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Can a rural community mental health center with limited resources meet the federal guidelines for program evaluation? This case example shows that a rural center can comply with the guidelines through evaluation activities tailored to its special needs and small size.
This report presents a summary and analysis of data from the Centers for Disease Control performance evaluation program in bacteriology for the 6-year period 1980 to 1985. During this period, the number of laboratories enrolled in the program ranged from about 750 to 1,000. Identification results reported by participating laboratories for representative species of six major groups of bacteria were placed into five response categories that were based on the level and accuracy of the identifications. Data on the performance of participants with bacterial groups and performance with selected species within each major group were analyzed. Overall, participants experienced the least difficulty in identifying species or serogroups of members of the gram-positive and gram-negative cocci. Participants encountered greater difficulties with anaerobes, gram-positive bacilli, and miscellaneous gram-negative bacteria. Identification of members of the family Enterobacteriaceae was of moderate difficulty. Problems in identifying certain bacterial species were probably related to a number of factors such as the characteristics of the species, its frequency of occurrence, the state of technology available for identification, and the state of proficiency and quality control in individual laboratories at the time of testing. Examples are given of improvements over time in the identification of certain bacterial species. Laboratories participating in an external proficiency testing program should take full advantage of the benefits of participation by instituting measures to correct testing deficiencies identified by the program.
The Level of Rehabilitation Scale (LORS) was prepared to aid in meeting program evaluation needs of rehabilitation facilities. Advantages of the original LORS-I, including economy of administration, behaviorally defined levels of function, multiple points of view, and concise presentation of findings were retained. Normative information concerning improvement levels for the activities of daily living subscale was developed for cerebrovascular accident inpatients. Data showed that expected improvement varies according to functional level at admission and patient age.
The importance of program evaluation is discussed, and issues to consider when designing and conducting program evaluations in the restructuring health-care environment are identified. Program evaluation is carried out for the purpose of supporting specific decisions for individual organizations. Unlike scientific research, program evaluation accepts time as a constraint, and its audience is composed of managers. Considering the likelihood of being fixed-dollar contractors or employees in an era of managed care, professionals must try to understand the cost objectives of management; similarly, managers must understand the patient-care objectives of professionals. Program evaluation can help provide the necessary documentation of a program's impact on the outcome of health care, which influences the total cost of care. Successful program evaluation requires careful planning, and issues related to six steps in the planning process are described: defining the objective of the evaluation, choosing and defining the program to be evaluated, choosing indicator variables, designing the evaluation, presenting the results, and planning follow-through. While program evaluation is too often understood in negative terms, particularly as something done because of external pressure, it is as much a part of management as is directing day-to-day operations or developing a long-range plan.
In the first part methodically satisfactory experimental designs for evaluating programs for preparation to old age on the basis of Cambell & Stanely (1963) are sketched including conditions which hinder the realization of the ideal notions. In the second part an experiment for comparing two preparatory courses to old age using different methods of instruction is described. It was observed that the more demanding teaching method resulted in more anxiety for old age. This led to the conclusion, that programs for preparation to old age should be planned as a sequence of several units in which the mastering of the new ideas may be learned and in which this learning process may be supervised.
Development and use of a drug-use evaluation (DUE) program for hospital and outpatient facilities of a health-maintenance organization (HMO) are described. A full-time pharmacist coordinates the DUE program. Primary components of the DUE program are (1) establishment and use of drug therapy management protocols, (2) periodic review and evaluation of drug-use statistics by the pharmacy and therapeutics (P&T) committee, (3) monitoring of pharmacist interventions, and (4) evaluation of specific drug use within individual medical staff departments. Information from all DUE activities is channeled through the P&T committee and linked to the HMO's overall quality assurance program. The DUE program has the support of the HMO physicians. It has enhanced the quality of drug use and identified opportunities to further improve the quality of patient care. In surveys by the Joint Commission on Accreditation of Healthcare Organizations, the HMO facilities have received no recommendations. Pharmacists and physicians have cooperated to develop a comprehensive DUE program for an HMO.
The background and development of a multicategory direct observation system, the Behavior Observation Instrument (BOI), is described. This time-sampling procedure for recording the behavior of persons is demonstrated in several treatment settings and the results applied to issues of program evaluation. Elements that have prevented direct observation from being widely adopted, such as costs, manpower, and training requirements, are systematically analyzed. A basic psychometric analysis of the instrument is used to determine optimum frequency and duration of observation intervals as well as observer agreement. The results imply that direct observation methods, once assumed by some to belong to the special province of the single-subject design, can be used to assess the effects of programs on groups of psychiatric clients in an efficient and economic manner.
The results of a survey to assess drug-use evaluation (DUE) programs in short-term-care general U.S. hospitals are reported. During February 1992, questionnaires were mailed to pharmacy directors at 491 randomly selected short-term-care general hospitals with 100 or more beds. The questionnaire was designed to collect information on the characteristics of surveyed hospitals and their pharmacies, DUE program characteristics, and the perceptions of pharmacists about the DUE programs. The net response rate was 66.6% (327 usable replies). Pharmacists involvement in DUE program activities was found to be very high, with two thirds of respondents indicating they participated in all five ASHP-recommended activities. Pharmacists rated the effectiveness of current DUE programs as moderate, while the importance of pharmacist participation was perceived to be very high. Pharmacists were members of 97.9% of the respondents' DUE committees, but only 65.5% of the pharmacist members held voting privileges. Pharmacists reported devoting an average of 11.27 hours weekly to DUE-related tasks. Reasons used to select drugs for DUEs, interventions employed, uses of DUE results, and methods of evaluating the effectiveness of DUE programs all varied widely. In short-term-care general hospitals with 100 or more beds, pharmacists assigned to DUE activities were highly involved in DUE committees and programs. The effectiveness of these activities needs to be assessed in more detail.
