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Biomedical subjects

R H Brook

Publications and source records attributed to R H Brook.

At least 127 records · Page 7Linked to original sources
PubMed1992

Relation between hospital experience and in-hospital mortality for patients with AIDS-related Pneumocystis carinii pneumonia: experience from 3,126 cases in New York City in 1987.

There is marked debate about whether outcomes of care, particularly mortality, vary as a function of hospital and physician experience with a disease. This issue is especially important with respect to AIDS because greater than 200,000 individuals have now been diagnosed with this disease. We analyzed discharge data for 3,126 persons with AIDS who had Pneumocystis carinii pneumonia and who were treated at one of 73 New York City hospitals in 1987. In-hospital mortality was 25%. Factors associated with higher chances of short-term death were older age, being black, not having private health insurance, and being severely ill. A logistic regression model indicated that after controlling for differences in patient and hospital characteristics, the chances of death decreased when care was given at hospitals with higher caseloads of patients with Pneumocystis carinii pneumonia. Our findings suggest that hospital experience may decrease mortality in this subset of patients with human immunodeficiency virus disease, although it is unknown whether this is due to differences in quality of care.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Appropriateness of care. A comparison of global and outcome methods to set standards.

The RAND-UCLA Health Services Utilization Study previously analyzed the appropriateness of use of carotid endarterectomy based on a literature review and global expert judgments. In this study, for 45 of the same clinical indications used in the RAND-UCLA Study, the authors compare the appropriateness judgments based on the global judgment method to appropriateness ratings based on probability estimates of specific outcomes that were provided by the same panel of experts. The authors asked these experts to estimate, for each clinical indication, the likelihood of important medical outcomes (i.e. stroke within a year) in the presence and absence of endarterectomy. Using decision analysis, the appropriateness of endarterectomy for these 45 indications was then calculated. For only two of the eight physicians were the Spearman rank-order correlations between these two methods of judging appropriateness significant and positive. (Correlations for the eight physicians ranged from 0.45 to -0.38). This result was produced by: 1) the tendency of the experts to estimate relatively poor outcomes for seriously ill patients whether or not endarterectomy was performed; and 2) a far less consistent effect of clinical factors on outcome estimates than on global judgments. Better methods for incorporating probability estimates into a global rating process must be developed. The authors found excellent agreement between the panelists' relative outcome estimates for common endarterectomy indications and the observed stroke rate for these same indications, suggesting that one promising method is to use specific outcome data to "anchor" expert judgments.

Aged↗
PubMed1991

The health care resource allocation debate. Defining our terms.

The problem of health care distribution in the United States demands immediate action. Many different solutions have been proposed to slow rising health care costs and to improve access to care for the poor and uninsured. Debate among proponents of these various proposals might be advanced if a common language were adopted with regard to certain key terms instead of the various meanings currently assigned to these terms. For this reason, we propose and defend the following three definitions: (1) rationing is the societal toleration of inequitable access to health services acknowledged to be necessary by reference to necessary-care guidelines; (2) health care needs are desires for services that have been reasonably well demonstrated to provide significant net benefit for patients with specified clinical conditions; and (3) basic benefit plans are insurance packages that provide for all and only acknowledged health care needs, again by reference to appropriate clinical guidelines.

Comprehensive Health Care↗
PubMed1991

Quality of care: do we care?

The quality of U.S. health care must improve. Practicing physicians need to become involved in generating new knowledge about what does and does not work in medical practice. Physicians might, for example, participate in building national databases on chronic and acute conditions using data from their patients or might help to enroll patients in cohort studies or experimental trials. Furthermore, our knowledge is now sufficient to support a substantial investment of funds in improving what physicians now do in medical practice and in developing publicly available standards of medical practice. Such standards or guidelines could be used by both physicians and patients as part of an explicit process to assess the medical appropriateness of expensive or dangerous procedures before they are done. In addition, the competence with which care is delivered also needs to be measured. Both of these assessments should be used prospectively by physicians to help patients choose the referral source that will maximize their preferences.

Clinical Protocols↗
PubMed1991

Patients who leave a public hospital emergency department without being seen by a physician. Causes and consequences.

