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Biomedical subjects

D M Berwick

Publications and source records attributed to D M Berwick.

At least 91 records · Page 5Linked to original sources
PubMed1987

Theory and practice for measuring health care quality.

As competition, cost control, and new modes of delivery emerge in health care, there is a need to reexamine both the traditional definitions of health care quality and the methods by which it is measured. Industries other than health care have much to teach regarding the methods for obtaining, analyzing, and displaying data; techniques for problem identification, problem solving, and reassessment; and ideas about organizational factors that produce a high quality product or service. The Quality-of-Care Measurement Department at the Harvard Community Health Plan has built a program that draws from a distinguished health care quality assurance tradition and incorporates techniques that have been successful in other industries.

Consumer Behavior↗
PubMed1987

Impact of rapid antigen tests for group A streptococcal pharyngitis on physician use of antibiotics and throat cultures.

Using case scenarios and an interview guided by a decision tree diagram, the clinical strategies of 150 physicians (50 private pediatricians, 50 health maintenance organization pediatricians and 50 pediatric residents) were assessed for the management of pharyngitis under three conditions: (1) no rapid antigen detection test available for diagnosing Group A streptococcal disease; (2) antigen test result available in 20 minutes; and (3) antigen test result available in 4 hours. The sensitivity of the antigen test was designated as 0.95 if the growth of rare or few Group A streptococci on throat culture was discounted and 0.82 if any growth was considered significant, and the specificity was set at 0.98. In a standardized pediatric case with a prior probability of Group A streptococcal disease of 0.58, 84% of clinicians would order a 20-minute test and 39% would order a 4-hour test. The 20-minute test would reduce throat culture use by 54%, reduce the proportion of patients exposed to antibiotics from 86% to 65% and reduce total antibiotic treatment days by 13.8%. Effects would be less pronounced for a low probability case or if results of antigen testing were not available for 4 hours. Provided a test with a documented high sensitivity and specificity were used, a rapid antigen test with results promptly available would substantially reduce throat culture use and unnecessary antibiotic exposures in children with a moderate prior probability of streptococcal disease.

Anti-Bacterial Agents↗
PubMed1986

Feedback reduces test use in a health maintenance organization.

In a cross-over design, three interventions were tested for their impact on the rate of use of 12 commonly ordered blood tests and roentgenograms among internists in a health maintenance organization. Overall use fell by 14.2% in a 16-week period during which physicians received confidential feedback on their individual rates of use compared with peers (cost feedback). Eleven of 12 tests showed some decrease. Similar feedback on rates of abnormal test results (yield feedback) and a program of test-specific education failed to show a consistent effect. Variability in rates of test use among physicians, as measured by the coefficient of variation, fell by 8.3% with cost feedback, by 1.3% with yield feedback, and by 2.3% with education, but these changes were inconsistent across tests.

Boston↗
PubMed1986

Detection of colorectal cancer.

In a series of 47 patients with colorectal cancer, early-stage lesions were detected more frequently on routine screening than on symptomatic screening. Signs and symptoms tended to occur in combination rather than singly. Guaiac positivity was the sole sign in only one patient. Physicians must consider the possibility of colorectal cancer in patients with suggestive signs or symptoms.

Biopsy↗
PubMed1985

Screening in health fairs. A critical review of benefits, risks, and costs.

Health fairs provide multiphasic screening to more than 2 million Americans each year, and the number is growing rapidly. Nearly 40 different tests are in use, commonly including the measurement of up to 30 different blood chemistry levels. This report reviews the activities in a sample of 940 health fair sites and examines the experience regarding six specific screening procedures (blood pressure, anemia, blood chemistries, glaucoma, hearing, and fecal occult blood testing). Widespread use of these and other tests raises complex issues of cost, risk, and benefit. Rates of false alarm of healthy people and false reassurance of those at risk may be high for some tests, and the benefits of detecting new disease are easily overestimated. Detailed data collection and evaluation could help health fair sponsors to identify more rational screening strategies.

Anemia↗
PubMed1985

Variation in clinical practice in the management of febrile seizures.

Febrile seizures are a common problem facing those who provide health care to children. Wide variation in physician management of the simple febrile seizure has been reported. Recent published data have helped to clarify some of the diagnostic and therapeutic issues confronting the physician managing a child with this entity. In order to assess the current management of the child with a first simple febrile seizure, a questionnaire was sent to 584 physicians who care for children. Twenty-five percent of the respondents reported that they would use anticonvulsant therapy in a manner that has been shown to be ineffective. The responses showed that wide variation still exists in the management of febrile seizures.

