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PubMed1978

The quality of medical care.

This article classifies the major approaches to the assessment of the process and outcomes of medical care. The apparent need to safeguard and enhance the quality of care has led to the institution of mechanisms that subject care to constant review so that deficiencies may be found and corrected. The article reviews the developments that led to the involvement of the federal government in this activity through its sponsorship of professional standards review organizations (PSRO's). The major features of the PSRO's are described and their possible effects discussed. It is too early to say how the PSRO's will fare, but should they fail to accomplish their objectives the pressure for more radical solutions will be difficult to resist.

Computers↗

PubMed1991

A novel comprehensive DUE program--five years of experience.

A comprehensive program has been developed to evaluate prescribing practices in diverse drug therapy categories and in all areas of the institution. Input for topic selection comes not only from the pharmacy department, but also from QA, medical staff, and nursing. The development of monitoring criteria and review of the results by the P&T Committee, Medical Executive Committee, and other key medical staff members, promotes ownership of the program by the medical staff. The benefit of this ownership is active support for the program and participation in peer review. Overall, the results of this cost-effective program include limited use of broad spectrum antibiotics, select prescribing of high-risk drugs, and focused educational efforts to improve quality of patient care. The primary goal for the future of the program is to develop criteria and documentation mechanisms for reporting measurable clinical outcomes. In making the transition, it is important to use the success and impact of the current program as the foundation. This is particularly true for the concurrent monitoring program and its immediate feedback mechanism. The major challenge will be evaluating negative clinical outcomes and developing corrective actions as well as documenting the positive outcomes and the avoidance of negative outcomes of the current program. To meet this challenge, the DUE program must be integrated with all other institutional QA programs. Although a difficult task, this is a significant yet necessary step in the right direction for assuring optimal patient care.

Anti-Bacterial Agents↗

PubMed1994

Comorbidity of migraine: the connection between migraine and epilepsy.

Although an association between migraine and epilepsy has long been discussed, it has rarely been studied systematically. According to the evidence from the large epidemiologic study reviewed in this article, individuals with epilepsy are 2.4 times more likely to develop migraine than their relatives without epilepsy. Risk of migraine is elevated in patients with partial-onset and generalized-onset seizures. The comorbidity of migraine and epilepsy may be explained by a state of neuronal hyperexcitability that increases the risk of both disorders. Clinical and EEG features useful in the differential diagnosis of migraine and epilepsy as well as in the diagnosis of both conditions when they occur concurrently are reviewed. When migraine and epilepsy occur together, therapy with agents effective for both conditions should be considered.

Adult↗

PubMed2002

Metric properties of the appropriateness evaluation protocol and predictors of inappropriate hospital use in Germany: an approach using longitudinal patient data.

BACKGROUND: The German health care system, renowned for its unrestricted access, high quality care, and comprehensive coverage, is challenged by increasing health care costs. This has been attributed partly to inefficiencies in the in-patient sector, but has been studied little. Attempts at quality improvement need to relate costs to outcomes. Until now, there has been no standardized methodology to evaluate the appropriateness of hospital care. OBJECTIVE: To develop and evaluate the metric properties of a method to assess inappropriate hospital care in Germany based on a widely used measure, the Appropriateness Evaluation Protocol (AEP). METHODS: The original AEP was translated and adapted to reflect differences in the provision of health care in Germany. Psychometric testing was performed in a stratified sample of all patients admitted to the Departments of Medicine and Surgery of a 400-bed teaching hospital during 1 year. Three board-certified physicians participated in each department to evaluate intra-rater reliability, while two additional independent physicians judged inter-rater reliability. RESULTS: Inter-rater agreement for the evaluation of hospital days among surgical patients was 84% (80-87%), with an average kappa value of 0.58 (0.48-0.68). Corresponding figures for patients in medicine were 76% (73-80%) with a K value of 0.42 (0.34-0.42). Inter-rater agreement for hospital admissions and K was 74% (62-86%) and 0.44 (0.21-0.67) in surgery, and 92% (85-100%) and 0.31 (0-0.80) in medicine, respectively. Thirty-three per cent of all admissions and 28% of consecutive hospital days were judged inappropriate in surgery; among medicine patients, reviewers found 6% of admissions and 33% of hospital days inappropriate. Time since admission was the strongest predictor of inappropriate hospital use adjusted for length of stay, comorbidity, age, and gender.

