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At least 1,639 records · Page 91Linked to original sources
PubMed1990

The Self-Adapting Focused Review System. Probability sampling of medical records to monitor utilization and quality of care.

Medical record review is increasing in importance as the need to identify and monitor utilization and quality of care problems grow. To conserve resources, reviews are usually performed on a subset of cases. If judgment is used to identify subgroups for review, this raises the following questions: How should subgroups be determined, particularly since the locus of problems can change over time? What standard of comparison should be used in interpreting rates of problems found in subgroups? How can population problem rates be estimated from observed subgroup rates? How can the bias be avoided that arises because reviewers know that selected cases are suspected of having problems? How can changes in problem rates over time be interpreted when evaluating intervention programs? Simple random sampling, an alternative to subgroup review, overcomes the problems implied by these questions but is inefficient. The Self-Adapting Focused Review System (SAFRS), introduced and described here, provides an adaptive approach to record selection that is based upon model-weighted probability sampling. It retains the desirable inferential properties of random sampling while allowing reviews to be concentrated on cases currently thought most likely to be problematic. Model development and evaluation are illustrated using hospital data to predict inappropriate admissions.

Bias↗
PubMed1985

Data quality and DRGs: an assessment of the reliability of federal beneficiary discharge data in selected Manhattan hospitals.

New York County Health Services Review Organization (NYCHSRO), the physicians' professional standards review organization of Manhattan, examined whether diagnostic coding errors identified in Manhattan hospitals would affect reimbursement under a diagnostic-related group (DRG) method of financing inpatient services. A sampling of 1,027 Medicare and Medicaid cases representing discharges from 18 Manhattan hospitals during 1982 and 1983 revealed incorrect DRG assignment for 17.5% of patient record abstracts, but these appear to have been unsystematic rather than deliberate errors. The difference between estimated reimbursement based on original and reabstracted records was not statistically significant either in the aggregate or for specific hospitals. It is emphasized that while New York State's Prospective Hospital Reimbursement Methodology (in effect during the study period) is not solely dependent upon DRG's case-mix is one of several factors used to make adjustments to existing per diem rates. A key recommendation is that hospitals conduct internal monitorings with all involved departments to improve the quality of the data abstracting process.

Diagnosis-Related Groups↗
PubMed2000

Race and sex differences in the management of coronary artery disease.

Although numerous studies have documented race and sex differences in the treatment of coronary artery disease, the available analyses have not been comprehensively evaluated. In this review, we summarize prior estimates of race and sex disparities in the utilization of standard tests and therapies, and we evaluate studies of factors that may contribute to gaps in care. The studies presented consistently demonstrate that blacks and women with coronary artery disease, compared with whites and men, are substantially less likely to receive standard interventions. Studies also indicate that racial differences relate in part to socioeconomic factors, process-of-care variables, and patient preferences, whereas sex differences relate in part to clinical factors. In both cases, however, our understanding is limited by deficiencies in currently available datasets. Moreover, factors that have been shown to contribute to race and sex disparities in medical care fail to explain them fully. In both cases, physician decision-making appears to contribute as well, suggesting that subconscious biases may contribute to treatment disparities. We conclude by proposing initiatives to remedy race and sex disparities in medical care. Efforts should focus on increasing physician awareness of this problem. Studies should gather data that are currently unavailable for analysis, including detailed clinical variables and patient-level socioeconomic information. Finally, novel quality assurance programs, designed to evaluate and improve the care of blacks and women with coronary artery disease, should be promptly undertaken.

Black People↗
PubMed2002

Neonatal resuscitation: toward improved performance.

BACKGROUND: As part of a continuous quality assurance process which we instituted in 1999, we review videotapes of selected high-risk deliveries at our hospital. We utilized our reviews to evaluate the occurrence of errors, and to evaluate team and leader functions during neonatal resuscitation. METHODS: We established accepted behavior for members of resuscitation teams and the team leader. The actual conduct of the resuscitation was judged against the standard of the guidelines of the Neonatal Resuscitations Program of the American Heart Association, and the American Academy of Pediatrics. The videotapes of resuscitations were reviewed, and significant deviations from accepted practices were noted, and discussed by a specifically developed quality assurance committee, including, whenever possible, the actual resuscitators. RESULTS: We were able to detect a number of problems, which included inappropriate leader and team member activities, inappropriate preparation, communication, and coordination, and made a number of changes to our practice. CONCLUSIONS: We believe that neonatal resuscitation may be improved by the provision of teaching about team and leader functions, encouraging debriefing following complicated resuscitations, developing a minimal form to be completed for any patient requiring compressions or epinephrine within the delivery room, and providing more direct observations regarding the actual conduct of resuscitation.

