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At least 19 recordsLinked to original sources
PubMed1996

But was the operation worth it? The limitations of quality of life and patient satisfaction research in health-care outcome assessment.

There is increasing recognition that clinically-derived measures of surgical outcome must be reconciled with patients' own perception of their post-treatment condition. Recently developed quality-of-life and symptom-score measures of outcome have drawn upon patients' own reports of functional status, in contrast to traditional, clinically-derived observations or technical measurements. Patient satisfaction research has been an independent growth industry whose focus has been patient feedback on quality of care received. This paper proposes that the research designs of neither tradition take full account of the personal significance, value or social meaning of a treatment for the patient, although the subject straddles both effectiveness and satisfaction. This begs the question of the value to clinicians of feedback on how worthwhile patients feel a procedure has been in their own cost-benefit terms? If this is also an important dimension of outcome assessment, the range of measures currently available cannot account for it. This paper explores possible reasons why existing patient-oriented measures address what is important to the clinician rather than the patient.

Attitude of Health Personnel↗
PubMed2000

Defining quality health care with outcomes assessment while achieving economic value.

The effectiveness of a procedure is increasingly guided by the evaluation of patient outcomes. Outcomes data is used to develop clinical pathways of care and to define appropriate resource-use levels without sacrificing quality of care. Integration of the economic implications of medical services into an outcome-based guideline allows for the development of disease-management strategies. In cardiovascular medicine, risk reduction is associated with high cost due to the "pay-back" of new technologies and therapies. A major challenge is to define a balance between "high tech" care and cost. This paper devises an outpatient evidence-based guideline using clinical and economic outcomes data for the diagnosis of coronary disease.

Cardiovascular Diseases↗
PubMed1996

A comparison of three techniques for rapid model development: an application in patient risk-stratification.

Accurately risk-stratifying patients is a key component of health care outcomes assessment. And, many health care organizations increasingly are relying upon automated means for assistance in making patient risk-stratification decisions. Unfortunately, the process of outcome model development, as it is currently practiced, is both time consuming and difficult. We investigated the relative abilities of three modeling techniques (logistic regression, artificial neural network (ANN), and Bayesian) to rapidly develop models for risk-stratifying patients. Our results demonstrated that all three modeling techniques perform equally well in certain situations. However, the Bayesian model with conditional independence had the best overall performance. Unfortunately, none of the models were able to achieve the degree of accuracy which would be required in a medical setting.

APACHE↗
PubMed2003

Responsiveness of the Bournemouth and Oswestry questionnaires: a prospective pilot study.

BACKGROUND: The assessment of health-related quality-of-life outcome information has become an essential feature in the delivery of quality health care. Outcome assessment and increased clinical research capacity have been identified as recommended areas of priority for chiropractic research, chiropractic colleges, and the profession. OBJECTIVE: This article reports the results of a multisite pilot project utilizing New York Chiropractic College's 3 off-campus health centers. In the project, we sought to examine generic issues related to research infrastructure and feasibility, perform pilot testing of the responsiveness of the revised Oswestry Disability Index (ODI) and the Bournemouth Questionnaire (BQ), and develop estimates of change and population size for the possible future projects. METHODS: We describe the infrastructure created to conduct the project, including an on-site clinician research manager; on-site student research assistants; identification, recruitment, and patient flow; demographic and clinical characteristics; and abstraction instruments. Responsiveness study subjects completed 3 health-related quality-of-life assessments at baseline, 15 days, and 30 days. At 45 days, or at discharge, subjects completed the same questionnaires and a global rating of change. Responsiveness is reported by analysis of standardized estimates of change, relative efficiency, and receiver operator characteristic (ROC) curve plots. RESULTS: We successfully identified 82% of possible study patients; the real eligibility rate in our population was 30%. In 4 months, 70 patients were accrued, and 26 patients followed through to provide global ratings of change scores. Responsiveness by standardized change scores was numerical rating scale (NRS) = 1.19, ODI = 0.91, BQ = 0.78; by relative efficiency it was BQ/ODI = 0.86, ODI/NRS = 0.76, BQ/NRS = 0.66. Area under the curves ranged from 0.69 for the BQ to 0.86 for the NRS. CONCLUSIONS: Recommendations for modification and use of the infrastructure, research capacity, and future outcome and appropriateness assessment projects are offered.

