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Biomedical subjects

T A Brennan

Publications and source records attributed to T A Brennan.

At least 19 recordsLinked to original sources
PubMed2006

Relationship between complaints and quality of care in New Zealand: a descriptive analysis of complainants and non-complainants following adverse events.

OBJECTIVES: To estimate the proportion and characteristics of patients injured by medical care in New Zealand public hospitals who complain to an independent health ombudsman, the Health and Disability Commissioner ("the Commissioner"). DESIGN: The percentage of injured patients who lodge complaints was estimated by linking the Commissioner's complaints database to records reviewed in the New Zealand Quality of Healthcare Study (NZQHS). Bivariate and multivariate analyses investigated sociodemographic and socioeconomic differences between complainants and non-complainants. SETTING: New Zealand public hospitals and the Office of the Commissioner in 1998. POPULATION: Patients who lodged claims with the Commissioner (n = 398) and patients identified by the NZQHS as having suffered an adverse event who did not lodge a complaint with the Commissioner (n = 847). MAIN OUTCOME MEASURES: Adverse events, preventable adverse events, and complaints lodged with the Commissioner. RESULTS: Among adverse events identified by the NZQHS, 0.4% (3/850) resulted in complaints; among serious, preventable adverse events 4% (2/48) resulted in complaints. The propensity of injured patients to complain increased steeply with the severity of the injury: odds of complaint were 11 times greater after serious permanent injuries than after temporary injuries, and 18 times greater after deaths. Odds of complaining were significantly lower for patients who were elderly (odds ratio (OR) 0.2, 95% confidence interval (CI) 0.1 to 0.4), of Pacific ethnicity (OR 0.3, 95% CI 0.1 to 0.9), or lived in the most deprived areas (OR 0.3, 95% CI 0.2 to 0.6). CONCLUSION: Most medical injuries never trigger a complaint to the Commissioner. Among complaints that are brought, severe and preventable injuries are common, offering a potentially valuable "window" on serious threats to patient safety. The relatively low propensity to complain among patients who are elderly, socioeconomically deprived, or of Pacific ethnicity suggests troubling disparities in access to and utilisation of complaints processes.

Adolescent↗
PubMed2004

Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991.

BACKGROUND: As part of an interdisciplinary study of medical injury and malpractice litigation, we estimated the incidence of adverse events, defined as injuries caused by medical management, and of the subgroup of such injuries that resulted from negligent or substandard care. METHODS: We reviewed 30121 randomly selected records from 51 randomly selected acute care, non-psychiatric hospitals in New York State in 1984. We then developed population estimates of injuries and computed rates according to the age and sex of the patients as well as the specialties of the physicians. RESULTS: Adverse events occurred in 3.7% of the hospitalizations (95% confidence interval 3.2 to 4.2), and 27.6% of the adverse events were due to negligence (95% confidence interval 22.5 to 32.6). Although 70.5% of the adverse events gave rise to disability lasting less than 6 months, 2.6% caused permanently disabling injuries and 13.6% led to death. The percentage of adverse events attributable to negligence increased in the categories of more severe injuries (Wald test chi(2) = 21.04, p<0.0001). Using weighted totals we estimated that among the 2671863 patients discharged from New York hospitals in 1984 there were 98609 adverse events and 27179 adverse events involving negligence. Rates of adverse events rose with age (p<0.0001). The percentage of adverse events due to negligence was markedly higher among the elderly (p<0.01). There were significant differences in rates of adverse events among categories of clinical specialties (p<0.0001), but no differences in the percentage due to negligence. CONCLUSIONS: There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.

Adolescent↗
PubMed2001

No-fault compensation for medical injuries: the prospect for error prevention.

Leading patient safety proposals promote the design and implementation of error prevention strategies that target systems used to deliver care and eschew individual blame. They also call for candor among practitioners about the causes and consequences of medical injury. Both goals collide with fundamental tenets of the medical malpractice system. Thus, the challenge of addressing error in medicine demands a thorough reconsideration of the legal mechanisms currently used to deal with harms in health care. In this article, we describe an alternative to litigation that does not predicate compensation on proof of practitioner fault, suggest how it might be operationalized, and argue that there is a pressing need to test its promise. We tackle traditional criticisms of "no-fault" compensation systems for medical injury-specifically, concerns about their cost and the presumption that eliminating liability will dilute incentives to deliver high-quality care. Our recent empirical work suggests that a model designed around avoidable or preventable injuries, as opposed to negligent ones, would not exceed the costs of current malpractice systems in the United States. Implementation of such a model promises to promote quality by harmonizing injury compensation with patient safety objectives, especially if it is linked to reforms that make institutions, rather than individuals, primarily answerable for injuries.

Actuarial Analysis↗
PubMed2001

Influence of financial productivity incentives on the use of preventive care.

