OBJECTIVE: To review the literature focusing on studies of patient satisfaction and patient involvement in the design of care and to suggest strategies for involving patients effectively in their care. While addressing issues in contraception and adherence to contraceptive regimens, we write from the perspective of general physicians who manage patients with a broad variety of problems. By learning systematically what patients want, need, and experience in health and illness, we can use such information in the redesign and improvement of care. DATA SOURCES: Individual anecdote, focus groups of patients, patient survey data, and a literature review were used. METHODS OF STUDY SELECTION: The literature review used an English-language search of MEDLINE from 1970 to 1996, with search terms including patient satisfaction, consumer participation, patient participation, self-care, contraception, and contraceptive behavior. Previous studies conducted by the authors were also reviewed. TABULATION, INTEGRATION, AND RESULTS: Patients report that providers who solicit patients needs and preferences for involvement in decision making, who encourage family involvement, and who tailor educational efforts to the individual adult learning style of the patient engender greater patient satisfaction, adherence to recommended therapies, and improved patient outcomes. Recent trends in the United States, such as the growing use of alternative therapies, the self-help movement, and consumerism have influenced patient attitudes and behaviors toward seeking care and are changing their behavior. We discuss several strategies to improve patient involvement in their care, including the use of patient diaries and contracts, pre- and post-visit preparation and communication, the involvement of patients in educating providers, and the use of information technologies to enhance communication between patients and providers. CONCLUSIONS: Patient involvement in the redesign of care may help promote greater effectiveness of contraceptive strategies.

Adult↗

PubMed1996

Severity measurement methods and judging hospital death rates for pneumonia.

Payers and policymakers are increasingly examining hospital mortality rates as indicators of hospital quality. To be meaningful, these death rates must be adjusted for patient severity. This research examined whether judgments about an individual hospital's risk-adjusted mortality is affected by the severity adjustment method. Data came from 105 acute care hospitals nationwide that use the Medis-Groups severity measure. The study population was 18,016 adults hospitalized in 1991 for pneumonia. Multivariable logistic models to predict in-hospital death were computed separately for 14 severity methods, controlling for patient age, sex, and diagnosis-related group (DRG). For each hospital, observed-to-expected death rates and z scores were calculated for each severity method. The overall in-hospital death rate was 9.6%. Unadjusted mortality rates for the 105 hospitals ranged from 1.4% to 19.6%. After adjusting for age, sex, DRG, and severity, 73 facilities had observed mortality rates that did not differ significantly from expected rates according to all 14 severity methods; two had rates significantly higher than expected for all 14 severity methods. For 30 hospitals, observed mortality rates differed significantly from expected rates when judged by one or more but not all 14 severity methods. Kappa analysis showed fair to excellent agreement between severity methods. The 14 severity methods agreed about relative hospital performance more often than expected by chance, but perceptions of individual hospitals' mortality rates varied using different severity adjustment methods for almost one third of facilities. Judgments about individual hospital performance using different severity adjustment approaches may reach different conclusions.

Adolescent↗

PubMed1996

Judging hospitals by severity-adjusted mortality rates: the influence of the severity-adjustment method.

OBJECTIVES: This research examined whether judgments about a hospital's risk-adjusted mortality performance are affected by the severity-adjustment method. METHODS: Data came from 100 acute care hospitals nationwide and 11880 adults admitted in 1991 for acute myocardial infarction. Ten severity measures were used in separate multivariable logistic models predicting in-hospital death. Observed-to-expected death rates and z scores were calculated with each severity measure for each hospital. RESULTS: Unadjusted mortality rates for the 100 hospitals ranged from 4.8% to 26.4%. For 32 hospitals, observed mortality rates differed significantly from expected rates for 1 or more, but not for all 10, severity measures. Agreement between pairs of severity measures on whether hospitals were flagged as statistical mortality outliers ranged from fair to good. Severity measures based on medical records frequently disagreed with measures based on discharge abstracts. CONCLUSIONS: Although the 10 severity measures agreed about relative hospital performance more often than would be expected by chance, assessments of individual hospital mortality rates varied by different severity-adjustment methods.

Adult↗

PubMed1996

Judging hospitals by severity-adjusted mortality rates: the case of CABG surgery.

