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Biomedical subjects

R H Brook

Publications and source records attributed to R H Brook.

At least 163 records · Page 9Linked to original sources
PubMed1988

The early effect of Medicare's prospective payment system on the use of medical intensive care services in three community hospitals.

To assess the impact of Medicare's prospective payment system (PPS) on patient care and outcome from the medical intensive care unit (MICU), we reviewed the medical records of 400 MICU patients from three community hospitals: 200 patients were admitted before the PPS and 200 were admitted after the PPS. We sampled Medicare patients, aged 65 years and over, and non-Medicare comparison patients, aged 50 to 64 years, collecting data on case mix, treatment intensity and discharge disposition, hospital and six-month mortality, length of stay, and number of intensive care unit beds. After the PPS, the number of intensive care unit beds decreased 31%, without changes in MICU patients' illness severity or treatment intensity. Hospital length of stay decreased 15% in the Medicare group and 43% in the comparison group. For both Medicare and comparison patients combined, MICU length of stay decreased 14% and patients after the PPS were less likely to be discharged to go home. There were no significant changes in in-hospital or six-month mortality. Thus, clinically meaningful decreases in length of stay among seriously ill patients did not result in a change in in-hospital or six-month mortality.

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PubMed1988

The use and misuse of upper gastrointestinal endoscopy.

STUDY OBJECTIVE: To determine how appropriately physicians in 1981 did upper gastrointestinal endoscopy in a randomly selected, community-based sample of Medicare patients. DESIGN: We developed a comprehensive and clinically detailed list of 1069 indications for upper gastrointestinal endoscopy. A national panel of nine clinicians rated the appropriateness of the indications. We categorized the indications as appropriate, inappropriate, or equivocal. We did a clinically detailed medical record review of a random sample of 1585 patients having upper gastrointestinal endoscopy to assess the appropriateness of using upper gastrointestinal endoscopy. SETTING: Patients were sampled from large geographic areas in three states. Two areas represented high use, and one area, low use. PATIENTS: Random sample of patients 65 years of age or older receiving diagnostic upper gastrointestinal endoscopy. INTERVENTIONS: None; the study was retrospective. MEASUREMENT AND RESULTS: Patient characteristics, histories, and clinical indications for upper gastrointestinal endoscopy were similar across low- and high-use areas. Overall, 72% of the endoscopies were done for appropriate indications, 11% for equivocal indications, and 17% for inappropriate indications. Upper gastrointestinal bleeding (26%), follow-up to an abnormal upper gastrointestinal series (21%), dysphagia (18%), and dyspepsia (15%) were the most frequent clinical reasons for doing endoscopy. Inpatient endoscopies were more often appropriate and less often inappropriate than outpatient endoscopies. CONCLUSIONS: This analysis of practice patterns among study sites provides the clinical basis for understanding the use of upper gastrointestinal endoscopy. The finding of 17% inappropriate use may be cause for concern.

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PubMed1988

Preventable deaths: who, how often, and why?

If the quality of care provided by a hospital affects its death rate, then some deaths must be preventable. We have developed a new method to investigate this issue and have reviewed 182 deaths from 12 hospitals (6 high outliers and 6 low outliers for death rate) for three conditions (cerebrovascular accident, pneumonia, or myocardial infarction). The investigators prepared a dictated summary of each patient's hospital course. Then, at least three physicians reviewed each summary and independently judged whether the death could have been prevented. Using a majority rules criterion (at least two of three physicians agreed), we found that 27% of the deaths might have been prevented. Using a unanimity criterion (all three physicians independently agreed), we found a 14% rate of probably preventable deaths. Patients whose deaths were probably preventable were younger (74.7 compared with 78.6 years, P less than 0.05), less often demented (12% compared with 26%, P less than 0.05), and less severely ill (mean Acute Physiology and Chronic Health Evaluation score, 15.6 compared with 21.2; P less than 0.001) than patients whose deaths were nonpreventable. The physicians also listed causes for each probably preventable death; nine reasons encompassed almost all of them. For myocardial infarction, preventable deaths reflected errors in management. For cerebrovascular accident, however, deaths primarily reflected errors in diagnosis. The severity of illness can help a hospital retrospectively identify probably preventable deaths. In the group of patients who died, 42% of those with a low severity of illness had probably preventable deaths as compared to 11% admitted with a high severity of illness. We found that a significant number of hospital deaths might have been prevented. Our findings were based on a new method that needs further testing to substantiate its validity. These findings also need replication before they can be generalized to other hospitals.