PURPOSE: We examined whether physician factors, particularly financial productivity incentives, affect the provision of preventive care. SUBJECTS AND METHODS: We surveyed and reviewed the charts of 4,473 patients who saw 1 of 169 internists from 11 academically affiliated primary care practices in Boston. We abstracted cancer risk factors, comorbid conditions, and the dates of the last Papanicolaou (Pap) smear, mammogram, cholesterol screening, and influenza vaccination. We obtained physician information including the method of financial compensation through a mailed physician survey. We used multivariable logistic regression to examine the association between physician factors and four outcomes based on Health Plan Employer Data and Information Set (HEDIS) measures: (1) Pap smear within the prior 3 years among women 20 to 75 years old; (2) mammogram in the prior 2 years among women 52 to 69 years old; (3) cholesterol screening within the prior 5 years among patients 40 to 64 years old; and (4) influenza vaccination among patients 65 years old and older. All analyses accounted for clus-tering by provider and site and were converted into adjusted rates. RESULTS: After adjustment for practice site, clinical, and physician factors, patients cared for by physicians with financial productivity incentives were significantly less likely than those cared for by physicians without this incentive to receive Pap smears (rate difference, 12%; 95% confidence interval [CI]: 5% to 18%) and cholesterol screening (rate difference, 4%; 95% CI: 0% to 8%). Financial incentives were not significantly associated with rates of mammography (rate difference, -3%; 95% CI: -15% to 10%) or influenza vaccination (rate difference, -13%; 95% CI: -28% to 2%). CONCLUSIONS: Our findings suggest that some financial productivity incentives may discourage the performance of certain forms of preventive care, specifically Pap smears and cholesterol screening. More studies are needed to examine the effects of financial incentives on the quality of care, and to examine whether quality improvement interventions or incentives based on quality improve the performance of preventive care.

Adult↗
PubMed2001

Primary care compensation at an academic medical center: a model for the mixed-payer environment.

The authors' academic medical center, Brigham and Women's Hospital, Boston, Massachusetts, developed a primary care physician (PCP) salary incentive program for employed academic physicians. This program, first implemented in 1999, was needed to meet the financial imperatives placed on the institution by managed care and the Balanced Budget Act of 1997; its goal was to create a set of incentives for PCPs that is consistent with the mission of the academic center and helps motivate and reward PCP's work. The program sought to simultaneously increase productivity while optimizing resource utilization in a mixed-payer environment. The salary incentive program uses work relative-value units (wRVUs) as the measure of productivity. In addition to productivity-derived base pay, bonus incentives are added for efficient medical management, quality of care, teaching, and seniority. The authors report that there was significant concern from several members of the physician staff before the plan was implemented; they felt that the institution's PCPs were already operating at maximum clinical capacity. However, after the first year of operation of this plan, there was an overall 20% increase in PCP productivity. Increases were observed in all PCP subgroups when stratified by professional experience, clinical time commitment, and practice location. The authors conclude that the program has succeeded in giving incentives for academic PCPs to achieve under the growing demands for revenue self-sufficiency, managed care performance, quality of care, and academic commitment.

Academic Medical Centers↗
PubMed2001

Intention to discontinue care among primary care patients: influence of physician behavior and process of care.

BACKGROUND: Specific elements of health care process and physician behavior have been shown to influence disenrollment decisions in HMOs, but not in outpatient settings caring for patients with diverse types of insurance coverage. OBJECTIVE: To examine whether physician behavior and process of care affect patients' intention to return to their usual health care practice. DESIGN: Cross-sectional patient survey and medical record review. SETTING: Eleven academically affiliated primary care medicine practices in the Boston area. PATIENTS: 2,782 patients with at least one visit in the preceding year. MEASUREMENT: Unwillingness to return to the usual health care practice. RESULTS: Of the 2,782 patients interviewed, 160 (5.8%) indicated they would not be willing to return. Two variables correlated significantly with unwillingness to return after adjustment for demographics, health status, health care utilization, satisfaction with physician's technical skill, site of care, and clustering of patients by provider: dissatisfaction with visit duration (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4 to 7.4) and patient reports that the physician did not listen to what the patient had to say (OR, 8.8; 95% CI, 2.5 to 30.7). In subgroup analysis, patients who were prescribed medications at their last visit but who did not receive an explanation of the purpose of the medication were more likely to be unwilling to return (OR, 4.9; 95% CI, 1.8 to 13.3). CONCLUSION: Failure of physicians to acknowledge patient concerns, provide explanations of care, and spend sufficient time with patients may contribute to patients' decisions to discontinue care at their usual site of care.

Boston↗
PubMed2001

Health care utilization among homeless adults prior to death.