In many health care marketplaces, outcomes assessment is central to monitoring quality while controlling costs. Comparing outcomes across providers generally requires adjustment for patient severity. For mortality rates and other adverse outcomes comparisons, severity adjustment ideally aims to control for patient characteristics prior to the health care intervention. A variety of severity methodologies, specifically for hospitalized patients, are commercially available. Some have been adopted by state or regional initiatives for publicly comparing hospital outcomes. We applied 14 common severity measures to the same data set to determine whether judgments about risk-adjusted hospital death rates are sensitive to the specific severity method. We examined 7,765 patients undergoing coronary artery bypass graft (CABG) surgery at 38 hospitals. Unadjusted death rates ranged from 0% to 11.2% across hospitals. Comparisons of relative hospital performance were relatively insensitive to the severity adjustment method.

Adolescent↗

PubMed1996

Comparison of efficacy of sulbactam: ampicillin to ampicillin and saline for treatment of experimentally induced Escherichia coli diarrhea in neonatal calves.

A study was conducted to compare the efficacy of sulbactam: ampicillin (SAMP) (3.3:6.6 mg/kg body weight (BW), IM, q24 h) to that of ampicillin trihydrate (AMP) (6 mg/kg BW, IM, q24 h) and 0.9% saline (SAL) (3 mL IM, q24 h) for the treatment of diarrhea in calves induced by oral inoculation with Escherichia coli strain B44 (O9:K30:K99:H-). Treatment was initiated when severe diarrhea was noted (T0) and continued for at least 3 d; or for 24 h after clinical signs resolved; or for a maximum duration of 7 d. Starting at T0, calves were examined twice daily: appetite; rectal temperature (TEMP); and fecal consistency (FECAL), mental status (ATTD), eye position (EYE), and skin elasticity (SKIN) scores were recorded. Feces collected at T0 were submitted for bacteriology, electron microscopy, and parasitology. A complete blood count was performed at T0 and T3 (24 h after third treatment). Severely dehydrated, depressed, and anorexic calves were euthanized and considered mortalities. Cause of death was determined by post mortem examination. A total of 30 calves were included in the study. Three calves were excluded from final analysis. E. coli strain B44 was cultured from feces of all calves at T0. At T2 (24 h after second treatment) mean TEMP of SAMP calves was significantly higher (P < 0.05) than mean TEMP of SAL calves; EYE and SKIN scores of SAMP calves were significantly lower (P < alpha beta = 0.025) than those of SAL and AMP calves; and ATTD and FECAL scores of SAMP calves were significantly lower (P < alpha beta = 0.025) than in SAL calves. At T3, SAMP calves had significantly lower (P < 0.05) mean hematocrit than SAL calves and lower mean total plasma protein concentration than AMP and SAL calves. Mean fibrinogen concentration in SAMP calves at T3 was significantly lower (P < 0.05) than that of calves receiving either SAL or AMP. The number of surviving SAMP calves (10/10) was significantly higher (P < alpha beta = 0.025) than the number of surviving SAL calves (2/9), but not significantly different from the surviving AMP calves (3/8).

Ampicillin↗

PubMed1995

Complication rates as a measure of quality of care.

Explore the source record for details and available documents.

Coronary Artery Bypass↗

PubMed1995

Predicting who dies depends on how severity is measured: implications for evaluating patient outcomes.

OBJECTIVE: To determine whether assessments of illness severity, defined as risk for in-hospital death, varied across four severity measures. DESIGN: Retrospective cohort study. SETTING: 100 hospitals using the MedisGroups severity measure. PATIENTS: 11 880 adults managed medically for acute myocardial infarction; 1574 in-hospital deaths (13.2%). MEASUREMENTS: For each patient, probability of death was predicted four times, each time by using patient age and sex and one of four common severity measures: 1) admission MedisGroups scores for probability of death scores; 2) scores based on values for 17 physiologic variables at time of admission; 3) Disease Staging's probability-of-mortality model; and 4) All Patient Refined Diagnosis Related Groups (APR-DRGs). Patients were ranked according to probability of death as predicted by each severity measure, and rankings were compared across measures. The presence or absence of each of six clinical findings considered to indicate poor prognosis in patients with myocardial infarction (congestive heart failure, pulmonary edema, coma, low systolic blood pressure, low left ventricular ejection fraction, and high blood urea nitrogen level) was determined for patients ranked differently by different severity measures. RESULTS: MedisGroups and the physiology score gave 94.7% of patients similar rankings. Disease Staging, MedisGroups, and the physiology score gave only 78% of patients similar rankings. MedisGroups and APR-DRGs gave 80% of patients similar rankings. Patients whose illnesses were more severe according to MedisGroups and the physiology score were more likely to have the six clinical findings than were patients whose illnesses were more severe according to Disease Staging and APR-DRGs. CONCLUSIONS: Some pairs of severity measures assigned very different severity levels to more than 20% of patients. Evaluations of patient outcomes need to be sensitive to the severity measures used for risk adjustment.

Adult↗