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C M Ashton

Publications and source records attributed to C M Ashton.

At least 37 records · Page 2Linked to original sources
PubMed1997

Chart review. A need for reappraisal.

Imperfections of chart review as a data collection method are detailed, with particular emphasis on the issue of reliability. The authors identify 125 journal articles published between 1991 and 1992 in which the authors' conclusions were based principally on chart review findings and were either clinical or health care epidemiology studies, or quality assessment studies. Eight percent of epidemiology studies and 56% of quality assessment studies presented data on interrater reliability. Forty-four percent of epidemiology studies and 20% of quality assessment studies did not describe the number of chart reviewers involved. Forty-three percent of epidemiology studies and 28% of quality assessment studies used supplementary data sources. The authors conclude that the validity and utility of studies based on chart review would be enhanced by attention to interrater reliability and the use of supplementary data sources.

Data Collection↗
PubMed1997

Symptomatic syndrome of inappropriate antidiuretic hormone secretion associated with azithromycin.

OBJECTIVE: To report a case of symptomatic syndrome of inappropriate antidiuretic hormone (SIADH) secretion associated with azithromycin and review the literature related to this adverse drug reaction. DATA SOURCES: Review articles identified by a computerized (MEDLINE) (1966-April 1996) and manual (Index Medicus) search. DATA SYNTHESIS: Azithromycin is a well-tolerated broad-spectrum macrolide antibiotic. We report a symptomatic case of SIADH secretion associated with azithromycin. The patient received two doses of azithromycin before the development of sudden mental status changes associated with severe hyponatremia. All other potential causes were ruled out. No previous reports exist in the literature. CONCLUSIONS: Azithromycin may be associated with symptomatic SIADH secretion. Awareness and attention are required if patients develop mental status changes or hyponatremia while receiving azithromycin so that appropriate diagnostic and therapeutic actions can be implemented.

Anti-Bacterial Agents↗
PubMed1996

A conceptual framework for the study of early readmission as an indicator of quality of care.

Despite the perennial popularity of readmission as an indicator of the quality of hospital care, the empiric evidence linking it to process-of-care problems during the prior hospitalization is inconsistent. We devised a conceptual model for the use of unscheduled readmission within 31 days as an indicator of the quality of medical-surgical inpatient care for adults, and then conducted a systematic review of the readmission literature to determine the extent to which the evidence supports the proposed relationships. A fairly complex web of relationships influences the association between the process of inpatient care and early readmission. From the evidence to date, it is impossible to say with confidence that early readmission is or is not a valid and useful quality indicator. In most negative studies, the absence of an association appears to be explainable on the basis of improper study design, omission of important variables, or mis-specification of variables. Variables intervening between or confounding the relationship of the process of inpatient care to early readmission have received inadequate attention in past work. Investigators can use the proposed model and literature review to ensure their work advances the field and puts the hypothesis that early readmission is a valid quality indicator to a rigorous test. This matter has a certain urgency in view of the vast amount of resources that providers and payers devote to monitoring readmission rates and reviewing readmissions.

Adult↗
PubMed1996

Research organizations in the Department of Veterans Affairs that focus on database analysis.

The Department of Veterans Affairs (VA) established several internal research organizations to analyze the many VA and non-VA databases. The information obtained assists VA in achieving its objective of providing cost-effective, high quality health care for veterans. Each group has a unique and well-defined function. All major informational inputs needed for VA planning are covered by the groups: resource allocation, workload requirements, population projections, and technology assessment, among others. Both managerial and academic research are conducted. The Department of Veterans Affairs has demonstrated flexibility in initiating new research center as the need arises, such as during the recent health care reform debates. The Department of Veterans Affairs has provided for the dissemination of information about research and databases by explicitly including this task as the focus of one group. A drawback to VA's research system is the minimal intercommunication among the groups. Learning about VA's internal research structure can assist other multihospital systems to identify their informational needs and establish suitable research organizations.

Health Care Rationing↗
PubMed1995

The association between the quality of inpatient care and early readmission.

