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Biomedical subjects

H R Rubin

Publications and source records attributed to H R Rubin.

At least 37 records · Page 2Linked to original sources
PubMed1998

Review of studies that compare the quality of cardiovascular care in HMO versus non-HMO settings.

OBJECTIVES: The authors compared the quality of cardiovascular care in health maintenance organizations (HMOs) versus traditional insurance arrangements through an analysis of existing literature. METHODS: Data were derived from all peer-reviewed studies published through November 1995 that used process or outcome measures to evaluate the quality of cardiovascular care in HMO versus non-HMO settings. A standardized form was used to extract information from each study on: condition studied, study time frame, type of study design, type of comparison groups, characteristics of patients and physicians, process and outcome measures used, data collection methods, reliability and validity of quality measurements, risk adjustment techniques, findings about quality of care, summary of other findings, study limitations, and other comments that explained the context of the research. RESULTS: Seven of the 11 studies that examined process measures for cardiovascular care in HMO versus non-HMO patients found more differences in one or more process measures that favored HMOs than non-HMOs. Seven of the 10 studies that examined outcome measures found no statistically significant differences in patient care between HMO and non-HMO settings. The other three studies presented contradictory results. CONCLUSIONS: The existing literature suggests that the outcomes of care for cardiovascular conditions do not differ between HMO and non-HMO settings, although selected measures of the process of cardiovascular care are actually better in HMO than in non-HMO settings.

Cardiovascular Diseases↗
PubMed1998

The importance of laboratory data for comparing outcomes and detecting 'outlier' wards in the treatment of patients with pneumonia.

OBJECTIVES: To evaluate whether routine laboratory data can improve the ability to compare risk-adjusted outcomes of different medical wards, and to detect 'outlier' wards with significantly better or worse outcome. METHODS: Patient data were taken from the Combined Patient Database Systematic Management and Research Tool, a database created by merging different computerized sources at a tertiary care hospital. All patients admitted to internal wards with the diagnosis of pneumonia during the years 1991-1995 were included (n = 2734). The outcome variable was mortality 30 days post-admission. We used three comorbidity measures based on ICD-9-CM codes as possible predictors of mortality: secondary diagnoses; the Health Care Financing Administration severity index; and the Charlson comorbidity index. Models were created using logistic regression. To each model, laboratory data gathered in the first 48 hours after admission were added. To identify 'outlier' services we determined whether the patients' ward was an independent predictor of mortality. The area under the receiver operator curve (ROC) of the models was used for comparisons. RESULTS: The area under the ROC was 0.65-0.72 for the models based on age and comorbid diagnoses. The addition of laboratory data improved markedly the discriminatory ability of each of the models, as reflected by an increase in the area under the ROC to 0.83-0.84. An 'outlier' ward with a higher risk-adjusted mortality rate was identified only by the models that included laboratory data. CONCLUSION: Basic, automated, routinely gathered laboratory data added significantly to the discriminatory power of risk models based on administrative data with abstracted diagnoses. Addition of laboratory data improved the ability to identify providers with possible exceptional quality of care.

Age Factors↗
PubMed1998

Quality assessment through patient self-report of symptoms prefiberoptic and postfiberoptic bronchoscopy.

STUDY OBJECTIVE: To apply the principles of quality improvement to measure the frequency and severity of symptoms that result from fiberoptic bronchoscopy (FOB), and to identify opportunities to improve FOB practice by identifying factors about patients and the process of care that predict these symptoms. DESIGN: Concurrent longitudinal cohort study. PATIENTS: Four hundred ninety-three adult patients who underwent FOB. MEASUREMENTS AND RESULTS: Patients completed questionnaires just prior to FOB and again at 48 h postprocedure. Patients were asked to rate the severity of nose pain, throat pain, swallowing pain, and chest pain, and the frequency of coughing, hemoptysis, phlegm, shortness of breath, wheezing, difficulty swallowing, fever, and chills. Symptom severity was reported on a four-point ordinal scale. FINDINGS: Significant worsening was found for nose pain, throat pain, swallowing pain, and hemoptysis. Shorter patients experienced more throat pain and hemoptysis, and longer procedure time predicted nose pain and hemoptysis. CONCLUSIONS: Bronchoscopy causes nose pain, throat pain, swallowing pain, and hemoptysis to a larger extent than previously has been recognized. There are opportunities to improve the patient experience with bronchoscopy by using smaller bronchoscopes in shorter patients, shortening the procedure length, and reanesthetizing the nares in longer procedures.

