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E C Nelson

Publications and source records attributed to E C Nelson.

At least 55 records · Page 3Linked to original sources
PubMed1996

Improving health care, Part 2: A clinical improvement worksheet and users' manual.

BACKGROUND: Small tests of change can be conducted in everyday clinical practice, thereby turning the health care delivery team into reflective practitioners who can learn from, and improve on, their work. CLINICAL IMPROVEMENT WORKSHEET AND USERS' MANUAL--CASE STUDY: The worksheet has been designed as a simple tool for applying clinical improvement to the core clinical delivery process. A carpal tunnel surgery (CTS) team was formed to improve outcomes and reduce costs for patients and to promote improvements in quality and value. The team wanted to determine if surgical patients treated with local anesthesia in an ambulatory setting have superior satisfaction with care, comparable clinical and functional outcomes, and lower medical (and social) costs. For the first time, standardized assessments of patient case mix, treatment processes, and health outcomes were designed into the delivery process by gathering data from the patient and from the surgeon presurgery and 4 weeks and 12 weeks postsurgery. Results for the first 49 of 50 to 100 consecutive patients show improved outcomes and reductions in costs, from $937 to $405 per patient. LESSONS LEARNED: Even though CTS was selected to be a quick and noncontroversial opportunity, considerable effort had to be expended to ensure that all clinicians and other affected staff would understand and support "the new way". RECOMMENDATIONS: "Ramp up" improvements as time passes, more and more change trials are conducted and their complexity increases. To ease implementation of changes, teams can diagram core process "components" and attach measures, use flowcharts to plan and monitor implementation and use change management thinking to help sharpen the plan and anticipate problems.

Adult↗
PubMed1996

Improving health care, Part 3: Clinical benchmarking for best patient care.

BACKGROUND: Benchmarking, which shows that a much better way of doing something may be possible, stimulates local interest in changing and in making changes previously thought not possible. A PLANNING WORKSHEET: The Worksheet has five basic steps: Identify measures, determine resources needed to find the "best of the best," design a data collection method and gather data, measure the best against own performance to determine gap, and identify the best practices producing best-in-class results. CASE EXAMPLE--BOWEL SURGERY: The Accelerating Clinical Improvement Bowel Surgery Team at Dartmouth-Hitchcock Medical Center (Lebanon, NH) was formed in November 1994 to improve the care of patients with diagnosis-related group (DRG) 148 or 149. Consulting two large, administrative databases and the medical literature, the team found that a substantial gap existed between the bowel surgery delivery process and the best results, as far as they were known, among comparable organizations. After flowcharting the delivery process, the team identified the high-leverage steps: same-day services, general surgery clinic, and routine care. The team then planned three successive PDCA (plan-do-check-act) cycles: utilization of same-day services for all elective surgery patients, establishment of a standardized preoperative bowel preparation, and utilization of pre- and postoperative routine care orders. These improvement cycles resulted in a reduction in length of stay from 9.66 to 8.29 days. Implementation of a critical pathway resulted in a further reduction to 5.04 days. CONCLUSION: Benchmarking can play an integral role in clinical improvement work and can stimulate wise clinical changes and promote measured improvements in quality and value.

Academic Medical Centers↗
PubMed1996

Improving health care, Part 4: Concepts for improving any clinical process.

BACKGROUND: One promising method for streamlining the generation of "good ideas" is to formulate what are sometimes called change concepts-general notions or approaches to change found useful in developing specific ideas for changes that lead to improvement. For example, in current efforts to reduce health care costs by discounting provider charges, the underlying generic concept is "reducing health care costs," and the specific idea is "discounting provider charges." Short-term gains in health care cost reduction can occur by pursuing discounts. After some time, however, limits to such reduction in costs are experienced. Persevering and continuing to travel down the "discounting provider charges" path is less likely to produce further substantial improvement than returning to the basic concept of "reducing health care costs." THE HIP REPLACEMENT CASE: An interdisciplinary team aiming to reduce costs while improving quality of care for patients in need of hip joint replacement generated ideas for changing "what's done (process) to get better results." After team members wrote down their improvement ideas, they deduced the underlying change concepts and used them to generate even more ideas for improvement. Such change concepts include reordering the sequence of steps (preadmission physical therapy "certification"), eliminating failures at hand-offs between steps (transfer of information from physician's office to hospital), and eliminating a step (epidural pain control). CONCLUSION: Learning about making change, encouraging change, managing the change within and across organizations, and learning from the changes tested will characterize the sustainable, thriving health systems of the future.

