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The Critical Care Research Network: a partnership in community-based research and research transfer.

The objectives of this study were to present a short history of the Critical Care Research Network (CCR-Net), describe its approach to health services research and to summarize completed and current research projects. In doing this, we explored the question is this research network accomplishing its goals? We reviewed the medical literature to identify studies on similar types of Networks and also the evidence supporting the methodology used by CCR-Net to conduct research using MEDLINE, HEALTHSTAR, CINAHL and the keywords network and health care or healthcare, benchmarking and health care or healthcare, and research transfer or research utilization. We also reviewed the bibliographies of retrieved articles and our personal files. In addition, we summarized the results of studies conducted by CCR-Net and outlined those currently in progress. A review of the literature identified studies on two similar networks that appeared to be succeeding. In addition, the literature was also supportive of the general process used by CCR-Net, although the level of evidence varied. Finally, the studies conducted to date within CCR-Net follow the suggested methodology. At the time of this preliminary communication CCR-Net appears to have adopted a valid approach to health services research within the area of Critical Care Medicine. Further direct evidence is required and appropriate studies are planned.

Canada↗

The effect of Evercare on hospital use.

OBJECTIVES: To examine the use of hospital and related medical care services of a novel managed care program using nurse practitioners (NPs) and directed specifically at long-stay nursing home residents. DESIGN: Quasi-experimental posttest design with two control groups to minimize selection bias. SETTING: Nursing homes. PARTICIPANTS: Evercare enrollees in five sites were compared with two sets of controls: nursing home residents in the same nursing homes who did not enroll in Evercare (control-in) and residents of nursing homes that did not participate in Evercare (control-out). MEASUREMENTS: Utilization data from Medicare and United Healthcare (the parent corporation for Evercare) were obtained for slightly more than 2 years. Patterns of use were assessed by calculating the monthly use rate for each group and aggregating to form annual rates. Usages addressed included hospital admissions and days, emergency room visits, therapy services, mental health services, and podiatry. Adjustments were made to correct for age, race, and sex. Because the groups differed in terms of the rate of cognitive impairment, the analysis was stratified on this variable. RESULTS: The incidence of hospitalizations was twice as high in control residents as in Evercare residents (4.63 and 4.67 per 100 enrollees per month vs 2.43 in the 15 months after census, P<.001). This difference corresponded to Evercare's use of intensive service days. The same pattern held for preventable hospitalizations (0.80 and 0.86 vs 0.28, P<.001). The pattern held when residents were stratified by cognitive status. On average, using a NP is estimated to save about $103,000 a year in hospital costs per NP. CONCLUSION: The use of active primary care provided by NPs may have prevented the occurrence of some hospitalizable events, but its major effect was allowing cases to be managed more cost-effectively.

Aged↗

The cost of implantable defibrillators: perceptions and reality.

AIMS: Recent guidelines have recommended more wide-ranging indications for the use of implantable cardioverter defibrillator (ICD) therapy, yet even more restrained previous guidelines have not been implemented for a variety of reasons. METHODS AND RESULTS: This brief review critically examines the reasons most frequently put forward to explain this failure. Contrary to the frequently repeated speculation that the risk stratification for sudden death and hence prophylactic placement of ICDs is reasonably accurate, there is little cost difference between pharmacotherapy and ICD treatment over the long term. ICD therapy does not utilize an undue proportion of the healthcare budget, and the healthcare systems in Europe can afford this therapy. CONCLUSION: Financial reasons are neither accurate nor adequate explanations for the failure of the European medical community to implement European guidelines for the implantation of ICDs for primary and secondary prevention of sudden cardiac death.

Cardiovascular Agents↗

The spider diagram nursing quality report card: bringing all the pieces together.

The proliferation of information about nurse-sensitive quality outcome measures in the current data-driven healthcare environment can be overwhelming. Effective utilization of such data is an even greater challenge. In this article, the authors describe how the use of a spider diagram can serve to combine data from various sources into more meaningful information for decision making. This innovative quality report card format helps nurse executives to quickly gain an understanding of the interrelationships among existing structure, process, and outcome quality indicators, as well as to identify actual or potential quality-of-care issues.

Benchmarking↗

Gastrointestinal diseases in the elderly.

