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Biomedical subjects

T E Kottke

Publications and source records attributed to T E Kottke.

At least 37 records · Page 2Linked to original sources
PubMed1998

The quality of Pap test specimens collected by nurses in a breast and cervical cancer screening clinic.

BACKGROUND: It is possible that nurses can help close the gap between the Healthy People 2000 clinical preventive services goals and current cancer screening rates by collecting Pap test specimens in clinical practices. The purpose of this analysis was to determine whether nurses can collect high-quality Pap tests. DESIGN: Retrospective cohort analysis of all Pap tests submitted to a commercial pathology laboratory between January 1, 1996 and July 31, 1996. Pap tests collected by the nurses at Rosebud Hospital (N = 404) were compared to the Pap tests collected by other providers at the Rosebud Hospital (N = 118) and the Pap tests collected by providers from all other sites (N = 22,696). SETTING: The Indian Health Service Hospital, Rosebud, South Dakota. SUBJECTS: Eight nurses who had been trained to collect Pap test specimens. MAIN OUTCOME MEASURES: The proportion of Pap test specimens that were wholly satisfactory and the proportion of Pap test specimens collected from nonpregnant patients that lacked endocervical cells. RESULTS: The proportion of specimens that were wholly satisfactory was 79.8% (95% CI = 75.9-83.7) for the nurses, 65.3% (95% CI = 56.7-73.9) for other Rosebud providers, and 81.7% (95% CI = 81.2-82.2) for non-Rosebud providers. The proportion of specimens that lacked endocervical cells and were from nonpregnant patients was 6.4% (95% CI = 4.0-8.8) for Rosebud nurses, 8.5% for other Rosebud providers (95% CI = 3.5-13.5), and 7.9% for non-Rosebud providers (95% CI = 7.6-8.2). CONCLUSIONS: After one week of training, nurses can collect Pap test specimens that are of the same quality as the specimens collected by physicians, nurse practitioners, and physician assistants. The widespread availability of female nurses and the high quality of their work suggest that they can contribute to the Healthy People 2000 goals by collecting Pap test specimens.

Ambulatory Care↗
PubMed1998

Quality improvement in primary care clinics.

BACKGROUND: Case studies from Project IMPROVE, the first randomized controlled trial to evaluate the effectiveness of continuous quality improvement (CQI) in primary care, were subjected to a qualitative analysis. Three questions were addressed: How does change in the health care environment affect a quality improvement (QI) process? How does clinic organization influence a QI process? and What is the impact of a QI process on clinic organization? METHOD: Case studies were conducted in 6 clinics that had been randomly selected from the 22 clinics participating in the IMPROVE intervention. The case study data consisted of observations of CQI team meetings, open-ended interviews with 30 informants (team members plus others in the clinics), interviews with IMPROVE consultants, and documentation from the project. The data were analyzed to identify themes and generate concepts, assess and compare the informants' experiences, and develop a conceptual framework stimulated by research and theory literature. RESULTS: Change and uncertainty in the health care environment both complicated the QI process and motivated participation in improvement. The smaller clinics appeared to have more difficulty with the QI process because of limited resources and lack of compatibility between the QI approach and their clinic organization. Project IMPROVE had two qualitative effects on clinics: increased awareness of preventive services and application of the CQI method to other problems and issues. CONCLUSION: QI initiatives can help clinics adapt to a changing health care environment and create functioning teams or groups that can address a variety of organization problems and tasks. The process should be flexible to accommodate varying organization structures and cultures.

Ambulatory Care Facilities↗
PubMed1998

IMPROVE: bridge over troubled waters.