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PubMed1988

Diagnosis and treatment of coronary disease: comparison of doctors' attitudes in the USA and the UK.

Two panels of doctors, one in the USA and one in the UK, were asked to indicate how appropriate they judged a series of possible indications for coronary angiography and coronary artery bypass graft (CABG) operations. "Appropriateness" was defined with respect to possible benefit to the patient and excluded considerations of cost. The indications were presented as a series of detailed clinical situations in which the procedure might be used, and for each indication individual panel members rated appropriateness on a scale of 1 to 9. The US panel judged more indications appropriate than did the UK panel, and there was more agreement among the members of the US panel than among those of the UK panel. Although the two panels tended to rate the appropriateness of the indications in the same order, the UK panel placed more emphasis than did the US panel on the importance of symptoms and the amount of medical treatment. Application of the panels' ratings to two groups of patients who had had coronary angiography showed that 17% and 27% of the investigations had been inappropriate by the standards of the US panel, whereas 42% and 60% were inappropriate by the UK panel ratings. 13% of the CABG operations studied were inappropriate by the US and 35% by the UK panel ratings.

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PubMed1988

The appropriateness of carotid endarterectomy.

Carotid endarterectomy is a commonly performed but controversial procedure. We developed from the literature a list of 864 possible reasons for performing carotid endarterectomy, and asked a panel of nationally known experts to rate the appropriateness of each indication using a modified Delphi technique. On the basis of the panel's ratings, we determined the appropriateness of carotid endarterectomy in a random sample of 1302 Medicare patients in three geographic areas who had had the procedure in 1981. Thirty-five percent of the patients in our sample had carotid endarterectomy for appropriate reasons, 32 percent for equivocal reasons, and 32 percent for inappropriate reasons. Of the patients having inappropriate surgery, 48 percent had less than 50 percent stenosis of the carotid artery that was operated on. Fifty-four percent of all the procedures were performed in patients without transient ischemic attacks in the carotid distribution. Of these procedures, 18 percent were judged appropriate, as compared with 55 percent judged appropriate in patients with transient ischemic attacks in the carotid distribution. After carotid endarterectomy, 9.8 percent of patients had a major complication (stroke with residual deficit at the time of hospital discharge or death within 30 days of surgery). We conclude that carotid endarterectomy was substantially overused in the three geographic areas we studied. Furthermore, in situations in which the complication rate is equal to or above the study's aggregate rate, carotid endarterectomy would not be warranted, even in cases with an appropriate indication, because the risks would almost certainly outweigh the benefits.

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PubMed1988

Use of the hospital in a randomized trial of prepaid care.

Health maintenance organizations (HMOs) achieve their cost savings through lower rates of hospital admissions. To determine whether HMOs selectively avoid discretionary hospitalizations, medical records were reviewed from a randomized trial where families were assigned to either HMO or free-for-service care. Physicians who were blinded to system reviewed 244 medical records and judged the appropriateness both of the hospital setting and of the medical indications for hospitalization. The rate of discretionary surgery was lower in the HMO, while the rate of nondiscretionary surgery was equivalent in the two systems. For medical admissions, rates of discretionary and nondiscretionary admissions were lower in the HMO. There were no observable adverse effects on health from the lower rates of nondiscretionary hospitalization, either because the net effect on health was small or because the HMO substituted appropriate ambulatory services. We conclude that HMO reductions in hospitalization rates do not occur "across the board"; discretionary surgery is selectively avoided.

