ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objectives.This study examined the validity of the Complications Screening Program (CSP) by testing whether (1) ICD-9-CM codes used to identify a complication are coded completely and accurately and (2) the CSP algorithm successfully separates conditions present on admission from those occurring in the hospital.Methods.We compared diagnosis and procedure codes contained in the Medicare claim with codes abstracted from an independent re-review of more than 1,200 medical records from Connecticut and California.Results.Eighty-nine percent of the surgical cases and 84% of the medical cases had their CSP trigger codes corroborated by re-review of the medical record. For 13% of the surgical cases and 58% of the medical cases, the condition represented by the code was judged to be present on admission rather than occurring in-hospital. The positive predictive value of the claim was greater than 80% for the surgical risk pool, suggesting the value of the CSP as a screening tool.Conclusions.The CSP has validity as a screen for most surgical complications but only for 1 medical complication. The CSP does not have validity as a "stand-alone" tool to identify more than a few in-hospital surgery-related events. The addition of an indicator to the Medicare claim to capture the timing of secondary diagnoses would improve the validity of the CSP for identifying both surgical and medical in-hospital events.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective.The use of administrative data to identify inpatient complications is technically feasible and inexpensive but unproven as a quality measure. Our objective was to validate whether a screening method that uses data from standard hospital discharge abstracts identifies complications of care and potential quality problems.Design.This was a case-control study with structured implicit physician reviews.Setting.Acute-care hospitals in California and Connecticut in 1994.Patients.The study included 1,025 Medicare beneficiaries ≥65 years of age.Methods.Using administrative data, we stratified acute-care hospitals by observed-to-expected complication rates and randomly selected hospitals within each state. We randomly selected cases flagged with 1 of 17 surgical complications and 6 medical complications. We randomly selected controls from unflagged cases.Main outcome measure.Peer-review organization physicians' judgments about the presence of the flagged complication and potential quality-of-care problems.Results.Physicians confirmed flagged complications in 68.4% of surgical and 27.2% of medical cases. They identified potential quality problems in 29.5% of flagged surgical and 15.7% of medical cases but in only 2.1% of surgical and medical controls. The rate of physician-identified potential quality problems among flagged cases exceeded 25% in 9 surgical screens and 1 medical screen. Reviewers noted several potentially mitigating circumstances that affected their judgments about quality, including factors related to the patients' illness, the complexity of the case, and technical difficulties that clinicians encountered.Conclusions.For some types of complications, screening administrative data may offer an efficient approach for identifying potentially problematic cases for physician review. Understanding the basis for physicians' judgments about quality requires more investigation.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Health care organizations face pressures from patients to improve the quality of care and clinical outcomes, as well as pressures from managed care to do so more efficiently. Coordination, the management of task interdependencies, is one way that health care organizations have attempted to meet these conflicting demands.Objectives.The objectives of this study were to introduce the concept of relational coordination and to determine its impact on the quality of care, postoperative pain and functioning, and the length of stay for patients undergoing an elective surgical procedure. Relational coordination comprises frequent, timely, accurate communication, as well as problem-solving, shared goals, shared knowledge, and mutual respect among health care providers.Research Design.Relational coordination was measured by a cross-sectional questionnaire of health care providers. Quality of care was measured by a cross-sectional postoperative questionnaire of total hip and knee arthroplasty patients. On the same questionnaire, postoperative pain and functioning were measured by the WOMAC osteoarthritis instrument. Length of stay was measured from individual patient hospital records.Subjects.The subjects for this study were 338 care providers and 878 patients who completed questionnaires from 9 hospitals in Boston, MA, New York, NY, and Dallas, TX, between July and December 1997.Measures.Quality of care, postoperative pain and functioning, and length of acute hospital stay.Results.Relational coordination varied significantly between sites, ranging from 3.86 to 4.22 (P<0.001). Quality of care was significantly