This study characterizes health care utilization prior to death in a group of 558 homeless adults in Boston. In the year before death, 27 percent of decedents had no outpatient visits, emergency department visits, or hospitalizations except those during which death occurred. However, 21 percent of homeless decedents had a health care contact within one month of death, and 21 percent had six or more outpatient visits in the year before death. Injection drug users and persons with HIV infection were more likely to have had contact with the health care system. This study concludes that homeless persons may be underusing health care services even when they are at high risk of death. Because a subset of homeless persons had extensive health care contacts prior to death, opportunities to prevent deaths may have been missed, and some deaths may not have been preventable through medical intervention.

Adult↗
PubMed2000

Incidence and types of preventable adverse events in elderly patients: population based review of medical records.

OBJECTIVE: To determine the incidence and types of preventable adverse events in elderly patients. DESIGN: Review of random sample of medical records in two stage process by nurses and physicians to detect adverse events. Two study investigators then judged preventability. SETTING: Hospitals in US states of Utah and Colorado, excluding psychiatric and Veterans Administration hospitals. SUBJECTS: 15 000 hospitalised patients discharged in 1992. MAIN OUTCOME MEASURES: Incidence of preventable adverse events (number of preventable events per 100 discharges) in elderly patients (>/=65 years old) and non-elderly patients (16-64 years). RESULTS: When results were extrapolated to represent all discharges in 1992 in both states, non-elderly patients had 8901 adverse events (incidence 2.80% (SE 0.18%)) compared with 7419 (5.29% (0.37%)) among elderly patients (P=0.001). Non-elderly patients had 5038 preventable adverse events (incidence 1.58% (0.14%)) compared with 4134 (2.95% (0.28%)) in elderly patients (P=0.001). Elderly patients had a higher incidence of preventable events related to medical procedures (such as thoracentesis, cardiac catheterisation) (0.69% (0.14%) v 0.13% (0.04%)), preventable adverse drug events (0.63% (0.14%) v 0.17% (0.05%)), and preventable falls (0.10% (0.06%) v 0.01% (0.02%)). In multivariate analyses, adjusted for comorbid illnesses and case mix, age was not an independent predictor of preventable adverse events. CONCLUSIONS: Preventable adverse events were more common among elderly patients, probably because of the clinical complexity of their care rather than age based discrimination. Preventable adverse drug events, events related to medical procedures, and falls were especially common in elderly patients and should be targets for efforts to prevent errors.

Accidental Falls↗
PubMed2000

Global capitation at a women's health referral center: the challenge of patient selection.

Global risk capitation as a preferred payment method in heavily penetrated managed care markets poses important challenges for women's health care tertiary referral centers that employ participating primary care physicians. Global risk capitation agreements expose those centers to the adverse financial effects of high frequency of obstetric visits, costly infertility and neonatal care, and care of a disproportionate number of patients with complex, resource-intensive conditions.

Capitation Fee↗
PubMed2000

Is the professional satisfaction of general internists associated with patient satisfaction?

BACKGROUND: The growth of managed care has raised a number of concerns about patient and physician satisfaction. An association between physicians' professional satisfaction and the satisfaction of their patients could suggest new types of organizational interventions to improve the satisfaction of both. OBJECTIVE: To examine the relation between the satisfaction of general internists and their patients. DESIGN: Cross-sectional surveys of patients and physicians. SETTING: Eleven academically affiliated general internal medicine practices in the greater-Boston area. PARTICIPANTS: A random sample of English-speaking and Spanish-speaking patients (n = 2,620) with at least one visit to their physician (n = 166) during the preceding year. MEASUREMENTS: Patients' overall satisfaction with their health care, and their satisfaction with their most recent physician visit. MAIN RESULTS: After adjustment, the patients of physicians who rated themselves to be very or extremely satisfied with their work had higher scores for overall satisfaction with their health care (regression coefficient 2.10; 95% confidence interval 0.73-3.48), and for satisfaction with their most recent physician visit (regression coefficient 1.23; 95% confidence interval 0.26-2.21). In addition, younger patients, those with better overall health status, and those cared for by a physician who worked part-time were significantly more likely to report better satisfaction with both measures. Minority patients and those with managed care insurance also reported lower overall satisfaction. CONCLUSIONS: The patients of physicians who have higher professional satisfaction may themselves be more satisfied with their care. Further research will need to consider factors that may mediate the relation between patient and physician satisfaction.

Adult↗
PubMed2000

Drug complications in outpatients.