Adult↗
PubMed1997

Patient's view of dialysis care: development of a taxonomy and rating of importance of different aspects of care. CHOICE study. Choices for Healthy Outcomes in Caring for ESRD.

Quality assessment efforts to enhance public accountability in dialysis care and to support provider efforts to improve care have lacked patient input. To develop brief patient evaluation or satisfaction surveys suitable for busy clinical settings, knowing patients' priorities can be helpful in deciding which aspects of care should be tracked. We conducted a study to identify salient attributes of dialysis care and to rank the importance of these attributes from the perspective of dialysis patients. We analyzed the content of patient focus group transcripts to characterize dialysis care from the patients' perspective. We then surveyed 86 patients to determine how patients would rank the importance of each aspect to quality of dialysis care. The 18 broad aspects of care identified in the focus group included: (1) care provided by nephrologists, (2) care provided by other physicians (nonnephrologists), (3) care provided by dialysis center nurses, (4) care provided by social workers and psychologists, (5) care provided by dieticians, (6) clergy, (7) care provided by technicians and physician assistants/nurse practitioners, (8) care provided by dialysis center staff in general, (9) supplies, (10) treatment choice and effectiveness, (11) patient education and training, (12) self-care, (13) dialysis machines, (14) unit environment and policies, (15) cost containment, (16) billing, (17) cost of care, and (18) health outcomes. Items ranked in the top 10 by both groups of patients included issues related to nephrologists, other doctors, nurses, and patient education and training. Compared with hemodialysis patients, peritoneal dialysis patients gave higher ratings to hospital doctors' and nurses' attention to cleanliness when working with access sites, how correct the nephrologist's instructions to patients are, whether emergency room doctors check with nephrologists, the amount of information patients get about their diet, and how well nurses answer patients' questions. Patients value certain aspects of dialysis care highly, and these aspects differed in some respects for the relatively small number of hemodialysis and peritoneal dialysis patients studied. Construction of brief questionnaires for quality assessment and assurance requires thoughtful consideration of what questions to include. Knowing patients' priorities regarding the most important aspects of care that have high potential for dissatisfaction may be helpful to continuous quality improvement of end-stage renal disease care.

Adult↗
PubMed1996

The appropriateness of coronary artery bypass graft surgery in academic medical centers. Working Group of the Appropriateness Project of the Academic Medical Center Consortium.