Group Processes↗
PubMed1996

The relationship between meeting patients' information needs and their satisfaction with hospital care and general health status outcomes.

OBJECTIVE: The objective of this study was to determine if there is an association between meeting patients' information needs and their overall satisfaction with care and their general health status outcomes. STUDY DESIGN: This non-experimental study used data from hospital medical records as well as patient-completed surveys conducted two and eight weeks post discharge. The setting involved three community hospitals in the southeastern section of the US that provided care to a series of 167 acute myocardial infarction (Acute MI) patients. MEASURES: The independent variable was an index measuring how well patients' information needs were met. The dependent variables were patient satisfaction (ratings of satisfaction with care process, global satisfaction, and health benefit) and general health status outcomes (physical function, psychosocial function and quality of life). Covariates used as control variables to hold patient characteristics constant, included demographics (age, gender) and clinical measures of acute MI severity, comorbidity, angina (at eight weeks), and dyspnea (at eight weeks). ANALYSIS: Univariate analyses were employed to: (1) describe patients' characteristics; (2) determine the relative importance of meeting different types of information needs; and (3) identify information need areas most likely not to be met. Multivariate linear regression and logistic regression was used to evaluate the association between patients' ratings of meeting information needs with satisfaction and health outcomes, respectively, after controlling for covariates. RESULTS: The multivariate regression results show that meeting information needs are positively and significantly associated with both patient satisfaction measures (i.e., Ratings of Care Processes, p < 0.01; Global Satisfaction, p < 0.05, Perceived Health Benefit, p < 0.01) and one general health status measure (i.e. Quality of Life, p < 0.01). CONCLUSION: The results suggest that providers of care should ensure that they meet the information needs of patients with specific conditions because patients' perceptions of both quality of care and quality of life are associated with the clinicians' ability to transfer key information to their patients.

Aged↗
PubMed1996

Patients' perceptions of office medical practice: judging quality through the patients' eyes.

With increasing pressure to measure quality, patient-based assessments of medical care are becoming increasingly important. Patients offer a unique perspective for evaluating the nontechnical aspects of medical care. This study reviews the importance of utilizing patients' perceptions to measure quality of care in office settings. It also reviews the principles required to conduct a well done survey. The concept of patient perceptions differs from the more commonly measured concept of patient satisfaction, in that perceptions measure whether a patients' needs and expectations are met, in addition to satisfaction. One of the most accurate and efficient means of measuring patients' perceptions is through the use of surveys. As with all standardized data collection, creating and performing high quality surveys of patients' perceptions can be challenging. Valid and reliable patient survey data can enable practitioners to identify areas for improvement, and demonstrate to external reviewers the quality of care they provide to their patients.

Humans↗
PubMed1995

The tridimensional personality questionnaire as a predictor of response to nefazodone treatment of depression.

Personality traits have emerged as the strongest identified predictors of response to antidepressant treatment of major depressive disorder (Peselow et al., 1992; Joyce et al., 1994). 18 subjects in the midst of a major depressive episode were treated with nefazodone in an open trial. All subjects completed Cloninger's tridimensional personality questionnaire (TPQ) before beginning treatment. A multiple regression analysis was performed in an attempt to replicate Joyce et al.'s (1994) finding that temperament type, as assessed by the TPQ, is a strong predictor of antidepressant response. A model involving TPQ reward dependence and harm avoidance scores, and their interaction, was found to significantly predict the response to nefazodone (r2 = 0.47, P < 0.027). When response was defined as a 50% decrease in HAM-D score at last visit, high reward dependence score alone significantly separated responders from nonresponders (Fisher's exact P = 0.050, df = 1). These results raise the intriguing possibility that TPQ scores may have direct clinical applications.

Adult↗
PubMed1995

Platelet paroxetine binding in major depressive disorder with and without comorbid obsessive-compulsive disorder.

