ISSN:0025-7079    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Objectives.This study attempts to develop a comprehensive set of comorbidity measures for use with large administrative inpatient datasets.Methods.The study involved clinical and empirical review of comorbidity measures, development of a framework that attempts to segregate comorbidities from other aspects of the patient's condition, development of a comorbidity algorithm, and testing on heterogeneous and homogeneous patient groups. Data were drawn from all adult, nonmaternal inpatients from 438 acute care hospitals in California in 1992 (n= 1,779,167). Outcome measures were those commonly available in administrative data: length of stay, hospital charges, and in-hospital death.Results.A comprehensive set of 30 comorbidity measures was developed. The comorbidities were associated with substantial increases in length of stay, hospital charges, and mortality both for heterogeneous and homogeneous disease groups. Several comorbidities are described that are important predictors of outcomes, yet commonly are not measured. These include mental disorders, drug and alcohol abuse, obesity, coagulopathy, weight loss, and fluid and electrolyte disorders.Conclusions.The comorbidities had independent effects on outcomes and probably should not be simplified as an index because they affect outcomes differently among different patient groups. The present method addresses some of the limitations of previous measures. It is based on a comprehensive approach to identifying comorbidities and separates them from the primary reason for hospitalization, resulting in an expanded set of comorbidities that easily is applied without further refinement to administrative data for a wide range of diseases.

ISSN:0025-7079    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Objectives.Severity-adjusted death rates for coronary artery bypass graft (CABG) surgery by provider are published throughout the country. Whether five severity measures rated severity differently for identical patients was examined in this study.Methods.Two severity measures rate patients using clinical data taken from the first two hospital days (MedisGroups, physiology scores); three use diagnoses and other information coded on standard, computerized hospital discharge abstracts (Disease Staging, Patient Management Categories, all patient refined diagnosis related groups). The database contained 7,764 coronary artery bypass graft patients from 38 hospitals with 3.2% in-hospital deaths. Logistic regression was performed to predict deaths from age, age squared, sex, and severity scores, and c statistics from these regressions were used to indicate model discrimination. Odds ratios of death predicted by different severity measures were compared.Results.Code-based measures had better c statistics than clinical measures: all patient refined diagnosis related groups, c = 0.83 (95% C.I. 0.81, 0.86) versus MedisGroups, c = 0.73 (95% C.I. 0.70, 0.76). Code-based measures predicted very different odds of dying than clinical measures for more than 30% of patients. Diagnosis codes indicting postoperative, life-threatening conditions may contribute to the superior predictive power of code-basedmeasures.Conclusions.Clinical and code-based severity measures predicted different odds of dying for many coronary artery bypass graft patients. Although code-based measures had better statistical performance, this may reflect their reliance on diagnosis codes for life-threatening conditions occurring late in the hospitalization, possibly as complications of care. This compromises their utility for drawing inferences about quality of care based on severity-adjusted coronary artery bypass graft death rates.

ISSN:0025-7079    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Objectives.The effectiveness of case-managed residential care (CMRC) in reducing substance abuse, increasing employment, decreasing homelessness, and improving health was examined.Methods.A five-year prospective experiment included 358 homeless addicted male veterans 3, 6, and 9 months during their enrollment and at 12, 18, and 24 months after the completion of the experimental case-managed residential care program. The customary control condition was a 21-day hospital program with referral to community services.Results.The experimental group averaged 3.4 months in transitional residential care with ongoing and follow-up case management for a total of up to 1 year of treatment. The experimental group showed significant improvement compared with the control group on the Medical, Alcohol, Employment, and Housing measures during the 2-year period. An examination of the time trends indicated that these group differences tended to occur during the treatment year, however, and to diminish during the follow-up year.Conclusions.Within groups, significant improvements were observed with time from baseline to all posttests on the four major outcomes. We learned, however, that veterans had access to and used significant amounts of services even without the special case-managed residential care program. This partially may account for improvements in the control group and may have muted the differences between groups.

