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Biomedical subjects

D B Nash

Publications and source records attributed to D B Nash.

At least 55 records · Page 3Linked to original sources
PubMed1995

Role of clinical evaluation in academic medical centers: results of a national survey.

BACKGROUND: It is widely acknowledged that academic medical centers (AMCs) must be committed to appropriate resource use and to the clinical evaluation research needed to accomplish this goal. The authors report the results of a national survey and series of site visits to further elucidate the role of centralized mechanisms for evaluating clinical practice, called clinical evaluation units (CEUs). A CEU is characterized by a separate operating unit with a physician director on at least a half-time basis complemented by data analysts, information system specialists, or other technical staff. METHOD: In April 1993, the authors mailed a survey instrument to the 60 hospitals that were members of the University Hospital Consortium (UHC) and to 28 non-UHC teaching hospitals. After four follow-up mailings and telephone reminders, a 69% response rate (61 responses) was achieved. The survey instrument highlighted areas such as the environment in which the hospitals operated, the structure and organization of clinical evaluation, the process of how these activities were carried out, and the outcomes from the CEUs. RESULTS: Twenty-two respondents had centralized mechanisms that met the authors' definition of a CEU. Support for most CEUs came from hospital administrations and not from medical school deans. An alternative structure emerged from the analysis: 18 respondents indicated that they did not have CEUs but that clinical evaluation activities were integrated into the medical staff hierarchy and dispersed throughout departments that reported to a physician executive. CONCLUSION: The discipline of clinical evaluation is in its infancy in teaching institutions. Many AMCs do not have a coordinated program of clinical evaluation; others are just starting. Clinical evaluation must become integrated into medical education and hospital operations to serve as one aspect of academic medicine's response to health care reform.

Academic Medical Centers↗
PubMed1994

Overview: public accountability of hospitals regarding quality.

In this overview, the guest editors highlight some of the issues concerning the accountability of hospitals regarding quality, as raised by these articles. They then raise additional critical questions yet to be addressed.

Community-Institutional Relations↗
PubMed1994

Formulary management of antiulcer drugs: economic considerations.

Peptic ulcer disease (PUD) is a common medical problem costing billions of dollars annually around the world. Since the availability of the first histamine H2-receptor antagonist, cimetidine, many economic analyses have been conducted to compare the impact of this drug class on resource consumption. H2-Antagonists have been shown to reduce mortality, hospitalisations, ambulatory care visits and endoscopy use caused by PUD. Because of changing risk factors and variations in diagnosis, it remains controversial whether these drugs have had a long term impact on PUD incidence and prevalence. Three studies conducted after the introduction of cimetidine showed it to reduce total direct medical healthcare expenditures, despite increases in drug costs. Studies investigating the short term treatment of PUD show mixed results because of diverse study designs and different comparator drugs. No specific therapy appears consistently superior economically because of variations in population studies, ulcer relapse rates and drug acquisition costs. However, maintenance therapy for PUD has been shown to be cost-effective. When compared with surgery--an extremely efficacious option--maintenance therapy (both daily and intermittent) is cost-effective over at least a 10-year period. Within the maintenance therapy options, daily ranitidine has been shown to be more cost-effective than intermittent therapy for up to 2 years. Omeprazole is the least costly and most efficacious treatment for gastroesophageal reflux disease (GORD or GERD) compared with ranitidine and/or lifestyle modification alone. It has also been shown that the costs for empirical treatment of GORD are offset by the costs of additional investigation of those who do not have the disease. Thus the decision of whether to treat empirically should be based on physician and patient preferences, and not on costs. The use of misoprostol for ulcers caused by nonsteroidal anti-inflammatory drugs is somewhat controversial. Three studies examining the short term (3-month) costs of misoprostol generally show it to be cost saving or cost neutral. Misoprostol is consistently more cost beneficial in elderly or other high risk patients. Results are highly sensitive, however, to several parameters, such as patient type, ulcer severity and rate, drug costs and patient compliance. One study examining prophylaxis using misoprostol over 1 year showed it to be a generally expensive therapy for primary prevention, but was more cost effective for those with a proven GI bleed in the previous year.(ABSTRACT TRUNCATED AT 400 WORDS)

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed1994

Relationship between practice guidelines, formulary management, and pharmacoeconomic studies.