Adult↗

PubMed1996

The evaluation of pediatric trauma care using audit filters.

OBJECTIVE: To evaluate the experience of a pediatric trauma system with specific reference to prehospital, trauma center resuscitation, and critical care phases of treatment. DESIGN: Descriptive review of concurrent audit. SETTING: A tertiary care referral adult and pediatric trauma center. PATIENTS: All pediatric trauma victims in the trauma registry (includes patients < or = 14 years old, who died or were hospitalized for > or = 24 hours). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age, pediatric trauma, injury severity, and Glasgow Coma Scale scores as well as outcome (death or discharge disability score) were analyzed. Primary filters (those with the potential to contribute to morbidity and mortality), secondary filters (minor deviations from care), missed injuries and all deaths were reviewed. Of 250 patients in the registry, 20 died. One hundred thirteen had filters, with 49 having primary filters (34 with one, 14 with two, and one with four filters). Fifty percent of primary filters occurred in the prehospital phase of care with inadequate airway management and venous access accounting for 60%. Overall, primary filters occurred more commonly in patients with severe injuries (lower Pediatric Trauma and Glasgow Coma Scale and higher Injury Severity scores). Primary filters were also statistically more common in patients who died or who were disabled. In three patients (25%) who died, our review suggested that filters may have contributed to demise. Missed injuries were mostly extremity fractures and did not contribute to mortality or long-term morbidity. CONCLUSION: Deviations from care occur, even in a dedicated pediatric trauma system. Mortality of and by itself is not an adequate indicator of the quality of function of a trauma system. Since most primary filters occurred outside of the trauma center, improvement in trauma outcome may be expected with better training of personnel involved in the prehospital care of injured children. A comprehensive review of death and disability should include audit filters of prehospital care, triage, definitive care, and rehabilitation.

Child↗

PubMed1990

Continuous quality assurance monitoring by staff pharmacists.

The article describes a system of continuous quality assurance monitoring which is accomplished by pharmacists at the medical center. This 856 bed Veterans Affairs facility is provided pharmacy services through a decentralized unit dose distribution system. Pharmacists are assigned to separate patient care areas and provide or coordinate all drug distribution functions and additionally provide clinically-oriented services including quality assurance intervention. Pharmacists are provided guidelines on selected medication therapy which warrant pharmacist monitoring to assure high quality of care. In addition to these guidelines, pharmacists are encouraged to intervene in other therapeutic areas where their expertise favorably impacts quality of patient care. A report of clinically significant intervention is prepared monthly and submitted to the Drug Use Evaluation Subcommittee for review. This report is distributed along with the Pharmacy and Therapeutic Committee minutes to all pharmacists, physicians, and supervisory nursing personnel. The system of continuous quality assurance monitoring encourages pharmacists to use their expertise in a manner which assures quality of medical care provided by the medical center. Documentation of pharmacist intervention meets many JCAHO requirements for quality assurance.

Concurrent Review↗

PubMed1981

Operational audit--the respiratory department.

Although our operational audit involved evaluating the cost effectiveness and efficiency with which procedures or functions are performed, our focus remained on the actual operational problem as defined in our criteria. The pre-determined standards, on which our criteria statements were based, provided the yardstick for measurement. Our assessment and Treatment Plan for patient care was audited, followed by a review of our policy and procedure compliance and the application of managerial systems and controls. Although the total impact of this audit tool on astute clinical care, management, judgement, and educational needs is yet to be addressed, we believe we have taken an important step in the direction of quality control through the initiation of an evaluation system in the Respiratory Department.

Concurrent Review↗

PubMed1980

Retrospective utilization review as a focused method of evaluation.

Retrospective UR may be the method of choice if, in general, a problem is best addressed through a sampling of completed records. Note that this type of review is currently different from a patient care evaluation or audit. Such studies usually compare optimum standards of care for a diagnosis with the actual care delivered to patients as documented in their records. Retrospective UR, however, may be used to focus on a problem in the delivery of care that has previously been identified. As such, it can be an effective component of a total quality assurance program.

Concurrent Review↗

PubMed1993

Implementation of an interdisciplinary psychotropic drug review process for community-based facilities.