ISSN:0025-7079    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

The perinatal mortality rate is used as an indicator of the quality of antenatal and perinatal care, yet uncritical application of this indicator in international comparisons can be misleading. The perinatal mortality rate depends on a number of factors and important determinants that need to be assessed separately before reaching conclusions about quality-of-care issues. This article provides a conceptual model of the construction of the perinatal mortality rate. It illustrates the relationship between quality of antenatal and perinatal care and risk factors for perinatal mortality and how these lead to the perinatal mortality rate. It also indicates how differences in registration procedures and practices influence the final mortality figures published by individual countries. For international comparison, the first step is to apply common definitions. The rate can vary by 50% depending on the definition used. Also, sources of registration bias need to be examined, because they differ considerably by country. Underregistration is known to be as high as 20% of perinatal deaths. The next step is to correct perinatal mortality figures according to differences in known risk factors. The perinatal mortality rate then can serve as a reasonable indicator for the quality of antenatal and perinatal care. In western countries, perinatal mortality could be reduced by as much as 25% with improved standards of care. Policies and practices in individual countries concerning ethical issues related to termination of pregnancy and care of newborn infants with (very) poor prognosis need to be taken into account as well. They are not related to quality of care, but do have a relatively large impact on the perinatal mortality rate.

ISSN:0025-7079    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Objectives.The introduction of the Medicare Prospective Payment System and the more recent rise of managed care plans have greatly increased the importance of effective hospital financial management. Because physicians play a central role in directing hospital resource use, policies to influence physician behavior and to align physician and hospital interests more effectively are being advocated increasingly. This article evaluates the effect of nine strategies to facilitate physician involvement and integration into the hospital on hospital financial performance.Methods.Data came primarily from the Prospective Payment Assessment Commission's hospital-physician relations survey of 1,485 hospitals and the Medicare Cost Reports. Both ordinary least squares and first differencing models were used to evaluate the effect of physician integration on hospital financial performance.Results.Hospitals with lower margins and higher costs were more likely to have implemented strategies to integrate physicians and to modify physician behavior than their counterparts. Analysis using first differencing models indicated that making department heads responsible for the profits and losses had a significant positive effect on margins, whereas including medical staff on the hospital's board and offering physicians management services had a significant negative impact on average Medicare costs. In addition the number of strategies implemented was associated positively with financial performance. The paper also emphasizes the importance of model specification in evaluations of hospital-physician arrangements.Conclusions.Changes in hospital-physician relations may have been one reason why hospitals have been relatively successful at containing costs and retaining profitability in recent years. More research needs to be done on which specific arrangements affect hospital financial performance, as well as their effect on the quality of patient care.

ISSN:0025-7079    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Objectives.The purpose of this study was to evaluate the effect of clinical direct reports (practice data with pertinent evidence from the literature) on dialysis modality selection for patients with end-stage renal disease.Methods.A randomized controlled clinical trial was conducted at five dialysis centers. Five of the 10 physician participants were assigned through centralized computerized randomization to the intervention group (who received 12 center-specific clinical direct reports encouraging the consideration of peritoneal dialysis), and five were assigned to the control group, who received usual information but no similar report. One hundred fifty-two patients were eligible for monitoring.Results.The number of patients allocated to peritoneal dialysis was significantly higher in the intervention group than in the control group (15.3% versus 2.4%;P= 0.044). Due to a need for transient initial hemodialysis by some patients, the percentage of patients receiving peritoneal dialysis further increased through the end of the 3-month follow-up (18.0% versus 4.9%,P= 0.041).Conclusions.There were no significant differences between the intervention and control groups in meeting patient preferences, metabolic status, and complication rates. The results of this study show that linking pertinent published evidence to actual practice data can support the implementation of practice recommendations and influence the selection of dialysis treatment for new patients.

ISSN:0025-7079    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Objectives.Although studies have documented women's greater use of prescribed psychotropic drugs, few have explicitly examined how women and men differ in psychotropic drug use. This study examines gender differences in aggregate psychotropic drug use, as well as use of specific therapeutic categories, and explores how other factors explaining psychotropic drug use vary by gender.Methods.Using 1989 National Ambulatory Medical Care Survey (NAMCS) data, logistic regression analysis is used to estimate the probability of psychotropic drug use in aggregate and for four therapeutic categories-anxiolytics, sedative-hypnotics, antidepressants, and antipsychotics. For equations where gender is statistically significant, separate logistic regression equations are estimated to determine the explanatory variables that vary by gender.Results.The probability of receiving any psychotropic drug is 55% greater in office visits by women than those by men, all else constant. Further, gender is a positive and significant predictor of anxiolytic and antidepressant use. Variables estimating anxiolytic and antidepressnt use that differ by gender include diagnosis, physician specialty, and payment source for the office visit.Conclusions.Findings confirm research that has demonstrated that women are more likely than men to receive any psychotropic drug in office-based care. This gender differential holds only for anxiolytics and antidepressants. In addition, there were significant differences in the predictors of drug use for women and men.

ISSN:0025-7079    

出版商:OVID    

年代:1998

数据来源: OVID