Pharmacy and therapeutics committees can use pharmacoeconomic and outcome studies as tools to evaluate and implement clinical guidelines for patient care. Results of studies help optimize the clinical effects and control the costs of drug therapy. Such data also assist in positioning products in competitive environments. A four-part classification of research studies is offered as an aid to strategic research planning.

Drug Evaluation↗
PubMed1994

Clinical evaluation units: a research agenda.

A new model for evaluating quality rests on the tripod of outcomes research, practice pattern analysis, and the tenets of continuous quality improvement. The hospital-based locus for this tripod could be clinical evaluation units. This article describes the conceptual framework, study design, and research challenges associated with an ongoing project whose purpose is to assess the current status of these clinical evaluation units in academic medical centers nationwide.

Academic Medical Centers↗
PubMed1994

Cost accounting supports clinical evaluations.

This article describes how a hospital cost accounting system was used to evaluate the financial impact of the use of a new and expensive drug at a 700-bed academic medical center.

Academic Medical Centers↗
PubMed1993

Evaluating the cost containment potential of clinical guidelines.

New expensive biotechnology products create financial as well as clinical dilemmas for hospitals. Clinical guidelines that govern the use of these new products are often viewed as the best response to these dilemmas. This article describes a prospective analysis of the impact of one new drug and the guidelines developed to control its use. A simple model of clinical decision making is used to evaluate alternative scenarios. The analysis illustrates the importance of evaluating the cost containment potential of clinical guidelines before they are implemented.

Antibodies, Monoclonal↗
PubMed1993

Evaluating the competence of physicians in practice: from peer review to performance assessment.

Evaluation of physician competence has traditionally been defined by the medical profession largely through standardized tests and board certifying examinations. However, a level of physician evaluation that takes place outside academic medical centers and certifying boards is rapidly developing. This article describes three programs for such physician evaluation: (1) the program of US Healthcare, a national managed health care company; (2) the DEMPAQ--Developing and Evaluating Methods to Promote Ambulatory Care Quality--project, a joint research effort between Harvard University (Cambridge, Massachusetts) and the State of Maryland's (and District of Columbia's) Peer Review Organization (PRO); and (3) a project initiated by the American College of Physicians (ACP) in Philadelphia, Pennsylvania, to assess both medical competence and technical performance in the hospital setting. The authors argue for the need to inform physicians-in-training about the types of evaluation to which they will be subjected over the courses of their careers. In order to further this goal, the authors advocate increased collaboration between leaders in the academic setting and those spearheading these new programs for assessment of physician performance.

Ambulatory Care↗
PubMed1993

The formulary decision-making process in a US academic medical centre.

This article reviews and describes the formulary decision-making process in an academic medical centre. The pharmacy and therapeutics (P & T) committee is the organisational nucleus of the drug use control process in the institutional environment. Thomas Jefferson University Hospital (TJUH), a 720-bed academic medical centre in an urban locality in the US, is used as a model representative of how most of these committees function. Survey responses collected from 29 peer academic medical centres are presented to compare and contrast the structure and function of the P & T committee at TJUH with corresponding procedures in other university hospitals in the US. TJUH is typical of the institutions which comprise the University Hospital Consortium (UHC). The P & T committee of TJUH is composed of 29 members, meets once per month for 10 months of the year, and has a network of 13 subcommittees. TJUH has an intermediately controlled (mixed) formulary, and uses both restricted drugs and treatment guidelines. Of the 29 UHC member institutions responding to the survey, the average P & T membership is 18, the average meeting frequency is 11 times per year, and 83% of these committees have a network of subcommittees. None describe their formulary system as open, 86% have a closed formulary and 14% have a mixed formulary system. There is a restricted drug programme in 76% of the institutions, 79% utilise treatment guidelines, 76% practice therapeutic interchange and all employ generic substitution. Specific areas addressed in this review include the history of the formulary system, the structure and function of the P & T committee, types of formularies, cost containment and the formulary decision-making process, the impact of organisational culture on physician decision making, the role of the pharmacy department, the role of pharmaceutical sales representatives and their impact on prescribing habits, the impact of the Joint Commission on Accreditation of Healthcare Organisations (JCAHO) Agenda for Change on the formulary process, and future challenges.