OBJECTIVE: To compare the appropriateness of use of coronary artery bypass graft (CABG) surgery in Academic Medical Center Consortium hospitals as judged 1) according to criteria developed by an expert panel, 2) according to revisions of those criteria made by cardiac surgeons from the Academic Medical Center Consortium, and 3) by review of cases by the surgeons responsible for those cases. DESIGN: Retrospective, randomized medical record review. SETTING: 12 Academic Medical Center Consortium hospitals. PATIENTS: Random sample of 1156 patients who had had isolated CABG surgery in 1990. MAIN OUTCOME MEASURES: 1) Percentage of patients with indications for which CABG surgery was classified as appropriate, Inappropriate, or of uncertain appropriateness and 2) percentage of cases in which CABG surgery was judged inappropriate or uncertain for which ratings changed after local case review. RESULTS: Data were retrieved from medical records by trained abstractors using an explicit data collection instrument. Cases in which CABG surgery was judged to be inappropriate or uncertain were individually reviewed by the responsible surgeons. According to the expert panel ratings, 83% of the CABG operations (95% CI, 81% to 85%) were necessary, 9% (CI, 8% to 10%) were appropriate, 7% (CI, 5% to 8%) were uncertain, and 1.6% (CI, 0.6% to 2.5%) were inappropriate. These rates are almost identical to those found in a previous study that was done in New York State and that used the same criteria (in that study, 91% of operations were classified as necessary or appropriate, 7% were classified as uncertain, and 2.4% were classified as inappropriate). Rates of inappropriate procedures varied from 0% to 5% among the 12 member hospitals (P = 0.02). The Academic Medical Center Consortium cardiac surgeons revised 568 (24%) of the indications used by the expert panel. However, because those revisions altered the appropriateness ratings in both directions and affected only 50 cases (4%), the net effect of the revisions was slight: The rate of inappropriate CABG surgery increased from 1.6% to 1.9%. Local review found that data collection errors had caused erroneous ratings in 12.5% of 64 cases in which surgery had been classified as inappropriate or uncertain. CONCLUSIONS: The Academic Medical Center Consortium hospitals had low rates of inappropriate and uncertain use of CABG surgery, regardless of the criteria used for assessment. Even though surgeons from the Consortium revised the appropriateness ratings extensively, their revisions had a negligible effect on the overall assessment of appropriateness. However, because of potential data collection errors, appropriateness criteria should be used for individual case audits only if supplemented by subsequent physician review.

Academic Medical Centers↗
PubMed1994

Internists' attitudes about clinical practice guidelines.

OBJECTIVE: To assess internists' familiarity with, confidence in, and attitudes about practice guidelines issued by various organizations. DESIGN: Cross-sectional, self-administered survey. PARTICIPANTS: Questionnaires were mailed to a stratified random sample of 2600 members of the American College of Physicians (ACP) in 1992. Of the 2513 internists who met our eligibility criteria, 1513 responded (60%). MEASUREMENTS AND RESULTS: Familiarity with guidelines varied from 11% of responders for the ACP guideline on exercise treadmill testing to 59% of responders for the National Cholesterol Education Program guideline. Confidence was reported in ACP guidelines by 82% of responders but by only 6% for Blue Cross and Blue Shield guidelines. Subspecialists had greatest confidence in guidelines developed by their own subspecialty organizations. It was thought that guidelines would improve the quality of health care by 70% of responders, increase health care costs by 43%, be used to discipline physicians by 68%, and make practice less satisfying by 34%. More favorable attitudes were held by internists who were paid a fixed salary, saw patients for less than 20 hours per week, had recently graduated from medical school, or were not in private practice. CONCLUSIONS: Although most ACP members studied recognized the potential benefits of practice guidelines, many were concerned about possible effects on clinical autonomy, health care costs, and satisfaction with clinical practice.

Attitude of Health Personnel↗
PubMed1994

For what should hospitals be accountable?

BACKGROUND: An underlying assumption in discussing for what hospitals should be accountable is that the public trusts that hospitals will act in patients' best interests. Therefore, hospitals must be accountable to demonstrate that they deliver high-quality care. They must also demonstrate that they are doing so as efficiently as possible for the patients of public payers (and others). ISSUES: Current mechanisms for public accountability are neither comprehensive nor do they incorporate a systematic approach for ensuring that hospitals deliver high-quality care. Current efforts to establish which information is helpful for monitoring the quality of hospital care are duplicative and incomplete. In addition, many current approaches are not reliable or valid; there is no routine mechanism for evaluating reliability and validity of data released to the public. CONCLUSION: Recommendations are made regarding what kinds of information hospitals should be required to give to federal agencies. A federally organized effort is needed to develop standard quality measures, as well as specification of the state or other agencies that should be required to monitor the quality of hospital care for all patients and of the requirements for ongoing evaluation of the reliability and validity of the data used to assess quality of care. Changes in policy are suggested that would facilitate a federal effort to develop and maintain standard quality measures.

Data Collection↗
PubMed1994

Patients' and healthcare providers' opinions regarding advance directives.

