplied for each diagnosis and the ICPM code for each operation. This makes on-line access to diagnosis and therapy codes embedded in a clinic documentation system advisable. Since 1 February 1995, in one department of traumatologic surgery the ICD diagnosis and ICPM therapy coding is managed on-line by the doctors in the outpatient clinic and operation theatre, using the "do it" coding system in combination with the KAUZ system for clinic documentation. The user guidance supplied by a frequency-oriented menu and specialist traumatological terms makes it possible to determine the ICD and ICPM codes without any great expenditure of effort. Furthermore, the appropriate flat rates per case and special charges are displayed. Comparison of manual and computer-assisted coding of operations during 1 month (160 patients, 173 operations) showed that manual coding could be corrected or improved by the computerized system in 35% of cases. The ICD-10 system has already been integrated: it improves the recording of diagnoses and will simplify the change over to the coming new revision.

Electronic Data Processing↗
PubMed1997

Noninvasive method for measuring thrombus formation in patients after peripheral angioplasty using three-dimensional B-mode and color-coded Doppler ultrasonography.

Clinical investigations studying the effect of newer medications on such complex pathophysiology as the formation of an arterial or venous mural thrombus have been limited to clinical symptomatic endpoints. Biochemical markers so far have not been convincing in quantifying ongoing thrombus formation. Consequently, clinical development of new antithrombotic compounds has had to rely on clinical symptoms that occur either comparably late in the course of the disease and may therefore be influenced by many other factors, or on those symptoms that occur at a relatively low incidence rate. Both circumstances make studies for dose-finding and determination of optimal drug regimens more difficult and time consuming. Using conventional clinical noninvasive ultrasonography, the volume and geometry of a peripheral arterial segment can be measured with high sensitivity and reproducibility in healthy volunteers (% coefficient of variation = 8.01%). In patients, thrombus volume was monitored after peripheral transluminal angioplasty of the femoral artery. All patients received a standard anticoagulant treatment with heparin for 24 hours after the procedure. Volume measurements were performed at 20, 29, 44, 53, and 68 hours after angioplasty. When compared with the obstruction volume at 20 hours, a slight increase could be detected at 29, 44, and 53 hours. At 68 hours there was a significant increase in obstruction volume. This indicates that volume measurements may detect changes in the course of thrombus formation, related to the antithrombotic treatment regimen, at a level at which clinical symptoms may not be present.

Aged↗
PubMed1993

American Health Information Management Association. Position Statement. Issue: roles of health information managers and coders in patient-focused care.

Patient-focused care is a new model of care delivery organized around the patient instead of the hospital structure. Care is provided by multi-disciplinary teams of healthcare workers on the patient care unit. As many services as possible are brought to the patient, rather than taking the patient to a decentralized department. Successful models have demonstrated increased operational efficiency and greater levels of satisfaction among patients, physicians, and staff members. Administrative tasks done in a variety of departments may be assigned to a member of the care team. Such tasks may include patient registration; insurance verification and financial arrangements; and medical record assembly, analysis, abstracting, and coding. Given the different educational levels and prior training administrative team members may have, careful consideration must be given to assignment of the medical record abstracting and coding functions. The quality of clinical data submitted by all providers in the US is critically important to the future of the nation's healthcare system. Under prospective payment systems, the accuracy of clinical data abstracting and coding has a significant impact on healthcare facilities. But the need for accurate clinical data goes beyond payment systems. As more and more clinical data are being captured and maintained in databases across the country, for uses that may be yet unknown, it is essential that such data be collected consistently and accurately. To assure the quality and validity of health information, only trained, experienced coders should abstract and code the data.(ABSTRACT TRUNCATED AT 250 WORDS)

Medical Record Administrators↗
PubMed1997

Comparing SNOMED and ICPC retrieval accuracies using relational database models.

While SNOMED International has been generally accepted by the international community of pathologists, its use for primary and secondary care remains limited. This can probably be attributed to the coding complexity of clinical concepts into this multiaxial postcoordinated nomenclature. The SNOMED editors propose the use of multiple codes (aggregates) for any nuanced clinical concept, thus allowing alternative rigorous representations of the concept with SNOMED codes. Some classification critics argue whether such redundant coding precludes precise retrieval of data. This research was initiated to compare the retrieval accuracies of a relational database using a simplified model of SNOMED against a classification-based model. SNOMED-based queries showed improvement over ICPC-based queries, regardless of the use of SNOMED cross-references. The addition of the latter significantly improved the queries sensitivity and false negative rate. In conclusion, the authors recommend using aggregates of SNOMED codes in relational database designs over classification-based designs in order to improve retrieval accuracy.

Classification↗
PubMedDate not supplied

Evaluation of the clinical LOINC (Logical Observation Identifiers, Names, and Codes) semantic structure as a terminology model for standardized assessment measures.

OBJECTIVE: The purpose of this study was to test the adequacy of the Clinical LOINC (Logical Observation Identifiers, Names, and Codes) semantic structure as a terminology model for standardized assessment measures. METHODS: After extension of the definitions, 1, 096 items from 35 standardized assessment instruments were dissected into the elements of the Clinical LOINC semantic structure. An additional coder dissected at least one randomly selected item from each instrument. When multiple scale types occurred in a single instrument, a second coder dissected one randomly selected item representative of each scale type. RESULTS: The results support the adequacy of the Clinical LOINC semantic structure as a terminology model for standardized assessments. Using the revised definitions, the coders were able to dissect into the elements of Clinical LOINC all the standardized assessment items in the sample instruments. Percentage agreement for each element was as follows: component, 100 percent; property, 87.8 percent; timing, 82.9 percent; system/sample, 100 percent; scale, 92.6 percent; and method, 97.6 percent. DISCUSSION: This evaluation was an initial step toward the representation of standardized assessment items in a manner that facilitates data sharing and re-use. Further clarification of the definitions, especially those related to time and property, is required to improve inter-rater reliability and to harmonize the representations with similar items already in LOINC.

Databases, Factual↗
PubMed2002

Improved pediatric multidetector body CT using a size-based color-coded format.

OBJECTIVE: CT technique should be adjusted while scanning infants and children. One format that has proven successful in simplifying pediatric care and reducing medical error is the size-based, color-coded Broselow-Luten pediatric system. This color-coded system can serve as a format for CT protocols. The purpose of this investigation was to compare variation (or error) occurrence and technologist preference for conventional and color-coded formats for pediatric multidetector body CT protocols. MATERIALS AND METHODS: Multidetector CT examinations were set up using either a conventional or a color-coded format for a period of 6 weeks each. Variations (errors) from protocol parameters (including tube current, detector configuration, table speed, and IV contrast media dose) were tabulated. Qualitative assessment consisted of a survey of CT technologists (n = 20) for preference in six areas related to ease of use and clarity of the formats. RESULTS: There were 44 CT examinations (n = 30 infants and children) in the conventional group and 55 CT examinations (n = 31 infants and children) in the color-coded protocol format group. Overall, the number of errors was significantly less in the color-coded group (p < 0.01), with a significantly lower error percentage in individual parameters affecting radiation dose, including tube current, detector configuration, and table speed (p < 0.05). In all areas, the color-coded format was preferred over the conventional format (p < 0.0003). CONCLUSION: Color-coded CT formatting is an extension of a clinical color-coded system. This system provides an easy, expeditious, consistent, and preferable format for general pediatric body CT protocols. Most importantly, the color-coded system can reduce variations (errors) in the radiology department.

Adolescent↗