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PubMed1997

Evaluating standardized coding and classification systems for clinical practice: a critical review of the nursing literature in the United States.

Developers of healthcare information systems are challenged by the difficulty of meeting the simultaneous goals of 1) capturing and electronically representing the broad array of data related to healthcare with sufficient expressibility to provide adequate documentation of the patient encounter, and 2) utilizing standardized coding and classification systems to facilitate linkages among computer-based systems. The evaluation studies to date have primarily focused on matching actual clinical data with terms in the recognized classification systems. These studies have provided evidence that the classification systems are relatively domain complete for categorizing patient problems and nursing interventions. Although several of the published criteria for evaluation relate to structure, it is noteworthy that this has not yet been a major focus of study in nursing. There are several areas of critical need that must be addressed. First, additional work is needed to develop and refine a standardized set of atomic-level terms relevant to nursing, including those for assessments, problems, and activities. Second, knowledge representations must be developed to support the building of complex concepts from atomic-level data.

Classification↗
PubMed1978

Computerization of clinical laboratory procedure manuals.

Current code requires federally licensed clinical laboratories to have standard operating procedure manuals describing all tests performed. A computerized system for generating, revising, and excerpting manuals, which produces hard copy and microfiche, has been developed and appears to meet the regulatory criteria. The salient aspects of pertinent federal regulations, the features of the computerized system, the format of the manual, the users' experience therewith are described.

Computers↗
PubMed1993

Computer-Assisted Retrospective Clinical Activities Statistics (CARCAS) Program.

Clinical pharmacy services have been demonstrated to have a positive impact on patient care in the hospital setting. Accurate and complete documentation of interventions aimed at improving drug use is essential to assess workload characteristics, determine the impact of pharmacist activities, justify current programs and predict future clinical staffing requirements. The need for an improved system of collecting and analyzing clinical workload statistics led to the development of a Computer-Assisted Retrospective Clinical Activities Statistics (CARCAS) Program in our department. Using a pre-defined clinical activity coding system, pharmacist activities were efficiently documented on a daily basis using an existing distributional computer system. Training requirements and data entry time were minimal. The CARCAS Program appeared to capture more clinical pharmacist activities than the earlier manual system. The flexibility of the CARCAS Program should permit adaptation to other hospitals with similar computer systems regardless of the nature of their clinical programs.

British Columbia↗
PubMed1982

An approach to the definition of periodontal disease syndromes by cluster analysis.

Clinical syndromes of 22 untreated patients with advanced destructive periodontal disease were analyzed using cluster analysis. Clinical characteristics coded for each patient included age, sex, measures of gingival inflammation, plaque, suppuration, pocket depth, attachment level, extent and pattern of bone loss, rate of change in pocket depth, and correlation coefficients between certain clinical measurements. Microbiologic features included darkfield enumeration of 10 morphologically distinct forms of organisms which were removed from the three sites showing the most advanced destruction in each patient, as well as viable counts of specific microbial groups from the same teeth using elective and selective media. Serum antibody levels were determined by the ELISA technique to 13 species of subgingival microorganisms. The Gower coefficient was used to estimate similarity between patients and clusters were formed using an average unweighted linkage sort. Three distinct patient clusters were observed with greater than 70% average intra-cluster similarity. One subject did not fall into any of the patient clusters. The features which defined and differentiated the clusters were found to include age of subject, extent and patterns of bone loss, percent of sites showing change in pocket depth and attachment level, percent of small motile rods, intermediate spirochetes and fusiforms and serum IgG levels against Bacteroides gingivalis, Selenomonas sputigena and a Wolinella strain.

Adolescent↗
PubMed1989

Over- and undercontrolled clinic referral problems of Jamaican and American children and adolescents: the culture general and the culture specific.

Child behavior problems and corresponding clinic referral patterns may be significantly influenced by cultural factors. Prevailing values and childrearing practices within a culture may discourage development of some child problems while fostering others. We explored this possibility, focusing on clinic referral problems of two different societies: (a) Jamaica, where the Afro-British culture discourages child aggression and other undercontrolled behavior and possibly fosters inhibition and other overcontrolled behavior, and (b) the United States, where undercontrolled child behavior is seemingly more generally accepted. We coded clinic-referred problems listed by parents of Jamaican and American youngsters (N = 720). Cross-cultural differences were striking: Overcontrolled problems were noted more often for Jamaican than American youngsters, whereas the converse was true for undercontrolled problems. These and other findings suggest that factors such as culture and sex may be linked to substantial differences in the problems for which youngsters of different countries are treated in clinics.

Adolescent↗
PubMed1999

The MCFONTZL classification system for soft-tissue injuries to the face.

