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Biomedical subjects

V A Kazandjian

Publications and source records attributed to V A Kazandjian.

At least 19 recordsLinked to original sources
PubMed2001

Errors: can indicators measure the magnitude?

Errors in medicine, especially medication errors, have long been recognized as a dimension of quality of care and organizational performance. Recently, however, the magnitude of the issue, or its potential impact on cost, quality of care and patient safety have catapulted this issue to the forefront of national debate on the appropriateness of patient care management. There are still fundamental issues associated with the measurement of errors. Should errors that do not cause patient harm receive much attention? Could there be organizational or system issues that predispose to errors? Are there acceptable measurement models that allow comparative analysis and trending of institutional error rate profiles? This paper presents a systematic review of the measurement aspects for errors in medicine, emphasizing the medication errors' dimension. An indicator-based, epidemiological model of measurement is proposed which will allow a systematic inquiry into the issues of both preventable and non-preventable errors and their potential for patient harm.

Drug-Related Side Effects and Adverse Reactions↗
PubMed1999

A new learning environment: combining clinical research with quality improvement.

The emphasis provided by quality improvement strategies on performance measurement and evaluation often results in our understanding of processes of care and, perhaps, better outcomes. There are different references for process evaluation: external peers, regional profiles of performance or a trending of one's own performance patterns. This paper proposes a methodology that enables learning from the daily practice of medicine by comparing alternative care processes and outcomes. Since it is estimated that 15-20% of medical practices are based on rigorous scientific data establishing their effectiveness, we have much to learn. We propose to learn from our daily practice by combining clinical research methods with quality improvement tools. The products comprise modified clinical trial and case-control studies. In a modified clinical trial, we would use a practice guideline as a control group and modify the guideline to create an experimental group. This method would maintain the internal validity of efficacy research while maintaining the external validity of effectiveness research. In the case-control method, it is possible to quantitate risk for a given outcome and focus improvement effort on factors associated with that outcome. We believe physicians will accept this learning approach because it is a more valid learning method than traditional quality improvement and, unlike randomized clinical trials, learning will occur in the daily practice of medicine.

Case-Control Studies↗
PubMed1999

Performance: a multi-disciplinary and conceptual model.

We contend that the scientific study of performance requires a model or paradigm. We propose a performance model with an underlying mathematical basis that is well defined, has explicit assumptions and has the potential to be both heuristic and scientifically testable. The model is based on an integration of concepts from health sciences and psychology that have been adapted to performance measurement in health care. The proposed performance model consists of a combination of four primary elements: quality of care, cost of care, access to care and satisfaction. Satisfaction is defined as a function of perceived and expected outcomes of care and perceived and expected input. This performance model can serve as both a tool for understanding and as a vehicle for comparing performance within and between health care organizations. We believe that this model can be used to develop a performance profile report and the future report card.

Delivery of Health Care↗
PubMed1998

Directly observed therapy for treatment completion of pulmonary tuberculosis: Consensus Statement of the Public Health Tuberculosis Guidelines Panel.

OBJECTIVE: To evaluate evidence on the relative effectiveness of directly observed therapy in achieving treatment completion for pulmonary tuberculosis. PARTICIPANTS: A panel of 11 practitioners representing the public health, behavioral, and clinical management of tuberculosis was convened by the Council on Linkages Between Academia and Public Health Practice in 1995 to develop public health guidelines for tuberculosis treatment completion. EVIDENCE: English-language articles identified through MEDLINE (1966 to August 1, 1996) with original data on directly observed therapy, supervised therapy, compliance, treatment completion, case management, and treatment adherence for tuberculosis. CONSENSUS PROCESS: Each eligible article underwent structured review by at least 2 panel members for study design, sample size, evaluation methods, and treatment completion as the primary outcome. The full panel was convened twice, with intercurrent small group meetings, conference calls, and summary workshop to review findings. Recommendations made through this process were drafted by the panel chair and circulated twice for additional panel comments. CONCLUSIONS: Treatment completion rates for pulmonary tuberculosis are most likely to exceed 90%, as recommended by the Centers for Disease Control and Prevention, when treatment is based on a patient-centered approach using directly observed therapy with multiple enablers and enhancers. Other less intensive interventions, including nonsupervised strategies and modified approaches to directly observed therapy, are unlikely to achieve this recommended treatment completion goal. Directly observed therapy also appears to be cost-effective compared with self-administered therapy, although data on cost-effectiveness are limited.

