Part 1: Quality of care--what is it?

Risk-adjusted surgical outcomes

Measures of risk-adjusted outcome are particularly suited for the assessment of the quality of surgical care. The reliability of measures of quality that use surgical outcomes is enhanced by prospective data acquisition and should be adjusted for the preoperative severity of illness. Such measures should be based only on reliable and validated data, and they should apply state-of-the-art analytical methods. The risk-adjusted postoperative mortality rate is useful as a quality measure only in specialties and operations expected to have a high rate of postoperative deaths. Risk-adjusted complications are more common but are limited as a comparative measure of quality by a lack of uniform definitions and data collection mechanisms. In specialties in which the expected postoperative mortality is low, risk-adjusted functional outcomes are promising measures for the assessment of the quality of surgical care. Measures of cost and patient satisfaction should also be incorporated in systems designed to measure the quality and cost-effectiveness of surgical care.

Factors associated with Medicare beneficiary complaints about quality of care

This article examines the number and types of formal complaints about quality of care that were made by Medicare beneficiaries and submitted to the California Peer Review Organization (PRO) during the period July 1, 1995-December 30, 1996. Logistic regression models were used to analyze the complaints in terms of sociodemographic factors, enabling factors (income and health maintenance organization [HMO] membership), diagnoses, and primary service providers. The complaint rate was found to be very low, and only 13% of complaints were confirmed by the PRO. HMO members and members receiving physician care and outpatient/emergency room care were more likely to complain about denials of or delays in services or the failure to be referred to specialists than were members in fee-for-service plans and those receiving other types of provider care. Complaints about poor nursing care were associated with receiving skilled nursing/rehabilitation care. Complaints about care that resulted in injury were associated with the denial of care, failure to be referred to a specialist, poor medical care, and poor communications. Complaints about care that led to disability were associated with medical errors, whereas those that led to death were associated with misdiagnosis and premature hospital discharge. It would be valuable for PROs to focus their complaint review efforts on common types of complaints in different settings. A review of PRO procedures should be undertaken to understand why so few complaints are submitted and confirmed.

The Oregon Health Plan: predictors of office-based diabetic quality of care

OBJECTIVE

In 1994, the Oregon Health Plan (OHP) expanded basic Medicaid insurance to residents under the federal poverty limit, adopted a prioritized limited benefits package, and converted to managed care. The quality of care in predominantly Medicaid populations with diabetes has not been previously described. In OHP enrollees, we examined predictors of diabetes care based on American Diabetes Association guidelines and described OHP diabetes care compared with national benchmarks.

RESEARCH DESIGN AND METHODS

Chart abstraction and Medicaid data for 1995-1996 yielded 996 nonpregnant diabetic patients who were 18-64 years of age. Using HbA1c, lipid panel, and urine protein/microalbumin documentation ordered during the study year, we constructed a standard care (SC) index: SC for all three tests, mixed care (MC) for one to two tests, or no tests documented (NTD).

RESULTS

Our sample was predominantly white, 48 +/- 11 years of age, 63% women, with 8 +/- 5 provider visits. Providers ordered HbA1c (70%), urine microalbumin/protein (57%), and lipid panel (41%) tests. Patients distributed into SC (22%), MC (62%), or NTD (16%). Thirteen variables predicted SC. Patients had a higher likelihood of SC if they were 18-24 years of age, had more clinic visits, were on insulin daily, were in several comorbid groups, were enrolled in salaried or capitated health plans, or lived in counties with more hospital beds. Four studies were used as comparable national benchmarks.

CONCLUSIONS

Care provided to OHP patients with diabetes compares favorably with national benchmarks. Yet, most OHP patients with diabetes are still not achieving optimal care. Examining predictors of SC may play an important role in further policy development.

Quality improvement in parenteral nutrition care

The therapeutic objective of parenteral nutrition, as well as any other pharmacological treatment, must be organized for and focused on the patient, to obtain outcomes associated with an improvement in health status and quality of life. On this basis, the present article starts with a view of quality improvement in health care, identifying the structure, process and outcome paradigm for drug therapy and parenteral nutrition elements of quality assessment, as well as strategies for quality improvement will be described. A model of the organization assigned to parenteral nutrition care is proposed. In the future, computerized programs of parenteral nutrition may increase the risk of uncoordinated and fragmented care. The programs must improve health care of patient by exposing caregivers to the full alternatives of decisions with clinical and therapeutic data on patient individual.

The Society of Gynecologic Oncologists Outcomes Task Force. Study of endometrical cancer: initial experiences

OBJECTIVE

The aim of this study was to develop an outcomes measure, which incorporates patient reported information, for The Society of Gynecologic Oncologists (SGO) to establish benchmarks in the treatment of endometrial cancer and demonstrate quality to third parties.

METHODS

The Outcomes Task Force (OTF) developed an outcomes tool that included preoperative, intraoperative, and 120-day-postoperative assessments. Measures included demographics, patient-reported health status (SF36), comorbid conditions, living status, satisfaction surveys, operative events and disease characteristics. Patients (n = 297) were surveyed at 11 pilot sites from 10/1/97 to 9/1/99.

RESULTS

The mean age of patients was 64.4 years and their mean Quetelet index was 33.2 kg/m(2). Forty-eight percent were Medicare beneficiaries and 25% were HMO patients. Mean comorbidity score was 19.1 (maximum possible 100). This represents approximately three comorbidities per average patient. Seventy-four percent were FIGO stage I, 9% stage II, 11% stage III, and 5% stage IV. Forty percent were FIGO grade 1, 35% grade 2, and 24% grade 3. Ninety-two percent of patients were able to live independently preoperatively and 91% were independent postoperatively. Seventy-seven percent of patients underwent total abdominal hysterectomy, 8% radical abdominal hysterectomy, 9% laparoscopic hysterectomy, and 1% vaginal hysterectomy. Mean length of stay was 3. 3 days and mean operative time was 119 min. Ninety-nine percent were staged and 80% underwent lymph node sampling. Two patients required unplanned returns to surgery and 8 required blood transfusion (27 units total). Postoperatively, 20% received radiation therapy and 13% received cytotoxic chemotherapy. Mean satisfaction score (scale 0 to 100) preoperatively was 86 and postoperative was 83. SF36 component summaries were preoperatively and 120 days postoperatively: physical component 43.6 vs 43.1; mental component 49.1 vs 50.6.

CONCLUSION

The SGO has developed a tool for assessing outcomes for the treatment of endometrial cancer that can be made available to the membership to assess and objectively demonstrate quality of care to third parties.

Defining quality of care

This paper defines quality of health care. We suggest that there are two principal dimensions of quality of care for individual patients; access and effectiveness. In essence, do users get the care they need, and is the care effective when they get it? Within effectiveness, we define two key components--effectiveness of clinical care and effectiveness of inter-personal care. These elements are discussed in terms of the structure of the health care system, processes of care, and outcomes resulting from care. The framework relates quality of care to individual patients and we suggest that quality of care is a concept that is at its most meaningful when applied to the individual user of health care. However, care for individuals must placed in the context of providing health care for populations which introduces additional notions of equity and efficiency. We show how this framework can be of practical value by applying the concepts to a set of quality indicators contained within the UK National Performance Assessment Framework and to a set of widely used indicators in the US (HEDIS). In so doing we emphasise the differences between US and UK measures of quality. Using a conceptual framework to describe the totality of quality of care shows which aspects of care any set of quality indicators actually includes and measures and, and which are not included.