Adult↗
PubMed1988

The effect of comorbidity on appropriateness ratings for two gastrointestinal procedures.

We evaluated the effect of patients' comorbidity on the appropriateness of performing esophagogastroduodenoscopy or cholecystectomy. A nine-member national physician panel rated 1118 brief clinical scenarios for patients without comorbidity. Ratings were then repeated for patients with increasing degrees of comorbidity. As comorbidity changed from none to medium, 60% of those scenarios that were originally rated as appropriate for endoscopy and cholecystectomy remained appropriate. As high comorbidity was introduced, only 13% of such scenarios remained appropriate for endoscopy, while 33% remained appropriate for cholecystectomy. These findings suggest that, although clinical reasons for performing procedures are a powerful determinant of when they should be used, comorbidity is also important and needs to be included in any assessment of the appropriateness of procedure use.

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PubMed1988

The quality of care received by older patients in 15 university-based ambulatory practices.

To evaluate how the medical problems of older patients are managed in university-based internal medicine practices, the authors reviewed the medical records of 1,527 outpatients treated at 15 university teaching hospitals. Specific treatments for hypertension or diabetes had similar frequencies in patients 65 years of age and over and in patients under age 65. However, although the medical records mentioned hypertension in 43 percent and diabetes in 12 percent of the patients 65 or over, dementia and incontinence were recorded in only 0.4 percent and 2 percent, respectively. This finding suggests either that these elderly patients were extremely atypical or that their geriatric problems were unrecognized.

Age Factors↗
PubMed1988

Measuring the clinical appropriateness of the use of a procedure. Can we do it?

Increasing attention is being paid to data on geographic differences in population-based rates of use of medical and surgical procedures. To understand these differences and to determine what level of use is appropriate, a method is needed to judge the clinical appropriateness of services. We recently developed and tested such a method in two large, urban geographic areas. Eighty-one medical records from a randomly selected sample of 30 billing entities (46 physicians) who performed upper gastrointestinal endoscopy (UGIE) on Medicare patients were abstracted. Ninety-four percent of physicians who were asked agreed to participate. Reliability testing showed 99% agreement on items abstracted from a subset of records independently reviewed by two abstractors. Based on the abstractions, each patient could be assigned at least one (mean 2.2) specific clinical indication for which UGIE was performed. Using ratings derived from a previously held panel meeting, it was possible to evaluate the appropriateness of the indications for each UGIE.

Data Collection↗
PubMed1988

Assessing clinical decision making: is the ideal system feasible?

While caring for patients, physicians make a variety of decisions. Can current methods adequately determine whether these decisions are correct? If not, what improvements are needed? This paper begins with a review of several explicit methods to assess physician decision making. It then describes a more comprehensive system that would use Bayesian logic to assess whether a physician responded appropriately to the needs of an individual patient. Although sophisticated branching logic may be theoretically desirable, it may not be feasible. The paper concludes by proposing an explicit, potentially practical method that would judiciously use branching logic.

Bayes Theorem↗
PubMed1987

Hospital inpatient mortality. Is it a predictor of quality?

Various potential measures of quality of care are being used to differentiate hospitals. Last year, on the basis of diagnostic and demographic data, the Health Care Financing Administration identified hospitals in which the actual death rate differed from the predicted rate. We have developed a similar model. To understand why there are high-outlier hospitals (in which the actual death rate is above the predicted one) and low-outlier hospitals (in which the actual death rate is below the predicted one), we reviewed 378 medical records from 12 outlier hospitals treating patients with one of three conditions: cerebrovascular accident, myocardial infarction, and pneumonia. After adjustment for the severity of illness, the death rate in the high outliers exceeded that predicted from the severity of illness alone by 3 to 10 percent, and in the low outliers, the actual death rate fell short of the severity-adjusted predictions by 10 to 15 percent (P less than 0.01). Reviews of the process of care using 125 criteria revealed no differences between the high and low outliers. However, detailed reviews by physicians of the records of patients who died during hospitalization revealed a higher rate of preventable deaths in the high outliers than in the low outliers. For the three conditions studied, we project that 5.7 percent of a standard cohort of patients admitted to the high-outlier hospitals would have preventable deaths, as compared with 3.2 percent of patients admitted to the low-outlier hospitals (P less than 0.05). A meaningful comparison of hospital death rates requires adjustment for severity of illness. Our findings indicate that high-outlier hospitals care for sicker patients. However, these same hospitals or their medical staffs may also provide poorer care. Our results need confirmation before death-rate models can be used to screen hospitals.