improved by relational coordination (P<0.001) and each of its dimensions. Postoperative pain was significantly reduced by relational coordination (P= 0.041), whereas postoperative functioning was significantly improved by several dimensions of relational coordination, including the frequency of communication (P= 0.044), the strength of shared goals (P= 0.035), and the degree of mutual respect (P= 0.030) among care providers. Length of stay was significantly shortened (53.77%,P<0.001) by relational coordination and each of its dimensions.Conclusions.Relational coordination across health care providers is associated with improved quality of care, reduced postoperative pain, and decreased lengths of hospital stay for patients undergoing total joint arthroplasty. These findings support the design of formal practices to strengthen communication and relationships among key caregivers on surgical units.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Clinical prediction rules have been developed that use preoperative information to stratify patients according to risk of complications after cardiac surgery.Objectives.To assess the methodological standards and performance of 7 models.Participants.The validation portion of the Quality Measurement and Management Initiative (QMMI) cohort included a random sample of all adult patients (n = 3,261) who underwent coronary artery bypass grafting (CABG) surgery not involving valvular or other concomitant procedures at 12 medical centers from August 1993 to October 1995.Outcome Measures.Methodological standards used for model comparison were adapted from published criteria. Model performance was assessed by receiver-operating characteristic (ROC) analysis, and calibration was evaluated with the Hosmer-Lemeshow (HL) statistic and observed-expected plots.Methods.We performed cross-validation by applying the published criteria for the development of each model to the validation subset of the QMMI cohort and by assessing the performance of each model in discriminating outcomes.Results.Wide variations existed in the methodologies used to develop and validate the 5 additive scores evaluated. Cross-validation of all 5 additive scores revealed degradation in their abilities to discriminate outcomes. The 2 logistic models examined performed similarly to the additive scores examined in predicting mortality.Conclusions.Substantial variation existed both in the methodologies used to develop models and in the ability of the models to predict outcomes. Models developed at single institutions or using fewer patients may be less generalizable when applied to diverse clinical settings. Additive and logistic regression models performed similarly, as assessed by ROC and HL analyses.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Primary care physicians (PCPs) exhibit widely varying referral rates, resulting in dramatic differences in the exposure of their patients to specialists. The relationships between this physician behavior and costs and patient outcomes are unknown.Objectives.To examine the relationships between PCP referral rates and costs, risk of avoidable hospitalization, health status, and satisfaction.Design.Cross-sectional analyses of claims and patient survey data.Setting and Subjects.Independent practice association (IPA)-style managed care organization in the Rochester, NY, metropolitan area. The 1995 claims data included 457 PCPs in the IPA and 217,606 adult patients assigned to their panels. Approximately 50 consecutive patients of each of a random sample of 100 PCPs completed a patient survey in 1997-1998.Measures.From the claims data, total expenditures per panel member, the risk of avoidable hospitalization, and physician referral rate were measured. Measures derived from the survey included SF-12 scores, satisfaction, and physician referral rate.Results.The relationship between physician referral rate and per-panel-member costs was not statistically significant after case-mix adjustment of the referral rate. There was no relationship between the case-mix-adjusted referral rate and risk of avoidable hospitalization. In the survey data, there was no adjusted relationship between the physicians' referral rate and their patients' self-rated physical or mental health. There was a modest direct relationship between patient satisfaction and survey-derived referral rate.Conclusions.Despite stable, wide variations in PCP referral rates, there are few discernible relationships between this physician behavior and costs and patient outcomes. Efforts to constrain PCP referrals to specialists may be misguided.