Biomedical subjects

A G Lawthers

Publications and source records attributed to A G Lawthers.

At least 19 recordsLinked to original sources

PubMed2004

Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991.

BACKGROUND: As part of an interdisciplinary study of medical injury and malpractice litigation, we estimated the incidence of adverse events, defined as injuries caused by medical management, and of the subgroup of such injuries that resulted from negligent or substandard care. METHODS: We reviewed 30121 randomly selected records from 51 randomly selected acute care, non-psychiatric hospitals in New York State in 1984. We then developed population estimates of injuries and computed rates according to the age and sex of the patients as well as the specialties of the physicians. RESULTS: Adverse events occurred in 3.7% of the hospitalizations (95% confidence interval 3.2 to 4.2), and 27.6% of the adverse events were due to negligence (95% confidence interval 22.5 to 32.6). Although 70.5% of the adverse events gave rise to disability lasting less than 6 months, 2.6% caused permanently disabling injuries and 13.6% led to death. The percentage of adverse events attributable to negligence increased in the categories of more severe injuries (Wald test chi(2) = 21.04, p<0.0001). Using weighted totals we estimated that among the 2671863 patients discharged from New York hospitals in 1984 there were 98609 adverse events and 27179 adverse events involving negligence. Rates of adverse events rose with age (p<0.0001). The percentage of adverse events due to negligence was markedly higher among the elderly (p<0.01). There were significant differences in rates of adverse events among categories of clinical specialties (p<0.0001), but no differences in the percentage due to negligence. CONCLUSIONS: There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.

Adolescent↗

PubMed2003

Rethinking quality in the context of persons with disability.

OBJECTIVE: To review the current health services literature related to quality of care for persons with disabilities and to highlight the need for a unique framework for conceptualizing quality and patient safety issues for this population. DESIGN: Drawing on quality measurement theory, we formulate a multi-dimensional model of quality of care for persons with disability. This model is then used to identify and summarize findings from existing health services research that relate to the quality, of care for persons with disability. STUDY SELECTION: We searched MEDLINE and other databases for primary research and review articles containing the phrases 'quality of care', 'patient safety', 'access', 'patient experience', and 'coordination of care' in conjunction with the words 'disability' or 'impairment'. RESULTS: A review of health services research suggests several potential issues in the areas of clinical quality, access, client experience, and coordination. Physical barriers, transportation, communication difficulties, and client and provider attitudes present barriers to receiving appropriate client-centered care. Communication difficulties between provider and client may increase risk for accidental injury and decrease the quality of the client experience. Frequent contact with the health care system and the complexity of an individual's situation also increase the risk of accidental injury. Coordination, the 'lubricant' that facilitates links for all areas of quality for a person with disability, presents the most significant opportunity for improvement, because multiple medical and social providers are typically involved in the care of individuals with disabling conditions. CONCLUSION: Health care providers need to embrace a multi-disciplinary approach to quality to meet the needs of persons with disabilities. Funders and purchasers need to provide flexibility in funding to enable a comprehensive primary care approach, while health service researchers need to adopt a broad view of quality to capture issues of importance for persons with disabilities.

Communication Barriers↗

PubMed2000

Identification of in-hospital complications from claims data. Is it valid?

OBJECTIVES: This study examined the validity of the Complications Screening Program (CSP) by testing whether (1) ICD-9-CM codes used to identify a complication are coded completely and accurately and (2) the CSP algorithm successfully separates conditions present on admission from those occurring in the hospital. METHODS: We compared diagnosis and procedure codes contained in the Medicare claim with codes abstracted from an independent re-review of more than 1,200 medical records from Connecticut and California. RESULTS: Eighty-nine percent of the surgical cases and 84% of the medical cases had their CSP trigger codes corroborated by re-review of the medical record. For 13% of the surgical cases and 58% of the medical cases, the condition represented by the code was judged to be present on admission rather than occurring in-hospital. The positive predictive value of the claim was greater than 80% for the surgical risk pool, suggesting the value of the CSP as a screening tool. CONCLUSIONS: The CSP has validity as a screen for most surgical complications but only for 1 medical complication. The CSP does not have validity as a "stand-alone" tool to identify more than a few in-hospital surgery-related events. The addition of an indicator to the Medicare claim to capture the timing of secondary diagnoses would improve the validity of the CSP for identifying both surgical and medical in-hospital events.