A review of the literature and case records reflected a need for the development of a clinically applicable assessment scheme and classification system for soft-tissue laceration injuries to the face. Herein, a systematic approach for assessing facial lacerations is proposed based on location, depth of penetration, branching, directionality, size, presence of soft-tissue defect, and translation of such injuries into the current procedural terminology (CPT) code. Moreover, a new classification system for facial laceration injuries is presented that may serve as the basis for simplification of current billing codes. Prospective clinical application of this classification system may lead to standardization of facial injury assessment and improvement in the incomplete and inconsistent patient record. This system will establish a reliable database that may identify factors in soft-tissue injuries that contribute to poor aesthetic results or secondary functional deformities. These data will lead to the modification of established treatment plans.

Facial Injuries↗
PubMed1993

[The development of an information network for new techniques in clinical microbiology].

In accordance with changes in our life styles and our social and biological environment, the techniques and methods of clinical microbiology must change and develop. New techniques, such as selected zone culture, direct drug susceptibility test, ATP bio-luminescence assay on membrane filter and expiratory gas analysis are among these developments. To ensure equal development among medical laboratories, an information network concerning these new microbiological methods in needed. An enormous quality of information can be contained and managed usefully by a two dimensional bar-code system. Clinical microbiology must not only contribute to clinical medicine but also respond to changes in the social and biological environment, and must include cost effectiveness, and preservation of natural resources. Using the new techniques effectively and introducing automatic systems will facilitate practical, useful and rapid clinical microbiological diagnoses.

Computer Communication Networks↗
PubMed1995

Clean intermittent catheterization: safe, cost-effective bladder management for male residents of VA nursing homes.

OBJECTIVES: To compare the safety and cost of clean versus sterile intermittent bladder catheterization in male nursing home residents. To provide evidence to support the hypothesis that intermittent catheterization is a valid, alternative method of bladder management in male residents of long-term care in whom urinary retention is a documented problem. DESIGN: Randomized clinical trial. SETTING: Three long-term care sites having predominantly male populations. PARTICIPANTS: Eighty male veterans, residents of three long-term care facilities, ranging in age from 36 to 96 years with a mean age of 72. INTERVENTIONS: Standardized procedures for clean and sterile intermittent catheterization (IC) were implemented by staff nurses at each site. Patients were randomized into clean and sterile IC groups. Nursing time and catheterization equipment usage were recorded using bar code readers. Clinical data were collected from the medical chart. Treatment of urinary tract infection was prescribed by the medical personnel responsible for each individual resident. MEASUREMENTS: We compared the number of treatment episodes for symptomatic bacteriuria between groups randomized to receive either clean or sterile intermittent catheterization. Laboratory analysis of blood and urine was done on predetermined days. Control variables were research site and patient history of urinary tract infection within the last 6 months. A cost comparison of nursing time and equipment usage for the two catheterization techniques was also performed. RESULTS: No significant differences were found between clean and sterile groups with regard to number of treatment episodes, time to first infection, type of organism cultured, or cost of antibiotic treatment. The cost of sterile technique was considerably higher both in terms of nursing time and supplies. CONCLUSIONS: Findings from this study demonstrate that clean technique intermittent catheterization is a safe and cost-effective bladder management technique with male, nursing home residents, despite the frailty of this high risk population. An annual savings of approximately $1460 per patient in nursing time and catheterization supplies could be anticipated if a patient were catheterized an average of four times per day substituting clean IC technique for sterile IC technique.

Adult↗
PubMed1998

Derivation of a clinical prediction model for the emergency department diagnosis of ectopic pregnancy.

OBJECTIVE: To derive a clinical prediction model for estimating the pretest probability of ectopic pregnancy in ED patients with first-trimester abdominal pain or vaginal bleeding. METHODS: All hemodynamically stable first-trimester patients presenting to the ED of a tertiary care military teaching hospital over a 14-month period with a chief complaint of abdominal pain and/or vaginal bleeding had clinical data coded prior to determining outcome. They were then followed longitudinally until a criterion standard pregnancy outcome was established. RESULTS: Of the 486 patients enrolled, 280 (58%) had viable intrauterine pregnancies, 167 (34%) had nonviable intrauterine pregnancies, and 39 (8%) had ectopic pregnancies. Using a recursive partitioning model, a high-risk group was derived (that was separated from intermediate and low-risk groups), consisting of patients with abdominal peritoneal signs or definite cervical motion tenderness, with a sensitivity of 31% (95% CI: 17-48%), a specificity of 93% (95% CI: 90-95%), a positive likelihood ratio of 4.3, and a negative likelihood ratio of 0.74. A low-risk group, consisting of patients with either fetal heart tones or tissue at the cervical os, or the absence of pain other than midline menstrual-like cramping and lacking any pelvic tenderness, was differentiated from an intermediate-risk group, with a sensitivity of 96% (95% CI: 81-100%), a specificity of 22% (95% CI: 18-26%), a positive likelihood ratio of 1.2, and a negative likelihood ratio of 0.17. CONCLUSION: A clinical prediction model for estimating the probability of ectopic pregnancy in ED patients has been derived. It may prove to have practical clinical application for estimating pretest probability of ectopic pregnancy as well as assisting in medical decision making when laboratory and ultrasonographic findings are nondiagnostic. Clinical application should await prospective validation in an independent sample.