Academic Medical Centers↗
PubMed1993

Ondansetron: costs and resource utilisation in a US teaching hospital setting.

A retrospective pharmacoeconomic analysis was conducted to compare lengths of hospital stay for, and usage of hospital resources by, patients (850 admissions) who received either ondansetron or standard antiemetic therapy during hospital admissions for cancer chemotherapy. Average hospital costs for patients admitted to a 720 bed academic medical centre for maintenance chemotherapy between October 1990 and September 1991 were analysed using the hospital's online computerised clinical financial management system. A separate prospective time-and-motion study was used to evaluate specific costs of nursing care associated with episodes of severe nausea and vomiting. In addition, patient perception of quality of life and satisfaction with therapy were evaluated for 27 chemotherapy patients using quality-of-life measurements on the Functional Living Index-Cancer (FLIC) scale. The results of these studies showed that the average length of hospital stay was shorter for patients who received ondansetron rather than standard antiemetic therapy, but that average hospital costs were not significantly different. The reduced hospitalisation costs offset the higher acquisition cost of ondansetron. Mean quality-of-life scores decreased significantly after chemotherapy for patients receiving either ondansetron or standard therapy, but the changes in scores were not strongly associated with the antiemetic agents used or with any of the clinical or demographic variables measured in this study.

Costs and Cost Analysis↗
PubMed1992

A privately financed fellowship model for management training of physicians.

This paper describes the ongoing need for physician executives and reviews current opportunities for training physicians in management. The authors discuss existing sources of funding and highlight one management training program that uses various mechanisms of a new funding model that can increase the number and diversity of learning opportunities, not only in management but also in all disciplines where training traditionally has been underfunded. The basic mechanism of this new model is as follows: a privately funded program uses a locum tenens arrangement whereby a physician fellow works in a community-based private practice in order to produce both compensation for work done and funding for training at an academic institution. Finally, the authors suggest that academic institutions and managed care organizations might consider such a model as one means of using clinical income to expand management training within the contexts of their existing academic missions and patient care commitments.

Fellowships and Scholarships↗
PubMed1991

Differences in mortality from coronary artery bypass graft surgery at five teaching hospitals.

OBJECTIVE: To measure hospital- and surgeon-specific mortality rates for patients with coronary artery bypass graft (CABG) surgery and to examine possible reasons for any differences. DESIGN: Cohort study using hospital discharge abstracts and itemized bills. SETTING: Five major teaching hospitals in Philadelphia, Pa. PATIENTS: Consecutive sample of all 4613 patients over a 30-month period. MAIN OUTCOME MEASURE: In hospital mortality rates. RESULTS: We observed differences in hospital mortality rates for patients who underwent coronary artery catheterization and CABG surgery during the same admission (diagnosis related group 106) but not for patients who underwent only CABG surgery during the admission (diagnosis related group 107). There were threefold differences in surgeon-specific mortality rates. The hospital mortality rates for coronary artery catheterization and CABG surgery during the same admission changed during the study and coincided with moves of surgeons among study hospitals. Our measures of illness severity did identify patients who were more likely to die, but differences in severity of illness did not explain differences in hospital- or surgeon-specific mortality rates. Patient mortality rates were not associated with the volume of procedures performed by individual surgeons. We found inconclusive evidence for an association with surgeons' clinical skills, and to a lesser extent, with the hospital's volume of procedures and the hospital's organization and staffing. A greater intensity of hospital services was not necessary for a lower mortality rate. CONCLUSIONS: We conclude that studies of CABG mortality should examine mortality rates by diagnosis related group, collect data from more than 1 year, examine associations with surgeons' clinical skills, include information on hospital organization and staffing, and cautiously explore more efficient ways of providing care.

Age Factors↗