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Biomedical subjects

R G Carey

Publications and source records attributed to R G Carey.

At least 19 recordsLinked to original sources
PubMed2000

Measuring health care quality. How do you know your care has improved?

Statistical process control (SPC) was developed in the 1920s as a way of detecting defects in manufacturing processes. During the past decade, SPC has been adopted by service industries and is increasingly being employed by health care organizations. The methodology involves the construction of a control chart to detect variation within processes. Variation is neither good nor bad in itself; therefore, the impact of variation must be interpreted within the context of expected outcomes, acceptable limits, and the process itself. In this article, the concept of statistical process control is explained, and examples are provided to illustrate how SPC can be applied in a clinical setting.

Audiovisual Aids↗
PubMed1999

Measuring for improvement: from Toyota to thoracic surgery.

BACKGROUND: Measuring quality has become a high priority in the era of managed care. Nevertheless, it can be counterproductive to use the same methods for measuring improvement in surgical procedures and processes as we use for measurement in basic research. Techniques of statistical process control have been used for many years to measure process improvement in industry and are now being applied to health care. METHODS: Examples of using statistical process control charts to monitor coronary artery bypass grafting mortality, intensive care unit admission time, and length of stay are reviewed. RESULTS: The major advantage of using control chart methodology is that it allows one to determine whether the process being evaluated is in fact stable and to detect when significant or special cause variation occurs. CONCLUSIONS: Summary statistics currently provided to purchasers of care and regulatory agencies do not ensure that the processes being evaluated are stable. We need to look at data over time with statistically validated methods such as control charts to better monitor our processes of care and thereby provide accurate statistics.

Coronary Artery Bypass↗
PubMed1996

Evaluating the physician office visit: in pursuit of a valid and reliable measure of quality improvement efforts.

In an effort to develop a patient questionnaire with sufficient validity and reliability to be used to measure patient perceptions of quality, over 30,000 patients from 178 solo and group practices completed the Physician Office Quality of Care Monitor (QCM). The study found strong evidence of construct validity, predictive validity, and internal consistency for the questionnaire. Physician interactions were the most important aspect of office care while coordination of care over time was found to be the best issue to differentiate patients likely to recommend a practice from those less likely to recommend. An inverse relationship was found between practice size and patient satisfaction. Health maintenance organization (HMO) patients reported lower satisfaction, as did younger patients.

Factor Analysis, Statistical↗
PubMed1995

CQI case study: reducing medication errors.

BACKGROUND: This article describes how the Pharmacy and Therapeutics Committee at Lutheran General Hospital (Park Ridge, IL) formed a continuous quality improvement (CQI) team and used statistical process control (SPC) tools to assess efforts to reduce medication errors. METHODS: The team worked with the nursing quality council to develop an intravenous (IV) training module for nurses that effectively decreased the average number of errors per month. The article illustrates the effective use of a run chart, a Pareto chart, and two types of control charts (p-charts and np-charts) to identify an opportunity for improvement, develop an improvement strategy, and measure the effectiveness of the intervention. CONCLUSION: Lessons learned from this case include the following: 1) Although run charts can be used as a preliminary step to determine whether a process has common-cause or special-cause variation, p-charts or np-charts are more precise tools for identifying special causes and for measuring the impact of interventions; 2) Pareto charts are useful for focusing on the areas of a process that will have the greatest impact in achieving the desired results; 3) When p-charts show little variation in control limits from month to month, the np-chart is an appropriate and more user-friendly alternative; and 4) In addition to validating the overall effectiveness of the intervention, the np-chart also helped to identify where the intervention failed.

Health Services Research↗
PubMed1993

A patient survey system to measure quality improvement: questionnaire reliability and validity.

This study describes the results of a four-year research effort to develop inpatient and outpatient questionnaires that have sufficient validity and reliability to be used to measure patient perceptions of quality. As part of this effort, over 50,000 inpatients, emergency room patients, and ambulatory surgery patients from over 300 hospitals representing every US census region were surveyed. Separate questionnaires, called Quality of Care Monitors, were developed for inpatients and outpatients. The inpatient questionnaire consisted of 8 scales: Physician Care, Nursing Care, Medical Outcome, Courtesy, Food Service, Comfort and Cleanliness, Admissions/Billing, and Religious Care. The outpatient questionnaire had 7 scales: Physician Care, Nursing Care, Medical Outcome, Facility Characteristics, Waiting Time, Testing Services and Registration Process. The study found strong evidence of construct validity, predictive validity, and internal consistency for both questionnaires. Each questionnaire is capable of measuring separate dimensions of patient experience. A data bank developed from these questionnaires is currently accessed regularly by participating hospitals to assess quality improvement and to make benchmark comparisons with similar hospitals.