Anticonvulsants↗
PubMed1985

Age-specific patterns of diagnosis of acute otitis media.

A retrospective review of clinical experience with the diagnosis of acute otitis media (AOM) in a large pediatric population (age, 0-12 years old) reveals two age-specific patterns of diagnosis: one in preschool children and one in schoolage children. In the population as a whole, AOM is diagnosed most frequently in the first 5 years of life; rates of diagnosis vary with gender (male: female ratio = 1.10) and season (fall/winter peak). In a linear regression model, age, gender, season, and interactions among these account for 52 percent of the variability in diagnostic rates. In children less than 5 years of age, rates of diagnosis vary strikingly with gender and season; the regression model accounts for 55 percent of observed variability in diagnostic rates. In schoolage children (5-11 years old), however, males and females are equally likely to be diagnosed to have AOM, and seasonal variability is blunted; among these children, the regression model predicts only 22 percent of diagnostic rate variability. These findings buttress existing knowledge of the epidemiology of AOM and have important implications for clinical practice, health planning, and pediatric research.

Acute Disease↗
PubMed1985

What do patients value? Willingness to pay for ultrasound in normal pregnancy.

Evaluations of diagnostic tests have focused primarily on their value in clinical decisions. Patients may attach value to 1) information that has little or no medical significance, and 2) information (medical or nonmedical) that has no bearing on decisions to be made by the doctor or the patient. Ultrasound in pregnancy, which provides a great deal of information to both doctor and patient, was chosen as the example with which to explore these hypotheses. Sixty-two women with current or recent normal pregnancies were given a structured interview to elicit their willingness to pay for ultrasound information. Among these women, 26% of the value attached to the test related to information having no decisional significance, and 37% of the value related to information of use to the patient, but not the doctor. Overall, 44% of the value of the test, from the patients' point of view, pertained to uses outside the realm of medical decisions. On the average, interviewees alleged that they would pay +706 for the information contained in an ultrasound test in an uncomplicated pregnancy. Decision analyses and cost-effectiveness analyses that take note only of the medical, decisional uses of test information may overlook a high proportion of the value patients attach to the information.

Decision Theory↗
PubMed1984

Preferences for health outcomes. Comparison of assessment methods.

This study compared standard gamble (SG), time trade-off (TTO), and category scaling (CS) methods for assessing preferences among hypothetical outcomes of coronary artery bypass surgery. High correlations among assessment methods, as found in some previous studies, do not assure the absence of systematic differences in rating obtained by different methods. This study used analysis of variance to test for differences among the three assessment methods. Questionnaire responses were obtained from 67 of 109 physicians participating in a postgraduate course on clinical decision making, following a lecture and workshop on utility theory. SG and CS were used to rate multivariate combinations of angina (none, moderate, and severe) and survival (0, 5, and 10 years); and SG, TTO, and CS were used to rate univariate outcomes with angina (none, moderate, and severe) for the remainder of their life expectancy. SG ratings were higher than TTO ratings, which were higher than CS ratings (p less than 0.001 for all comparisons). Multivariate responses revealed a significant interaction between angina and survival dimensions using CS, but not using SG. We conclude that these methods are not interchangeable and that differences between SG and CS require a more complex explanation than differences in attitude toward risk.

Angina Pectoris↗
PubMed1983

Receiver operating characteristic analysis of diagnostic skill.

In an effort to assess diagnostic skill, the authors collected estimates of the probability of positive results for 392 chest x-rays and 595 throat cultures from 56 pediatricians at different stages in training. Positivity rates were 28.6% for x-rays and 32.9% for throat cultures. The ability to predict the outcome of chest x-rays (pneumonia or not) improved with training on two measures: 1) "calibration," the accuracy of the guessed probability of positivity, and 2) "operating characteristic," the ability to sort patients with negative x-rays from patients with positive x-rays. Improvement was most marked in the ability to predict that a patient with a positive x-ray would have a positive x-ray. For throat culture results, no regular improvement was found with training either in calibration or in operating characteristic. Measurements of calibration and operating characteristic are useful for assessing the effect of training on diagnostic skill.