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objectives.This was an ancillary methodological study within the Prostate Cancer Outcomes Study (PCOS) to assess the validity of 6-month retrospective recall of prediagnostic disease-targeted function among men diagnosed with prostate cancer.Methods.A convenience sample of 133 prostate cancer cases were administered a baseline questionnaire shortly after diagnosis that asked about prediagnostic urinary, sexual, and bowel function. They were surveyed again concerning the same items 6 months later and asked to recall their prediagnostic function. Reports of prediagnostic function obtained at baseline and 6 months are compared, as are measures of change derived from these reports. Percent agreement and weighted kappas are calculated to measure the extent of agreement.Results.Over 70% of the men reported prediagnostic functioning at the highest level on 12 of 17 survey items. For each of these items, recall at 6 months was identical to the baseline survey response for ≥69% of the men. The values of the weighted kappas for changes computed with baseline reports (prospective) and changes computed with 6-month recall (retrospective) ranged from 0.396 to 0.919 for the 17 individual items. Intraclass correlations for the retrospective versus prospective changes in the multi-item function scores were 0.828 for urinary, 0.618 for bowel, and 0.692 for sexual function.Conclusions.At baseline, men recently diagnosed with prostate cancer report few disease-related problems before diagnosis, and a high percentage of men recall this accurately 6 months later. There is reasonably high agreement between baseline and 6-month estimates of prediagnostic function and between prospective and retrospective measures of change over 6 months.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objectives.Although personality is known to influence patients' self-ratings of health, its effects on reports of health-related quality of life (HRQOL) have not been fully described. We examined the relationship between a dimension of personality called negative affectivity (NA; a general disposition to experience negative mood states) and HRQOL, controlling for age and common chronic physical and mental diseases.Methods.We used data from 3 samples of veterans: the Department of Veterans Affairs (VA) Normative Aging Study (NAS), the Veterans Health Study (VHS), and the VA Women's Health Project (VA WHP). For each of the 8 SF-36 scales and the physical and mental component summary scales, 2 regression models were estimated, the first of which included only chronic diseases and age and the second of which added NA.Results.NA was consistently negatively associated with SF-36 scale scores in bivariate analyses. The regression models indicated that across the 3 samples, NA explained between 0% and 13.9% additional variance in the scales, with the least additional variance in the physical function domains (range 0-2.6%) and the most in the mental function domains (range 0-13.9%). Results from the summary scales were similar: NA explained none of the variance in the physical component summary and 3.5% to 10.4% in the mental component summary. These results were largely consistent across the 3 samples.Conclusions.These results suggest the importance of NA in patients' ratings of HRQOL beyond that of age and chronic conditions. Thus, clinicians and researchers who rely on measures such as the SF-36 to assess health status should consider that personality, as well as underlying health, can affect self-ratings of HRQOL.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Hospital discharge diagnoses, coded by use of theInternational Classification of Diseases, 9th Revision, Clinical Modification(ICD-9-CM), increasingly determine reimbursement and support quality monitoring. Prior studies of coding validity have investigated whether coding guidelines were met, not whether the clinical condition was actually present.Objective.To determine whether clinical evidence in medical records confirms selected ICD-9-CM discharge diagnoses coded by hospitals.Research Design and Subjects.Retrospective record review of 485 randomly sampled 1994 hospitalizations of elderly Medicare beneficiaries in California and Connecticut.Main Outcome Measure.Proportion of patients with specified ICD-9-CM codes representing potential complications who had clinical evidence confirming the coded condition.Results.Clinical evidence supported most postoperative acute myocardial infarction diagnoses, but fewer than 60% of other diagnoses had confirmatory clinical evidence by explicit clinical criteria; 30% of medical and 19% of surgical patients lacked objective confirmatory evidence in the medical record. Across 11 surgical and 2 medical complications, objective clinical criteria or physicians' notes supported the coded diagnosis in >90% of patients for 2 complications, 80% to 90% of patients for 4 complications, 70% to <80% of patients for 5 complications, and <70% for 2 complications. For some complications (postoperative pneumonia, aspiration pneumonia, and hemorrhage or hematoma), a large fraction of patients had only a physician's note reporting the complication.Conclusions.Our findings raise questions about whether the clinical conditions represented by ICD-9-CM codes used by the Complications Screening Program were in fact always present. These findings highlight concerns about the clinical validity of using ICD-9-CM codes for quality monitoring.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID