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Biomedical subjects

D M Berwick

Publications and source records attributed to D M Berwick.

At least 73 records · Page 4Linked to original sources
PubMed1990

Hospital leaders' opinions of the HCFA mortality data.

The release of hospital-specific mortality data by the Health Care Financing Administration has stirred controversy about the adequacy of current case-mix adjustment models and about the wisdom in general of public release of outcome data. We surveyed a national sample of hospitals, stratified by measured mortality rate, in the 1987 Health Care Financing Administration data release to determine the reactions of hospital leaders to the data and to learn if hospitals with high mortality had different attitudes from those of hospitals with average or low mortality as measured by the Health Care Financing Administration. Seventy-eight percent (N = 195) responded. All hospitals, regardless of mortality rate, shared an extremely negative view of the accuracy, usefulness, and interpretability of the Health Care Financing Administration's mortality data. The lowest possible rating (poor) was given by 70% of the respondents on the question of usefulness of the data to the hospital, by 54% on accuracy of the data, and by 85% on usefulness of the data to consumers. Only 31% of the respondents said that they had used the data at all for internal purposes and 20% reported that the data release had caused problems for the hospital. Hospitals in the high-mortality group were more likely than others to report both use of the data and problems from its release. Publication of outcome data to encourage quality improvement may face severe and pervasive barriers in the attitudes and reactions of hospital leaders who are potential clients for such data.

Attitude of Health Personnel↗
PubMed1990

Improving the quality of ambulatory health care with enhanced medical information systems: using the computer to diagnose faulty clinical processes.

The lack of consistency in the performance of the processes which implement clinical decisions is an important problem in ambulatory care. Since delayed or neglected actions in patient care may have serious consequences, we studied the use of industrial quality management techniques to determine where three clinical processes could be improved. These quantitative and graphical tools were useful in showing that in some processes, the failure rate could be as high as 33%. However, lack of readily available process data prevented a full analysis of the extent of the failures, so specific suggestions for improvement could not be made. Medical informatics and management specialists have an important role in designing enhanced medical information systems with which to examine and improve patient care processes. This new generation of MIS's should include order entry systems with flags for selected transactions, audit trails for all automated processes, functional integration of the separate departmental information systems, and enhanced communications features.

Ambulatory Care↗
PubMed1989

Who pays?

Explore the source record for details and available documents.

California↗
PubMed1989

Variations in rates of hospitalization of children in three urban communities.

Hospitalization accounts for a large portion of the expenditures for child health care, and differences in the rate of hospitalization may produce important variations in the cost of that care. We studied the rates of hospitalization in Boston, Rochester (N.Y.), and New Haven (Conn.) in 1982. We assigned the risk of hospitalization in Rochester a score of 1.00. Boston children were hospitalized at more than twice the rate of Rochester children for most medical diagnostic categories (relative risk, 2.65; 95 percent confidence interval, 2.53 to 2.78), and the rate for the New Haven group was intermediate (relative risk, 1.80; 95 percent confidence interval, 1.68 to 1.93). Rates of inpatient surgery differed less (Boston relative risk, 1.12; New Haven relative risk, 0.93). The relative risks of hospitalization (as compared with Rochester children) for Boston and New Haven children, respectively, were 3.8 and 2.3 for asthma, 6.1 and 2.9 for toxic ingestions, and 2.6 and 2.7 for head injuries. Fractures of the femur, appendicitis, and bacterial meningitis (conditions uniformly treated in the hospital) had similar rates of hospitalization across the three cities, but the relative risk of hospitalization for aseptic meningitis was 3.7 in Boston. The rates of hospitalization of children in all three communities were below the national averages in 1982. Although this study does not define the reasons for the variation in rates of hospitalization, it is possible that they were related in part to differences in socioeconomic status or access to primary care. The implications of these data for the cost and quality of pediatric care therefore remain to be determined.

Adolescent↗
PubMed1989

The measurement of health status in clinical practice.

Functional status measurement and the assessment of health status are reaching their maturity as technical disciplines. Good tools exist that meet requirements such as brevity, validity, reliability, ease of administration, and ease of scoring, which make them potentially suitable for use in clinical practice. Despite this progress, widespread adoption of measurement tools has not occurred in the clinical world. The authors analyze both the potential and the barriers to use of health assessment tools in practice and note the need for better scientific evidence of their clinical utility, as opposed to their information content. Dissemination of these tools among practitioners will require, above all, evidence and conviction that the use of measurement instruments will actually enhance the very health status outcomes they assess.