Platelet 3H-paroxetine binding measures were compared in three age-matched groups each containing 11 individuals: a group with DSM-III-R major depressive disorder (MDD) and comorbid obsessive-compulsive disorder (OCD), a group with DSM-III-R MDD alone, and a psychiatrically screened normal comparison group. No differences were found between groups in Bmax values. The patients with MDD only were found to have significantly higher Kd values than either the group with comorbid OCD or the normal subjects. No significant correlations were found between binding measures and either depressive or OCD symptoms. Our data suggest that inconsistencies remain in the literature on 3H-imipramine binding in OCD and that a variety of confounding factors may explain them. Duration of illness, for example, may be one such factor as decreases in uptake site number tend to dissipate with longer duration of illness.

Adult↗
PubMed1995

Serum prolactin levels and behavior in infants.

This study examined the relationship between serum prolactin levels and behavior in infants and toddlers who experienced two potentially stressful experiences (developmental testing and venipuncture). Serum prolactin levels showed considerable consistency over a 3-month period (r = 0.64 between study entry and three months, p < 0.001, n = 50). There was also stability in having either a normal or a high value (> or = 25 ng/ml). Among children who had a normal value on initial testing, 97% also has a normal value after 3 months; 55% of those with initial high values continued to have high values (chi 2 = 19.26, p < 0.001). Children with high serum prolactin levels were more likely to be rated as unusually hesitant and unhappy during developmental testing. Overall, 53% of the children with serum prolactin levels > or = 25 ng/ml were considered abnormal in affect, compared to 20% of those with lower serum prolactin values (total n = 138, chi 2 = 13.56, p < 0.001). These results suggest that, even in early life, serum prolactin levels may reflect characteristic individual behavioral and neuroendocrine responses to stress.

Female↗
PubMed1995

Adolescent health and social problems. A method for detection and early management. The Dartmouth Primary Care Cooperative Information Project (COOP).

OBJECTIVE: To develop and test a method for identification and early management of the health and social problems of adolescents, many of which go undetected and untreated. METHODS: Picture-and-word charts for the measurement of health and social problems formed the core of a brief, self-teaching lesson. Other sections of the lesson were designed to help teenagers interpret, invent solutions for, and communicate concerns about these problems. We examined the impact of the lesson on teenagers' understanding of themselves, their feelings, and their actions. Two hundred ninety-one adolescents served as subjects for this research. RESULTS: Less than 5% of the respondents found the chart-based lesson difficult or bothersome in the way it probed personal topics. Ninety percent reported that the lesson would have some positive impact on their actions or feelings. Three to six weeks after completing the lesson, their opinion of its impact remained high, and 36% of the students reported that they had shown it to others outside the school. CONCLUSION: A chart-based lesson is well accepted by adolescents and can be used to overcome obstacles for the detection and early management of adolescents' health and social problems.

Adolescent↗
PubMed1995

Report cards or instrument panels: who needs what?

BACKGROUND: The report card movement in health care is a positive response to legitimate customer needs and requirements for comparative information on quality and costs. At the same time, providers have a legitimate concern about potential problems with gathering and using valid data in a prudent manner. Report cards have problems that often detract from their potentially constructive uses. In response to this concern, the authors propose that instrument panels--a newer concept in health care--compared to the static, judgmental image of report cards project an action-oriented, decision-making image. EXAMPLES: Descriptions are given of three types of instrument panels based on work in progress in the Dartmouth-Hitchcock health care system, a regional, integrated delivery system that serves the population of New Hampshire and parts of Vermont and Massachusetts: a 450-physician group practice (The Hitchcock Clinic), which provides more than one million visits per year in more than 25 locations; a tertiary health care facility (Mary Hitchcock Memorial Hospital) with more than 300,000 patient days; and prepaid health plan (Matthew Thornton Health Plan) with approximately 120,000 members. SUMMARY: It would be wise and efficient for providers to design instrument panel data collection systems that can feed directly into report cards, leading to the triple benefit of enhancing accuracy, reducing total costs, and increasing overall utility to both providers and their customers.

Health Services Accessibility↗
PubMed1995

Comparing outcomes and charges for patients with acute myocardial infarction in three community hospitals: an approach for assessing "value".