PURPOSE/OBJECTIVES: To gain a better understanding of patients' and healthcare providers' preferences regarding when, how, and by whom advance directive information should be given and to explore the nursing role in advance directives. DESIGN: A qualitative study using focus group methodology. SETTING: A National Cancer Institute-designated comprehensive cancer center located within a large, university-affiliated, tertiary care hospital in the northeastern United States. SAMPLE: Two samples participated in the study: eight adult ambulatory patients with cancer and 15 healthcare providers (4 physicians, 10 nurses, and 1 social worker). METHODS: Separate patient and provider focus groups were conducted in private rooms by experienced facilitators using an interview guide with questions based on the literature, the hospital's advance directive materials, and the investigators' experience; sessions were audio-taped, transcribed, and analyzed using qualitative data analysis techniques. FINDINGS: Patients and healthcare providers discussed focus group questions and commented that advance directive discussions should be provided early in the treatment or illness, presented in a short and simple format with reading materials at a level appropriate for the patient, and continued throughout the illness with those who desire follow-up. Nurses, doctors, social workers, or a designated/trained advance directive person were individuals that the patients identified as people with whom they could have advance directive discussions. CONCLUSIONS: Results suggested that advance directive information should be given prior to hospital admission, be provided in a variety of formats, and that nurses, social workers, doctors, or designated staff representatives could all be part of the advance directive process. NURSING IMPLICATIONS: Nursing roles should include early assessment of patients to determine needs for discussion, advocacy on behalf of patients, and provision of information. Future research should examine use of specific personnel for facilitating advance directives and compare different formats for presenting advance directive information to patients.

Advance Directives↗
PubMed1993

Patients' ratings of outpatient visits in different practice settings. Results from the Medical Outcomes Study.

OBJECTIVE: To determine how patients in different kinds of practices--solo or single specialty (SOLO), multispecialty group (MSG), or health maintenance organizations (HMOs)--and with fee-for-service (FFS) or prepaid physician payment arrangements evaluate their medical care. DESIGN: Survey of adult outpatients after office visits, with sample weighted to represent population of patients visiting physicians in each practice type. SETTING: Offices of 367 internists, family practitioners, endocrinologists, cardiologists, and nurse practitioners, in HMOs (prepaid only), MSGs (prepaid and FFS), and SOLO practices (prepaid and FFS). PATIENTS: Adults (N = 17,671) at start of the Medical Outcomes Study. OUTCOME MEASURES: Overall rating of the visit (five choices from excellent to poor). A random half of the sample also rated the provider's technical skills, personal manner, and explanations of care as well as time spent during the visit, the appointment wait, the office wait, the convenience of the office location, and telephone access. RESULTS: Fifty-five percent of patients rated their visit overall as excellent, 32% very good, 11% good, and 2% fair or poor. Patients of SOLO practitioners were more likely (64%) to rate their visit excellent than MSG (48%) or HMO (49%) patients (P < .001). Patients of SOLO practitioners rated all aspects of care better than HMO patients did, most markedly appointment waits (64% vs 40% excellent; P < .0001) and telephone access (64% vs 33% excellent; P < .0001). Within SOLO and MSG practices, FFS patients rated most specific aspects better than prepaid patients, but these differences were not statistically significant and were inconsistent across cities. Adjusting for patients' demographics, diagnoses and self-rated health did not change results. Physicians with visit ratings in the lowest 20% were nearly four times as likely to be left by patients within 6 months than physicians in the highest 20% (16.7% vs 4.6%; P < .001). CONCLUSION: Of the five practice type and payment method combinations, SOLO FFS patients rated their visits best and HMO patients worst. Whether FFS or prepaid, care was rated better in small than in large practices. Our study shows that a brief visit rating form can be used to compare practice settings and health plans, and that patient ratings predict what proportion of patients, on average, will leave their physicians in the next several months.

Data Collection↗
PubMed1993

More informative abstracts of articles describing clinical practice guidelines.