OBJECTIVE: To determine whether patients who sought care at a public hospital emergency department and left without being seen by a physician needed immediate medical attention and whether they obtained care after leaving. DESIGN: Follow-up study of patients who left without being seen and of patients who waited to be seen by a physician. SETTING: A public hospital's emergency department in Torrance, Calif. PATIENTS: All patients who registered for care and left without being seen (n = 186) and a 20% random sample of patients who waited until they were seen (n = 211) in a 2-week period during spring 1990. MAIN OUTCOME MEASURES: At time of presentation: triage nurse urgency assessment, clinical acuity rating, and self-reported health status. At follow-up: hospitalization rates. RESULTS: Patients who left reported that they had waited 6.4 hours before leaving; those who stayed reported a 6.2-hour wait before being seen. There were no differences between those who left and those who stayed in chief complaint, triage nurse assessment, acuity ratings, or self-reported health status. Forty-six percent of those who left were judged to need immediate medical attention, and 29% needed care within 24 to 48 hours. Eleven percent of those who left were hospitalized within the next week, and three patients required emergency surgery. Nine percent of those who waited to be seen were hospitalized. Forty-nine percent of patients who left did not see a physician during the 1-week follow-up period. CONCLUSION: Overcrowding in this public hospital's emergency department restricts access to needed ambulatory medical care for the poor and uninsured.

Acute Disease↗
PubMed1991

Failure of physicians to recognize functional disability in ambulatory patients.

OBJECTIVE: To assess the ability of internists to identify functional disabilities reported by their patients. DESIGN: Comparison of responses by physicians and a random sample of their patients to a 12-item questionnaire about physical and social function. SETTING: A hospital-based internal medicine group practice in Boston, Massachusetts, and selected office-based internal medicine practices in Los Angeles, California. SUBJECTS: Five staff physicians, three general internal medicine fellows, and 34 internal medicine residents in the hospital-based practice and 178 of their patients. Seventy-six physicians in the office-based practices and 230 of their patients. MEASUREMENTS AND MAIN RESULTS: Physicians underestimated or failed to recognize 66% of disabilities reported by patients. Patient-reported disabilities were underestimated or unrecognized more often in the hospital-based practice than in the office-based practices (75% compared with 60%, P less than 0.05). Physicians overstated functional impairment in 21% of paired responses in which patients reported no disability. CONCLUSIONS: Physicians often underestimate or fail to recognize functional disabilities that are reported by their patients. They overstate functional impairment to a lesser degree. Because these discrepancies may adversely affect patient care and well-being, medical educators and clinicians should pay more attention to the assessment of patient function.

Activities of Daily Living↗
PubMed1991

Effects of cost sharing in health insurance on disability days.

We assess how cost sharing for medical services affects restricted activity days (RADs) and work loss disability days (WLDs), using data from a controlled experiment. We grouped the experimental insurance plans into four categories, one providing free care and the other three requiring varying amounts of cost sharing. RADs per person per year decreased by one to two days with greater cost sharing, with the strongest effects among those of average or poor health status, especially the non-poor. Unlike RADs, WLDs showed no systematic differences by plan.

Absenteeism↗
PubMed1991

A community-based study of the use of chiropractic services.

BACKGROUND: Little population-based information is available on the use of chiropractic services. METHODS: We analyzed data from the RAND Health Insurance Experiment (HIE), a community-based study of the use of health services. Insurance claim forms for all fee-for-service patients who completed the study were examined for all visits coded as being seen by a chiropractor. Services provided and patient-specified symptoms were taken from these forms. Population-based use rates were calculated for each HIE site. Use rates and services were calculated separately for first visits and repeat visits. RESULTS: There were 5,279 persons who contributed 19,021 person-years of exposure during the study; 395 different persons used 7,873 chiropractic services for a visit rate of 41 per 100 person-years and rate of use of 7.5 percent. Forty-two percent of all visits were for pain in the back. Spinal manipulation accounted for 61 percent of all services provided. Compared to non-users, users tended to be White, middle-aged, married, and high school educated. Seven-fold geographic variations in the use of chiropractic services were seen. CONCLUSIONS: Chiropractors deliver a substantial amount of health care to the US population, and there are significant geographic variations in the rate and intensity of use of chiropractic services.

Adolescent↗
PubMed1991

Appropriate and necessary.