Abdominal Pain↗
PubMed1997

Use of calcium channel blockers and breast carcinoma risk in postmenopausal women.

BACKGROUND: The use of calcium channel blockers in an elderly population recently was reported to be associated with the incidence of cancer. The Cardiovascular Health Study, a multisite observational cohort study, provided the opportunity to investigate the epidemiologic association between the use of calcium channel blockers and breast carcinoma risk in 3198 women age > or = 65 years. METHODS: Standard questionnaires and clinical procedures were administered at four study sites annually from 1989-1990 to 1993-1994. Drug usage was assessed by a medication inventory and hospitalizations for 75 incident invasive breast carcinoma cases were identified using International Classification of Diseases-9 Clinical Modification codes. Time-dependent Cox proportional hazards regression models were used to assess associations between incident breast carcinoma and the use of specific antihypertensive medication including calcium channel blockers. RESULTS: In adjusted Cox proportional hazards models, an elevated risk of breast carcinoma was associated with use of calcium channel blockers (hazard ratio [HR]: 2.57; 95% confidence interval [CI], 1.47-4.49). This association persisted when the comparison group was users of other antihypertensive medication. No associations between the use of other antihypertensive medication with incident breast carcinoma were found. Associations were enhanced by assessment of high dose at baseline (HR: 4.42; 95% CI, 1.37-14.27) and when calcium channel blockers were combined with estrogen use (HR: 4.48; 95% CI, 1.58-12.75). The association was found to be strongest for the use of estrogens with immediate release calcium channel blockers (HR: 8.48; 95% CI, 2.99-24.08). CONCLUSIONS: Although the number of cases was limited in this observational study, associations found between the use of calcium channel blockers and incident invasive breast carcinoma warrant further investigation. Site specific carcinomas should be included as an outcome of ongoing and planned long term clinical trials using calcium channel blockers.

Age Factors↗
PubMedDate not supplied

Trends in the prescribing of antidepressant pharmacotherapy: office-based visits, 1990-1995.

Data from the National Ambulatory Medical Care Survey for the period 1990 through 1995 were used to discern the population-adjusted rate of office-based physician-patient encounters at which the prescribing or continuation of antidepressant pharmacotherapy (tricyclic antidepressants [TCAs], selective serotonin reuptake inhibitors [SSRIs], or others), a diagnosis of depression (International Classification of Diseases, 9th Revision, Clinical Modification codes 296.2 through 296.36, 300.4, or 311), or both were documented. National estimates of the number of office-based visits resulting in a prescription for or continuation of antidepressant pharmacotherapy for any purpose escalated from 16,534,268 in 1990 to 28,664,796 in 1995, a 73.4% increase. Although the number of office-based visits at which a diagnosis of depression was documented increased 23.2% during this period, the proportion of patients with a diagnosis of depression who were prescribed or continued antidepressant pharmacotherapy increased only 14.9%, from 52.1% in 1990 to 67.0% in 1995. Among patients with a diagnosis of depression, use of a TCA declined from 42.1% in 1990 to 24.9% in 1995. In contrast, use of an SSRI for the treatment of depression increased from 37.1% in 1990 to 64.6% in 1995. The rate of office-based visits at which the use of antidepressant pharmacotherapy for any purpose was documented increased from 6.7 per 100 US population in 1990 to 10.9 in 1995, a 62.7% increase; documentation of a diagnosis of depression increased from 6.1 per 100 US population in 1990 to 7.1 in 1995, a 16.4% increase; and the recording of a diagnosis of depression in concert with the prescribing or continuation of antidepressant pharmacotherapy increased from 3.2 per 100 US population in 1990 to 4.8 in 1995, a 50.0% increase. Further research is required to elucidate the effect of observed trends on clinical and financial outcomes.

Adolescent↗
PubMedDate not supplied

The cost of antibiotics in treating upper respiratory tract infections in a medicaid population.