Towards an optimal model for community-based diabetes care: design and baseline data from the Mayo Health System Diabetes Translation Project

The objective of the Mayo Health System Diabetes Translation Project is to assess the impact of three different models of care on the overall quality of diabetes care in the community. The unit of study is the primary care practice with a different model of care implemented at each of three sites. The design incorporates a comparison of a diabetes guideline implementation team initiative (Practice model A), a guideline initiative combined with clinical use of a Diabetes Electronic Management System (DEMS) by primary care providers (Practice model B) and a guideline initiative combined with DEMS utilization combined with electronic review of DEMS patient encounters by an endocrinologist (Practice model C). Administrative data sets were used to define the patient population at each practice. Patients were designated as new, attending or non-attending based on their pattern of visits over the preceding 12 months. A random sample of 200 charts from attending patients at each site was audited at baseline for diabetes-related process and outcome measures. This audit will be repeated yearly during the 2 years of the project. Baseline data revealed significant differences across sites in adherence to certain key indicators of the quality of diabetes care including: frequency of documentation of eye examinations (19, 39 and 37% for sites A, B and C, respectively), haemoglobin A1c monitoring (64, 89 and 77%) and microalbumin monitoring (3, 15 and 6%). The interventions being assessed in this study include traditional (diabetes education; guideline implementation) and modern (DEMS; telemedicine specialist review) methods for improving the quality of diabetes care. In spite of variation in baseline quality indicators, the setting and design should lead to broad applicability of the results and help determine an optimal model of diabetes care in the community.

Structure quality management in pediatric diabetes care

The aim of all diabetes treatment in childhood and adolescence is to counteract the development of complications (acute as well as late), to achieve normal growth and development, and to provide the patients with as good as possible a quality of life. Many studies have confirmed the benefits of intensified medical management regarding the prevalence and/or the progression of diabetic microvascular complications. Intensified medical management means of course much more than intensified insulin substitution; diabetes care includes diet, physical exercise, diabetes education, continuous monitoring, and psychosocial support. To improve the outcome of patients with diabetes mellitus, optimizing structure quality is one of the goals. A number of prerequisites (regarding the social-socioeconomic-health care system) are not yet fulfilled everywhere; structures necessary to provide qualified diabetes care (e.g. pediatric diabetes center, team of experts, outpatient care) are not yet sufficiently available in some areas. According to both the declarations of St. Vincent and of Kos, every effort should be made to enhance structure quality in an attempt to improve the situation and the outcome of our young patients with diabetes.

Quality in health care and ethical principles

Quality in health care and ethical principles The last three decades have seen rapid changes in the way United States of America (USA) health care has been delivered, financed and regulated. Four major stakeholders have emerged in the health care debate: patients, providers, payers and public regulatory agencies. These groups do not agree on a definition of quality health care. This paper suggests five ethical principles - autonomy, justice, beneficence, non-maleficence, and prudence - be included in the framework of quality health care. A framework that outlines possible relationships among these ethical attributes and four major stakeholders is presented.

Influence of quality of care on quality of life in inflammatory bowel disease (IBD): literature review and studies planned

Inflammatory bowel disease (IBD) is a chronic disorder with an early onset in life. Therefore, it is reasonable to assume that IBD patients are in considerable need of health care. The quality of life of IBD patients is reported to be impaired. Whether optimizing the quality of health care for these patients may positively influence their quality of life is a question that has been raised often during recent years. This review of the literature on health care research discusses different concepts regarding the quality of care assessment in chronic disease, stresses the need to see things from the patient's perspective, and provides recommendations to optimize health care research. The two most important conclusions that can be drawn are that: (1) the relationship between quality of health care and quality of life in IBD is one that is certainly worth studying; and (2) when developing a means to assess patient data on quality of care, it is essential to involve patients from the very start.

Understanding the intersection between quality improvement, managed behavioral health accreditation, and the private practitioner

