摘要:

The quiescent interest in understanding the variations in the quality of hospital care has been revitalized recently with the government's release of hospital-specific mortality data. The authors reviewed all published studies that either named hospitals and gave their death rates or explored which of their characteristics explained the differences in their rates. The literature is only in fair condition. It is sparse and flawed, and, before the government's release, did not identify an individual hospital's mortality experience by name. Twenty-two studies were analyzed; only five (23%) met criteria for validity. Seventeen (77%) focused on in-hospital mortality. Data were collected for a short time, were not gathered uniformly, and came from a sample of local hospitals. Researchers identified and explained limitations in their studies and were particularly concerned with their inability to measure differences in patients that might affect death rates. Several characteristics of hospital care were found to be associated with lower inpatient mortality: communication among and commitment of staff, clinical experience and performing operations frequently, board certification, size, and teaching status. The authors urge caution in applying the literature's findings to evaluations of hospital quality and offer suggestions for researchers. Improved research is critically important in facilitating current policy discussions regarding the use of mortality as a measure of hospital quality.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Mortality of aged Medicare enrollees in three demonstration health maintenance organizations (HMOs) was compared with that of three cohorts of local fee-for-service (FFS) beneficiaries as a measure of group differences in health status. Mortality of the HMO and FFS cohorts was tracked via life-table analysis for 6 years after enrollment to measure the persistence of health status differences existing at enrollment. After adjustment for age, sex, Medicaid-eligibility, and institutional status, HMO enrollee mortality was lower than FFS at all three plans in the first year after enrollment. Enrollee mortality at two plans increased to near FFS levels in year 2 and remained relatively stable thereafter. Enrollee mortality at the third plan increased toward FFS levels more gradually and was significantly below FFS levels for the first 5 years of follow-up. Mortality of disenrollees in the 2 years after disenrollment was significantly higher than that of the continuously enrolled in one plan and marginally significantly higher in a second. These findings suggest a pattern of favorable selection at enrollment, followed by different rates of decay in the favorable health status of enrollees. Other health status measures may exhibit different patterns, however. Selection effects may cause payments based on Medicare's AAFCC to be too high or low, in some cases for several years after enrollment.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

To determine the quality of proxy health reports by telephone the 1984 Wisconsin Health Status Survey employed a repeated-measure design in an interview covering 22 recently occurring health and psychologic complaints. Comparisons on individuals in households containing two or more adults revealed a relatively weak correspondence between the respondent and proxy reports. While a previous analysis of these data found that certain characteristics thought to underlie reporting differences are not useful in explaining proxy underreporting, the current analysis focuses on spousal pairs and achieves greater success by applying somewhat more sophisticated methods. The authors examined the nature, persistence, and number of health complaints as factors in reporting bias. They find evidence that female proxies vary by symptom in their ability to report common complaints and also observed that proxy underreporting diminishes somewhat as the persistence of symptoms increases. Using multiplicative models, the authors show that the gross misclassification of complaints is concentrated in the respondent-proxy pairs with the shortest exposure to the symptom. Finally, an examination of the disagreements on all 22 health complaints simultaneously revealed that neither mutual misallocation by respondents and proxies nor a diminished health status of the individual reported on are important influences on reporting behavior.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

The General Health Questionnaire (GHQ) is a widely used method of assessing psychiatric distress in clinical settings and in the community. The authors administered a 20-item interview version of the GHQ and a battery of survey items on use of ambulatory health care services to 3,389 respondents in eastern Baltimore as part of the Epidemiologic Catchment Area survey. In addition, a subsample of these respondents (n = 810) was examined by research psychiatrists who provided a reference mental disorder diagnosis for comparison with GHQ results. Psychiatrists determined that 102 respondents had American Psychiatric Association's Diagnostic and Statistical Manual, third edition, (DSM-III) disorders suitable for detection by the GHQ. These respondents were categorized by the health service use they reported over the previous 6 months. A comparison indicated that 82% of the diagnosed cases with recent specialty care also had elevated GHQ scores. Among cases with recent general medical care, 52% had elevated GHQ scores. Among diagnosed cases reporting no recent ambulatory health care, only 38% had elevated GHQ scores. Receiver operating characteristic analysis demonstrated a similar trend. Cases of depression were separated into less severe cases (adjustment disorder with depressed mood) and more severe cases (major depression). There were relatively more cases of severe depression than cases of mild depression in those respondents reporting recent health service use compared with those respondents reporting no recent service use. This may account for the higher sensitivity of the GHQ in detecting psychiatric disorders for those persons utilizing health services compared with individuals using no health services.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