OBJECTIVE: To examine the use and cost of the nonindicated treatment regimens of antibiotics for nonspecific upper respiratory tract infections (URIs) in a Medicaid population. DESIGN: A cross-sectional sample of Kentucky Medicaid claims for 50000 people (July 1, 1993-June 30, 1994). SETTING: Episodes of care were created linking outpatient and emergency department visits for URIs to medications filled within a 5-day period. PARTICIPANTS: Individuals who were seen in ambulatory care for a URI as defined by the International Classification of Diseases, Ninth Revision, Clinical Modification codes 460 and 465. Of the 15706 episodes, 95% were outpatient office episodes. The outpatient episodes were accounted for by 8784 patients and 946 physicians. MAIN OUTCOME MEASURES: Use of antibiotics in URI episodes. Proportionate costs and costs per episode were computed based on claims paid by Medicaid. RESULTS: Sixty percent of outpatient episodes and 48% of emergency department episodes resulted in an antibiotic prescription being filled. In outpatient settings, episodes in which secondary diagnoses of either otitis media or acute sinusitis were found accounted for less than 6% of the episodes that resulted in an antibiotic prescription being filled. The most frequently filled antibiotic was amoxicillin, although second- and third-generation cephalosporins were the second most frequently occurring antibiotic class. Twenty-three percent and 9% of outpatient and emergency department episodes, respectively, resulted in a prescription filled for antihistamines. In outpatient episodes, antibiotics account for 23% of the total cost of care. In emergency department visits, antibiotics account for 8% of the cost of URIs. Antibiotics cost, on average, $9.91 for each episode of care in outpatient office visits. An estimate of the cost of antibiotics for URIs in a year for the Kentucky Medicaid program is $1.62 million. CONCLUSIONS: The results indicate that a substantial proportion of resources in Medicaid are being used for nonindicated and ineffective treatments for URIs. With the increase in antibiotic-resistant pathogens and shrinking public health care funding, the current treatment for URIs should be reexamined.

Aged↗
PubMed1998

Patterns of emergency department visits for disorders of the eye and ocular adnexa.

OBJECTIVE: To characterize the magnitude and patterns of visits to the emergency department (ED) for problems related to the eye and ocular adnexa. METHODS: The National Hospital Ambulatory Medical Care Survey was used to obtain information on ED visits in the United States for conditions of the eye and ocular adnexa in 1993. Patients were identified by International Classification of Diseases, Ninth Revision, Clinical Modification, codes. National projections were based on a staged probability design. RESULTS: There were 2.32 million projected ED visits for problems of the eye and ocular adnexa in 1993. Forty-nine percent of visits were for injuries, two thirds of which occurred in males. Thirty-five percent of injuries occurred in the home and 18% occurred in the workplace. Only 3% of patients required hospitalization. Most patients had private insurance, but substantial variations in coverage existed for patients who used the ED for injury- vs non-injury-related care. CONCLUSIONS: Emergency departments in the United States provide a large amount of eye care, much of which is for conditions other than trauma. Differences in insurance coverage for injury- and non-injury-related eye care indicate that factors other than medical urgency are involved in the decision to use ED services. Further studies are needed to determine the cost-effectiveness and quality of ocular-related ED visits.

Adolescent↗
PubMed1999

Racial difference in the incidence of retinal detachment in Singapore.

OBJECTIVE: To determine the incidence of retinal detachment (RD) operations in a multiracial Southeast Asian population. DESIGN: Population-based incidence study using a universal medical savings database in Singapore. METHODS: Information on all RD operations performed for rhegmatogenous RD (International Classification of Diseases, Ninth Revision, Clinical Modification code 361.0) between 1993 and 1996 was retrieved and analyzed from a population-wide, government-administered medical savings database. Exudative, tractional, and unoperated-on rhegmatogenous RD are excluded. The 1990 Singapore population census was used to allow an estimation of age-, sex-, and race-specific annual incidence of RD. RESULTS: Between 1993 and 1996, 1126 RD operations were performed on Singapore residents. The average annual incidence of RD operations was 10.5 per 100,000 population (95% confidence interval [CI], 10.2-10.9). The annual incidence was highest for Chinese (age-adjusted incidence, 11.6 per 100,000), followed by Malays (7.0 per 100,000), and lowest for Indians (3.9 per 100,000). The age-adjusted relative risk of RD operation for Chinese compared with Indians was 3.0 (95% CI, 2.9-3.1). Males were twice as likely as females to require RD surgery (age-adjusted relative risk, 2.0; 95% CI, 1.7-2.4). Chinese men 40 years and older had a 30.9 times higher risk (95% CI, 9.9-96.1) than Indian females younger than 40 years. CONCLUSION: The incidence of RD is strongly associated with male sex and ethnic origin.