Aged↗

PubMed1999

Using patient surveys to measure the quality of outpatient care in Kraków, Poland.

OBJECTIVE: To test the feasibility of using patient reported information to create indicators of quality (access, patient experience--including satisfaction, and clinical quality) with the goal of providing Kraków city clinic managers (and potentially other audiences) with information about the quality of outpatient care in selected clinics. Setting and methods. Almost 2,000 patients from 19 outpatient clinics in Kraków, Poland were surveyed in November and December 1997 and January 1998. We prepared a self-completed questionnaire to capture data about the patient's experience with access to services, interactions with registration staff, communication with the doctor, information received from the doctor, and receipt of preventive services. RESULTS: Access varied across clinics. For example, 84% of patients waited less than 10 minutes at registration, whereas only 53% of patients waited less than 30 minutes to see the doctor. Among those who tried to register by telephone, only 72% were successful. Satisfaction was highest with the doctor visit (satisfaction=79, on a scale of 1-100) and lowest with telephone registration (satisfaction = 59). Preventive health care screening was generally disappointing, particularly for Papanicolaou smear and clinical breast examination, although frequent users of a clinic (with more opportunities for screening) generally had higher rates of screening. CONCLUSION: We demonstrated the feasibility of constructing indicators of multiple dimensions of the quality of outpatient care using patient-reported information. Quality dimensions captured by survey included access, patient experience and clinical quality. Results were successfully summarized in easy to read and understand formats for clinic managers and city health department officials.

Adolescent↗

PubMed1996

Identifying adverse events caused by medical care: degree of physician agreement in a retrospective chart review.

OBJECTIVE: To 1) assess the degree of agreement among physicians on the cause of previously flagged adverse outcomes and 2) relate the findings to systems of quality assurance and performance assessment and proposals for no-fault compensation for medical injuries. DESIGN: Observational study of 7533 pairs of "structured implicit" reviews (subjective opinions based on guidelines) of medical records done by 127 physicians working independently. SETTING: Random sample of 51 inpatient facilities in New York State. PATIENTS: Random sample of inpatient medical records from the selected facilities. MEASUREMENTS: 1) Number of agreed-upon adverse events compared with the number of cases of extreme disagreement and 2) internally and indirectly standardized rates at which physician reviewers found adverse events (injuries to patients caused at least in part by medical management). RESULTS: In 12.9% of cases (971 of 7533), the two physicians in a pair had extreme disagreement about the occurrence of an adverse event. These cases outnumbered those in which both reviewers found an adverse event (10%; n = 757). Agreement was highest for wound infections and lowest for adverse events attributed to failure to diagnose or lack of therapy. The amount of experience the physicians had in reviewing records tended to increase the level of agreement. Even after standardization to the results of the entire sample, individual physicians' rates of finding at least slight evidence of an adverse event varied widely (range, 9.9% to 43.7%) (P < 0.001). CONCLUSIONS: Structured implicit reviews produced disagreement on the causes of adverse patient outcomes. If systems of quality assurance, performance audits, or no-fault patient compensation are to succeed, methods for overcoming the common tendency toward disagreement among experts must be developed.

Humans↗

PubMed1996

Processing the tort deterrent signal: a qualitative study.