UNLABELLED: Recommendations are proposed for preparing more informative abstracts of articles describing clinical practice guidelines. Information about the development and content of guidelines should be summarized with the following structure. OBJECTIVE: a succinct statement of the objective of the guideline, including the targeted health problem, the targeted patients and providers, and the main reason for developing recommendations concerning this problem for this population. OPTIONS: principal practice options that were considered in formulating the guideline. OUTCOMES: significant health and economic outcomes identified as potential consequences of the practice options. EVIDENCE: Methods used to gather, select, and synthesize evidence, and the date of the most recent evidence obtained. VALUES: persons and methods used to assign values (relative importance) to potential outcomes of alternative practice options. BENEFITS, HARMS, AND COSTS: the type and magnitude of the main benefits, harms, and costs that are expected to result from guideline implementation. RECOMMENDATIONS: a brief and specific list of key recommendations. VALIDATION: the results of any external review, comparison with guidelines developed by other groups, or clinical testing of guideline use. SPONSORS: key persons or groups that developed, funded, or endorsed the guideline. Abstracts adhering to these recommendations could enhance readers' ability to appraise the applicability, importance, and validity of guidelines for specific providers, patients, and settings. More informative abstracts could also promote the use of more explicit methods of guideline development, more consistent reporting of guideline documents, and the more appropriate use of guidelines by clinicians.

Abstracting and Indexing↗
PubMed1993

How reliable is peer review of scientific abstracts? Looking back at the 1991 Annual Meeting of the Society of General Internal Medicine.

OBJECTIVE: To evaluate the interrater reproducibility of scientific abstract review. DESIGN: Retrospective analysis. SETTING: Review for the 1991 Society of General Internal Medicine (SGIM) annual meeting. SUBJECTS: 426 abstracts in seven topic categories evaluated by 55 reviewers. MEASUREMENTS: Reviewers rated abstracts from 1 (poor) to 5 (excellent), globally and on three specific dimensions: interest to the SGIM audience, quality of methods, and quality of presentation. Each abstract was reviewed by five to seven reviewers. Each reviewer's ratings of the three dimensions were added to compute that reviewer's summary score for a given abstract. The mean of all reviewers' summary scores for an abstract, the final score, was used by SGIM to select abstracts for the meeting. RESULTS: Final scores ranged from 4.6 to 13.6 (mean = 9.9). Although 222 abstracts (52%) were accepted for publication, the 95% confidence interval around the final score of 300 (70.4%) of the 426 abstracts overlapped with the threshold for acceptance of an abstract. Thus, these abstracts were potentially misclassified. Only 36% of the variance in summary scores was associated with an abstract's identity, 12% with the reviewer's identity, and the remainder with idiosyncratic reviews of abstracts. Global ratings were more reproducible than summary scores. CONCLUSION: Reviewers disagreed substantially when evaluating the same abstracts. Future meeting organizers may wish to rank abstracts using global ratings, and to experiment with structured review criteria and other ways to improve raters' agreement.

Abstracting and Indexing↗
PubMed1993

Functional status and well-being in a placebo-controlled trial of zidovudine in early symptomatic HIV infection.

To determine the effect of zidovudine on functional status and well-being in patients with early symptomatic human immunodeficiency virus (HIV) infection, 70 subjects in a randomized, placebo-controlled trial (ACTG Protocol 016) were observed for 1 year using a brief quality-of-life questionnaire. Thirty-four subjects were assigned to placebo and 36 subjects to zidovudine, 200 mg orally every 4 h (1,200 mg daily). Functional status and well-being were measured every 3 months using a 30-item self-administered questionnaire derived from health ratings from the Medical Outcomes Study. The mean changes from baseline for zidovudine versus placebo groups were compared using paired and two-sample t tests. Subjects receiving a placebo reported better quality of life compared to baseline than subjects receiving zidovudine at 24 weeks for all dimensions of well-being, including overall health, energy, mental health, health distress, pain, and quality of life. The difference between the two groups' changes from baseline for overall health was 11.5 points on a 100-point scale (p = 0.02), and 11.1 points for energy (0.002). There were no differences between changes from baseline along various dimensions of functional status (physical, social, role, and cognitive function). At 52 weeks both groups reported worse overall health than at baseline, and changes in scores were more similar for the two groups. Although zidovudine has previously been demonstrated to delay progression of disease for patients with mildly symptomatic HIV infection, early in treatment the net effect of a 1,200 mg daily dose of zidovudine may diminish patients' subjective well-being.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

Watching the doctor-watchers. How well do peer review organization methods detect hospital care quality problems?