A continuing psychotropic drug review process developed and implemented in 1986 by a community-based agency serving individuals with mental retardation was described. This process has proven to be a feasible and effective system that has taken into account the practical realities of integration into the community and the use of community-based resources. The goals of establishing data-based interdisciplinary team review, utilizing concurrent alternative treatments, and prescribing psychotropic medication at the lowest effective dosage only to those individuals for whom it proves to make a positive difference have been met. For the residents of the agency's facilities, this process has led to a low psychotropic utilization rate of 17%. Dosage levels have been reduced for 75% of the individuals who have been prescribed psychotropic medication.

Drug Prescriptions↗

PubMed1989

Inspection of care: findings from an innovative demonstration.

In this article, information is presented concerning the efficacy of a sample-based approach to completing inspection of care reviews of Medicaid-supported nursing home residents. Massachusetts nursing homes were randomly assigned to full (the control group) or sample (the experimental group) review conditions. The primary research focus was to determine whether the proportion of facilities found to be deficient (based on quality of care and level of care criteria) in the experimental sample was comparable to the proportion in the control sample. The findings supported such a hypothesis: Deficient facilities appear to be equally identifiable using the random or full-sampling protocols, and the process can be completed with a considerable savings of surveyor time.

Certification↗

PubMed1995

The impact of preadmission approval and continued stay review on hospital stay and outcome among children and adolescents.

Managed care has emerged as the centerpiece of the health care industry's efforts to control costs and ensure appropriate use of hospital services. This study assesses the impact of managed care by preadmission approval and/or continued stay review on length of psychiatric hospitalization and clinical outcome of children and adolescents. The sample included 277 cases hospitalized in nine psychiatric specialty hospitals in 1990. Demographic and clinical characteristics, hospital ownership type, and preadmission approval or continued stay review were used as independent variables in a multiple regression model to predict length of stay and clinical outcome. Results indicate that the model accounted for 27% of the variance in length of stay. Previous psychiatric hospitalization and for-profit hospital status predicted longer hospitalization. Clinical outcome was not significantly predicted by the model. Managed care did not predict either length of stay or clinical outcome. Implications for health care reform are discussed.

Adolescent↗

PubMed1996

Patients not included in medical audit have a worse outcome than those included.

The aim of the present investigation was to analyse a clinical database in order to see how many patients were not included in medical audit and to see whether the outcome of the non-registered patients differed from that of the registered patients. Two independent surgeons studied the records of all infrainguinal bypass operations performed at six vascular surgical departments over a three-year period. A total of 684 bypass operations was reported to the register, of which 636 could be reviewed. One-hundred and twenty-eight cases that had not been reported were found from other sources. The outcome variables were mortality, amputation rate and patency. Sixteen per cent of eligible cases had not been reported. Mortality and amputation rate were twice as high among the missing cases as among the reported cases. There was no difference in patency. Overall judgement of the performance of an individual department may be impaired by cases not included in the register.

Amputation, Surgical↗

PubMed1988

The development and implementation of a drug utilization review program.

In response to rising drug expenditures and pressure from hospital administration to contain drug costs, the department of pharmaceutical services at The Mississauga Hospital initiated a Drug Utilization Review (DUR) Program. The main purpose of this program was to contain the escalating drug budget through identifying and correcting areas of drug misuse, without compromising the quality of patient care. This article will describe the procedures involved in developing and implementing such a DUR program at our hospital and our experience to date. Both structured and informal strategies have been implemented, which have identified factual and potential cost savings. Overall, the DUR program has been well accepted by the medical staff and hospital administration.

Concurrent Review↗

PubMed1979

The evolution of the PSRO hospital review system.

Over the past several years, the PSRO hospital review system has evolved to such an extent as to merit re-examination of its objectives, accomplishments and potential, as well as the obstacles to success that still remain. The combination of review experience, political and funding pressures has reshaped the hospital review system. There is still controversy concerning the relative emphasis of the program on quality or costs, but there is no longer any question about the priority goal of the program for the remainder of this decade--to reduce the excessive use of hospital care and services that exists throughout the country. There is widespread and growing evidence of significant variation in hospital practice patterns from region to region and hospital to hospital. Elimination of much of the variation would benefit the quality of patient care and help to contain costs. Improvements in PSRO hospital review, particularly profile analysis and medical care evaluation studies, make possible the exposure of apparent local problems in hospital quality and utilization and the precise definitions of their causes. Many PSROs have made substantial progress in the application and refinement of these techniques. The current state of the art is described in detail. Still to be determined over the next several years is the extent to which PSROs will be able to succeed in correcting these problems and whether the support and cooperation PSROs need form sister agencies and the political process will be adequate.

