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At least 145 records · Page 8Linked to original sources
PubMed1997

Brief cognitive-behavioral group treatment for children's headache.

OBJECTIVE AND DESIGN: Using a randomized design with a waiting list control condition, we assessed the effectiveness of an abbreviated cognitive therapy group program for headaches in children 7 to 12 years of age. In the treatment condition, small groups of five to eight children were taught relaxation, distraction, visualization, and stress management skills in two 90-minute sessions. Parent groups, seen concurrently, reviewed the children's program and addressed parenting strategies. The waiting list control groups were treated 5 weeks later. Thirty-six children meeting inclusion criteria were included in the study; complete data were available for 29 participants (mean age, 9.4 years; 66% female). DEPENDENT MEASURES: We obtained children's ratings of headache frequency, intensity, duration, and five other variables in a diary kept for 3 weeks before and 3 weeks after treatment. Parent measures were collected once before treatment and once at 3-month follow-up. RESULTS: CHILD RATINGS: The control condition showed a significant reduction in children's self-rated headache frequency, while the treatment condition did not. On all other self-reported variables, there were no significant differences between the control and treatment conditions. Two participants in each condition achieved a 50% or greater reduction in a self-rating headache index. RESULTS: PARENT RATINGS: Follow-up ratings, obtained over the telephone from parents after the children in both conditions had been treated, indicated that the children in both conditions had experienced reduced intensity, frequency, and duration of headaches and that 82% of the children were using the techniques taught in the program. Fourteen children achieved a 50% or greater reduction in a headache index based on parent ratings. CONCLUSIONS: Although parents were very positive about the effectiveness of the program, the results for children's self-ratings do not support the use of this highly abbreviated treatment method.

Behavior Therapy↗
PubMed1984

Teaching cost-effective diagnostic test use to medical students.

The purpose of this project was to develop and evaluate a program to teach medical students how to order diagnostic tests in a cost-effective manner. The 1-month educational program included a seminar, a simulated patient-care exercise, special case presentations by students, newsletters about diagnostic tests, and concurrent review of patients' bills. Content analysis of answers to open-ended questions and pretests and posttests were used to measure differences in the study and control groups. Although students said the program was useful, no significant differences were found in students' knowledge, attitudes, or simulated test-ordering behavior. The authors conclude that the lack of improvement in objective measures limits the potential effectiveness of restricted efforts such as this one and that the discrepancy between the subjective and objective measures reinforces the need for more rigorous evaluations of programs that teach cost-effective diagnostic test use.

Attitude of Health Personnel↗
PubMed1999

Controlling workers' compensation medical care use and costs through utilization management.

Little is known about the performance of utilization management (UM) programs, which are now widely used within the workers' compensation system to contain medical costs and improve quality. UM programs focus largely on hospital care and rely on preadmission and concurrent reviews to authorize hospital admissions and continued stays. We obtained data from a large UM program representing a national sample of 9319 workers' compensation patients whose medical care was reviewed between 1991 and 1993. We analyzed these data to determine the denial rate for hospital admission and outpatient surgery and the frequency of length-of-stay restrictions among hospitalized patients. The denial rate was approximately 2% to 3% overall, but many of the denials were later reversed. On average, the UM program reduced the length of stay by 1.9 days relative to the number of days of care requested. The estimated gross cost savings resulting from reduced hospitalization time and decreased outpatient care was approximately $5 million. UM programs may offer a viable approach to cost containment within the workers' compensation system. Their value as a tool to improve the quality of care for workers' compensation patients remains to be demonstrated.

Adult↗
PubMed1993

Comparison of one-day and three-day calorie counts in hospitalized patients: a pilot study.

OBJECTIVE: To determine whether a 1-day calorie count can replace the labor-intensive 3-day calorie count commonly, performed in hospitalized patients when estimates of caloric and protein intake are required. DESIGN: Pilot study using prospective, non-concurrent review of medical records. SETTING: Hospital. PARTICIPANTS: Thirty patients (mean age 67 years). RESULTS: Mean 3-day intake (952 +/- 91 calories, 41 +/- 4 g protein) was about half of calculated requirements; first-day intake was similar (918 +/- 116 calories, 40 +/- 5 g protein). The first day had high sensitivity (calories 96%; protein 93%) and positive predictive value (calories 100%; protein 96%). Malnutrition was evident; three-fourths of patients had weights below recommended ranges, and 83% were hypoalbuminemic. CONCLUSIONS: Three-day calorie counts are frequently performed in patients suspected of eating poorly. Results of this pilot study suggest that 1-day calorie counts may be a valid alternative. However, readily available anthropometric and biochemical data may be as good an indicator of inadequate dietary intake.