BACKGROUND: The original collaborative project was described in a 1995 Journal article titled "Competing HMOs Collaborate to Improve Preventive Services." IMPROVE (IMproving PRevention through Organization, Vision, and Empowerment) was a large randomized controlled trial using continuous quality improvement to implement clinical systems to improve the delivery of adult preventive services in primary care settings. The project was funded by the Agency for Health Care Policy and Research and initiated as a collaboration between two health maintenance organizations (HMOs) in the Twin Cities: Health Partners and Blue Plus. METHODOLOGY: Forty-four clinics were recruited for the study. Initially the 22 intervention clinics received the multifaceted intervention of leadership support, training on CQI and prevention systems, and consultation and networking opportunities. Next, the comparison clinics received similar assistance, and other clinics were invited into the collaboration. Ultimately, 57 clinics were involved in the project. Multiple collaborations--among clinics, leaders, and HMOs--developed during the project. STATUS: Despite turmoil in the environment during the project, many benefits have been described, including enhanced leadership, growth of systems thinking, better change management skills, and collaboration of competing organizations. SUMMARY: The IMPROVE collaboration survived and flourished in a very competitive market. It was viewed positively by clinicians, medical clinics, and HMOs, and its benefits have extended into the community.

Adult↗
PubMed1998

Continuous quality improvement in primary care: what's happening?

OBJECTIVES: Despite much health care interest in quality and Continuous Quality Improvement, there is little quantitative information about it. The purpose of this study was to measure the attitudes, activities, and organizational cultures concerning Continuous Quality Improvement in a group of Midwestern primary care clinics. METHODS: Three surveys of the clinicians, nurses, and other staff in 44 primary care clinics in the metropolitan area of Minneapolis and St. Paul were conducted. These surveys assessed: (1) attitudes about quality improvement, (2) previous efforts in these clinics to use process improvement teams, and (3) the extent to which the clinics' organizational cultures were perceived as supporting quality. The Provider Attitude Survey was completed by clinicians and nurses; the Process Improvement Progress was completed by members of the best Continuous Quality Improvement teams, if any; and the Quality Systems Inventory was completed by all personnel. RESULTS: Most of the clinical personnel reported support for various Continuous Quality Improvement concepts, but their understanding and experience were limited. Only 20 (45%) clinics had had at least one Continuous Quality Improvement team in the past, only five of the 12 teams with adequate information had completed an improvement cycle, and only seven reported improving a process with it. The mean clinic scores for quality culture were no better than those in other types of organizations. CONCLUSIONS: Despite relatively favorable attitudes and some Continuous Quality Improvement activities, there appears to be a need to help clinics build skill and experience for the required care improvements.

Attitude of Health Personnel↗
PubMed1998

Implementing nurse-based systems to provide American Indian women with breast and cervical cancer screening.

OBJECTIVE: To describe the factors critical to implementation of a nurse-based system to increase access for American Indian women to breast and cervical cancer screening. MATERIAL AND METHODS: We report the experience of 103 nurses at 40 clinics who were trained to use the nurse-based screening system. In addition, the critical elements are discussed in the context of one particularly successful site. RESULTS: Fifteen factors were identified as critical to the implementation of a nurse-based cancer screening process once a nurse had been trained to perform clinical breast examinations and collect Papanicolaou (Pap) test specimens: knowledge of benefit, skills, organization, adequate return, perceived patient demand, perceived effectiveness, legitimacy, confidence, commitment, adequate resources, a data-driven iterative approach to program implementation, an objective measure of quality, leadership, the passage of time, and a focus on delivering the service to the patient. For example, in one site that was particularly successful, the nurses, administrators, and other key health-care professionals contributed their respective resources to implement the screening program. The program was also supported by the lay community, the state board of nursing, and the state health department breast and cervical cancer control program. During the 3-year study period, the 103 nurses performed screening tests on 2,483 women, and only 18 of the Pap test specimens were unsatisfactory. CONCLUSION: Nurse-based systems designed to collect high-quality Pap test specimens and perform detailed clinical breast examinations can be implemented if the factors that are critical to implementation are identified and addressed.

Breast Neoplasms↗
PubMed1997

Predictive value of electrophoretically detected lipoprotein(a) for coronary heart disease and cerebrovascular disease in a community-based cohort of 9936 men and women.