Ambulatory Care↗
PubMed1998

Cesarean section rates: effects of participation in a performance measurement project.

BACKGROUND: A decade-old indicator-based research initiative, Maryland's Quality Indicator (QI) Project, analyzed data for cesarean section rates among its approximately 1,100 voluntarily participating hospitals. It was posited that continuous participation in this performance measurement initiative would be associated with decreased primary and repeat C-section rates. METHODS: A retrospective study compared a group of 110 hospitals that reported on the C-section indicator continuously between 1991 and 1996 with a group of hospitals that did not continuously report data on the C-section rate. RESULTS: Among the 110 continuously participating hospitals in the QI Project, the total C-section rate declined from 22.5% in 1991 to 19.4% in 1996 (p < .01). For this same group, the primary C-section rate declined from 15.8% to 13.9% (p < .01), and the repeat C-section rate declined from 75.0% to 61.2% between 1991 and 1996 (p < .01). The comparison group of 957 hospitals that did not continuously participate in C-section reporting between 1991 and 1996 did not experience a statistically significant difference in total C-section rates during this time (from 21.2% in 1991 to 20.7% in 1996). In attempting to investigate alternative explanations for these results, a subsequent analysis of eight hospital variables potentially related to cesarean delivery rates found no significant differences between the two groups. CONCLUSIONS: This study provides support for the positive association between continuous participation in a performance measurement project and performance improvement.

Analysis of Variance↗
PubMed1996

Do performance indicators make a difference?

BACKGROUND: The Maryland Hospital Association, Inc (MHA) Quality Indicator (QI) Project, a program of indicator development and application, includes more than 1,100 participating hospitals. Access to data is limited to participants to promote improvement through comparison across hospitals. Participating hospitals have identified and acted on opportunities for improvement in information systems, communication across departments and functions, processes of care, identification of appropriateness of practice, and improvement ¿beyond the hospital door¿. CASE STUDY 1: Two teams were formed to address waiting time in the emergency department and failure of patients to find treatment. Improvements, including rapid notification of available inpatient beds, additional staffing during high-census periods, and streamlined processes for lab work and imaging turnaround times, were followed by better indicator performance. CASE STUDY 2: A hospital discovered three causes for a high rate of unscheduled admissions following ambulatory surgery. Interventions included extending the hours of the Same Day Surgery Unit (to solve a urination problem) and changing the anesthesia used (to reduce nausea and vomiting). CASE STUDY 4: To successfully bring its cesarean section (C-section) rate down closer to the statewide rate, one hospital had physicians encourage patients with previous C-sections to undergo a trial of labor, promoted the use of epidural anesthesia, and took advantage of new packaging to facilitate the use of prostaglandin gel to induce cervical dilation. CONCLUSIONS: The QI Project continues to deal with issues concerning quality of data versus quality of care, the correlation between indicator rates and care processes, and the usefulness of severity adjustment.

Adult↗
PubMed1995

Balancing science and practice in indicator development: the Maryland Hospital Association Quality Indicator (QI) project.

This paper describes the technical and conceptual aspects in the development of an indicator project to measure hospital performance. Almost a decade ago, a research based--hence explorative, series of inpatient and ambulatory care indicators were developed. This paper describes some of the most fundamental technical and applied knowledge gleaned from the study and applicable to all quality assurance/quality improvement activities. These findings, and the resulting indicator development guiding principles, are based on more than 900 hospitals' experience in the US, Japan, and England. Although this paper presents the necessary scientific underpinning for a valid and reliable analysis, its principal emphasis is on the practical applicability of this decade old research project aimed at measuring select outputs of performance and identifying and explaining the determinants of these outputs.