PURPOSE OF REVIEW: The subject of gastrointestinal disorders in the elderly is timely and important because of the demographic reality that soon over 20% of our population will be older than 65 years of age, utilizing perhaps 50% of our total healthcare costs. The purpose of this review is to draw attention to some areas of clinical information that point in the direction of better clinical care for the elderly. Medicine is finally advancing from the era when most symptoms in older patients were ascribed to the aging process itself. Indeed, within gastroenterology there are few changes that occur inevitably as part of aging. RECENT FINDINGS: Progress has been made in several areas of gastrointestinal pathophysiology. These include: the pathophysiology of swallowing and evacuation disorders and the beginning of the application of techniques derived from physiological studies to improve function; recognizing the importance of reflux esophagitis and its complications and improving treatment; understanding the importance of disorders of malabsorption and their impact upon nutrition in the elderly; major issues in the diagnosis and management of inflammatory bowel disease in this age group; and approaches to the prevention and treatment of gastrointestinal cancer, particularly colorectal cancer. SUMMARY: As we pay more attention to these areas and encourage clinical research we expect to improve the treatment of older patients with these diseases and to reduce the burden of morbidity in this population.

Aged↗

Current modalities and new advances in the treatment of basal cell carcinoma.

Basal cell carcinoma (BCC) is one of the most common cancers. Surgical extirpation is currently the standard of care for BCC, which is associated with several advantages and disadvantages. Procedures such as surgical excision used to treat superficial BCC (sBCC) and nodular BCC (nBCC) may have high 5-year recurrence rates if tumors are not completely excised. Curettage with electrodesiccation is a common method for treating primary BCC. However, multiple cycles are recommended and the procedure can have unsatisfactory cosmetic results (e.g. scarring and hypopigmentation). Mohs micrographic surgery has a low rate of disease recurrence but is a specialized procedure usually limited to specific indications (e.g. high-risk tumors). Cryosurgery and photodynamic therapy require multiple cycles and are associated with variable cosmetic outcomes and recurrence rates. As with any procedure, potential risks and patient quality-of-life issues need to be considered. In addition, substantial patient and healthcare provider inconvenience limit the practical utility of some modalities. Pharmacologic interventions provide another treatment option as adjunctive or monotherapy. Investigations of imiquimod, a novel immune response modifier, have indicated that this topical, noninvasive agent is safe and well tolerated and may be efficacious in the treatment of BCC. This review will highlight the role of standard treatment modalities and introduce new advances in the treatment of BCC.

Administration, Cutaneous↗

Medicare-approved drug discount cards and renal transplant patients: how much can these cards reduce prescription costs?

BACKGROUND: Post-transplant prescription medications are expensive, often costing over 12,000 dollars annually. Many solid-organ transplant patients have Medicare coverage and patients enrolled in Medicare-approved drug discount card (MADDC) programs may be able to receive prescription medications at a reduced price. However, many transplant healthcare practitioners are unaware of the utility of MADDCs. The purpose of this study was to determine whether enrolling renal transplant patients (RTPs) into a MADDC produces significant savings in prescription costs. METHODS: Two Medicare RTPs, with prescription medication profiles representative of an RTP within 3 months post-transplant and an RTP greater than 5 yr post-transplant, were randomly selected from the Medication Access Program's database. Cost benefit analyses were from the patients' perspective and were performed using the: (i) prescription cost from the Medicare website of MADDCs that listed the greatest and least prescription costs compared with the retail cash price of the same prescription without using the MADDCs; and (ii) MADDCs' annual enrollment fee. The potential cost difference of using MADDCs and not using MADDCs to purchase the prescription medications were calculated. RESULTS: RTPs' monthly out-of-pocket cost for prescription medications ranged from 162 dollars to 340 dollars, and MADDCs offered discounts of 20-37% from retail prices; thus outweighing the MADDC enrollment cost. CONCLUSION: MADDCs, when selected and used appropriately, can reduce prescription medication cost for RTPs. Card selection is of great importance as discount rates vary greatly among cards, and only under restricted circumstances is a patient allowed to switch to another card. It is imperative that practitioners are aware of these programs and utilize cost-effective prescribing practices.

Cost Savings↗

Prognosis in critical care.

Prognostic risk prediction models have been employed in the intensive care unit (ICU) setting since the 1980s and provide health care providers with important information to help inform decisions related to treatment and prognosis, as well as to compare outcomes across institutions. Prognostic models for critical care are among the most widely utilized and tested predictive models in healthcare. In this article, we review and compare mortality prediction models, including the APACHE (1981), SAPS (1984), APACHE-II (1985), MPM (1987), APACHE-III (1991), SAPS-II (1993), and MPM-II (1993). We emphasize the importance of model calibration in this domain. In addition, we present a brief review of the statistical methodology, multiple logistic regression, which underlies most of the models currently used in critical care.

Artificial Intelligence↗

Prediction of length of stay of first-ever ischemic stroke.

BACKGROUND AND PURPOSE: Accurate information about hospital resource utilization is necessary for management of healthcare service. The purpose of this study was to determine the demographic and clinical predictors of length of hospital stay (LOS) of acute care hospitalization for first-ever ischemic stroke patients. METHODS: A group of 330 patients who suffered from first-ever ischemic stroke and were consecutively admitted to a medical center in southern Taiwan were followed prospectively. Because our intention was to identify the major predictors of LOS from the information available at admission, we evaluated only those factors that could be assessed at the time of admission. Univariate analysis and multiple regression analysis were used to identify the main predictors of LOS. RESULTS: The median LOS was 7 days (mean, 11 days; range, 1 to 122 days). Among the prespecified demographic and clinical characteristics, National Institutes of Health Stroke Scale (NIHSS) score at admission, the quadratic term of the initial NIHSS score, modified Barthel Index score at admission, small-vessel occlusion stroke, sex, and smoking were the main explanatory factors for LOS. In particular, for each 1-point increase in the total score of NIHSS, LOS increased approximately 1 day for patients with mild or moderate (score 0 to 15 points) neurological impairments, while LOS decreased approximately 1 day for patients with severe (score >15 points) neurological impairments. CONCLUSIONS: The severity of stroke, as rated by the total score on NIHSS, is an important factor that influences LOS after acute stroke hospitalization.

Adolescent↗

Cost-utility analysis of chemotherapy in symptomatic advanced nonsmall cell lung cancer.

When using chemotherapy in patients with a short life expectancy, outcomes such as symptom improvement or clinical benefit receive increasing attention. Outcomes of subjective benefit to the patient can be rated as a utility in order to perform health economic analyses and comparisons with other treatment conditions. A cost-utility analysis has been performed alongside a prospective randomised clinical trial comparing single agent gemcitabine to cisplatin-based chemotherapy in symptomatic advanced nonsmall cell lung cancer patients. Global quality of life as well as resource utilisation data were collected during first-line chemotherapy for both treatment arms. Incremental costs, utilities and cost-utility ratio were calculated. Per patient, an incremental cost of 1,522 was obtained for gemcitabine compared to cisplatin-vindesine, mainly as a consequence of the direct cost of the cytotoxic drugs. When combined with utilities, this resulted in an incremental cost-utility ratio for gemcitabine of 13,836 per quality-adjusted life year gained. In conclusion, although the least expensive strategy is cisplatin-vindesine, the greater clinical benefit of gemcitabine, resulting in an acceptable incremental cost-utility ratio as compared with other healthcare interventions, balances its higher cost. The gains in subjective outcome achieved with palliative chemotherapy are critical from both a clinical and a health economic point of view.

Adult↗

Cost effectiveness of recombinant human insulin-like growth factor I therapy in patients with ALS.

OBJECTIVE: Amyotrophic lateral sclerosis (ALS) is a fatal, degenerative neuromuscular disease characterised by a progressive loss of voluntary motor activity. Recombinant human insulin-like growth factor I (rhIGF-I) has been shown to be useful in treating ALS. The purpose of this study was to examine the cost effectiveness of rhIGF-I therapy in patients who have ALS. DESIGN: We performed a cost-effectiveness analysis from the societal perspective on 177 patients who received treatment with rhIGF-I or placebo in a North American randomised clinical trial. We estimated the incremental cost-effectiveness ratio of rhIGF-I using resource utilisation and functional status measurements from the clinical trial. Costs were estimated from 1996 US Medicare reimbursement schedules. Utility weights were elicited from ALS healthcare providers using the standard gamble technique. MAIN OUTCOME MEASURES AND RESULTS: The overall cost per quality-adjusted life-year (QALY) gained for rhIGF-I therapy compared with placebo was $US67,440. For the subgroups of patients who were progressing rapidly or were in earlier stages of disease at enrolment, rhIGF-I cost $US52,823 and $US43,197 per QALY gained, respectively. CONCLUSIONS: Treatment with rhIGF-I is most cost effective in ALS patients who are either in earlier stages of the disease or progressing rapidly. The cost effectiveness of rhIGF-I therapy compares favourably with treatments for other chronic progressive diseases.