BACKGROUND: Elevated lipoprotein(a) [Lp(a)] levels have been associated with the presence of atherosclerotic disease. However, the results of prospective studies of Lp(a) and cardiovascular disease have been contradictory. METHODS AND RESULTS: From 1968 through 1982, lipoprotein analysis was performed in 11,335 Olmsted County residents. Quantitative cholesterol and triglycerides were obtained along with semiquantitative Lp(a) levels based on electrophoretic pattern. Lp(a) bands were scored from 0 (absent) to 3 (increased). A cohort of 4967 men and 4968 women with no prior history of atherosclerotic disease who had baseline Lp(a) determinations were followed up for 14 years for development of coronary artery disease (CAD) and cerebrovascular disease (CVD). During 131,330 person-years of follow-up, there were 1848 CAD events and 841 CVD events. Age, diabetes, hypertension, cholesterol, and triglycerides were significantly and independently associated with an increased risk of CAD and CVD in men and women. There was a significant increase in the adjusted hazards ratio for CAD with increasing Lp(a) levels for men and women. For Lp(a) level 3, the hazard ratio was 1.9 (range, 1.3 to 2.9) in women and 1.6 (range, 1.0 to 2.5) in men. The adjusted hazard ratio for CVD showed an irregular association with Lp(a) levels in men and no association in women. CONCLUSIONS: In this cohort of 9936 men and women initially free of cardiovascular disease who were followed up for 14 years, Lp(a) was a significant predictor of risk of future CAD. Lp(a) was a weak risk factor for CVD in men and was not a significant predictor of CVD risk in women.

Adult↗
PubMed1997

Delivering clinical preventive services is a systems problem.

A steadily increasing number of research trials and prevention advocates are identifying the practice environment as the main source of both problems and solutions to the improved delivery of clinical preventive services. Although these sources are correctly focusing on office systems as solutions, there is a tendency to focus on only parts of a system and to relate this to just one or a few related preventive services. However, the effort required to set up and maintain an office system makes it difficult to justify doing so for a single clinical activity. The process and system thinking of Continuous Quality Improvement (CQI) theory suggests that there may be both efficiency and effectiveness advantages to the concept of all clinical preventive services being served by a single system with many interrelated component processes. Such a system should be usable for all age groups. This system and its literature base are described. The feasibility of applying this concept is being tested in a randomized controlled trial in 44 primary care clinics in Minnesota and Wisconsin.

Delivery of Health Care↗
PubMed1997

Primary care, process improvement, and turmoil.

The current health care environment in the United States is in turmoil, especially in regions that are further ahead in the transition from free-for-service to managed care. This article examines turmoil within primary care during a health-maintenance-organization-sponsored and federally funded randomized trial of using continuous quality improvement for adult clinical preventive services. The external and internal changes in structure and leadership occurring in primary care clinics are profound and prevalent. The sponsors of the project have responded to the turmoil by encouraging greater leadership involvement within the clinic and by supporting more skill building for change management.

Adult↗
PubMed1997

Are coronary-care unit changes in therapy associated with improved survival of elderly patients with acute myocardial infarction?

OBJECTIVE: To determine whether changes in coronary-care unit therapy for elderly patients with acute myocardial infarction have been associated with improved survival. MATERIAL AND METHODS: We conducted a retrospective cohort analysis of all patients 70 years of age or older from Olmsted County, Minnesota, who were hospitalized in a coronary-care unit in this county for the treatment of acute myocardial infarction during one of three periods: 1976 through 1978, 1987 through 1989, and 1991. The effect of aspirin, heparin, beta-blockers, thrombolysis, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting on these elderly patients with acute myocardial infarction was assessed. RESULTS: Improvement in 30-day survival was significant for patients 80 years of age or older (45%, 69%, and 78% in 1976 through 1978, 1987 through 1989, and 1991, respectively; P = 0.01 for the trend) but not for patients 70 to 79 years of age (77%, 76%, and 81% for the three time periods, respectively; P = 0.65 for the trend). The opposite pattern was observed for survival in the period more than 30 days after the event. More intensive treatment in the hospital was associated with better 30-day survival (P < 0.0001). CONCLUSION: The improved survival of the elderly patients with acute myocardial infarction in these cohorts can be accounted for by changes in the therapy they received in the coronary-care units.