Asphyxia Neonatorum↗
PubMed1979

The relationship between diagnostic information available at admission and discharge for patients in one PSRO setting: implications for concurrent review.

Professional Standards Review Organization (PSRO) operating guidelines recommend the use of Professional Activity Study (PAS) length of stay norms for conducting concurrent review. These norms, determined by aggregating discharge abstracts from PAS hospitals in the same United States census region, are assigned to patients based only on information known at admission. This study investigated the relationship between patient information available at admission and the information available at discharge in light of its effects on the concurrent review process. Analyzing 52,210 patient records from 68 hospitals in one PSRO setting, it was found that changes in patients' primary diagnosis resulted in changes in their PAS diagnostic category for 41.3 per cent of the patients. A change in PAS diagnostic caetgory after the assignment of the review norm resulted in missed and unnecessary reviews as well as early and late reviews. These findings indicate that there are serious operational problems with the current method of performing concurrent review.

Commission on Professional and Hospital Activities↗
PubMed1997

The impact of aging and chronic disease on use of hospital and outpatient services in a large HMO: 1971-1991.

OBJECTIVES: To examine overall and diagnosis-specific trends in the use of inpatient and outpatient medical services (1970-1988) among older members of a large HMO. DESIGN: Two cohorts of approximately 3000 persons aged 65 or older in 1971 and 1980 were compared for hospital and outpatient utilization during 9-year follow-up periods (1971-79 and 1980-88). All subjects were evaluated for vital status throughout the follow-up period as well. PARTICIPANTS: All 6057 subjects were members of the Northern California Kaiser Permanente Medical Care Program in 1971 or 1980. The study sample was sex-age stratified (65-69,70-79,80+) at baseline. MEASUREMENTS: Data on demographics, outpatient health services utilization, categories of outpatient utilization and disease diagnoses were obtained from membership lists or medical chart review; inpatient utilization, including admitting and discharge diagnosis, length of stay, and number of hospital days was assessed from computerized hospitalization records. RESULTS: Hospital discharge rates (sex-age adjusted) increased by 12% between cohorts, with the largest increases at the oldest ages. There was a 25% increase among women and a 9% increase among men. Length of stay decreased by 20%. Hospitalization for ischemic heart disease decreased by 17%. Congestive heart failure (CHF) discharge rates (sex-age adjusted) were 92% higher in the 1980-88 cohort. For diagnoses related to nursing home institutionalization and frailty, discharge rates were significantly higher in the 1980-88 cohort: pneumonia (+34%), urinary tract infections (+104%), dehydration (+110%), osteoarthritis (+64%), syncope (+246%), leg cellulitis (+70%). In-hospital survival improved, but overall percent of readmissions also increased by 4%; readmissions for CHF increased by 13% and those for conditions of frailty by 120%. Overall outpatient visits increased by 17%. Use of laboratory tests (+57%) and outpatient surgeries (+99%) increased for all age strata in 1980-88 compared with 1971-79. CONCLUSIONS: While overall outpatient and inpatient utilization has largely decreased over the past 30 years, as a result of economic factors and improved treatments for some major diseases, there has been an increase in utilization among older people. Hospitalization for diagnoses associated with end-stage cardiovascular disease (CHF), musculoskeletal disease, frailty and iatrogenic aspects of institutionalization are clearly increasing substantially. The largest impact of aging on health care may be the result of institutionalization and its sequelae. Improved treatment for cardiovascular disease may also be leading to increased utilization at later stages in the disease process.

Aged↗
PubMed2004

Ulcerative colitis practice guidelines in adults (update): American College of Gastroenterology, Practice Parameters Committee.

Guidelines for clinical practice are intended to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind placebo-controlled studies are preferable, but compassionate use reports and expert review articles are utilized in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject without regard to the specialty training or interests and are intended to indicate the preferable but not necessarily the only acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any health-care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. Each has been extensively reviewed and revised by the Committee, other experts in the field, physicians who will use them, and specialists in the science of decision of analysis. The recommendations of each guideline are therefore considered valid at the time of their production based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at the publication in order to assure continued validity.

Adult↗
PubMed2003

Drugs and professional interactions: the modern day pharmacist.

Pharmacists are not yet fully integrated into the primary health care team and their skills could be better used to help patients with their long term medicines. The government is encouraging the setting up of medicines management services. Community pharmacists are well placed to help patients who have cardiovascular disease or who are at risk of this: they have an opportunity to identify at-risk patients, they can identify under treated patients at the point of dispensing, and they can provide education and advice on lifestyle and diet. They are also involved in smoking cessation services. Practice based pharmacists can improve patient care through medication review clinics.

Community Pharmacy Services↗