Activities of Daily Living↗
PubMed1989

A comparison of three psychiatric screening tests using receiver operating characteristic (ROC) analysis.

Self-administered screening questionnaires are available to assist primary care physicians in detecting undiagnosed depression and anxiety disorders. This study used receiver operating characteristic (ROC) analysis to evaluate three such tests: the General Health Questionnaire (GHQ), the Mental Health Inventory (MHI), and the Somatic Symptom Inventory (SSI). Stratified by the results of a preliminary GHQ, 364 health maintenance organization (HMO) members were given these tests and a Diagnostic Interview Schedule (DIS), the latter used as a "truth" standard for current psychiatric diagnosis. The MHI performed significantly better than the GHQ in detecting mental disorders generally and anxiety disorders in particular, and somewhat better in detecting affective disorders. The SSI performed best in detecting anxiety disorders and was significantly better than the GHQ. When subjects who had participated in a previous study involving repeated GHQ administration were excluded, sensitivity of all tests improved, especially the GHQ. We conclude that the MHI can be a useful tool for screening primary care patients, and that the SSI has additional predictive value with respect to anxiety disorders.

Adult↗
PubMed1989

Health services research and quality of care. Assignments for the 1990s.

The unabated rise in health care costs is bringing health services research into center stage as an applied science to help guide health care managers, purchasers, and regulators. To be equal to the task, health services research must pursue at least four intellectual agendas: the study of efficacy (knowing what works), the study of appropriateness (using what works), the study of the execution of care (doing well what works), and the study of the purposes of care (the values that underlie action). The responsibility for the financing and conduct of the research agendas varies with the level of aggregation of data and effort needed for each topic. All four topics must be pursued effectively if health care quality is to be successfully defined, measured, and protected.

Economics, Hospital↗
PubMed1989

No clinical effect of back schools in an HMO. A randomized prospective trial.

In a prospective trial, 222 adults with low-back pain of at least 2 weeks' duration in a Health Maintenance Organization (HMO) were randomly assigned to usual care (UC), a 4-hour back school psychoeducational session (LBS), or the same back school plus a 1-year "compliance package" program designed to encourage appropriate self-management for back pain (CP). Sixty-four percent of LBS and CP subjects attended their back school sessions. Follow-up measurement of pain level (using the Visual Analogue Scale), functional status (using the Sickness Impact Profile), and various other indicators of health status showed no measurable effect of either treatment condition (LBS or CP) compared with UC at 3, 6, 12, and 18 months after entry into the study. Initial disability resolved by 3 months in most patients, and a minority of subjects (10-15%) showed residual or recurrent functional impairment 1 year after entry. Health care utilization tended to be slightly higher after intervention in the CP group. With or without follow-up encouragement, back school instructions given in a single 4-hour session had no measurable impact on the comfort or functional status of the majority of patients with new onset back pain in this HMO.

Adult↗
PubMed1987

Performance of screening and diagnostic tests. Application of receiver operating characteristic analysis.

Evaluation of psychiatric screening and diagnostic tests has benefited from the application of sensitivity, specificity, the kappa-statistic, and predictive values. These measures derive their meaning from a single criterion threshold. Receiver operating characteristic (ROC) analysis extends assessment of test performance by providing information about all possible pairs of achievable sensitivity and specificity values. The ROC analysis offers a comprehensive means for comparing different tests or different scoring procedures for one test. As a demonstration we used the ROC analysis to evaluate three types of scoring rules for one psychiatric test, the Health Opinion Survey. The demonstration indicated that ROC analysis can profitably take a place among the standard methods for test evaluation in psychiatric research. In addition, ROC analysis can assist clinicians in selecting appropriate test procedures for particular patient populations.

Borderline Personality Disorder↗
PubMed1987

Assessment of psychological morbidity in primary care: explorations with the General Health Questionnaire.

The 30-item version of the General Health Questionnaire (GHQ) was completed by 1649 new adult enrollees in a Health Maintenance Organization (HMO). Factor analysis of responses disclosed six factors (Anxiety/Strain, Confidence, Depression, Energy, Social Function, and Insomnia) and a strong tendency for items of similar wording (positive phrasing) to cluster together. Elevations of GHQ scores, especially when persistent over two administrations of the GHQ separated by 7 months, were strongly associated with the probability of both mental health and non-mental health care within 12 months of enrollment. Anxiety/Strain, Depression, and Social Function scores were associated with the probability of use; Confidence and Energy factors were not. Once in care a member's rate of use of service was relatively independent of the response pattern to the GHQ at enrollment.

Adult↗