Adult↗

Employee participation programs after electromation: they're worth the risk!

Employee participation programs (¿EPP¿s) can be an invaluable means of utilizing employee input, particularly in the healthcare industry. However, the National Labor Relation Board's (¿NLRB¿) recent decision in Electromation, Inc. affects the structure and use of EPPs. There are still ways in which EPPs can be structured to meet the NLRB's requirements.

Decision Making, Organizational↗

Medial branch neurotomy in management of chronic spinal pain: systematic review of the evidence.

Zygapophysial or facet joints have been implicated as cause of low back, mid back, upper back and neck pain with referred pain. Cervical, thoracic and lumbar facet joints are innervated by the medial branches of the dorsal rami. Zygapophysial (facet) joints have been implicated as the source of chronic pain in 15% to 45% of the patients with chronic low back pain, 54% to 60% of the patients with chronic neck pain and 48% of the patients with thoracic pain. A systematic review of the evidence of effectiveness of radiofrequency denervation in the management of chronic spinal pain was undertaken. This review included randomized clinical trials, as well as non-randomized or observational studies in the analysis. Literature search included MEDLINE, EMBASE, systematic reviews, narrative reviews, cross-references to the reviews and various published trials; and peer reviewed abstracts from scientific meetings during the past two years. An algorithmic approach was followed in study evaluation with a description of inclusion and exclusion criteria. A set of high-performing scales or checklists pertaining to randomized clinical trials and observational trials derived from the Agency for Healthcare Research and Quality (AHRQ) was utilized; Systems to Rate the Strength of Scientific Evidence. Qualitative analysis was conducted, using five levels of evidence for effectiveness of medial branch neurotomy. Our search strategy identified over 1,000 citations as the result of electronic and manual screening. A total of 7 randomized trials of radiofrequency neurotomy for spinal pain were identified. However, only 4 related to medial branch neurotomy. Two of the four met the inclusion criteria. Among the multiple observational studies considered for inclusion, 4 prospective evaluations were included in the systematic review. In addition, 3 retrospective evaluations were also included. Two randomized trials comprised of 27 patients receiving active treatment. The first study consisted of cervical facet joint pain and the second consisted of lumbar facet joint pain. Both studies showed positive results. Similar to randomized trials, prospective, as well as retrospective evaluations showed positive evidence, both in short-term and long-term. The results of this systematic review of 2 well-designed randomized trials, 4 prospective well-designed trials without randomization and 3 retrospective evaluations provided strong evidence that radiofrequency denervation offers short-term relief and moderate evidence of long-term pain relief of facet joint origin.

Journal Article↗

Using staffing and scheduling information to support change.

The growing demand for information about healthcare providers can be met by utilizing the enormous amount of information stored in computerized staffing and scheduling systems. Faster and more accurate staffing, along with optimal use of the available skill mix, enhances both productivity and quality of care. Decreasing overtime and minimizing or eliminating agency care can be far more effective cost savers than direct FTE reduction. Also, data related to staff retention can be invaluable in planning proactive approaches.

Humans↗

Impact of cost cutting on laboratories: new business strategies for laboratories.

Cost reduction is the primary force driving healthcare reform. To survive and thrive in these tumultuous times, laboratories must adapt and implement new business strategies. Business paradigm shifts create opportunities for organizations with a plan; a wait-and-see attitude forecasts failure. Drawing upon an 11-year experience with the "ARUP business model," this work will highlight business strategies that have contributed to the success of this university-based reference laboratory. In the future, successful laboratories will implement new business strategies to become more effective members of the emerging integrated healthcare delivery teams. Within the laboratory, traditional organizational disciplinary boundaries, i.e., chemistry, microbiology, and hematology, are melding together to increase efficiency. Laboratorians must become influential members of institutional healthcare delivery teams formed to control utilization. Laboratory services are being adjusted to optimize patient care. Incremental pricing is only one of the strategies to be implemented to expand outpatient business to those in the region. Expanded computer capabilities, client services, specimen handling, marketing, and sales are also required. On a regional basis, service laboratories are increasingly joining forces to increase efficiency while at the same time improving the quality of patient care.