The application of output value analysis, a type of benefit/cost analysis, to a psychiatric patient population is reported. A method for discounting the value of the program if a patient was readmitted within a year after discharge was introduced. The application of this discount factor reduces the value produced by the program and thereby reduces both productivity and effectiveness indices. When applied to groups known to differ in readmission rates, such as first admissions and readmissions or voluntary and involuntary admissions, the discount factor can accentuate group differences markedly. When selected diagnostic groups were compared, the discount factor could even reverse the relative standing of the groups.
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The call for evidence-based medicine and information on health outcomes has brought with it performance measurement systems. The necessary attributes of these systems are now being addressed as are the attributes of the measures themselves. In this paper the Australian Council on Healthcare Standards Care Evaluation Program is reviewed in relation to these various attributes. The more focused systems should prove useful in achieving change in clinical practice.
Recent changes in health care have focused attention on new tools for planning and managing clinical processes. The use of one tool in particular, clinical pathways, has increased dramatically. Pathways employ a concept long used in other industries: the explicit design and documentation of a process. However, the most common tools used in other industries to perform process design, the Program Evaluation and Review Technique (PERT) and the Critical Path Method (CPM), have not migrated to health care. This article presents a methodology for incorporating PERT/CPM into the design and management of clinical processes.
A drug usage evaluation (DUE) program was successfully implemented in a busy teaching medical center within 12 months of adding a full-time coordinator. The success of this program was due largely to its approval by hospital administration, the recruitment of a pharmacist with the necessary background, and the creation of a structure and process that encouraged participation by leaders of the medical staff. Although the primary objective of hiring the coordinator was to meet Joint Commission on Accreditation of Healthcare Organizations requirements for accreditation, another achievement was confirmed cost savings. Techniques used in selecting DUE subjects and the steps taken in implementing and managing the program are presented.
BACKGROUND: Recent reports have documented the occurrence of treatment-related acute myeloid leukemia (AML) following therapy with epipodophyllotoxins. These reports have led to growing concern among oncologists, which could lead to premature abandonment of these agents at a time when the relationship between cumulative dose of epipodophyllotoxin and risk of treatment-related AML has not been determined. PURPOSE: Because of the increasingly important role of epipodophyllotoxins in the treatment of several types of adult and pediatric tumors, the Cancer Therapy Evaluation Program (CTEP) of the National Cancer Institute (NCI) has developed a monitoring plan to obtain reliable estimates of the risk of treatment-related AML following epipodophyllotoxin treatment. METHODS: We identified 12 NCI-supported Cooperative Group clinical trials in which patients with solid tumors are being treated with epipodophyllotoxins at different cumulative doses. One trial is using a moderate dose of teniposide (900 mg/m2), and 11 trials are using etoposide at a low dose (< 1500 mg/m2), a moderate dose (1500-3999 mg/m2), or a high dose (> or = 4000 mg/m2). Cases of treatment-related AML and treatment-related myelodysplastic syndrome (MDS) (hereafter referred to as treatment-related AML/MDS) occurring in these trials are reported to CTEP, with initial analysis for each cumulative dose group triggered by the reporting of four cases of treatment-related AML/MDS in that group. For each analysis, total patient follow-up for the group is determined and cumulative 6-year incidence rate is calculated. RESULTS: Three cases of treatment-related AML and one case of treatment-related MDS (with documented monosomy 7) were reported in a group of 207 patients who received etoposide at a low cumulative dose. The calculated 6-year rate of development of treatment-related AML/MDS was 3.2% (95% upper confidence interval bounded by 7.2%). CONCLUSIONS: The 6-year cumulative rate of treatment-related AML/MDS (3.2%) is within the range previously reported for alkylator-based regimens that did not include epipodophyllotoxins. IMPLICATIONS: Previous reports have suggested that higher cumulative doses of alkylators are associated with increased risk of treatment-related AML, and a critical goal of the monitoring plan is to determine whether a similar relationship exists for the epipodophyllotoxins. Estimates will be developed for leukemogenic risk for the moderate- and high-cumulative-dose groups when four cases of treatment-related AML/MDS have been identified within each group.
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This report presents the methodology and outcomes of an evaluation of the Chemical Dependency Recovery Program (CDRP) of Southern California Kaiser-Permanente, a large group model HMO. CDRP treatment includes specialized detoxification inpatient facilities, day treatment and outpatient services. Substance use outcomes in a population of 1,986 patients consecutively entering treatment were obtained via telephone at six and twelve months post intake. For patients who consumed only alcohol at baseline (N = 621), significantly higher six month point prevalence abstinence rates were found among those who remained in treatment for a minimum of three months (89%), compared to those patients who failed to return for treatment after their intake (31%). For polydrug users (N = 1365), as contrasted with patients who utilized services only on their intake date, significantly higher six month point prevalence rates were restricted to those who remained in treatment for a minimum of six months (74% versus 21%). The evaluation documented the need for CDRP services, validated program effectiveness and highlighted areas for systematic improvement.
CDC's Division of Laboratory Systems, Public Health Practice Program Office, is implementing three new laboratory performance evaluation (PE) programs. The first assesses the performance of laboratories that perform tests to determine the viral RNA copy number (viral load) in the blood of persons infected with human immunodeficiency virus type 1 (HIV-1); the second assesses the performance of laboratories that perform HIV p24 antigen (Ag) testing; and the third assesses the performance of laboratories that perform nucleic acid amplification (NAA) tests for Mycobacterium tuberculosis.