Age Factors↗
PubMed1997

Delivery rates for preventive services in 44 midwestern clinics.

OBJECTIVE: To determine the rates at which private primary-care clinics are recommending blood pressure and cholesterol measurement, smoking cessation, clinical breast examination, screening mammography, Papanicolaou testing, and influenza and pneumococcus immunizations. MATERIAL AND METHODS: We conducted a mail survey of 7,997 randomly selected patients from 44 primary-care clinics in and around Minneapolis-St. Paul, Minnesota, of whom 6,830 (85.4%) completed the questionnaire on preventive services delivery rates. The responses were analyzed statistically, including stratification by reason for the clinic visit. RESULTS: On the average, about two-thirds of the patients in each clinic reported being up-to-date on preventive services before their clinic visit; an exception was pneumococcus immunization (mean rate, 33%). Except for blood pressure and smoking cessation advice, less than 30% of patients who were not up-to-date on a preventive service were offered it if the clinic visit was for a reason other than a checkup or physical examination. For patients who said that they saw their physician for a checkup or physical examination, the rate was more than 50% only for Papanicolaou smear. In contrast, nearly all responding practitioners agreed that each of the eight preventive services was very important or important. CONCLUSION: Preventive services consensus goals are not being met, even for patients who report that their clinic visit was for a checkup or physical examination. This finding suggests that it may be necessary to develop clinical systems that support and enable the delivery of preventive services.

Adult↗
PubMed1997

A process IMPROVEment approach to preventive services: case studies of CQI demonstration projects in two primary care clinics.

The IMPROVE Project is a 4-year randomized controlled trial to test the hypothesis that HMOs can improve preventive services in their contracted primary clinics by assisting clinics to implement continuous quality improvement (CQI) and an organized system for preventive services. This paper describes findings from case studies of CQI teams in two demonstration sites where the CQI approach was tested. The case study analysis is based on interviews and observations conducted about 10 to 12 months after the CQI teams began. Initial responses of clinic staff to the IMPROVE Project included a mixture of interest in CQI, enthusiasm for prevention-oriented care, concern about the burden the project might impose, and skepticism. There were two formidable barriers to change: time and inertia. Environmental changes in the parent organizations also complicated and impeded the CQI process within the clinics. The thematic analysis identified four factors that appear to be important in implementing a CQI process in a clinic setting: awareness, momentum, ownership, and communication.

Awareness↗
PubMed1997

How important are clinician and nurse attitudes to the delivery of clinical preventive services?

BACKGROUND: The purpose of this study was to determine the relation between primary care clinic physician and nurse attitudes toward preventive services and the rates at which their clinics provide these services to their adult patients. METHODS: Forty-four private primary care clinics contracting with the sponsoring health maintenance organizations were recruited for a randomized controlled trial of an intervention consisting of training and consultation in continuous quality improvement and office prevention systems. Before the intervention began, 647 clinic physicians, midlevel practitioners, and nurses in the 44 participating clinics completed a questionnaire addressing their attitudes toward prevention, and 6830 patients visiting those clinics completed a questionnaire about their own up-to-date preventive care status as well as clinic actions to provide eight important preventive services during the visit. Scales were developed from significantly intercorrelated sets of attitude questions. Correlations were calculated by clinic for the relation between mean provider scores on those scales and specific service rates. RESULTS: The questionnaire provided three scales with high internal consistency reliabilities that appear to measure generally favorable attitudes toward preventive services and toward improving them in an organized way. There was little association between these attitudes and rates of providing preventive services. CONCLUSIONS: While favorable attitudes may be helpful, they are clearly insufficient to affect the actual delivery of preventive services. There is reason to believe that preventive services rates could be improved more effectively by targeting factors related to the provision of preventive services, particularly those that shape the clinical environment in which clinicians work.