Adult↗
PubMed2002

CT angiography with whole brain perfused blood volume imaging: added clinical value in the assessment of acute stroke.

BACKGROUND AND PURPOSE: In CT angiographic and perfusion imaging (CTA/CTP), rapid CT scanning is performed during the brief steady state administration of a contrast bolus, creating both vascular phase images of the major intracranial vessels and perfused blood volume-weighted parenchymal phase images of the entire brain. We assessed the added clinical value of the data provided by CTA/CTP over that of clinical examination and noncontrast CT (NCCT) alone. METHODS: NCCT and CTA/CTP imaging was performed in 40 patients presenting with an acute stroke. Short clinical vignettes were retrospectively prepared. After concurrent review of the vignettes and NCCT, a stroke neurologist rated infarct location, vascular territory, vessel(s) occluded, and Trial of Org 10172 in Acute Stroke Treatment (TOAST) and Oxfordshire Community Stroke Project classifications. The ratings were repeated after serial review of each of the CTA/CTP components: (1) axial CTA source images; (2) CTP whole brain blood volume-weighted source images; and (3) maximum-intensity projection 3-dimensional reformatted images. The sequential ratings for each case were compared with the final discharge assessment. RESULTS: Compared with the initial review after NCCT, CTA/CTP improved the overall accuracy of infarct localization (P<0.001), vascular territory determination (P=0.003), vessel occlusion identification (P<0.001), TOAST classification (P=0.039), and Oxfordshire Community Stroke Project classification (P<0.001) by 40%, 28%, 38%, 18%, and 32%, respectively. CONCLUSIONS: Admission CTA/CTP imaging significantly improves accuracy, over that of initial clinical assessment and NCCT imaging alone, in the determination of infarct localization, site of vascular occlusion, and Oxfordshire classification in acute stroke patients.

Aged↗
PubMed2002

Psychometric properties and utility of the problem severity summary for adults with serious mental illness.

OBJECTIVE: The authors studied the psychometric properties and utility of the Problem Severity Summary (PSS), a 13-item instrument that assesses symptom severity and functioning among adults with severe and persistent mental illness. METHODS: Case managers rated the PSS among more than 1,000 adults with severe and persistent mental illness who were receiving services at either mainstream community mental health centers or specialty community mental health centers (serving various minority groups) in one county in Washington State. A subsample of clients was used to assess the concurrent validity of the PSS with the Psychiatric Symptom Assessment Scale. RESULTS: Interrater reliability was adequate for ten of the 13 PSS items. Four meaningful factors were derived, each with adequate internal consistency: community functioning, negative social behavior, affective distress, and psychotic disturbance. The PSS demonstrated adequate concurrent and predictive validity. Sensitivity of the PSS factors to change showed that scores on three of the four scales changed significantly over one year. Discriminant validity indicated that the PSS is generally unbiased in terms of demographic characteristics. CONCLUSIONS: The PSS is a brief, easily administered instrument that shows psychometric promise for use in clinical contexts, such as treatment planning, concurrent review of care, and guidance for level-of-care decisions, as well as for quality management purposes.

Adult↗
PubMedDate not supplied

A quality improvement project for better glycemic control in hospitalized patients with diabetes.

PURPOSE: A quality improvement (QI) study was designed to improve nursing interventions that impact glycemic control in hospitalized patients with diabetes. The objective was to improve the timing of premeal insulin to allow a half hour lag time for regular insulin. METHODS: An interdisciplinary planning team was established that included both medical and surgical units. Data were collected by concurrent review of electronic charts, evaluated monthly by management and the diabetes clinical coordinator, and shared with staff. RESULTS: This QI study increased staff nurses' awareness of the importance of their role in achieving better glycemic control for inpatients with diabetes. By the end of the study, the nurses delivered premeal insulin correctly 82% of the time on the medical unit, 65% of the time on the cardiac unit, and 61% of the time on the surgical unit. Even with concerted effort, however, it was difficult to consistently administer regular insulin with a half hour lag time in the hospital environment. CONCLUSIONS: By working together with the patient, family, and other staff, nurses can more consistently deliver premeal insulin at appropriate times to help improve glycemic control in the hospitalized patient with diabetes.

Blood Glucose↗
PubMed2006

Prophylaxis against venous thromboembolism in acutely ill medical patients: an observational study.