Medical mistakes often are responsible for patient injury and suffering, but not all such mistakes are negligent. In the United States, injured patients have recourse to legal action under the common law. The medical malpractice tort trial system is intended to provide compensation for patients who have been negligently injured and to deter future negligent acts by physicians. The deterrent function of torts largely rests on practitioners' capacity and willingness to internalize, or 'process', the lessons of tort trials. However, physicians' willingness or ability to process the tort deterrent signal, while widely assumed in much contemporary legal writing on medical malpractice, has never been empirically verified. This study is a qualitative assessment of how practicing physicians process the tort deterrent signal. We interviewed a random sample of 47 internists, surgeons, and obstetrician/gynecologists from New York State as part of the Harvard Medical Practice Study. The interviews reveal three notable findings: physicians in our sample largely define medical negligence by reference to moral qualities of the practitioner; they claim that lawyers and the legal process of tort trials lack the moral authority to guide medical practice; and finally, while they consequently reject the lessons of lawyer-dominated, confrontational tort trials, they indicate that they would respond more favorably to hospital-based, physician-led, educational quality-control measures. Based on these findings, we identify several potential impediments to the receipt and processing of the tort deterrent signal by individual physicians and we suggest that the interview results support the notion of institutional liability for medical malpractice.

Attitude of Health Personnel↗

PubMed1996

Validity review of performance measures.

A structured process for evaluating the validity of performance measures is essential if the rates generated by these measures are to be relied upon for large-scale programmes to improve clinical care. In this evaluation process a panel of objective clinicians who were not involved in developing the performance measures examines the criteria, coding instructions, and coding form. The panel's job is to determine the degree to which a sample of patient records containing treatment elements that have been flagged for nonconformance to certain criteria are truly nonconformant. Modification of the performance measure according to the recommendations of the panel provides an important means of reducing measurement error by eliminating obvious sources of false positive findings. This article describes the procedures followed and the materials used to validate the performance measures developed for the project to Develop and Evaluate Methods for Promoting Ambulatory Care Quality (DEMPAQ), a research project contracted by the Health Care Financing Administration of the United States government [1-3]. DEMPAQ is described in Fig. 1. In the DEMPAQ project, record review is conducted by entering data directly from patient ambulatory records into a computer system. Instructions for abstracting the data are displayed on the computer monitor.

Alabama↗

PubMed1996

Education to improve the quality of clinical care in group practices.

Intervening to improve the quality of medical care is an essential component of an effective quality improvement program. Although interventions may take many forms, most have some educational component. This article discusses different types of educational strategies that may be used in group practices and describes our experience with a continuing medical education (CME) program based on the results of clinical performance measurement. Data are presented showing the effectiveness and acceptability of the educational intervention in the DEMPAQ project.

Curriculum↗

PubMed1996

Profiling resource use by primary-care practices: managed Medicare implications.

Variations in elderly Medicare beneficiaries' health service use are examined using a 100-percent sample of fee-for-service (FFS) claims data from Alabama, Iowa, and Maryland. Provider specialty, group practice type, practice size, and location are found to be significant factors affecting hospital and ambulatory care utilization and cost, after controlling for patient and regional characteristics. These results provide insights into utilization and cost expectations from different types of primary-care gatekeepers as the Medicare managed care market develops.

Aged↗

PubMed1996

Physicians' discourses on malpractice and the meaning of medical malpractice.

Recent analyses of the professions have considered the question of the changing nature of professional power. This study is an interpretive analysis of the meaning of physicians' discourse in the face of a perceived challenge to the traditional boundaries of clinical practice from malpractice suits. The data for this analysis were drawn from interviews with physicians from three specialties and from documents produced by the AMA/Specialty Society. Four modes of discourse were observed: (1) affective lament; (2) rejection of tort law; (3) complaints about a deterioration in the culture of clinical practice; and (4) a call for active campaigning. Analysis of the modes of discourse highlights both the ways in which professional power is subjected to challenge and the forms of political, financial, and cultural struggle that professional organizations and individuals engage in to resist such challenges.

American Medical Association↗

PubMed1995

Variation in office-based quality. A claims-based profile of care provided to Medicare patients with diabetes.