Adult↗
PubMed1996

Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort.

OBJECTIVE: To determine the impact of tobacco- and alcohol-related deaths on overall mortality following inpatient treatment for alcoholism and other nonnicotine drugs of dependence. DESIGN: Population-based retrospective cohort study. SETTING: Olmsted County, Minnesota (the Rochester Epidemiology Project), and the Inpatient Addiction Program (IAP) at Mayo Clinic, Rochester. PATIENTS: All 845 Olmsted County residents admitted to an inpatient addiction program for treatment of alcoholism and other nonnicotine drugs of dependence during the period 1972 through 1983. METHODS: Patients were followed up through the medical record linkage system of the Rochester Epidemiology Project through December 1994 to obtain vital status, and death certificates were obtained for those who died. The underlying cause of death was classified as alcohol related, tobacco related, both, or neither based on the classification from the Centers for Disease Control and Prevention. The observed number of deaths by underlying cause were compared with the expected number using cause-specific 1987 death rates for the white population of the United States. All-cause mortality was also compared with that expected for persons in the West North Central Region of the United States of like age, sex, and year of birth. Univariate and multivariate assessments were made to identify predictors of all-cause mortality from baseline demographic information. RESULTS: At admission, the mean (SD) age of the 845 patients was 41.4 (14.5) years, and 35% were women. Altogether, 78% had alcohol as their only nonnicotine drug of dependence and 18% had alcohol and other nonnicotine drugs of dependence, while 4% were classified as having a nonalcohol, nonnicotine drug dependence alone. At admission, 75% were current and 8% former cigarette smokers, 3% were current cigar or pipe smokers, and 2% were current users of smokeless tobacco. Follow-up after the index IAP admission totaled 8913 person-years (mean [SD] of 10.5 [5.6] years per patient). Death certificates were obtained for 96% (214) of the 222 patients who died. Of these 214 deaths, 50.9% (109) had a tobacco-related and 34.1% (73) had an alcohol-related underlying cause (P<.001). The cumulative mortality significantly exceeded that expected (P<.001); at 20 years, the observed mortality was 48.1% vs an expected 18.5%. Multivariate predictors of mortality, even after adjusting for expected mortality, were older age at admission (P<.001) and male sex (P<.001). CONCLUSIONS: Patients previously treated for alcoholism and/or other nonnicotine drug dependence had an increased cumulative mortality that was due more to tobacco-related than to alcohol-related causes. Nicotine dependence treatment is imperative in such high-risk patients.

Adolescent↗
PubMed1996

The Pine Ridge-Mayo National Aeronautics and Space Administration telemedicine project: program activities and participant reactions.

OBJECTIVE: To determine the response of participants to the Pine Ridge-Mayo National Aeronautics and Space Administration telemedicine project. DESIGN: We describe a 3-month demonstration project of medical education and clinical consultations conducted by means of satellite transmission. Postparticipation questionnaires and a postproject survey were used to assess the success of the activity. MATERIAL AND METHODS: Patients and employees at the Pine Ridge Indian Health Service Hospital in southwestern South Dakota and employees at Mayo Clinic Rochester participated in a telemedicine project, after which they completed exit surveys and a postproject questionnaire to ascertain the acceptability of this mode of health care. RESULTS: Almost all Pine Ridge and Mayo Clinic participants viewed the project as beneficial. The educational sessions received favorable evaluations, and almost two-thirds of the patients who completed evaluations thought the consultation had contributed to their medical care. More than 90% of the respondents from Pine Ridge and more than 85% of the respondents from Mayo Clinic Rochester said that they would recommend participation in this project to others. More than 90% of respondents from Pine Ridge and 80% of Mayo respondents agreed with the statement that the project should continue. CONCLUSION: These data suggest that a program of clinical consultation services, professional education, and patient education available by telemedicine might be viewed as beneficial.

Adult↗