Health Services Research↗
PubMed1992

Reduced nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) profiles in the amygdala of human and New World monkey (Saimiri sciureus).

The topographic distribution of nicotinamide adenine dinucleotide-diaphorase (NADPH-d) stained profiles in the amygdala of the human and new world monkey (Saimiri sciureus) were studied histochemically. Fiber and terminal staining were heterogeneously distributed within the amygdala. The most intense staining occurred in the basolateral subdivision, consisting of the lateral, basolateral and accessory basal nuclei. Moderate staining intensity was observed throughout the cortical and media nuclei and cortical transition area, constituents of the corticomedial subdivision. The central amygdaloid area was characterized by minimal NADPH-d histochemical reactivity. NADPH-d positive neurons were pleomorphic and divisible into two classes based on their staining characteristics: intensely or lightly stained neurons. Their distribution was generally complementary, with the majority of intensely stained neurons occupying the basolateral subdivision. There were no appreciable species differences in the patterns of neuronal, fiber and terminal staining between monkey or human amygdala. These results may be relevant to our understanding of the selective vulnerability of neural systems within the human amygdala in neurodegenerative diseases.

Acetylcholinesterase↗
PubMed1990

Reduced nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) histochemistry in the hippocampal formation of the New World monkey (Saimiri sciureus).

Nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) containing fibers and neurons within the hippocampal formation and entorhinal cortex of the new world monkey were determined using a direct histochemical procedure. Occasional intensely stained bipolar NADPH-d positive neurons were seen in the polymorphic zone within the hilus of the dentate gyrus and molecular layer of the hippocampus. Although virtually no intensely stained cells were seen in the CA subfields, a few small oval lightly stained NADPH-d perikarya were found subjacent to CA2. An occasional intensely stained multipolar NADPH-d containing neuron was observed in the subiculum, presubiculum and parasubiculum. In the entorhinal cortex, NADPH-d cells were scattered in all layers with the greatest preponderance in layers 5-6 and underlying white matter. Dense bands of NADPH-d fibers occurred in the outer layer of the molecular layer of the dentate gyrus and the hippocampo-subicular border. NADPH-d fibers also were seen in pre- and parasubicular regions. NADPH-d fiber staining in entorhinal cortex varied mediolaterally with an increasing laminar distribution more caudally. The heaviest bands of NADPH-d fibers occurred in layers 1 and 4 and the white matter-layer 6 border. The distribution patterns of this select neuronal population may be relevant to the study of hippocampal and entorhinal areas in neurodegenerative diseases.

Animals↗
PubMed1990

Gliomas: classification with MR imaging.

The findings at magnetic resonance (MR) imaging in a group of 36 pathologically verified supratentorial gliomas were analyzed and compared with the biopsy diagnoses (a) to determine whether MR imaging could be used to classify astrocytic-series tumors into a three-tiered system of low-grade astrocytoma, anaplastic astrocytoma, and glioblastoma multiforme; and (b) to evaluate MR imaging features that may aid in this classification. The MR characteristics evaluated were crossing of the midline, edema, tumor signal heterogeneity, hemorrhage, border definition, cyst formation or necrosis, and mass effect. The statistically significant MR characteristics (positive predictors) were mass effect (P = .0000) and cyst formation or necrosis (P = .0512). The MR accuracy rate approached that of neuropathologic diagnosis, which is subject to sampling errors. MR imaging may serve as an adjunct in case management when the clinical course and MR findings appear to be at odds with the neuropathologic diagnosis.

Anaplasia↗
PubMed1989

Immunohistochemical localization of GABAA receptors in the retina of the new world primate Saimiri sciureus.