Adult↗
PubMed1998

Overview of outcomes research and management and its role in oncology practice.

Outcomes assessment describes a variety of activities, including classic clinical trials with quality of life and cost end points, observational studies examining the outcomes of treatment in the course of routine clinical care, and the process of managing patterns of care in clinical practice. These activities share important common features, including an emphasis on quality of life and economic outcomes, an explicit consideration of the importance of patient characteristics in determining outcomes, and a broad definition of what constitutes cancer care. The primary uses of outcomes data are to evaluate treatments and to assess the quality of care provided by physicians, health care institutions, and health insurance plans. Outcomes management integrates these activities through the implementation of guidelines, ideally based on empiric data on the relationship between medical interventions and outcomes; and the measurement of performance against a set of quality indicators derived from those guidelines. One of the biggest challenges facing clinicians today is how to reconcile the need to do what is best for patients with the need to practice cost-conscious medicine. High-quality outcomes data are at the heart of the solution. This presentation is a brief overview of outcomes research and management and its role in oncology practice.

Decision Making↗
PubMed1996

Is the short form 36 (SF-36) suitable for routine health outcomes assessment in health care for older people? Evidence from preliminary work in community based health services in England.

STUDY OBJECTIVE: To examine the short form 36 (SF-36) health status measure when used to assess older people's views of the outcome of community based health care. DESIGN: Completion of a structured questionnaire, before and after intervention alongside in-depth interviews with a subsample of the interviewees. SETTING: Community based continence and mental health services in two health authorities in the North West Health Region. PATIENTS: Forty seven older people newly referred to mental health services or continence services between December 1992 and April 1993 participated. MAIN RESULTS: The SF-36 showed minimal change over time for both patient groups. The more detailed in-depth interviews showed that people experienced positive changes and derived value from contact with services in a number of important ways. For many reasons these benefits were not reflected in their SF-36 scores. CONCLUSIONS: The SF-36 is not likely to be the "measure of choice" for this type of evaluation, particularly where it involves older patient groups who have high levels of comorbidity. The content of the SF-36 and its lack of detail for individual assessment of change means it masks rather than illuminates patients' views of outcome.

Aged↗
PubMed1998

Do specialists do it better? The impact of specialization on the processes and outcomes of care for cancer patients.

OBJECTIVE: To assess the impact of specialization on processes and outcomes of care for cancer patients. DATA SOURCE: Papers published in English between 1980 and 1995 and identified through MEDLINE and Embase (MeSH terms: NEOPLASM (exploded), and PHYSICIAN PRACTICE PATTERNS (or DECISION MAKING, ATTITUDE OF HEALTH PERSONNEL, QUALITY OF HEALTH CARE, DELIVERY OF HEALTH CARE, HEALTH EDUCATION or OUTCOME ASSESSMENT HEALTH CARE), or through the reference lists of review articles. STUDY SELECTION: Studies providing information on the association between quality of care indicators for cancer patients and clinician/centre degree of specialization. A total of 47 papers concerning 46 empirical studies were considered. DATA EXTRACTION: For studies using process of care indicators, the proportion of specific procedures performed by specialists and non-specialists was abstracted. For studies using outcome indicators (e.g., mortality), the effect of specialization was quantified in terms of odds ratio (OR) expressing relative reduction in risk of death. The quality of individual studies using process or outcome indicators was assessed according to study design, avoidance of selection bias in patient identification and data analysis, degree of adjustment of the comparison between clinicians/centres with different levels of specialization. DATA SYNTHESIS: Specialized centres/clinicians fared better both when process and outcome indicators were used. While the former varied widely in different studies and their clinical relevance was often questionable, mortality was consistently lower when care was provided by specialized centres/clinicians, with the effect size being greater in smaller studies. For breast cancer, where all the studies were of sufficiently good quality, a pooled estimate of the effect of specialization was performed which showed that specialized cancer care was associated with an 18% (95% CI: 12%-23%) reduction in mortality. CONCLUSIONS: Despite the fact that care provided by specialized centres/clinicians appeared to be better both when assessed in relation to process indicators and to mortality, this evidence should be considered far from conclusive because of major methodological flaws in these studies. Relative to current efforts to promote evidence-based policy-making, this review underscores the limited capability of scientific information to provide reliable guidelines for structuring better health care systems.