The many parties, which now possess a role in behavioral health care services, are each concerned about the quality of these services. The concept of accreditation of MBHOs differs little from the board certification and licensure mechanisms used to ensure a minimal standard of care among practitioners. In the same way that behavioral health patients use licensure to seek competent providers, payers use accreditation as a way to ensure that MBHOs, given the task of cost control, are also active in ensuring that cost containment does not translate into decreased quality of care. Accreditation has established standards that fundamentally require MBHOs to implement QI programs directed at assessing and implementing efforts to improve care on a systemic level. NCQA accreditation of MBHOs reflects an effort to both regulate a novel industry as well as establish standards that reflect an ideal of health care. Currently, relatively few MBHOs receive full accreditation. This suggests that NCQA maintains its ideals but also that many MBHOs do not have the quality improvement programs that adequately demonstrate an interest in assessing and improving upon continuity and population-based quality care. As a fledgling industry, MBHOs are subject to unique market demands and trial and error. These forces have alienated many practitioners who provide services to MBHO members; however, practitioners must be able to tease out those aspects of managed care that facilitate quality care for their patients. Fundamental to this is the need for practitioners to understand and contribute meaningfully to QI initiatives directed at meeting NCQA standards. Despite their impositions, the new demands they place on practitioners, and the conflicted relationship in which they take place, QI efforts reflect an effort on the part of accrediting organizations and MBHOs to define, through empirical assessment and improvement efforts, quality care at a systemic level. Such care directly relates to effective behavioral health care by ensuring that a population of members receives care over a continuum of time and setting. Accreditation standards ultimately translate into quality of care and service, which patients and practitioners as well as the other stakeholders in the health care marketplace, agree is important.

Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care

PURPOSE

To conduct a comprehensive review of the health services literature to search for evidence that hospital or physician volume or specialty affects the outcome of cancer care.

METHODS

We reviewed the 1988 to 1999 MEDLINE literature that considered the hypothesis that higher volume or specialization equals better outcome in processes or outcomes of cancer treatments.

RESULTS

An extensive, consistent literature that supported a volume-outcome relationship was found for cancers treated with technologically complex surgical procedures, eg, most intra-abdominal and lung cancers. These studies predominantly measured in-hospital or 30-day mortality and used the hospital as the unit of analysis. For cancer primarily treated with low-risk surgery, there were fewer studies. An association with hospital and surgeon volume in colon cancer varied with the volume threshold. For breast cancer, British studies found that physician specialty and volume were associated with improved long-term outcomes, and the single American report showed an association between hospital volume of initial surgery and better 5-year survival. Studies of nonsurgical cancers, principally lymphomas and testicular cancer, were few but consistently showed better long-term outcomes associated with larger hospital volume or specialty focus. Studies in recurrent or metastatic cancer were absent. Across studies, the absolute benefit from care at high-volume centers exceeds the benefit from break-through treatments.

CONCLUSION

Although these reports are all retrospective, rely on registries with dated data, rarely have predefined hypotheses, and may have publication and self-interest biases, most support a positive volume-outcome relationship in initial cancer treatment. Given the public fear of cancer, its well-defined first identification, and the tumor-node-metastasis taxonomy, actual cancer care should and can be prospectively measured, assessed, and benchmarked. The literature suggests that, for all forms of cancer, efforts to concentrate its initial care would be appropriate.

Measurement of quality of recovery in 5672 patients after anaesthesia and surgery

Quality of recovery after an operation is an important dimension of the patient's experience and may be related to the quality of anaesthesia care. Satisfaction with anaesthesia is a vital component of quality care but difficult to measure. We examined our database of 5672 adult patients to determine if quality of recovery is associated with satisfaction with anaesthesia and to identify the perioperative factors that might influence both these outcome measures. We found that a nine-item quality of recovery score ("QoR Score") was related to satisfaction with anaesthesia (P < 0.0005): the overall level of satisfaction was high (97.2%; median QoR Score 16); 106 patients (2.1%; median QoR Score 14) were "somewhat dissatisfied" and 32 patients (0.6%; median QoR Score 13) were "dissatisfied" with their anaesthesia care. Patients who experienced any of a number of perioperative complications had lower QoR Scores (P < 0.0005). We have further demonstrated the validity and clinical utility of the QoR Score, and in particular, its relationship to patient satisfaction in adult surgical patients.