Clinical Competence↗
PubMed1982

Cost effectiveness of lead screening.

Lead-screening programs may reduce childhood disabilities, but at what cost? Through a review of the literature, we performed a cost-effectiveness analysis in which the costs, savings, and health benefits of two lead-screening strategies--employing either a free erythrocyte protoporphyrin assay or blood lead measurement--were compared with each other and with a strategy of no screening in a population of three-year-old children. When the prevalence of lead poisoning among the children screened is 7 per cent or more, we estimate that free erythrocyte protoporphyrin screening averts morbidity and results in net savings: It is both better and cheaper than no screening. At prevalences below 7 per cent, the net positive costs from screening and early treatment must be weighed against the noneconomic benefits of improved quality of life and considered in relation to other investments that could be made to benefit society. At all prevalence rates, free erythrocyte protoporphyrin screening is more cost effective than blood lead screening.

Child, Preschool↗
PubMed1982

Failure to thrive: diagnostic yield of hospitalisation.

Review of hospital records of 122 infants, aged between 1 and 25 months, admitted to a teaching hospital with the diagnosis of failure to thrive but without an underlying disease apparent at admission, showed that about one-third of them had no diagnosis after evaluation. Thirty-two per cent were thought to have a social or environmental explantation for poor growth, and 31% were given a specific organic or physiological diagnosis. Of the last group, 2 out 3 were diagnosed as having either gastro-oesophageal reflux or non-specific chronic diarrhoea. Vomiting was often associated with organic or structural disease. On average about 40 laboratory tests and x-ray films were performed per infant, but only 0.8% of all tests showed an abnormality which contributed to the diagnosis of the cause of failure to thrive. Our results stress the importance of social and environmental factors as basic causes of failure to thrive, and suggest that admission to hospital and laboratory testing is unlikely to lead to a specific organic diagnose in a child whose failure to thrive is unexplained after careful history taking and a physical examination.

Child, Preschool↗
PubMed1981

When doctors meet numbers.

A Statistical Skills Self-Assessment Questionnaire (SAQ) was developed using hypothetical clinical questions to explore respondents' mastery of vocabulary and rules of inference that seem relevant to the use of quantitative information. The SAQ was administered to 281 subjects, including 36 medical students, 45 interns and residents, 49 physicians engaged in research and 151 physicians in full-time practice. All groups of subjects showed frequent lack of consensus on the meaning of terms in common use (e.g., "false-positive rate" and "p values") and unfamiliarity with some important principles in quantitative inference (e.g., the Central Limit Theorem and Regression to the Mean). Subjects often seemed willing to draw conclusions unsupported by available data. Performance on the SAQ was inversely correlated with length of time since graduation from medical school, and practicing physicians tended to err more frequently than the other three groups.

Education, Medical↗
PubMed1981

Cholesterol, children, and heart disease: an analysis of alternatives.

Cost-effectiveness analysis is used to compare proposed cholesterol control programs. The analysis employs estimates of such biologic variables as effect of diet on cholesterol level, stability of level, and change in morbidity with level. Sensitivity analysis identifies the biologic and behavioral uncertainties that most critically affect policy choices. At a discount rate of 5%, a cholesterol-screening program for all 10-year-old children would cost about 10,000 per year of life saved. Rescreening would not improve efficiency. Targeted screening a high-risk children could improve efficiency by 25%, but would benefit only one sixth as many people. Community-wide interventions without screening may be more efficient by a factor of 3. The cost per year of life saved is most affected by the rate of discount and the dollar cost of changing behavior, but is insensitive to stability of cholesterol rank order and to the cost of screening.

Adult↗
PubMed1980

Variation in rates of diagnosis of acute otitis media.

Over 13 weeks during two periods in 1978 the diagnostic rate for acute otitis media was monitored among febrile children (aged one to five years) in the emergency room of a large children's hospital. Of the total 228 eligible children, 53 (23 percent) were diagnosed as having otitis media. The observed variation in the weekly diagnostic rates was significantly (p < .005) greater than that expected if the diagnosis rate were a constant 23 percent. Temporal variation in diagnostic rates was largely attributable to differences among individual providers and independent of level of training. For junior residents short-term learning, within the seven-week emergency room rotation, contributed significantly to the week-to-week temporal variation in diagnostic rates for acute otitis media.

Acute Disease↗