STUDY OBJECTIVES: To determine the risk factors for venous thromboembolism (VTE) and the rates of prophylactic measures used in acutely ill medical patients. DESIGN: Prospective observational study. SETTING: Academic tertiary care medical center. PATIENTS: One hundred seventy-nine patients admitted to three general medical units over 30 consecutive days and hospitalized for at least 3 days. MEASUREMENTS AND MAIN RESULTS: On concurrent review of the patients' medical records, 138 (77.1%) of 179 patients received one or more forms of VTE prophylaxis during their hospital stay. Of 41 (22.9%) patients receiving no VTE prophylaxis, 22 (53.7%) had and 19 (46.3%, or 10.6% of the total population) did not have a documented contraindication to anticoagulation. One hundred ten patients (61.5%) had three or more documented VTE risk factors for VTE. The most common prophylaxis was unfractionated heparin 5000 U injected subcutaneously twice/day. Therapeutic anticoagulation was given to 51 patients (28.5%) at some time during their hospitalization for indications other than VTE treatment. Two developed symptomatic VTE (1.1%) while hospitalized. Four patients (2.2%) receiving anticoagulants had adverse outcomes. One patient had minor bleeding, and one developed heparin-induced thrombocytopenia without thrombosis. CONCLUSION: Rates of VTE prophylaxis were higher than previously reported rates, although no formalized guidelines, standardized order sets, alerting programs, training, or risk-stratification tools were used during the study period. Rates of adverse events were low.

Academic Medical Centers↗
PubMed1999

Guiding the decision to transfuse.

Guiding the decision to transfuse can improve transfusion practices. Effective processes must first identify problem(s) in transfusion practice and then include the attending physician as an educational target. Process improvements that have been shown to be effective include the following: (1) briefly meeting one-on-one with physicians, (2) teaching at scheduled conferences, (3) making daily clinical rounds of patients who receive transfusion, (4) concurrently reviewing orders for transfusion before issue of the blood product, and (5) installing algorithms and guidelines in the operating room. Transfusion practices improved with these process improvements.

Blood Transfusion↗
PubMed2006

Outcomes of community-acquired, methicillin-resistant Staphylococcus aureus, soft tissue infections treated with antibiotics other than vancomycin.

Community-acquired, methicillin-resistant Staphylococcus aureus (cMRSA), soft tissue infections are becoming increasingly prevalent in the outpatient setting. Few studies have been specifically designed to examine the efficacy of oral antibiotic therapy for these infections. We performed an observational study to determine the effect of alternative, orally administered antibiotics on cMRSA soft tissue infections. Consecutive patients between January 2001 and March 2004 who had skin or soft tissue infections from which cMRSA was isolated and who had never received vancomycin were studied through retrospective and concurrent review. Primary outcome measures were improvement or resolution of infection 5 and 14 days after initiation of treatment with orally administered antibiotics and rates of recurrence within 30 days after completion of treatment. Thirty subjects met the inclusion criteria. Twenty-one subjects received either clindamycin, trimethoprim/sulfamethoxazole, doxycycline/minocycline, or a fluoroquinolone. Five subjects received a beta-lactam antibiotic with abscess drainage, and four subjects underwent abscess drainage alone. Improvement was noted for all subjects at 5 days, complete resolution of infection occurred for all subjects by 14 to 17 days, and in no case did relapse occur within 30 days. cMRSA skin and soft tissue infections can be successfully treated with orally administered antibiotics to which the organism has demonstrable in vitro susceptibility.

Adolescent↗
PubMed1991

Pulse oximetry monitoring outside the intensive care unit: progress or problem?

OBJECTIVE: To evaluate the use of continuous pulse oximetry monitoring in general care units. DESIGN: Hemoglobin oxygen saturation data collected prospectively by use of pulse oximetry with concurrent review of the medical record. SETTING: General medical-surgical nursing units in a large, tertiary care university hospital. PATIENTS: Forty patients on two nursing units monitored with continuous, bedside pulse oximetry at the request of their primary physicians. MEASUREMENTS: All patients had continuous pulse oximetry monitoring. A research associate visited the bedside two or three times daily and recorded saturation compared with time data from the previous 8.75 hours. Patients were studied for 36 hours or until pulse oximetry monitoring was discontinued. Episodes of desaturation were counted. Patient charts were reviewed for documentation of desaturation in either nursing or physician notes. Orders adjusting oxygen therapy or other respiratory therapy within 12 hours of any desaturation episode were also recorded. MAIN RESULTS: Thirty of the 40 patients (75%) had at least one episode of desaturation to less than 90%; 23 (58%) had at least one episode to less than 85%. Desaturation episodes were documented in nursing notes for only 33% of those patients who desaturated to less than 90% and in physician notes in only 7% of cases. Changes in respiratory therapy were ordered in 20% of patients who desaturated to less than 90% and in only 26% who desaturated to less than 85%. CONCLUSIONS: Despite their repeated occurrence, episodes of hypoxemia were rarely documented in either nursing or physician notes. Further, even in patients who had episodic desaturation, pulse oximetry monitoring had little effect on changes in physician-directed respiratory care.