The dialysis outcomes quality initiative: history, impact, and prospects

Rigorously developed clinical practice guidelines have the potential to improve patient outcomes. It is toward that end that the National Kidney Foundation (NKF) launched in March 1995 the Dialysis Outcome Quality Initiative (DOQI), an ambitious effort to develop evidence-based clinical practice guidelines for the care of patients with end-stage renal disease (ESRD). Independent, interdisciplinary work groups conducted a structured review of the content and methodologic rigor of all the published literature pertinent to four selected topics: hemodialysis adequacy, peritoneal dialysis adequacy, vascular access, and anemia. Following expert, organizational, and public review, the guidelines were issued in September and October 1997. An implementation plan that called for widespread dissemination of the guidelines and facilitation of adoption of them has resulted in their broad acceptance and Integration into quality improvement efforts. Additional guidelines on nutrition have recently been completed, while others on bone disease, hypertension, and hyperlipidemia are in various stages of planning or development. A major determinant of poor outcome of maintenance dialysis patients is the debilitated state of many individuals with ESRD at the time that they commence dialysis therapy. The recognition of this problem has stimulated an interest in extending the guidelines to management of patients with less severe renal insufficiency, well before they need renal replacement therapy; and to the early detection of renal insufficiency by a proteinuria and albuminuria risk assessment, detection, and elimination (PARADE) program. What started as an initiative to improve the quality of care of dialysis patients has evolved into a considerably expanded effort to making lives better for all individuals with any level of renal insufficiency.

Quality and outcome determination in health care and orthopaedics: evolution and current structure

Quality health care has many definitions. Among those definitions is "care that consistently contributes to the improvement or maintenance of the quality and/or duration of life." The current evolution in health care has been fueled by three necessities frequently demanded by payers and employers: improvement in access, lowering of cost, and definition and quantification of the quality of care. This evolution has been facilitated by the so-called industrialization of medicine. This concept includes the adoption of industrial economic principles and techniques that facilitate the measurement of processes and outcomes. Quality health care is currently recognized as health care that is characterized by three elements: the use of practice guidelines or standards, the implementation of continuous quality improvement techniques, and the use of outcome determination and management. Practice guidelines demand the adoption of evidence-based principles in evaluation and care, as well as minimization of variations in evaluation and care. Continuous quality improvement seeks to determine why variations in processes of care occur and then to minimize those variations. Outcomes may be measured in terms of both very objective and very subjective variables and also on the basis of cost-efficiency. Most tools currently used to quantify outcomes, especially in orthopaedics, involve measurements of general health and of specific body part or organ system function. This evolution in health care is producing significant alterations in methods of traditional health-care delivery. The accumulating evidence indicates that these changes, although frequently unpopular, are improving the quality of health care.

A quality management project in Israeli navy primary care clinics

The objective of this project was to establish a measurable process of continuous quality improvement of health care services in the Israeli naval primary care clinics. All navy clinics were surveyed at 6-month intervals. The quality of medical recording was evaluated, and instructive workshops were given on the matter. Real-time physician-patient interactions were evaluated, and immediate feedback was given to the examining physician. Complementary medical services were evaluated and steps toward improvement were taken. A total of 1043 medical records were examined. A general improvement in medical-record documentation (from a score of 6.0 +/- 2.5 to a score of 7.4 +/- 1.9, P < .001) was demonstrated during the first 3 years of the project. No significant change was noticed in the physician-patient interaction score. Complementary medical services improved from a score of 4.9 +/- 1.5 in 1994 to a score of 7.4 +/- 0.9 3 years later (P < .02). This project achieved a significant improvement in the quality of medical recording and of complementary medical services.

Proposed agenda for the measurement of quality-of-care outcomes in oncology practice

Cancer is an important disease, and health care services have the potential to improve the quality and quantity of life for cancer patients. The delivery of these services also has recently been well codified. Given this framework, cancer care presents a unique opportunity for clinicians to develop and test outcome measures across diverse practice settings. Recently, the Institute of Medicine released a report reviewing the quality of cancer care in the United States and called for further development and monitoring of quality indicators. Thus, as we move into the 21st century, professional and regulatory agencies will be seeking to expand process measures and develop and validate outcomes-oriented measures for cancer and other diseases. For such measures to be clinically relevant and feasible, it is key that the oncology community take an active leadership role in this process. To set the stage for such activities, this article first reviews broad methodologic concerns involved in selecting measures of the quality of care, using breast cancer to exemplify key issues. We then use the case of breast cancer to review the different phases of cancer care and provide examples of phase-specific measures that, after careful operationalization, testing, and validation, could be used as the basis of an agenda for measuring the quality of breast cancer care in oncology practice. The diffusion of process and outcome measures into practice; the practicality, reliability, and validity of these measures; and the impact that these indicators have on practice patterns and the health of populations will be key to evaluating the success of such quality-of-care paradigms. Ultimately, improved quality of care should translate into morbidity and mortality reductions.