OBJECTIVE: To determine whether the quality of care during a hospital stay is associated with unplanned readmission within 14 days. DESIGN: Case-control study. SETTING: 12 Veterans Affairs hospitals. PATIENTS: Men discharged after a hospitalization for diabetes (n = 593), chronic obstructive lung disease (n = 1172), or heart failure (n = 748). The ratio of controls (men without an unplanned readmission within 14 days to any Veterans Affairs hospital) to cases (men with such a readmission) was 3:1. MAIN OUTCOME MEASURES: Unplanned readmission to any of the 159 Veterans Affairs hospitals within 14 days of discharge. Quality of care during the index stay was assessed by chart review using disease-specific explicit criteria for the process of inpatient care, which were developed by panels composed of expert physicians. Adherence scores (the percentage of applicable criteria that were met) were calculated for the admission workup, evaluation and treatment, and readiness for discharge. RESULTS: After adjustment was made for demographic characteristics, severity of illness, and need for care, adherence scores correlated with early unplanned readmission (P < 0.05). For patients with diabetes and heart failure, decreased readiness-for-discharge adherence scores correlated with increased risk for readmission (P = 0.001 and P = 0.016, respectively). In patients with obstructive lung disease, decreased admission-workup scores correlated with increased risk for readmission (P = 0.013). One of 7 readmissions in patients with diabetes, 1 of 5 readmissions in patients with heart failure, and 1 of 12 readmissions in patients with obstructive lung disease were attributable to substandard care. CONCLUSIONS: Lower quality of inpatient care increases the risk for unplanned early readmission in patients with heart failure, diabetes, or obstructive lung disease. Under certain circumstances, readmission is associated with remediable deficiencies in the process of inpatient care.

APACHE↗
PubMed1995

Postoperative delirium. A review of 80 primary data-collection studies.

We conducted an on-line search and manual searches for 1966 through 1992 to determine the incidence, diagnosis, risk factors, and treatment of postoperative delirium. Of the 374 citations found, 277 articles were excluded after criteria of relevance were applied. After methodologic criteria for validity were applied to the remaining 80 articles, 26 studies were retained for the final information synthesis. The incidence of postoperative delirium was 36.8% (range, 0% to 73.5%). Primary reasons for this disparity were insufficient sample size and inconsistent application of numerous diagnostic tools. One study provided statistically significant data that demonstrated that postoperative delirium is underdiagnosed by physicians and nurses. Four of the articles that met the established criteria provided risk factor data. Although age, preoperative cognitive impairment, and the use of anticholinergic drugs were significantly associated with postoperative delirium, gender, type and route of anesthesia, and sleep deprivation were not. Two studies demonstrated a decreased incidence of postoperative delirium when patients underwent preoperative psychiatric counseling or participated in a structured perioperative program. These findings indicate a need for (1) accurate incidence data with further definition of risk factors and (2) studies that address the diagnosis and treatment of this common postoperative problem.

Delirium↗
PubMed1995

In-hospital complications among survivors of admission for congestive heart failure, chronic obstructive pulmonary disease, or diabetes mellitus.

OBJECTIVE: To determine the frequency of hospital complications among survivors of inpatient treatment for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or diabetes mellitus (DM). DESIGN: Retrospective cohort study. SETTING: Nine Veterans Affairs hospitals in the southern United States. PATIENTS: 1,837 men veterans discharged alive following hospitalization for CHF, COPD, or DM between January 1987 and December 1989. This patient population represents a subset of cases gathered to study the process of care in the hospital and subsequent early readmission; thus, veterans who died in the hospital were not included. MEASUREMENTS: Medical record review to record the occurrence of any of 30 in-hospital complications such as cardiac arrest, nosocomial infections, or delirium (overall agreement between two reviewers = 84%, kappa = 0.37). RESULTS: Complications occurred in 15.7% of the CHF cases, 13.1% of the COPD cases, and 14.8% of the DM cases. Hypoglycemic reactions were the most frequent individual adverse events in the CHF and DM cases (3.6% and 11.4% of the cases, respectively), and theophylline toxicity was most frequent among the COPD cases (4.9%). Patient age, the presence of comorbid diseases, and the Acute Physiology Score (APS) of APACHE II were associated with complication occurrence. For each disease, the patients who had a complication had significantly longer mean hospital stays than did the patients who did not have complications (14.6 to 14.9 days vs 7.2 to 8.2 days, p < 0.01). CONCLUSIONS: Complications are frequent among patients discharged alive with CHF, COPD, or DM. The patients who experienced complications were more ill on admission and had longer hospital stays.

APACHE↗
PubMed1995

Using administrative databases to evaluate the quality of medical care: a conceptual framework.