Confidence Intervals↗
PubMed2001

An approach to quality management in anaesthesia: a focus on perioperative care and outcome.

Health care systems throughout the world are faced with continuously rising health care expenditure. In Germany, a fee per capita system will be introduced by 2003 to keep the budgets for hospital care within limits. As a result, numbers of hospital beds and hospitals will be cut in the coming years. On the other hand, more and more patients and health care providers are asking if they are really receiving an adequate value for their money in the treatment they receive. All this will have a strong impact on the anaesthesiologist's work and her/his perception of the different facets of quality. Quality has various aspects for the anaesthesiologist. The patient as a customer should not incur any detrimental effects after a surgical procedure, and is accompanied by the anaesthesiologist throughout the perioperative setting. The surgeon needs optimal conditions to perform a procedure. The hospital must balance equally costs and income; this requires optimal operating room utilization. Finally, health insurance companies and the government are responsible for covering the cost of treatment according to the quality of the care delivered. Quality assessment concerning structure, process and outcome has to take these demands into account. Continuous quality improvement in the spirit of Deming's 'plan-do-check-act cycle' has to be part of anaesthesiologist's everyday routine. In future, the traditional barriers between the specialities treating a patient will be disrupted when reimbursement for treatment is made according to quality and efficacy of treatment.

Anesthesia↗
PubMed1996

Severity of a case for outcome assessment in health care--definitions and classification of instruments.

Severity of a case is one of the ingredients in management systems. Severity adjustment systems have limitations, and confusion and diversity characterize definitions of severity of a case. These facts may be a consequence of lack of conceptual knowledge. Based on a holistic theory of health, we introduce a definition of severity of a case from a patient perspective. Here severity is characterized as having two basic components: disease severity and illness severity; and five dimensions: suffering, disabilities, risk of suffering, risk of disabilities and risk of death. A classification of instruments as measures of severity dimensions is presented. This classification is based on definition and application criteria. The article's main contribution is to combine theoretical and practical knowledge about severity of a case, which may empower implementations of outcome management systems in health care.

APACHE↗
PubMed2005

Quality improvement for depression in primary care: do patients with subthreshold depression benefit in the long run?

OBJECTIVE: Quality improvement programs for depression can improve outcomes, but the utility of including patients with subthreshold depression in quality improvement programs is unclear. The authors examined 57-month effects of quality improvement on clinical outcomes and mental health care utilization of primary care patients with depressive disorder and subthreshold depression. METHOD: In a group-level, randomized, controlled trial, 46 primary care clinics were randomly assigned to provide usual care or care with a quality improvement intervention that included provider training and other resources for either medication management (medications quality improvement) or evidence-based psychotherapy (therapy quality improvement). Among 1,356 enrolled depressed patients, 991 completed the 57-month follow-up interview (604 patients with depressive disorder and 387 with subthreshold depression). Outcomes measured at 57 months were presence of probable depressive disorder, unmet need for appropriate care (untreated probable disorder), and mental health care utilization in the prior 6 months. RESULTS: Among patients with subthreshold depression at baseline, those seen in clinics with quality improvement programs with special resources for therapy were less likely to have probable depressive disorder and unmet need for care at follow-up, compared with those seen in clinics that provided usual care. Among patients with depressive disorder at baseline, those seen in clinics with quality improvement programs with special resources for medication management were less likely to have unmet need for care at follow-up, compared with those seen in clinics that provided usual care. Patients with subthreshold depression at baseline seen in clinics with a quality improvement intervention were less likely at follow-up to have had a mental health visit (in primary care or specialty care, depending on the intervention) in the prior 6 months. CONCLUSIONS: Relative to usual care, quality improvement interventions improved 57-month outcomes (probable depression, unmet need, or both) for primary care patients with depressive disorder and subthreshold depression and lowered use of mental health visits for those with subthreshold depression. The results highlight the feasibility and utility of including patients with subthreshold depression in such programs.