OBJECTIVES: To demonstrate that claims data "profiling" can be used as an ongoing method to support ambulatory care quality improvement; to measure the quality of office-based care provided to elderly patients with diabetes in three states; and to identify factors associated with better attainment of quality standards. STUDY DESIGN: A cross-sectional study based on a 100% sample of the Medicare claims (Part B and Part A) submitted between July 1, 1990, and June 30, 1991. SETTING: All primary care practices (both solo and group) actively seeing Medicare patients with diabetes in Alabama, Iowa, and Maryland (n = 2980). PATIENTS: All elderly (> or = 65 years) Medicare patients seen by the study physicians and assigned a diagnosis of diabetes (n = 97,388) by any office-based physician during the year. MAIN OUTCOME MEASURES: The proportion of patients with diabetes receiving the following procedures (from any provider) at least once during the study period: hemoglobin A1C measurement, ophthalmologic examination, total cholesterol measurement, and blood glucose measurement. We considered the first three services to be optimally recommended and blood glucose measurement to be of limited use. RESULTS: Based on analyses of services provided in the ambulatory setting, we found that 84% of diabetics did not appear to receive the recommended hemoglobin A1C measurement, 54% did not see an ophthalmologist, and 45% received no cholesterol screening. Practice patterns varied considerably across the three states (up to 2.38-fold), even after adjusting for patient case mix and physician characteristics. Patients of general practitioners were less likely to meet recommended quality criteria than patients of internists or family practitioners. Patients receiving care from rural practitioners were less likely to receive services, either recommended or not, than those in urban locations. CONCLUSIONS: Elderly patients with diabetes do not appear to be receiving optimal care. This study underscores the value of practice guideline development and dissemination in the ambulatory arena. This study provides substantial evidence that existing administrative claims data can be used to support ambulatory quality improvement activities.

Aged↗

PubMed1995

Designing and using measures of quality based on physician office records.

This article presents our principles for developing performance measures to assess the quality of ambulatory care. The measures were developed as part of a project for developing and evaluating methods to promote ambulatory care quality (DEMPAQ). We describe our design for the performance measures, present examples of the DEMPAQ review criteria, and show the formats we used to feed back information to physicians. We conclude by presenting the results of our appraisal of the performance measures showing how evaluation can aid in the interpretation of measurement findings.

Ambulatory Care↗

PubMed1995

Developing a quality improvement database using health insurance data: a guided tour with application to Medicare's National Claims History file.

Health policy researchers are increasingly turning to insurance claims to provide timely information on cost, utilization, and quality trends in health care markets. This research offers an in-depth description of how to systematically transform raw inpatient and ambulatory claims data into useful information for health care management and research using the Health Care Financing Administration's National Claims History file as an example. The topics covered include: (a) understanding the contents and architecture of claims data, (b) creating analytic files from raw claims, (c) technical innovations for health policy studies, (d) assessing data accuracy, (d) the costs of using claims data, and (e) ensuring confidentiality. In summary, claims data are found to have great potential for quality of care analysis. As in any analysis, careful development of a database is required for scientific research. The methods outlined in this study offer health data novices as well as experienced analysts a series of strategies to maximize the value of claims data for health policy analysis.

Aged↗

PubMed1995

Agreement between physicians' office records and Medicare Part B claims data.

This article tests agreement between demographic, diagnostic, and procedural information from primary-care physicians' office records and Medicare Part B claims for Maryland Medicare beneficiaries. The extent of agreement depended on the category of information being compared. Demographics matched poorly, probably due to incomplete record samples. Important diagnoses were often missing from the medical record. When claims indicated presence of disease, the patient was likely to have the disease, but claims did not capture all people who have the disease. Additionally, many laboratory tests and procedures were missing from the primary-care record. The appropriate use of either of these data sources depends on the specific research question that is being asked.

Demography↗

PubMed1994

A computerized system for reviewing medical records from physicians' offices.