Adult↗
PubMed1991

The use of norfloxacin in a university hospital.

Because of increasing norfloxacin use and the development of resistant organisms, an evaluation was undertaken in a University Hospital to assess the appropriateness of norfloxacin for the treatment of urinary tract infections and to calculate the potential cost savings associated with more cost-effective antibiotic therapy. Medical records of 64 patients receiving norfloxacin for a 31-day period were concurrently reviewed. Of these, 58 patients were treated for urinary tract infections and four patients received urinary tract infection prophylaxis. Fourteen patients were prescribed solely empiric therapy whereas an additional 44 patients received definitive treatment confirmed by culture results. Based on the predetermined criteria, norfloxacin use for the definitive treatment of urinary tract infections was deemed to be appropriate in 34 of the 44 patients. Three additional courses of therapy were also judged to be appropriate due to documented signs and symptoms associated with urinary tract infections, despite cultures with less than 10(5) colony forming units per mL urine. Reasons for inappropriate use in the remaining seven patients included isolation of fewer bacteria than required by the criteria in asymptomatic patients (3 cases), isolation of organisms not sensitive to norfloxacin (1 case) and lack of dosage adjustment for renal insufficiency (3 cases). Nineteen of 32 evaluable inpatients (59%) received norfloxacin when a less expensive, equally effective agent was available. Although savings from more cost-effective therapy of urinary tract infections are minimal, due to the potential emergence of resistant organisms, norfloxacin should be reserved for infections not amenable to treatment with other oral antibiotics.

Cost Control↗
PubMed1993

How to assemble a patient-centered pharmacy QI program.

The QI program is patient driven. The question "How does this monitoring affect the patient?" is central to decisions on designing indicators. Time spent on the various levels of quality assessment in the Pharmacy QI Committee is proportional to patient impact. Personnel time devoted to concurrent review of dosing and drug interaction overrides, drug information response accuracy, and therapeutic drug monitoring reflects the importance the Pharmacy Department places on maintaining a drug therapy safety net. The patient is central to the pharmacy QI program. The spirit of the Joint Commission's standards is met; acceptable documentation completes the requirements.

Adverse Drug Reaction Reporting Systems↗
PubMed1976

Development of hospital levels of care criteria.

A modification of the Nominal Group/Delphi Technique can be applied to the problem of developing among physicians levels-of-care criteria for use in "concurrent review" activities. UR requirements can be rationalized through a process that uses physicians' scarce time effectively, allows for cyclical feedback on their peers' views, and insures input from both dominant and reticent individuals.

Asthma↗
PubMed1989

The provision of home health care services through health maintenance organizations.

The vast majority of the HMOs responding to the survey in this study use home health care as a substitute for acute inpatient hospitalization, contract out for services with community-based home health agencies, reimburse on a discounted fee-for-service basis, and use prior authorization and concurrent review as the primary methods to control the use of home health care. These findings suggest that HMO home health care services mirror the inadequacies of Medicare home health care in that they are acute care-focused and not intended to fill the supportive and maintenance care needs of the chronically ill elderly. HMOs, however, are typically more flexible in their service provision than is Medicare. Need for home health care is determined primarily on prospective, case-by-case evaluations of cost effectiveness, not on retrospective determinations based on strict, and sometimes arbitrary, guidelines and limitations. This, however, does raise some important issues for access and quality and for the relationship between HMOs and home health agencies. Is cost containment the only legitimate reason for providing home health care? Should home health care be used solely as a substitute for acute inpatient hospitalization? Where does the locus of authority lie for deciding coverage of home health care services? This study uncovered several issues related to the provision of home health care in HMOs that created conflict and uncertainty for all parties. These issues included: conflicting roles for HMOs, whether to provide services internally or externally, contracting between HMOs and home health agencies, the locus of authority for utilization review, the role of physicians, quality assurance, and perceived problems with the Health Care Financing Administration. HMOs are often perceived as failing to do an adequate job of providing home health care services because of the difficulty in satisfying conflicting considerations in three key areas: whether home health care should be focused on cost containment or meeting unmet needs, whether home health care should be focused on acute or long term care, and the unrealistic expectations patients and providers have of HMOs. HMOs primarily provide home health care in an effort to contain costs, particularly by using home health care to substitute for inpatient hospitalization. While HMO representatives acknowledge the importance of home health care in improving the patient's and family's quality of life by providing supportive or chronic maintenance care, the use of home health care for this purpose is generally not allowed by HMOs.(ABSTRACT TRUNCATED AT 400 WORDS)

Acute Disease↗
PubMed1989

Legal issues in neonatal intensive care.