Adolescent↗
PubMed1989

Pediatric patients, race, and DRG prospective hospital payment.

The diagnosis related group (DRG) prospective hospital payment system contains inequities in hospital payment for certain groups of patients. Patients of lower socioeconomic status may be underreimbursed by DRGs. We analyzed pediatric patients and hospital resource consumption by race (white, Hispanic, and black) using a DRG prospective payment "all payer" system. All hospitalized pediatric admissions over a 3-year period (N = 14,489) were analyzed by race at a large academic medical center. Mean hospital length of stay and cost per patient (adjusted for DRG weight index) was significantly greater for black and Hispanic pediatric patients compared with whites. Financial risk as measured by outliers and losses under DRGs was greater for blacks and Hispanics compared with whites. Black and Hispanic patients had a higher proportion of emergency admission to the hospital compared with whites, a greater severity of illness (as measured by total International Classification of Diseases, ninth revision, Clinical Modification codes), and (on average) higher diagnostic costs for each episode of illness. Our data suggest that black and Hispanic pediatric patients have a greater hospital resource consumption (adjusted for DRG group case mix) compared with whites, at least at our large medical center in the Northeast. Hospitals that treat greater numbers of black and Hispanic pediatric patients may be at a substantial disadvantage under per-case DRG payment.

Academic Medical Centers↗
PubMed1989

Weighted ventriculographic wall motion score for improved survival prediction in patients with coronary artery disease. Coronary Artery Surgery Study.

Global ventricular function parameters such as the ejection fraction and the sum of wall motion scores for segments of the left ventricle are excellent predictors of long-term survival in patients with coronary heart disease. These are usually determined from a monoplane right anterior oblique view. It was hypothesized that a biplane weighted wall motion score that included the left anterior oblique projection might better predict survival. A new score (BISCORE) was derived for 1,433 Mayo Clinic ventriculograms coded by the methods of the Coronary Artery Surgery Study (CASS). Weighting coefficients for each left ventricular segment were derived by the proportional hazards technique, and this resulted in the equation BISCORE = 120 - (8.6 x anterobasal + 3.4 x basal septum + 2.9 x apical + 2.7 x posterolateral + 2.4 diaphragmatic), which yielded a score from 0 (all segments aneurysmal) to 100 (all segments normal). This score stratified the original 1,433 patients into distinct groups by survival. As a single variable it was better than previous wall motion scores and ejection fraction at predicting survival. When prospectively applied to 5,172 Coronary Artery Surgery Study patients, this new score again proved to be a better predictor of survival than previous unweighted scores. Since the new score contains terms from the left anterior oblique ventriculographic projection, it is concluded that this projection adds information to that of the right anterior oblique projection regarding survival. Furthermore, this weighted score appears more highly associated with survival than unweighted scores.

Coronary Disease↗
PubMedDate not supplied

The ratio of AIDS to non-AIDS Medicaid medical costs from 1992 to 2000.

Our research objective was to calculate and forecast the monthly increase in medical and prescription costs for Medicaid patients with acquired immunodeficiency syndrome (AIDS) and compare these values with costs for non-AIDS patients. A retrospective analysis of AIDS patients and a control group of Georgia Medicaid beneficiaries was conducted between January 1, 1988, and December 31, 1991. AIDS patients were defined using the Keyes algorithm of combinations of International Classification of Diseases, 9th Revision, Clinical Modification codes. The AIDS patient group was matched demographically to a group of non-AIDS patients. Data were adjusted to account for eligibility status, and the ratio of AIDS costs to non-AIDS costs was modeled with an econometric time series procedure. A total of 1966 AIDS patients were identified from 900,000 Medicaid recipients in the study period; 58.0% were male and 59.8% were black. Age was bimodal at < or = 1 year and 33 years. The best fit for the medical cost ratios produced a significant regression coefficient of .37. The initial ratio of AIDS to non-AIDS forecast was 4.25 in January 1992. The January 2000 forecast of this ratio increased to 42.56. This increase equates to an additional $8510.19 per AIDS patient-month for January 2000 in 1991 dollars. The outpatient prescription ratio for AIDS versus non-AIDS patients was not predictable. However, the greatest observed discrepancies were attributed to the expense for antihemophilia products. Overall, the most important finding was the accelerating medical costs for treating AIDS patients compared with costs for treating non-AIDS patients. These results may, in part, reflect additional costs for treating intravenous drug users and pediatric AIDS patients.

Acquired Immunodeficiency Syndrome↗