OBJECTIVE: To assess the value of care (i.e. outcomes in relation to charges) for acute myocardial infarction (Acute MI) patients in three community hospitals after controlling for patient mix differences. DESIGN: An observational study of a cohort of acute MI patients admitted to hospital for care were studied based on medical record review and on patient-completed questionnaires at 8 weeks post-discharge. SETTING: Three community hospitals located in urban areas in the southeastern region of the United States. PATIENTS: A consecutive sample of 133 non-transfer Acute MI patients were entered into the study based on EKG results, enzyme tests and chest pain characteristics. Hospital medical record and charge data were available on all patients and patient-reports on 86% of survivors. MAIN OUTCOME MEASURES: Data were gathered on clinical outcomes (death, angina, dyspnea), functional outcomes (physical and psychosocial), satisfaction, and resource intensity (length of stay, total hospital charges, ancillary charges). Because of patient mix differences across hospitals, outcomes were adjusted for severity of Acute MI, comorbidity and demographics. RESULTS: There were important patient mix differences across hospitals. For example, Hospital C had more comorbidity than Hospital B (57.78% of Hospital C patients vs 15.00% of Hospital B patients were rated moderate or severe using a well tested index, p < 0.0001). After adjusting for patient mix differences, Hospital C scored significantly better on four of six outcome measures (i.e. angina, dyspnea, physical functioning, psychosocial functioning). For example, Hospital C's patients' mean scores on physical functioning at 8 week follow-up averaged 75.19 (on a 0-100 scale), while Hospital A's was 63.03 and Hospital B's was 48.57 (F-ratio = 4.95; p < 0.05). However, Hospital A scored significantly lower on all three resource intensity indicators (length of stay, ancillary charges, and total charges). For example, Hospital A's ancillary charges averaged $10,752 while Hospital B's and C's averaged $11,432 and $16,598 respectively. Between-hospital comparisons on adjusted mortality and satisfaction did not differ significantly. CONCLUSION: The "value" profiles (i.e. outcomes related to charges) produced by these three hospitals were substantially different. Studies that simultaneously measure outcomes, costs, patient mix and processes have potential to: (a) enable clinical teams to improve the measurable value of clinical care; and (b) enable purchasers to better evaluate which providers to select as preferred sources of care.

Acute Disease↗
PubMed1994

Linking outcomes measurement to continual improvement: the serial "V" way of thinking about improving clinical care.

BACKGROUND: Outcomes measurement, process improvement, and continual improvement all have been used to improve quality in health care. However, the mutually complementary approaches have been used primarily in isolation from each other. The "Serial V" ("Vee") concept attempts to integrate these approaches to provide a fuller assessment and practical approach to quality improvement. METHODS: Outcomes measurement is used primarily to identify variations in care and possibly to determine corrective actions that may minimize those variations. Process improvement focuses on breaking down the components of a specific process of health care delivery, identifying or reworking problem areas in the process, then rebuilding the process. Continual improvement involves pinpointing a particular area for improvement, proposing specific changes, testing the instituted changes, and evaluating the success of such changes. The Serial V concept is an integrative strategy that incorporates aspects of all three approaches to create a comprehensive way to evaluate, institute, and reflect on change aimed at improvement. While this way of thinking appears complex at first glance, a practical worksheet that details each step in the process can be used to begin the clinical improvement work. Use of the Serial V approach, which unites measurement of outcomes, analysis of the clinical process, and repeated pilot tests to improve outcomes in real-world clinical settings, will accelerate improvement in health care outcomes and eliminate unnecessary costs.

Clinical Protocols↗
PubMed1994

An open-label study of nefazodone in the treatment of depression with and without comorbid obsessive compulsive disorder.

An 8-week open-label study of nefazodone treatment of DSM-III-R major depressive episode (MDE) (n = 18) is reported. Nine of 15 individuals completing treatment also met DSM-III-R criteria for obsessive compulsive disorder (OCD). A significant reduction in depressive and anxiety symptoms was observed in treatment completers; no differences were found between those patients with and those without comorbid OCD. A trend toward an antiobsessional response was seen among those with OCD. The degree of anxiolytic response was found to be significantly correlated with the degree of antidepressant response. Nefazodone was well tolerated in most patients, with dizziness, joint pain, dry mouth, and sedation as the most commonly reported adverse events.