The authors compared the personal characteristics, measures of functional status/case mix, and discharge outcomes of nursing home patients admitted to skilled nursing facilities (SNFs) in 1984 for the first time (first admissions) to those of patients with a prior history of nursing home care (readmissions). Compared to first admissions, readmitted patients were more disabled and debilitated, significantly less likely to return home, and more likely to be hospitalized. History of a prior nursing home admission is an important indicator of prognosis, service needs, length of stay (LOS) of patients in the nursing home, and their discharge outcomes. Location before admission—home versus hospital—was associated with case-mix descriptors and LOS but was unrelated to discharge outcomes, except for those readmitted from hospitals, who returned home less often and were more likely to die in the SNFs.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

This paper offers an explanation for the counterintuitive relationship between physician competition and Medicaid participation found by many investigators. Contrary to standard predictions, a number of studies have found strong negative relationships between the supply of physicians and Medicaid participation and equally strong positive relationships between supply and the concentration of Medicaid patients in small numbers of large Medicaid practices. The model advanced here argues that the residential segregation of Medicaid patients and differences in the minimum-efficient scale of practice for treatment of Medicaid and private patients create strong incentives for physicians in competitive urban areas to: 1) take either few Medicaid patients or 2) many and 3) make it costly to maintain a Medicaid practice share between these two extremes. In less competitive areas, these incentives are weaker, if not altogether absent.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Health Insuring Organizations (HIOs) are capitated plans that serve all of the Medicaid beneficiaries in a defined catchment area. While this approach to capitation eliminates the incentive to enroll only the healthiest beneficiaries in the area, it does not alleviate concerns that the HIO will respond to the incentives for efficiency created by capitation payment by underproviding services. The authors studied change in service utilization patterns produced by the HIO by using a multivariate strategy to identify case-mix groups at the population level to adjust analyses of hospital and nursing home utilization for case mix. This approach was applied to service utilization data for Medicaid beneficiaries in Philadelphia who received medical services from an HIO and for two control groups. In addition to identifying changes in service use, they evaluated the performance of the HIOs on three dimensions—access to care, quality of care, and the efficiency with which the care was provided. While limitations on the information available in the billing files did not allow definitive statements to be made regarding these issues, case-mix adjusted patterns of service use (and mortality) across sets of service may enable Medicaid programs to identify areas where problems in one of these three critical areas exist. This would allow the program to target its limited utilization and quality review resources toward the areas, types of people, and/or providers where problems in one or more of these areas are more likely.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

This report describes the development and validation of a computerized system for converting ICD-9CM rubrics to Abbreviated Injury Scale (AIS) scores. In collaboration with the Committee on Injury Scaling of the Association for the Advancement of Automotive Medicine, AIS-85 scores were assigned to 2,062 injury-related ICD-9CM rubrics. To validate the conversion table, AIS and Injury Severity Scores (ISS), derived using the conversion, were compared with those obtained by reviewing the complete medical record for 1,120 trauma cases. Percent agreement in maximum AIS scores (MAXAIS) ranged from 48% for head/neck injuries to 74% for extremity injuries. In 68% of the cases, grouped ISS scores (one to 12; 13 to 19; 20+) were in agreement. Previous studies of the interrater reliability of AIS coding directly from the medical charts have shown that agreement in MAXAIS scores ranges, on average, between 62% for head/neck injuries to 76% for extremity injuries. Grouped ISS scores agree, on average, 75% of the time. The results show that while the computerized conversion is not perfect, it provides reasonably good information on severity that might otherwise be unavailable for large population-based research and evaluation. This paper discusses the potential applications of the conversion table with specific attention to its use in evaluating the extent of trauma care regionalization.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

The authors describe a new model for classifying hospitalized patients with acquired immunodeficiency syndrome (AIDS) according to their severity of illness. In the first phase of the project, a clinical model indicating the relative severity of AIDS complications was formulated, based on the clinical literature and expert opinion. In the second phase, the model was tested empirically using data on in-patient mortality of over 6,000 adult AIDS hospitalizations in New York State during 1985. The ordering of AIDS-related complications in the clinical model was revised to reflect a continuum of increasing likelihood of death in the hospital. The final classification system for AIDS hospitalizations has 20 substages, grouped into three stages, with in-patient, mortality rates increasing from 6% to 60%. The system is automated and can be applied to different AIDS populations to analyze resource use and outcomes of hospital care.

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:1989

数据来源: OVID