The issues surrounding the selective nontreatment of disabled neonates are complex. These difficult problems are exacerbated by an ambiguous legal environment in which existing statutes are not enforced and case law provides guidance but little clear leadership (Weir 1984). It is difficult to measure the effect such legal mire has on those who make the nontreatment decisions and those who guide those who make them. While some published material suggests that physicians will act in what they believe to be the patient's best interests without regard for the law, others may be more intimidated (Frohock 1986), and even among those who are not, it is not clear whether their decisions are indeed wise and just. The status quo of laws selectively enforced is desirable to some, but having laws that are selectively enforced may make others fearful and suspicious. Nonenforcement of the laws also allows individual parents and physicians wide discretion in the making of these decisions that may not be in the best interest of the infants involved (Crossley 1987). There should be, within the legal system, a goal of providing a framework that provides consistency in the application of nontreatment decisions, removes the legal ambiguity that surrounds such decisions, and reflects a societal consensus about neonatal intensive care treatment issues (Robertson 1981; Weir 1984). Such a framework might be institution based, legislated, or a combination using state-provided child advocates and hospital ethics committees. In the absence of such a framework hospitals should be cautious to provide the necessary mechanisms for the concurrent review of neonatal nontreatment decisions so as to prevent liability for themselves and their staffs. Such reviews should be made by a committee of experts. The committee should be willing to comply with the reporting laws and to turn to the courts when necessary.

Child Advocacy↗
PubMed2000

Variability in code selection using the 1995 and 1998 HCFA documentation guidelines for office services. Health Care Financing Administration.

BACKGROUND: Documentation guidelines have been developed by the Health Care Financing Administration (HCFA) to promote consistent selection of physician evaluation and management (E & M) codes. Our goals were to determine whether medical providers and auditors agree in their assignment of office codes using 1995 and 1998 guidelines and to ascertain if the code levels assigned are affected by auditor experience and training. METHODS: A total of 1,069 established patient charts from private family physician offices were reviewed by a family practice faculty physician, a family practice resident physician, and a professional coder. The main outcome measures were the agreement between the auditors and the medical care provider on code selection and the degree to which documentation supported the code selected. RESULTS: All auditors agreed with the medical provider code selection in only 15.2% (1995 guidelines) and 29.2% (1998 guidelines) of visits. Professional coders were more likely than faculty physicians or resident physicians to agree with the code assigned by the medical provider (51.7% vs 40.7% and 39.6%, P <.001). Documentation adequately supported the most common office code selection, 99213, in 92.7% (1995) and 91.0% (1998) of the charts reviewed. Concurrence among all auditors was only 31.0% (1995) and 44.3% (1998). CONCLUSIONS: Interobserver differences exist in the assignment of E & M codes by auditors using both 1995 and 1998 HCFA guidelines. The 1998 documentation guidelines produce greater agreement among auditors. The documentation supported the level of code billed in the majority of established patient office visits.

Ambulatory Care↗
PubMed2003

Problem-based learning in a managed care seminar for all new residents at an academic medical center.

One of the most important challenges in resident education is to train residents how to function in relation to managed care companies and systems so as to enhance the quality, accessibility, and efficiency of health care. Since 1996, The University of Texas Medical Branch in Galveston has presented an annual half-day seminar on managed care to new residents. The format involves training sessions and didactic presentations aimed at small groups (led by faculty physicians and nonphysicians from throughout the medical and managed care establishments). Problem-based learning sessions conducted in these groups focus on topics such as the organization of managed care systems, access, network, admit versus observation, inpatient status, denials, avoidable hospital days, concurrent reviews, gatekeepers, referrals, behavioral health, disease management programs, and financial considerations. Pretests and posttests are given to those participating to gauge the effectiveness of the program. In addition, participants complete evaluation forms that can be used by program coordinators to assess resident satisfaction with the learning format and to determine what improvements can be made in the process. For the 1999 and 2000 seminars, posttest results were significantly higher than pretest results for the new residents who participated in the seminar. Each year, seminar evaluations show that the small-group format is well received. We conclude that the small-group learning format is effective and enjoyable for the residents and their leaders. The format necessitates the training of 30 group leaders to increase their knowledge of managed care systems.

Humans↗