Hospitals↗
PubMed1987

Effects of the National Institutes of Health Consensus Development Program on physician practice.

The effects of the National Institutes of Health Consensus Development Program on physician behavior were investigated. The medical records of 2770 patients treated in ten hospitals throughout the state of Washington were reviewed to determine if quality of care improved with respect to 12 recommendations put forth by four consensus panels concerning surgical management of primary breast cancer, the use of steroid receptors in breast cancer, cesarean childbirth, and coronary artery bypass surgery. Care was studied during 24 months before and 13 to 24 months after each consensus conference. Results showed that the conferences mostly failed to stimulate change in physician practice, despite moderate success in reaching the appropriate target audience. It was concluded that the consensus development conference is an important educational tool whose effects might be enhanced by focusing on areas of practice that need improvement and by encouraging follow-up programs at the state and local level.

Breast Neoplasms↗
PubMed1987

Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures.

We studied the appropriateness of use of coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy and its relationship to geographic variations in the rates of use of these procedures. We selected geographic areas of high, average, and low use of these procedures and randomly sampled Medicare beneficiaries who had received one of the procedures in 1981. We determined the indications for the procedures using a detailed review of medical records and used previously developed ratings of appropriateness to assign an appropriateness score to each case. Differences among sites in levels of appropriateness were small. For example, in the high-use site for coronary angiography, 72% of the procedures were appropriate, compared with 81% in the low-use site. Coronary angiography was performed 2.3 times as frequently in the high-use site compared with the low-use site. Under the conditions of this study, we did find significantly levels of inappropriate use: 17% of cases for coronary angiography, 32% for carotid endarterectomy, and 17% for upper gastrointestinal tract endoscopy. We conclude that differences in appropriateness cannot explain geographic variations in the use of these procedures.

Carotid Arteries↗
PubMed1987

Obtaining clinical data on the appropriateness of medical care in community practice.

We sought the voluntary cooperation of a randomly selected sample of community physicians and hospitals in five states for a study of how appropriately they performed coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy. Ninety percent of 913 sampled physicians (n = 819) consented to a review of up to 20 of their 1981 Medicare patients' records. These physicians represented seven different specialties and subspecialties and performed 4988 procedures, 92% of the desired sample. Only three of 230 hospitals did not participate. We attribute our method's success primarily to the formation of a network to connect the branches of the profession, respect for office and hospital practice routine, confidentiality, and the development of carefully designed medical record abstraction systems. We conclude that, with effort, cooperative research among disparate segments of the medical community can become a reality even if the topic studied is relatively sensitive.

Community Health Services↗
PubMed1987

How coronary angiography is used. Clinical determinants of appropriateness.

Using ratings of appropriateness derived from an expert physician panel, we measured how appropriately physicians in 1981 performed coronary angiography in a randomly selected, community-based sample of cases in the Medicare population. We studied large geographic areas (three sites) in three states, representing regions of high and low use. The high-use site had fewer procedures classified as appropriate (72%) than either low-use site (77% and 81%, respectively). Over all sites, 17% of procedures were classified as inappropriate. Patients in the high-use site were older, had less severe angina, and were less intensively medically treated than patients in either of the low-use sites. Patients without angina who had not undergone exercise testing constituted the most common subgroup of inappropriate cases. Although overall differences in appropriateness were not large, practice differences do exist. This analysis of practice differences among study sites provides the clinical basis for understanding the small, but significant, differences in the appropriateness of use of coronary angiography. The finding of 17% inappropriate use may be cause for concern.

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