Concurrent Review↗

PubMed1992

Implementing practice guidelines through a utilization management strategy: the potential and the challenges.

Although there is currently much enthusiasm for practice guidelines, far more energy and resources have been expended on their development than on their implementation. A prospective interventional trial was performed using a previously validated explicit practice guideline (decision aid) to decrease the hospital length of stay for selected "low-risk" patients with chest pain. Utilization management (UM) coordinators (RNs) and physicians were chosen to implement the guideline since these resource people are available in most hospitals, allowing for generalization of the experience. With explicit review criteria used for 624 patients, it was found that when the guideline was applied by UM coordinators, it had a sensitivity of 0.85, a specificity of 0.90, a positive predictive value of 0.76, and a negative predictive value of 0.94. The attending physicians failed to override falsely classified low-risk patient recommendations 51% of the time. Implicit review judged that outcome might have theoretically been worsened in two of these patients. Follow-up at 30 days after admission, however, revealed no untoward sequelae in falsely categorized patients discharged according to the guideline. Utilization management appears to be a promising mechanism for guideline implementation that is available in most institutions. However, the accuracy with which UM coordinators implement guidelines should be assessed rigorously. Guidelines should be implemented in an environment of checks and balances in which physicians have the ultimate responsibility for their patients' care.

Adult↗

PubMed1976

Experimental models for DNA-RNA viral interactions: a brief review.

Evidences that demonstrate or imply the occurrence of DNA-RNA viral interactions in man and animals are reviewed. The concurrent presence of two dissimilar oncogenic viruses influenced responses both in vivo and in vitro. Cell-mediated immune responses to Marek's disease herpesvirus were altered in specific-pathogen-free chickens inoculated as embryos with an avian leukosis virus. The possible roles of immunological factors in the pathogenesis and control of tumor development associated with DNA-RNA viral interactions remain to be investigated.

Animals↗

PubMedDate not supplied

The impact of verbal communication on physician prescribing patterns in hospitalized patients with diabetes.

PURPOSE: The purpose of this descriptive clinical research study was to identify which method of communication, verbal or written, has the greatest impact on physician adjustment of the antidiabetes medication regimen for hospitalized patients with hyperglycemia. METHODS: The medical records for 1026 patients hospitalized with diabetes at a large, metropolitan, not-for-profit teaching hospital were reviewed by the diabetes inpatient clinicians to identify hyperglycemia and the potential need to initiate or adjust the antidiabetes medication regimen. The study evaluated the effectiveness of verbal versus written communication between the diabetes inpatient clinician and the physician regarding cases where the current antidiabetes medication regimen was not optimal. RESULTS: Verbal interaction between the diabetes inpatient clinician and the physician resulted in a greater number of changes in the antidiabetes medication regimen. CONCLUSIONS: Communication modality correlates with changes in antidiabetes medications prescribed by physicians and may be an effective tool to facilitate inpatient glycemic control.

Communication↗

PubMed1995

Implementing a computer-assisted appropriateness review using DRG 182/183.

BACKGROUND: The focus on patient outcomes as performance measures and on processes of care as systems to improve is intensifying. Nevertheless, appropriateness reviews are likely to remain essential (for example, studies evaluating inpatient admission, laboratory testing, invasive procedures, and discharge planning) for several reasons. METHODS: Forbes Regional Hospital (Monroeville, PA) undertook to redesign the process of appropriateness reviews using a computer-assisted methodology. The change was predicated on accessing electronically recorded clinical data collected as part of a state-mandated discharge reporting requirement. RESULTS: More than 90% of diagnosis-related group 182/183 (gastrointestinal/esophagitis) admissions were deemed appropriate on the basis of later manual reviews. This redesign was accomplished at no added expense while the amount of time required to complete the study was decreased. The ability to easily examine relationships identified during the evaluation was also expanded. The experience led to greater enthusiasm on the part of the medical staff to pursue more quality improvement projects. Creation of software programs that can be used repeatedly, modified to change existing thresholds, or expanded to include other conditions was another benefit. Clinicians gained valuable experience and familiarity with information systems. Lastly, all this was accomplished without purchasing new hardware, acquiring updated software, or relying on the presence of an electronic medical record.

Concurrent Review↗