OBJECTIVE: To determine how well one state's peer review organization (PRO) judged the quality of hospital care compared with an independent, credible judgment of quality of care. DESIGN: Retrospective study comparing a PRO's review, including initial screening, physician review, and final judgments, with an independent "study judgment" based on blinded, structured, implicit reviews of hospital records. SETTING: One state's medical and surgical Medicare hospitalizations during 1985 through 1987 audited randomly by the state's PRO. SAMPLE: Stratified random sampling of records: 62 records that passed the PRO initial screening process and were not referred for PRO physician review; 50 records that failed the PRO screen and then were confirmed by PRO physicians to be "quality problems." INTERVENTION: None. MAIN OUTCOME MEASURE: A study judgment of below standard or standard or above based on the mean of overall ratings by five internists for records in medical diagnosis related groups (DRGs) and by five internists and five surgeons for surgical DRGs. Each step in the PRO review was evaluated for how many records passing or failing that step were judged standard or above or below standard in the study (positive and negative predictive value) and how well that step classified records that the study judged below standard or standard or above (sensitivity and specificity). RESULTS: An estimated 18% of records reviewed by the PRO were below standard according to the study judgment, compared with 6.3% quality problems according to the PRO's final judgment (difference, 12%; 95% confidence interval, 1 to 23). The PRO's initial screening process failed to detect and refer for PRO physician review two of three records that the study judged below standard. In addition, only one of three of the records that PRO physicians judged to be quality problems were judged below standard by the study judgment. Therefore, the PRO's final quality of care judgment and the study judgment agreed little more than expected by chance, especially about poor quality of care. Although the PRO correctly classified 95% of the records that the study judged standard or above, it detected only 11% of records judged below standard by the study. CONCLUSIONS: Most of all, this PRO review process would be improved by additional preliminary screens to identify the 67% of records that the study judged below standard but that passed its initial screening. The screening process also must be more accurate in order to be cost-effective, as it was only slightly better than random sampling at correctly identifying below standard care. More reproducible physician review is also needed and might be accomplished through improved reviewer selection and training, a structured review method, and more physician reviewers per record.

Hospital Records↗
PubMed1991

A health status questionnaire using 30 items from the Medical Outcomes Study. Preliminary validation in persons with early HIV infection.

Many current health status instruments either are too long to use in many acquired immune deficiency syndrome (AIDS) clinical trials or omit important concepts. In this study, human immunodeficiency virus (HIV)-relevant items developed for the Medical Outcomes Study (MOS) from subscales for cognitive function, energy/fatigue, health distress, and a single quality of life item were added to a portion of the MOS Short-form General Health Survey. The resulting 30-item questionnaire reliably and distinctly measured ten aspects of health and took less than 5 minutes to complete. To test its validity, this modified measure was used to compare the health of 73 subjects with asymptomatic HIV infection and 44 with early AIDS-related complex (ARC). Compared with ARC subjects, asymptomatic individuals reported superior overall health, less pain, and better physical function, role function, cognitive function, and quality of life (rank-sum, P less than 0.02). Asymptomatic subjects' scores were higher on most subscales than the age-adjusted scores of MOS outpatients with hypertension, diabetes, recent myocardial infarction, or depression; ARC patients scored closest to hypertensive patients. This instrument, containing a subset of the MOS measures of health-related quality of life, may be a useful outcome measure for AIDS clinical trials.

AIDS-Related Complex↗