In summary, we seem to be on our way to increasing our knowledge about what works and what does not. This information is desperately needed to help develop standards by which quality and appropriateness will be measured. However, enough information is currently available to allow hospitals and their medical staffs to develop standards, guidelines and parameters today in an effort to improve performance. The information produced from the application of the guidelines to actual practice can in turn be used to guide new effectiveness research into what works or does not. For instance, procedures that are frequently performed for equivocal reasons could become the focus of the effectiveness-research agenda. Meanwhile, methods research in both the effectiveness and appropriateness areas will continue so that more valid techniques in both of these areas can be developed. If cooperation between the people who generate new knowledge, the people who develop standards and the people who use the standards to improve institutional performance can be achieved, then we can improve the health of the American people at a price we will be willing to pay.

Academies and Institutes↗
PubMed1990

Carotid endarterectomy for elderly patients: predicting complications.

OBJECTIVE: To determine whether the complication or death rate from carotid endarterectomy can be predicted from hospital and physician structural variables, such as the hospital's teaching status or the number of endarterectomies done by the surgeon per year. DESIGN: Survey of medical records. After controlling for the severity of the patient's condition on the basis of data in the medical record at the time of the endarterectomy, regression analyses were used to predict the postoperative stroke, heart attack, and 30-day death rate as a function of patient, physician, and hospital characteristics. SETTING: Three geographic areas (states or large parts of states; average population, 3 million) in the United States. PATIENTS: Random sample of 1302 patients 65 years of age or older having carotid endarterectomy in 1981. INTERVENTION: Carotid endarterectomy. MEASUREMENTS AND MAIN RESULTS: Of 1302 patients, 11.3% had a postoperative stroke or heart attack or died within 30 days of the operation. Patient age, race, income, and gender; physician volume, board certification status, and age; and hospital size, for-profit status, ownership, and teaching status were not significantly related to the postoperative complication or death rate. If the surgeon was a graduate of a foreign, but not a Western European or Canadian, medical school, however, the average complication or death rate rose from 10.4% to 19.6% (P less than 0.05). CONCLUSIONS: The effectiveness of carotid endarterectomy depends heavily on its complication rate. Because complications after surgery cannot, in general, be predicted from structural variables, referring physicians cannot rely solely on the surgeon's experience and qualifications when recommending a carotid endarterectomy. The surgeon's and the hospital's actual postoperative complication and death rate should be considered.

Age Factors↗
PubMed1990

Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography.

BACKGROUND AND METHODS: In a nationally representative population 65 years of age or older, we have demonstrated that about one quarter of coronary angiographies and upper gastrointestinal endoscopies and two thirds of carotid endarterectomies were performed for reasons that were less than medically appropriate. In this paper we examine whether specific characteristics of patients (age, sex, and race), physicians (age, board-certification status, and experience with the procedure), or hospitals (teaching status, profit-making status, and size) predict whether a procedure will be performed appropriately. RESULTS: In general, we found that little of the variability in the appropriateness of care (4 percent or less) could be explained on the basis of standard, easily obtainable data about the patient, the physician, or the hospital. For all three procedures, however, performance in a teaching hospital increased the likelihood that the reasons would be medically appropriate (P = 0.09 for angiography, P = 0.30 for endoscopy, and P less than 0.01 for endarterectomy). In addition, angiographies were more often performed for appropriate reasons in older or more affluent patients (P less than 0.01 for both). Being treated by a surgeon who performed a high rather than a low number of procedures decreased the likelihood of an appropriate endarterectomy by one third, from 40 to 28 percent (P less than 0.01). CONCLUSIONS: Appropriateness of care cannot be closely predicted from many easily determined characteristics of patients, physicians, or hospitals. Thus, for the present, if appropriateness is to be improved it will have to be assessed directly at the level of each patient, hospital, and physician.

Aged↗
PubMed1990

The effects of the DRG-based prospective payment system on quality of care for hospitalized Medicare patients. An introduction to the series.

In 1985, we began a 4-year evaluation of the effects of the diagnosis related groups-based prospective payment system on quality of care for hospitalized Medicare patients. This article provides an overview of the study's background, aims, design, and methods. We used a clinically detailed review of the medical record supplemented by data on postdischarge outcomes drawn from the files of the Health Care Financing Administration and fiscal intermediaries to (1) compare outcomes of care after adjustment for sickness at admission, (2) assess the process of in-hospital care and relationships between processes and outcomes, and (3) assess status at discharge for a nationally representative sample of patients hospitalized before and after prospective payment was implemented.