Health care is consuming an ever larger share of national resources in the United States. Measures to contain costs and evidence of unexplained variation in patient outcomes have led to concern about inadequacy in the quality of health care. As a measure of quality, the evaluation of hospitals through analysis of their discharge databases has been suggested because of the scope and economy offered by this methodology. However, the value of the information obtained through these analyses has been questioned because of the inadequacy of the clinical data contained in administrative databases and the resultant inability to control accurately for patient variation. We suggest, however, that the major shortcoming of prior attempts to use large databases to perform across-facility evaluation has resulted from the lack of a conceptual framework to guide the analysis. We propose a framework which identifies component areas and clarifies the underlying assumptions of the analytic process. For each area, criteria are identified which will maximize the validity of the results. Hospitals identified as having unexpectedly high unfavorable outcomes when our framework is applied will be those where poor quality will most likely be found by primary review of the process of care.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗
PubMed1995

Selecting disease-outcome pairs for monitoring the quality of hospital care.

Health care payors and providers are increasingly monitoring hospital discharge data bases for adverse events as markers for quality of care. The principal criticisms of these analyses have focused on the impediments to risk adjustment posed by the incompleteness and inaccuracy of the data bases. However, efforts to address the inadequacies of the data bases will not correct deficiencies of the analytic process. These deficiencies arise from the application of one adverse outcome to all disease states. Instead, analysis should be restricted to comparisons of subgroups of patients in which a close fit exists between the quality of care for the disease state and the expected outcome. Furthermore, these disease-outcome pairs should be minimally subject to measurement error. The authors present a conceptual framework for developing such meaningful disease-outcome pairs, and using the hospital discharge data base of the Department of Veterans Affairs, show how the framework can be used to devise a monitoring strategy for re-admission.

Data Collection↗
PubMed1995

Outpatient surgical utilization in Veterans Affairs hospitals, 1981-1989.

In the 1980s, there was a large increase in the percentage of surgical operations performed in the United States without an overnight hospital admission. This shift may have been related to changes in reimbursement for outpatient surgery; studies of this relationship have had conflicting results. The Department of Veterans Affairs (VA) has a budgeting strategy significantly different from reimbursement strategies used by nonfederal hospitals. The VA strategy underwent changes in terms of budgeting for outpatient surgery in the 1980s. Data from the American Hospital Association (AHA) Annual Survey of Hospitals collected during the years 1981 through 1989 inclusive were analyzed in an effort to examine VA outpatient surgical utilization and to compare changes in VA outpatient surgical utilization with changes in outpatient surgical utilization in the nonfederal sector. The VA had an apparent rapid expansion of outpatient surgical utilization in the mid-1980s compared with the nonfederal sector. This increase occurred without a concomitant decrease in inpatient surgical procedures. This apparent rapid expansion may represent a combination of real changes in surgical utilization, changes in utilization of services not traditionally thought to be surgical but counted as such by VA hospitals, and changes in VA record-keeping. All of the components of this expansion may have been accelerated by the implementation of the VA Resource Allocation Methodology in 1985 and 1986.

Ambulatory Surgical Procedures↗
PubMed1995

In-patient workload in medical specialties: 2. Profiles of individual diagnoses from linked statistics.

We analysed hospital use for 58 common clinical conditions in the medical specialties, using data from the two districts covered by the Oxford record linkage study 1968-1986. Episode rates, person rates, and ratios of multiple admissions per person were computed. In young adults, poisoning was the most common reason for admission. In older adults, the most common clinical conditions included atherosclerotic diseases and smoking-related lung diseases. Comparing the first and last time periods studied, admission rates increased by 10% or more in 37 of the 58 conditions, including 7 of the 10 conditions with the highest overall hospitalization rates. Conditions in which admissions increased by 10% or more included myocardial infarction, other ischaemic heart disease, chronic obstructive lung disease, asthma, pneumonia, diabetes, poisoning, dementia, prostate cancer and breast cancer among others. Workload declined by 10% or more in 13 conditions, including stroke, subarachnoid haemorrhage, hypertension, thyrotoxicosis, acquired hypothyroidism, and tuberculosis. Secular trends in hospital use are generally attributable either to changes in disease frequency in the population or to changes in clinic- or hospital-based technology and practice.

Adolescent↗
PubMed1995

Identifying complications and low provider adherence to normative practices using administrative data.