Assessment of quality of care for managed care and fee-for-service patients based on analysis of avoidable hospitalizations

As managed care has grown to dominate the US health care delivery system, questions have been raised about the impact on the quality of care provided to its enrollees. Two important aspects of health care quality are access to care and the appropriateness of care. This analysis evaluated the occurrence of preventable hospitalizations among managed care (MCO) versus fee for service (FFS) populations to compare access to and appropriateness of preventive, primary, and surgical health care services. Rates of preventable hospitalizations associated with ambulatory sensitive conditions (ASCs) were calculated based on all discharges from Massachusetts hospitals in 1995, and categorized by population characteristics including: age, sex, ethnicity, and insurance status. Multivariate logistic regression models were employed to explain the likelihood of having a preventable hospitalization. Rates of preventable hospitalizations for two of the conditions evaluated (perforated appendix and diabetes complications) were lower for MCO enrollees. For two additional indicators (immunization preventable pneumonia and low birth weight), MCO rates were no different from FFS rates. Results for pediatric asthma were inconclusive. For four out of five quality indicators evaluated, individuals in Massachusetts MCOs are doing better or no worse than their counterparts in FFS plans. Until population-based data on managed care enrollees becomes available, and until such data can be linked to utilization and health outcomes information, investigations into the quality of services provided by MCOs compared to FFS plans cannot be definitive.

Improvement in quality of life measures after laparoscopic antireflux surgery

OBJECTIVE

To determine if patients with gastroesophageal reflux "well controlled medically" had a different quality of life from those with residual symptoms receiving aggressive medical therapy, and to determine whether laparoscopic antireflux surgery significantly altered quality of life in patients with gastroesophageal reflux.

SUMMARY BACKGROUND DATA

Clinical determinants of outcome may not adequately reflect the full impact of therapy. The medical outcomes study short form (SF-36) is a well-validated questionnaire that assays eight specific health concepts in three general fields. It may provide a more sensitive tool for judging the success of antireflux therapy.

METHODS

A total of 345 patients undergoing laparoscopic antireflux surgery completed at least one questionnaire during the study period. Preoperative questionnaires were completed by 290 patients, 223 completed a questionnaire 6 weeks after surgery, and 50 completed the same questionnaire 1 year after surgery. A subgroup of 70 patients was divided before surgery into two groups on the basis of their response to standard medical therapy.

RESULTS

Preoperative scores were extremely low. All eight SF-36 health categories improved significantly 6 weeks and 1 year after surgery. In the 70-patient subgroup, 53 patients (76%) underwent laparoscopic antireflux surgery because of symptoms refractory to medical therapy and 17 patients (24%) reported that their symptoms were well controlled but elected to have surgery because they wished to be medication-free. The preoperative quality of life scores of these two patient groups were equivalent in all but one category. Postoperative scores were significantly improved in all categories and indistinguishable between the two groups.

CONCLUSIONS

Laparoscopic antireflux surgery is an effective therapy for patients with gastroesophageal reflux and may be more effective than medical therapy at improving quality of life.