A large population of amacrine cells in the retina are thought to use GABA as an inhibitory neurotransmitter in their synaptic interactions within the inner plexiform layer. However, little is known about their synaptic targets; the neurons that express the receptors for GABA have not been clearly identified. Recently, the GABAA receptor has been isolated and antibodies have been raised against it. These antibodies have proven useful for the immunocytochemical localization of the receptor, and two brief reports describing the distribution of GABAA receptor immunoreactivity in the retina have appeared (Richards et al., 1987; Mariani et al., 1987). We used a monoclonal antibody (62-3G1) against the GABAA receptor to study the retina of the New World primate Saimiri sciureus. Labeled somata were found in the inner nuclear layer (INL) and ganglion cell layer (GCL). The staining was confined to what appeared to be the cell's plasmalemma and small cytoplasmic granules. Most of the labeled neurons in the INL had small somata (5-7 microns in diameter) located at the vitreal edge of the layer. They arborized in two laminae (approximately 2 and 4) of inner plexiform layer (IPL). Ventral to the optic disc (2.5 mm) they comprised 29% of the cells present. A few of the labeled neurons appeared to be interplexiform cells or flat bipolar cells, with labeled processes that extended into both the IPL and the inner half of the outer plexiform layer. In the GCL, the labeled somata were among the largest present (13-20 microns in diameter), and 2.5 mm ventral to the optic disc they made up 15% of the cells present. Experiments in which immunoreactive somata were retrogradely labeled following the injection of fluorescent tracers into the optic tract provided a conclusive demonstration that some of the immunoreactive somata were ganglion cells. The antibody often labeled their axons in the optic fiber layer. This suggests that the GABAA receptors are transported anterogradely to the retinal terminal fields. The dendrites of the immunoreactive ganglion cells extended into the 2 laminae of labeled processes in the IPL, and their primary dendritic arbors were, at any given eccentricity, quite similar in appearance. This homogeneity suggests that they comprise a particular subset of the ganglion cells. Sections simultaneously labeled with the monoclonal antibody against the GABAA receptor and antisera against either L-glutamic acid decarboxylase (GAD) or GABA revealed that the GAD/GABA was distributed much more widely in the IPL than the GABAA receptor.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗
PubMed1989

Using hospital surveys to enhance the quality of care.

Hospitals need the data that valid surveys can provide. However, no data are better than inaccurate or poorly interpreted data. Survey research appears to be deceptively simple. Many hospital managers are not sensitive to the pitfalls in writing a quality questionnaire and some who have their own personal computers believe that they can enter and tabulate the data. However, just as medical technology has advanced and become more complicated in recent years, survey research has also become more sophisticated during the past decade. The use of computers has assisted in the display of vast amounts of survey data, but interpretation is still the key to effective survey research. Many people can read the same table of data but come to different conclusions, depending on their point of view and their level of involvement with the issues being discussed. It is only human nature to interpret data to support what we believe to be the truth. Hospital managers should understand that interpretation of survey data is best done by neutral and skilled professionals who have worked closely with those who have authority to make costly decisions based on the results. A radiologist will tell you that reading a CT scan is an art as well as a science. So is quality survey research.

Data Collection↗
PubMed1988

New view of the organization of the pulvinar nucleus in Tupaia as revealed by tectopulvinar and pulvinar-cortical projections.

The projections of the superficial layers of the superior colliculus to the pulvinar nucleus in Tupaia were reexamined by injecting WGA-HRP into the tectum. The main result was finding two different patterns of terminations in the pulvinar nucleus: a zone remote from the lateral geniculate nucleus, which occupies the dorsomedial and caudal poles of the pulvinar nucleus, was almost entirely filled with terminals in every case irrespective of the location of the injection site; and a second division of the pulvinar nucleus, adjacent to the lateral geniculate nucleus, contained irregular patches--much more densely populated--and the distribution of patches varied from case to case. We call the first projection "diffuse" and the patchy projection "specific." Next we injected several divisions of the extrastriate visual cortex to find the cortical target of each pathway. The diffuse path terminates in the ventral temporal area (Tv). The specific path terminates in the dorsal temporal area (Td) and area 18. We speculated about the significance of the two pathways: the specific path may be responsible for the preservation of vision after removal of the striate cortex; the diffuse path may have an important place in the evolution of the visual areas of the temporal and occipital lobe. We argued that the target of the diffuse path is in a position to relate limbic and visual impulses and relay the product of such integration to the other visual areas, striate as well as extrastriate cortex.

Animals↗
PubMed1988

Origin of butyrylcholinesterase in the lateral geniculate nucleus of tree shrew.