OBJECTIVE: Outpatient drug complications have not been well studied. We sought to assess the incidence and characteristics of outpatient drug complications, identify their clinical and nonclinical correlates, and evaluate their impact on patient satisfaction. DESIGN: Retrospective chart reviews and patient surveys. SETTING: Eleven Boston-area ambulatory clinics. PATIENTS: We randomly selected 2,248 outpatients, 20 to 75 years old. MEASUREMENTS AND MAIN RESULTS: Among 2,248 patients reporting prescription drug use, 394 (18%) reported a drug complication. In contrast, chart review revealed an adverse drug event in only 64 patients (3%). In univariate analyses, significant correlates of patient-reported drug complications were number of medical problems, number of medications, renal disease, failure to explain side effects before treatment, lower medication compliance, and primary language other than English or Spanish. In multivariate analysis, independent correlates were number of medical problems (odds ratio [OR] 1.17; 95% confidence interval [95% CI] 1.05 to 1.30), failure to explain side effects (OR 1.65; 95% CI, 1.16 to 2.35), and primary language other than English or Spanish (OR 1.40; 95% CI, 1.01 to 1.95). Patient satisfaction was lower among patients who reported drug complications (P <.0001). In addition, 48% of those reporting drug complications sought medical attention and 49% experienced worry or discomfort. On chart review, 3 (5%) of the patients with an adverse drug event required hospitalization and 8 (13%) had a documented previous reaction to the causative drug. CONCLUSIONS: Drug complications in the ambulatory setting were common, although most were not documented in the medical record. These complications increased use of the medical system and correlated with dissatisfaction with care. Our results indicate a need for better communication about potential side effects of medications, especially for patients with multiple medical problems.

Adult↗
PubMed2000

A comparison of the preventive health care provided by women's health centers and general internal medicine practices.

OBJECTIVE: To evaluate women's health centers as alternatives to traditional internal medicine practices. DESIGN: Cross-sectional mailed survey. SETTING: A women's health center and an internal medicine practice at each of three university-affiliated teaching hospitals. PATIENTS: There were 3,035 female patients randomly selected to receive a mailed survey after their office visits. MEASUREMENTS AND MAIN RESULTS: The survey asked for patient characteristics, patient satisfaction, and rates of gender-specific preventive health services. The survey response rate was 64% (1, 942/3,035). Patients at women's health centers were younger, more educated, had higher physical functioning but lower mental health functioning, and more of them were single and employed. Patient satisfaction was similar at the two types of practices, although patients at women's health centers were more satisfied with certain aspects of the patient-provider interaction. After adjusting for measured differences in patient characteristics and site, patients at women's health centers were more likely to receive discussions on hormone replacement therapy (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.1, 2.2) and dietary calcium (OR 1.3; 95% CI 1.1, 1. 6). They were also more likely to receive their gender-specific preventive health services from their primary care provider: breast examination (OR 2.0; 95% CI 1.5, 2.6), Pap smear (OR 2.4; 95% CI 1.9, 3.1), hormone replacement therapy discussion (OR 2.2; 95% CI 1.5, 3. 3), and dietary calcium discussion (OR 2.6; 95% CI 1.7, 3.9). These findings remained when the analyses were limited to patients of female providers only. CONCLUSIONS: In this study, patients at women's health centers were more likely to receive gender-specific health prevention counseling than patients at internal medicine practices. Moreover, patients were more likely to receive their gender-specific preventive health services from their primary care providers.

Boston↗
PubMed2000

Differences in the quality of care for women with an abnormal mammogram or breast complaint.

OBJECTIVE: To examine factors associated with variation in the quality of care for women with 2 common breast problems: an abnormal mammogram or a clinical breast complaint. DESIGN: Cross-sectional patient survey and medical record review. SETTING: Ten general internal medicine practices in the Greater Boston area. PARTICIPANTS: Women who had an abnormal radiographic result from a screening mammogram or underwent mammography for a clinical breast complaint (N = 579). MEASUREMENTS AND MAIN RESULTS: Three measures of the quality of care were used: (1) whether or not a woman received an evaluation in compliance with a clinical guideline; (2) the number of days until the appropriate resolution of this episode of breast care if any; and (3) a woman's overall satisfaction with her care. Sixty-nine percent of women received care consistent with the guideline. After adjustment, women over 50 years (odds ratio [OR], 1.58; 95% [CI], 1.06 to 2.36) and those with an abnormal mammogram (compared with a clinical breast complaint: OR, 1.75; 95% CI, 1.16 to 2.64) were more likely to receive recommended care and had a shorter time to resolution of their breast problem. Women with a managed care plan were also more likely to receive care in compliance with the guideline (OR, 1.72; 95% CI, 1.12 to 2.64) and have a more timely resolution. There were no differences in satisfaction by age or type of breast problem, but women with a managed care plan were less likely to rate their care as excellent (43% vs 53%, P <.05). CONCLUSIONS: We found that a substantial proportion of women with a breast problem managed by generalists did not receive care consistent with a clinical guideline, particularly younger women with a clinical breast complaint and a normal or benign-appearing mammogram.

Adult↗