Adult↗
PubMed2005

Understanding results from randomized trials: use of program- and client-level data to study medical and nonmedical treatment programs.

OBJECTIVE: To address unanticipated results from randomized trials, researchers often focus on client-level data about services received during treatment. Program-level observations can also be helpful, especially in understanding treatment delivered in groups. Using both approaches, this article strives to better understand inconsistent results from a trial comparing medical and nonmedical group-format day treatment. METHOD: Dependent treatment seekers were randomized to a hospital-based medical day-treatment program or to one of two community-based nonmedical day treatment programs. Services received during treatment were captured from clients using the Treatment Services Review (N = 230 subjects; 78 women), and group sessions were observed to measure therapeutic style using an Event Form (N = 48 observations). RESULTS: The trial had found better medical outcomes at the hospital than at either nonmedical program, but most other tests had demonstrated similar outcomes at day hospital and one of the nonmedical sites and worse outcomes (psychiatric, family/social and employment) at the other nonmedical study site. Our analysis of services reported by study participants found a pattern of fewer substance misuse-oriented groups and less serious discussions about medical, psychiatric and family/social problems at the same nonmedical site that had worse outcomes. The way that services were delivered at that site further helped to explain the poorer outcomes there: Groups tended to be more didactic, classroom-like and less discussion-oriented. CONCLUSIONS: Although services received are helpful in explaining treatment outcome, treatment observation adds explanatory value. Without increasing the cost of service provision, programs that rely heavily on didactic approaches might improve their outcomes simply by encouraging more interactive discussions that engage the clients.

Adult↗
PubMed1999

The effectiveness of the use of patient-based measures of health in routine practice in improving the process and outcomes of patient care: a literature review.

Despite a number of potential benefits to both the clinician and the patient, patient-based measures of health have not been routinely or systematically used within routine practice by clinicians in the care of individual patients. There are a number of practical, methodological and attitudinal barriers which have so far limited the use of patient-based measures of health within routine practice. The extent to which these barriers are overcome is likely to influence the effectiveness of such instruments in improving the process and outcomes of patient care. This study reviewed the evidence for the effectiveness of this intervention and identified some of the factors that may influence its effectiveness. Thirteen relevant studies were located using search strategies on three computerized databases for 1987-97. The study found that clinicians see information from patient-based measures of health as valuable in the overall assessment of the patient and that its feedback to clinicians increases the detection of psychological and, to a lesser extent, functional problems. However, there was little evidence to suggest their use substantially changed patient management or improved patient outcomes. Our findings suggest that the ways in which patient based measures of health are implemented in routine practice may have an impact on their effectiveness. It is recommended that implementation strategies that are guided by theories of individual and organizational change might allow the barriers to using patient-based measures of health in routine practice to be identified and overcome more effectively.

Health Services Research↗
PubMed1997

Patient outcomes used by advanced practice psychiatric nurses to evaluate effectiveness of practice.

Health care in the 1990s requires Advanced Practice Psychiatric Nurses (APPNs), like other health care providers, to identify and evaluate the outcomes of their practices. Many APPNs report that they are not currently engaging in outcome evaluation, and many report that they would like more resources on outcome measurement. This study identifies outcome evaluations currently in use, through an analysis of the responses of 364 Certified Clinical Nurse Specialists in a survey conducted by the Society for Education and Research in Psychiatric Nursing in 1994-1995. Specific tools that APPNs report using to assess outcomes are also identified and referenced.

Data Collection↗