Chemistry, Clinical↗

Dental hygienists in Hong Kong: present and future status.

PURPOSE: This study assessed the current employment status of dental hygienists practicing in Hong Kong, investigated factors affecting their employment, evaluated the satisfaction of local dental hygienists and their employers, and explored the career prospects of dental hygienists in Hong Kong. METHODS: All registered dental hygienists (n = 64), all dentists who employed dental hygienists (n = 25), and a systematic sample of dentists who did not employ dental hygienists (n = 278) were surveyed in June 1994 concerning employment situation, salaries, job satisfaction, and opinions on future prospects for dental hygienists. RESULTS: Response rates were 86% for dental hygienists (n = 55), 88% for employers (n = 22), and 63% for dentists at large (n = 175). Among the dental hygienists, 87% still were employed as dental hygienists, and both the dental hygienists and their employers agreed that the employment situation was satisfactory; however, several dental hygienists were considered to be working below their level of qualification. Major reasons for dentists not to employ a dental hygienist were having only one operatory and having an inadequate number of patients. In general, employers expressed satisfaction with the performance of the dental hygienists. Major reasons for employing a dental hygienist were that a dental hygienist would add professional and economical benefit to their clinic. Few dentists would support expanded duties for dental hygienists. CONCLUSIONS: In Hong Kong, dental hygienists and their employers comprise a small group with limited impact on oral healthcare services. Dental hygienists' perceptions of their future roles and ambitions are higher than those of their employers. To further the development of dental services in Hong Kong and meet documented oral healthcare needs in the population, greater utilization of dental hygienists should be promoted.

Career Mobility↗

Converting an integrated hospital formulary into an object-oriented database representation.

Controlled Medical Vocabularies (CMVs) have proven to be extremely useful in their support of the tasks of information sharing and integration, communication among various software applications, and decision support. Modeling a CMV as an Object-Oriented Database (OODB) provides additional benefits such as increased support for vocabulary comprehension and flexible access. In this paper, we describe the process of modeling and converting an existing integrated hospital formulary (i.e., set of pharmacological concepts) into an equivalent OODB representation, which, in general, we refer to as an Object-Oriented Healthcare Vocabulary Repository (OOHVR). The source for our example OOHVR is a formulary provided by the Connecticut Healthcare Research and Education Foundation (CHREF). Utilizing this source formulary together with the semantic hierarchy composed of major and minor drug classes defined as part of the National Drug Code (NDC) directory, we constructed a CMV that was eventually converted into its OOHVR form (the CHREF-OOHVR). The actual conversion step was carried out automatically by a program, called the OOHVR Generator, that we have developed. At present, the CHREF-OOHVR is running on top of ONTOS, a commercial OODB management system, and is accessible on the Web.

Databases as Topic↗

Public health improvement in Iran--lessons from the last 20 years.

INTRODUCTION: Health services are historically based on providers's and policy makers's understanding of population health status. This does not necessarily reflect the real needs of a population. Health needs assessment (HNA) should improve individual or population health and optimize the way that limited resources are utilized. OBJECTIVES: To review health needs literature and to describe Iranian primary healthcare (PHC) achievements in developing a needs-driven health system. FINDINGS: The Iranian PHC system was established to meet healthcare needs identified through population health status surveys. Since 1984, the PHC system has become highly organized and efficient, resulting in a dramatic decrease in infant, maternal and neonatal mortality rates, population growth, increasing life span and a marked shift towards non-communicable diseases. Through an organized partnership of the general population, volunteers, health workers and health professionals, a needs-oriented healthcare system became central to health policy in Iran. Several information sources were utilized to establish need. Improving death certification was an immediate and important part of this process. COMMENT: Improved knowledge about personal rights, community and environmental health policies, and involvement of the media led to an increased range and depth of needs. Moving towards quality improvement and a needs-driven healthcare system requires continuous needs assessment. Novel methods of HNA, such as postal and telephone surveys, group discussions, surrogates for need such as quality-of-life measurement (commonly used in developed countries) or other locally designed methods such as the basic development needs approach, may be relevant to the Iranian PHC network.

Data Collection↗