England↗
PubMed1993

Relating outcomes to processes of care: the Maryland Hospital Association's Quality Indicator Project (QI Project).

BACKGROUND: The Maryland Hospital Association's Quality Indicator Project (QI Project) is a program of indicator development and application that has grown from 7 hospitals in 1987 to more than 700 hospitals today. METHODOLOGY: Expert panels help to create sets of indicators that describe events involved in a specific sequence of patient care. Each hospital collects data elements for the 21 indicators on a quarterly basis using specifically designed data-collection software. Indicator data are adjusted for case complexity, risk of adverse outcomes, and patient group characteristics. A report is developed that states the rate of occurrence of each indicator and how the hospital's indicator rate compares to other hospitals in the database. Hospitals then use this information to determine if specific processes in their delivery of care yield results that deviate from those of other hospitals. The QI Project promotes regional sharing of information about specific hospital initiatives that might benefit other participants. It also provides a model to use in interpreting what the indicator data reveal about hospital performance. OPERATIONAL ISSUES: QI Project is testing process indicators for patient-level and service-level data to supplement current aggregate-level trend and profile analysis. Indicator data are shared solely with participating systems, but changes in the confidentiality policy are being studied. Reliability assessment surveys are periodically conducted. EXAMPLES: Case studies portray improvement of processes prompted by indicator data for unscheduled admission following ambulatory surgery, for surgical wound infections, and for reducing emergency room waiting times. CONCLUSIONS: The chief contribution of the QI Project and similar projects may not be that they identify all issues of quality, but rather that they may help develop a generation of hospital professionals who will be better able to quantify, evaluate, and improve health care quality.

Confidentiality↗
PubMed1993

Hysterectomy and race.

OBJECTIVE: To investigate black-white differences in factors related to hysterectomy. METHODS: Discharge summary data were analyzed for 53,159 hysterectomies that occurred in Maryland from 1986-1991. RESULTS: The average annual age-adjusted hysterectomy rate was higher for black women (49.5 per 10,000) than for white women (41.2 per 10,000). For 65.4% of the hysterectomies in black women, the principal diagnosis was uterine fibroids, compared to 28.5% for white women. Logistic regression was used to measure the effect of race on complications, length of stay, and mortality after adjustment for a variety of factors including age, comorbidities, diagnosis, route (abdominal, vaginal, or subtotal), hospital characteristics, and source of payment. In comparison to white women, black women having hysterectomy were found to have an increased risk of one or more complications of surgical or medical care (odds ratio 1.4, 95% confidence interval [CI] 1.3-1.5), a length of stay of more than 10 days (odds ratio 2.7, 95% CI 2.5-3.1), and in-hospital mortality (odds ratio 3.1, 95% CI 2.0-4.8). CONCLUSIONS: In a study of more than 53,000 hysterectomies, black women were more than twice as likely to have a diagnosis of uterine fibroids as white women, were more likely to have complications, had a longer hospitalization, and had more than three times the in-hospital mortality rate.

Adolescent↗
PubMed1992

Geographic variation in lumbar diskectomy: a protocol for evaluation.

In 1989 the Maryland Hospital Association (MHA) began developing a protocol related to lumbar diskectomy, a procedure with widely reported geographic variation in its use. The MHA's Laminectomy Advisory Committee drafted three criteria for performance of lumbar diskectomy and also developed a data-collection instrument with which the eight hospitals participating in a pilot study could abstract the necessary data from medical records. Both individual hospital and aggregate results showed wide variation in compliance with the criteria. These findings suggest research and development activities such as refinement of the data-collection instrument, use of the protocol for bench-marking, further investigation of clinical and other determinants of rate variation, and study of the effect of new diagnostic technology on utilization rates for this procedure.

Catchment Area, Health↗