BACKGROUND: Review of clinical performance in office-based care is increasing in importance as more medical care shifts to outpatient settings. Decisions made in primary care settings can save lives and limit disability through prevention and early intervention in disease. Information is needed to assess quality of care by answering such questions as whether drugs are prescribed and monitored appropriately, follow-up on serious health threats is carried out promptly, or procedures are performed for appropriate indications. Moreover, data from medical records are essential to provide important clinical information not found in the more widely used administrative data sets. Managed care organizations, too, face the need to respond to requests for objective information about the quality of primary care that they provide. Those organizations now planning assessments of primary care will need to consider the cost of obtaining information from medical record review. METHODS: The DEMPAQ Record Review System (DRRS) is a tool for peer review organizations (PROs) to use to review ambulatory care given to Medicare beneficiaries in physicians' offices. The system is described in terms of functions (activities commonly performed in the course of an office visit, such as drug prescribing), indicators (summary measures of quality for each key function of clinical care), and clinical items (for example, specific drugs or tests for each function and indicator)--a total of 263 indicators in all. A framework is provided for measuring the operational costs of a review system based on medical records. RESULTS: The costs directly associated with a fully operational review system were less than $48 per case in Iowa and Alabama and $72 per case in Maryland. On average, reviewers spent about an hour per case signed on to DRRS; average review times declined over time with practice. About half the cost of the review process is accounted for by administrative costs. Therefore, once the effort has been made to obtain records, the additional cost of abstracting more data items is relatively low. Since samples of 300-500 records suffice to measure average performance for a region or state, costs per region/state approximate $15,000 to $25,000 per measurement cycle for assessment of a wide array of clinical areas. SUMMARY: The cost of collecting information on quality of care from medical records using the review system falls within current budgets for PRO review. However, organizations planning to implement a quality improvement campaign should also consider the costs of analyzing the data, reporting information to physicians, and continuing to monitor changes in performance.

Aged↗

PubMed1994

Focus on quality: profiling physicians' practice patterns.

This article presents a physician practice profiling system developed using Medicare data to evaluate the quality of care provided by primary care physicians. We discuss four attributes to physicians' practice profiles that make them useful for quality improvement: flexibility, user involvement in developing profiles, explicit plans for evaluation, and fairness to groups of providers. This system serves as a model for physician profiling with a focus on quality of care measurement.

Aged↗

PubMed1993

Relationship between malpractice claims and cesarean delivery.

OBJECTIVE: To investigate whether an association exists between the probability of a cesarean delivery and the level of malpractice claims risk faced by hospitals and physicians. DESIGN: Survey of computerized discharge data linked with physician and hospital malpractice claims records based on stratified, random sample of hospitals. SETTING: Acute care hospitals in New York State in 1984. POPULATION: All deliveries (60 490) at 31 hospitals. RESULTS: After controlling for the clinical risk of a cesarean delivery, patient socioeconomic status, and physician and hospital characteristics, cesarean delivery was positively associated with physician malpractice premiums (odds ratio [OR], 3.00; 95% confidence interval [CI], 2.13 to 4.24 for the difference between upstate and New York City levels), with the number of physician claims opened per 100 physicians at the hospital level (OR, 1.15; 95% CI, 1.02 to 1.30 for a 1-SD change), and with the number of hospital claims opened per 1000 discharges (OR, 1.26; 95% CI, 1.10 to 1.43 for a 1-SD change). Measures of physician-perceived risk of suit also showed a significant association with cesarean delivery (OR, 1.96; 95% CI, 1.53 to 2.52, upstate vs New York City). Within hospitals, there was no significant association (OR, 1.15; P = .126) between the odds of cesarean delivery and the claims history (none vs one or more) of an individual physician. CONCLUSION: Results support previous speculations of a positive association between malpractice claims risk and the rate of cesarean delivery.

Cesarean Section↗

PubMed1993

Preventing medical injury.

Although adverse events (AEs) are not uncommon in hospitalized patients, they are by no means inevitable. A review of records from a population-based study in New York revealed that nearly 4% of hospitalized patients suffered AEs. Two-thirds of those events were considered to be caused by errors in management, most of which were not because of negligence. A large part of the reason preventable AEs occur is that today's medical care is extremely complex, involving a variety of personnel, equipment, and procedures. By seeking to eliminate errors in the system of providing care and raising the awareness of health care providers about the potential for AEs, programs can be established to address and possibly remedy this serious problem.

Accident Prevention↗