Adult↗
PubMed1994

Do patients' health status reports predict future hospital stays for patients with an acute myocardial infarction?

OBJECTIVE: Although patients' reports of health status and functioning have been shown to be reliable and valid measures for use in health care research, there is limited information on their practical utility in clinical settings. The purpose of this study was to determine if patients' reports of physical and psychosocial health status have prognostic value by predicting future hospital stays in acute myocardial infarction (AMI) patients. METHODS: Research design was an observational, longitudinal follow-up study involving a sample of 132 AMI patients recently discharged from nine community hospitals. One hundred twelve patients (85%) completed the study. Patient reports of general health status, diagnosis-specific measures of health status, medical history, and demographic characteristics were collected one to two months post AMI; follow-up data were gathered six months later to identify occurrence of new cardiac-related stays. RESULTS: Poor psychosocial functioning and cardiac symptoms were significantly associated with the likelihood of being rehospitalized (odds ratios of 4.62 and 4.00). Multivariate results, however, show that poor psychosocial function and younger age--but not cardiac symptoms--are significant independent predictors of new hospital stays, after controlling for medical history and demographic variables. CONCLUSION: Simple patient reports of health status, which physicians can obtain easily from AMI patients shortly after an infarction, are predictive of rehospitalization.

Acute Disease↗
PubMed1994

A short survey for assessing health and social problems of adolescents. Dartmouth Primary Care Cooperative Information Project (The COOP).

BACKGROUND: Many significant problems of adolescents are undetected and untreated. To aid in the discovery of these problems, we have developed and tested picture-and-word charts for use in the classroom or the physician's office. This report presents the results of these tests and describes how the charts may be used. METHODS: We assessed test-retest reliability of the picture-and-word charts. We also compared picture-and-word chart scores with corresponding multi-item questionnaires. Six charts were determined to be the most effective in measuring mutually exclusive dimensions of health and social problems. We used these six charts to examine factors that might affect the distribution of chart scores. RESULTS: We administered the picture-and-word charts to a diverse population of 658 adolescents whose median age was 15 years. Compared with multi-item questionnaires, respondents found the charts easier to understand and less likely to induce dishonest replies. Girls scored significantly worse (P < .001) than boys on the Physical Fitness and Emotional Feelings charts but better on the (at-risk) Health Habits chart (P < .001). The scores of teenagers known to have behavioral problems were worse on the Health Habits chart than were those of other adolescents (P < .001). CONCLUSIONS: The charts are an efficient and acceptable method for detecting health and social problems of adolescents.

Adolescent↗
PubMed1993

Synthesis of potential metabolites of ethyl (E)-4-[2-(3,4-dihydro-4,4-dimethyl-2H-1-benzopyran-6-yl)-1-propenyl] benzoate.

Potential metabolites of ethyl (E)-4-[2-(3,4-dihydro-4,4-dimethyl-2H-1-benzopyran-6-yl)-1-propenyl] benzoate were synthesized. The new compounds include ethyl 3-[3,4-dihydro-4,4-dimethyl-2H-1-benzopyran-6-yl]crotonate, 3-[3,4-dihydro-4,4-dimethyl-1H-1-benzopyran-6-yl]crotonic acid, 3,4-dihydro-4,4-dimethyl-2H-1-benzopyran-6-carboxylic acid, 4-[3,4-dihydro-4,4-dimethyl-2H-1-benzopyran-6-yl]delta 2-butenolide, ethyl (E)-4-[3,4-dihydro-4,4-dimethyl-2H-1-benzopyran-6-yl)-3-hydroxy-1- propenyl]benzoate, ethyl (E)-4-[2-(3,4-dihydro-4,4-dimethyl-2H-1-benzopyran-6-yl)-2-propenal] benzoate, and ethyl (E)-4-[2-(3,4-dihydro-4,4-dimethyl-2H-1-benzopyran-6-yl)-2-propenoic+ ++ acid]benzoate. Stereospecific oxidizing reagents and/or conditions were developed for these sensitive systems and include the use of SeO2, Clorox bleach, activated MnO2, and NaClO2 in the presence of resorcinol as a chlorine scavenger.

Benzopyrans↗