OBJECTIVE: This study investigated whether unexpected length of stay (LOS) could be used as an indicator to identify hospital patients who experienced complications or whose care exhibited low adherence to normative practices. DATA SOURCES AND STUDY SETTING: We analyzed 1,477 cases admitted for one of three medical conditions. All cases were discharged from one of nine participating Department of Veterans Affairs (VA) hospitals from October 1987 through September 1989. Analyses used administrative data and information abstracted through chart reviews that included severity of illness indicators, complications, and explicit process of care criteria reflecting adherence to normative practices. STUDY DESIGN: We developed separate multiple linear regression models for each disease using LOS as the dependent measure and variables that could be assumed present at the time of admission as explanatory variables. Unexpectedly long LOS (i.e., discharges with high residuals) was used to target complications and unexpectedly short LOS was used to target cases whose care might have exhibited low adherence to normative practices. Information gleaned from chart reviews served as the gold standard for determining actual complications and low adherence. PRINCIPAL FINDINGS: Analyses of administrative data showed that unexpectedly long LOS identified complications with sensitivities ranging from 40 through 62 percent across the three conditions. Positive predictive values all were at greater than chance levels (p < .05). This represented substantial improvement over identification of complications using ICD-9-CM codes contained in the administrative database where sensitivities were from 26 through 39 percent. Unexpectedly short LOS identified low provider adherence with sensitivities ranging from 33 through 45 percent with positive predictive values all above chance levels (p < .05). The addition to the LOS models of chart-based severity of illness information helped explain LOS, but failed to facilitate identification of complications or low adherence beyond what was accomplished using administrative data. CONCLUSIONS: Administrative data can be used to target cases when seeking to identify complications or low provider adherence to normative practices. Targeting can be accomplished through the creation of indirect measures based on unexpected LOS. Future efforts should be devoted to validating unexpected LOS as a hospital-level quality indicator. RELEVANCE/IMPACT: Scrutiny of unexpected LOS holds promise for enhancing the usefulness of administrative data as a resource for quality initiatives.

Diabetes Mellitus, Type 1↗
PubMed1994

A methodology for teaching ethics in the clinical setting: a clinical handbook for medical ethics.

The pluralism of methodologies and severe time constraints pose important challenges to pedagogy in clinical ethics. We designed a step-by-step student handbook to operate within such constraints and to respect the methodological pluralism of bioethics and clinical ethics. The handbook comprises six steps: Step 1: What are the facts of the case?; Step 2: What are your obligations to your patient?; Step 3: What are your obligations to third parties to your relationship with the patient?; Step 4: Do your obligations converge or conflict?; Step 5: What is the strongest objection that could be made to the identification of convergence in step 4 or the arguments in step 4? How can this objection be effectively countered?; and Step 6: How could the ethical conflict, or perceived ethical conflict, have been prevented?

Beneficence↗
PubMed1994

The association between residents' work-rounds styles and the process and outcome of medical care.

OBJECTIVE: To determine whether the manner in which residents conduct work rounds is associated with the adequacy of their care processes and the outcomes of their patients. METHODS: Two types of data were collected: time and motion data for residents (n = 12) during work rounds, and clinical and outcome data for the patients they cared for during the observation period (n = 211). Five residents were classified as data gatherers because they spent twice as much time gathering clinical data about their patients as they spent engaging in other activities. Three physicians blinded to the resident's identity rated the quality of the care process and assessed the frequency of undesirable events occurring during the stay and after discharge. RESULTS: A data-gathering style was associated with higher quality of care as judged by both process and outcomes. The data gatherers were more likely to comply with the "stability of medications before discharge" criterion (86% of the data gatherers' cases vs 73% of others', p = 0.07), and their patients were less likely to have unanticipated problems, in that fewer required calls from nurses (20% vs 37%, p < 0.01) and visits by on-call housestaff (33% vs 50%, p = 0.01). The data gatherers' patients were less likely to be readmitted within 30 days (14% vs 38%, p < 0.01). CONCLUSIONS: A data-gathering work-rounds style is associated with better process and outcome. Residency programs should provide formal instruction to trainees in the conduct of work rounds.

Aged↗
PubMed1994

Perioperative myocardial infarction with noncardiac surgery.

The incidence of perioperative myocardial infarction with noncardiac surgery varies by the type of procedure and the prevalence of coronary atherosclerosis in the study population. Incidence is < or = 1% with minor procedures and may exceed 10% with vascular operations. The case fatality rate continues to be 30% to 50%. Pathogenesis is not understood completely. Diagnosis is sometimes problematic, because less than 50% of patients complain of chest pain. In addition, a high frequency of notable but apparently innocent postoperative electrocardiograph changes limits the diagnostic use of the electrocardiogram. Fortunately, the creatine kinase MB isoenzyme retains its sensitivity and specificity for acute infarction in perioperative patients. Different approaches to preoperative risk assessment have been developed, including a summative cardiac risk index and a stratification system based on the likelihood that the most powerful risk factor (coronary artery disease) is present. Although many interventions have been recommended to lower perceived risk, none has been tested in a randomized controlled trial, and their comparative efficacy and safety is unknown.

Humans↗