Diagnosis-Related Groups↗
PubMed1990

Changes in sickness at admission following the introduction of the prospective payment system.

We developed disease-specific measures of sickness at admission based on medical record data to study mortality of Medicare patients with one of five conditions (congestive heart failure, acute myocardial infarction, cerebrovascular accident, pneumonia, and hip fracture). We collected an average of 73 sickness variables per disease, but our final sickness-at-admission scales use, on average, 19 variables. These scales are publicly available, and explain 25% of the variance in 30-day postadmission mortality for patients with acute myocardial infarction, pneumonia, or cerebrovascular accident. Sickness at admission increased following the introduction of the prospective payment system (PPS). For our five diseases combined, the 30-day mortality to be expected because of sickness at admission was 1.0% higher in the 1985-1986 period than in the 1981-1982 period (16.4% vs 15.4%), and the expected 180-day mortality was 1.6% higher (30.1% vs 28.5%). Studies of the effects of PPS on mortality must take this increase in sickness at admission into account.

Aged↗
PubMed1990

Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system.

We developed explicit process criteria and scales for Medicare patients hospitalized with congestive heart failure, myocardial infarction, pneumonia, cerebrovascular accident, and hip fracture. We applied the process scales to a nationally representative sample of 14,012 patients hospitalized before and after the implementation of the diagnosis related group-based prospective payment system. For the four medical diseases, a better process of care resulted in lower mortality rates 30 days after admission. Patients in the upper quartile of process scores had a 30-day mortality rate 5% lower than that of patients in the lower quartile. The process of care improved after the introduction of the prospective payment system; eg, better nursing care after the introduction of the prospective payment system was associated with an expected decrease in 30-day mortality rates in pneumonia patients of 0.8 percentage points, and better physician cognitive performance was associated with an expected decrease in 30-day mortality rates of 0.4 percentage points. Overall, process improvements across all four medical conditions were associated with a 1 percentage point reduction in 30-day mortality rates after the introduction of the prospective payment system.

Aged↗
PubMed1990

Comparing outcomes of care before and after implementation of the DRG-based prospective payment system.

We compared patient outcomes before and after the introduction of the diagnosis related groups (DRG)-based prospective payment system (PPS) in a nationally representative sample of 14,012 Medicare patients hospitalized in 1981 through 1982 and 1985 through 1986 with one of five diseases. For the five diseases combined; length of stay dropped 24% and in-hospital mortality declined from 16.1% to 12.6% after the PPS was introduced (P less than .05). Thirty-day mortality adjusted for sickness at admission was 1.1% lower than before (16.5% pre-PPS, 15.4% post-PPS; P less than .05), and 180-day adjusted mortality was essentially unchanged at 29.6% pre-vs 29.0% post-PPS (P less than .05). For patients admitted to the hospital from home, 4% more patients were not discharged home post-PPS than pre-PPS (P less than .05), and an additional 1% of patients had prolonged nursing home stays (P less than .05). The introduction of the PPS was not associated with a worsening of outcome for hospitalized Medicare patients. However, because our post-PPS data are from 1985 and 1986, we recommend that clinical monitoring be maintained to ensure that changes in prospective payment do not negatively affect patient outcome.

Diagnosis-Related Groups↗
PubMed1990

Quality of care before and after implementation of the DRG-based prospective payment system. A summary of effects.

In this series we have described changes in the quality of care that have occurred in the treatment of hospitalized elderly Medicare patients with one of five conditions between 1981-1982 and 1985-1986. In this article we report on a mortality analysis, patient and hospital subgroup comparisons, and time series studies we have conducted in an attempt to determine whether changes in quality of care can be linked causally to the introduction of the prospective payment system. Based on these analyses we conclude that (1) mortality following hospitalization has been unaffected by the introduction of the prospective payment system, and improvements in in-hospital processes of care that began prior to the prospective payment system have continued after its introduction, but (2) the prospective payment system has increased the likelihood that a patient will be discharged home in an unstable condition. We recommend that efforts to correct this problem be intensified and that clinical monitoring of the impact of the prospective payment system continue as hospital cost-containment pressures intensify.

Continuity of Patient Care↗