We examined the distribution and possible origins of pseudocholinesterase activity within the lateral geniculate nucleus (LGN) of the tree shrew. Butyrylcholinesterase (BuChE) activity was spread diffusely throughout the LGN and not localized to neuronal perikaryon. Lesions of the LGN eliminated this BuChE activity while not affecting acetylcholinesterase (AChE) activity; however, removal of retinal input by unilateral ocular enucleations failed to affect the BuChE activity within the denervated layers of the LGN. This lack of effect suggests that, unlike the macaque monkey, retinal terminals within the LGN of tree shrew are not the source of BuChE. Thus, in the tree shrew LGN it appears that BuChE is not metabolically related to or dependent upon AChE nor does it originate from retinal sources, but rather BuChE appears to represent an enzyme that is endogenous to the LGN.

Acetylcholinesterase↗
PubMed1988

Getting the best return on the employee benefit dollar.

The value of employee benefits depends largely on employees' perceptions of those benefits, rather than on any intrinsic value the benefits have. If employees do not value a benefit highly, the hospital is not getting its money's worth. Hospital management now faces the challenge of reallocating benefit dollars to best meet employees' perceived needs and have the maximum positive impact on employee morale, while holding the line on benefit costs. To meet this challenge, administrators must first determine which benefits employees value the most, with which benefits they are most satisfied, and whether an employee's job category makes a difference. Parkside Associates, Inc., the hospital survey corporation of the Lutheran General Health Care System, Park Ridge, IL, has developed a system for gathering hospital-specific benefit data as part of an employee attitude survey. Employees rate each of their benefits according to (1) the benefit's importance to them and (2) their level of satisfaction with the benefit. Based on the assessment of employees' perceptions of the value and quality of benefits they receive, management can plan one or more strategies for response. For example, hospitals can: 1. Reduce benefits a majority of employees identify as having little importance. 2. Restructure benefits identified as being very important, but which produce little satisfaction. 3. Offer flexible, or "cafeteria," benefit plans so individual employees can increase the level of the benefits they value most and decrease the level of other benefits. 4. Offer educational activities, such as an annual benefits statement, to heighten the employees' awareness of the value of the benefits they are receiving.

Attitude of Health Personnel↗
PubMed1988

Who makes the most progress in inpatient rehabilitation? An analysis of functional gain.

This study describes the functional gain made by 6,194 inpatients in 22 rehabilitation facilities in 1985 and 1986. Functional gain was measured by the Revised Level of Rehabilitation Scale (LORS-II). Results showed that age, length of stay, and functional ability at admission were all factors in patient progress, but not always in the way expected. Younger patients and those with a longer length of stay generally made more progress, but there were variations by impairment group. A curvilinear relationship between functional status at admission and functional gain was observed for several impairment groups. Head injury patients made the most functional gains. However, orthopedic patients made the most gains of all impairment groups when length of stay, age, functional ability at admission, and consistency of progress were considered.

Activities of Daily Living↗
PubMed1987

Topographic projections to the visual cortex from the basal forebrain in the rat.

Recent studies have shown that cholinergic neurons within the basal forebrain give rise to a projection that terminates throughout the neocortex. The purpose of the present study is to determine the topographic organization of the basal forebrain projection to a single cortical region: the visual cortex. Injections of wheat germ agglutinin-horseradish peroxidase were placed within the infragranular layers of areas 17, 18a or 18b in Long-Evans hooded rats. Following injections placed within area 18a, retrogradely labeled neurons were located primarily within the caudal components of the basal forebrain including the basal nucleus of Meynert. Injections placed within area 18b, on the other hand, resulted in retrograde labeling of numerous neurons within rostral basal forebrain nuclei, including the horizontal limb of the diagonal band of Broca, whereas only a few labeled cells were located within the basal nucleus. Two patterns of labeled cells were evident following injections placed within area 17 and they resembled the results from injections within the adjacent extrastriate area; i.e. either area 18a or area 18b. Thus, injections restricted to the lateral portions of area 17 resulted in retrograde labeling of neurons located within the caudal levels of the basal forebrain, whereas injections within the medial portions of area 17 were followed by retrograde labeling of neurons within the rostral levels of the basal forebrain. Based on these results we suggest that the cholinergic corticopetal projection terminates within the visual cortex in a medial to lateral pattern.

Animals↗