Health care professional staffing, hospital characteristics, and hospital mortality rates

To evaluate associations among hospital characteristics, staffing levels of health care professionals, and mortality rates in 3763 United States hospitals, a data base was constructed from the American Hospital Association's Abridged Guide to the Health Care Field and hospital Medicare mortality rates from the Health Care Financing Administration. A multivariate regression analysis controlling for severity of illness was employed to determine the associations. Hospital characteristics associated with lower mortality were occupancy rate and private nonprofit and private for-profit ownership. Mortality rates decreased as staffing level per occupied bed increased for medical residents, registered nurses, registered pharmacists, medical technologists, and total hospital personnel. Mortality rates increased as staffing level per occupied bed increased for hospital administrators and licensed practical-vocational nurses. To our knowledge, this is the first study to show that pharmacists were associated with lower mortality rates.

Impact of language barriers on patient satisfaction in an emergency department

OBJECTIVE

To examine patient satisfaction and willingness to return to an emergency department (ED) among non-English speakers.

DESIGN

Cross-sectional survey and follow-up interviews 10 days after ED visit.

SETTING

Five urban teaching hospital EDs in the Northeastern United States.

PATIENTS

We surveyed 2,333 patients who presented to the ED with one of six chief complaints.

MEASUREMENTS AND MAIN RESULTS

Patient satisfaction, willingness to return to the same ED if emergency care was needed, and patient-reported problems with care were measured. Three hundred fifty-four (15%) of the patients reported English was not their primary language. Using an overall measure of patient satisfaction, only 52% of non-English-speaking patients were satisfied as compared with 71% of English speakers (p < .01). Among non-English speakers, 14% said they would not return to the same ED if they had another problem requiring emergency care as compared with 9.5% of English speakers (p < .05). In multivariate analysis adjusting for hospital site, age, gender, race/ethnicity, education, income, chief complaint, urgency, insurance status, Medicaid status, ED as the patient's principal source of care, and presence of a regular provider of care, non-English speakers were significantly less likely to be satisfied (odds ratio [OR] 0.59; 95% confidence interval [CI] 0.39, 0.90) and significantly less willing to return to the same ED (OR 0.57; 95% CI 0.34, 0.95). Non-English speakers also were significantly more likely to report overall problems with care (OR 1.70; 95% CI 1.05, 2.74), communication (OR 1.71; 95% CI 1.18, 2.47), and testing (OR 1.77; 95% CI 1.19, 2.64).

CONCLUSIONS

Non-English speakers were less satisfied with their care in the ED, less willing to return to the same ED if they had a problem they felt required emergency care, and reported more problems with emergency care. Strategies to improve satisfaction among this group of patients may include appropriate use of professional interpreters and increasing the language concordance between patients and providers.

Assessing the predictive validity of the RAND/UCLA appropriateness method criteria for performing carotid endarterectomy

We assessed the predictive validity of an expert panel's ratings of the appropriateness of carotid endarterectomy by comparing ratings to the results of subsequent randomized clinical trials. We found the trials confirmed the ratings for 44 indications (covering almost 30% of operations performed in 1981) and refuted the ratings for none.

A method for evaluating health care providers' decision making: the Provider Decision Process Assessment Instrument

Valid and reliable assessment of the clinical decision-making process is essential for the evaluation of decision aiding methods and effective quality assurance programs. The Provider Decision Process Assessment Instrument is a 12-item questionnaire that measures a health care provider's degree of comfort with a medical decision. Its measurement properties were studied in two general internal medicine practices. Reliability, measured using Cronbach's alpha, was 0.90 (95% Cl = 0.87 to 0.92). Construct validity was also high, with expected negative correlations ranging from -0.53 to -0.67. The instrument also satisfied standard criteria for item homogeneity and was readily completed by clinicians. These results suggest that the Provider Decision Process Assessment Instrument will prove to be a valuable tool for assessing medical decision making in busy clinical settings.

An overview of the National Kidney Foundation-Dialysis Outcomes Quality Initiative Implementation

Rigorously developed clinical practice guidelines have the potential to improve outcomes and favorably alter practice patterns. Because of widespread community concerns over the quality of dialysis care, the National Kidney Foundation initiated a Dialysis Outcomes Quality Initiative (NKF-DOQI) in March 1995 in an effort to create evidence-based best-practice clinical guidelines. Independent interdisciplinary Work Groups reviewed the available body of scientific literature on four selected topics: hemodialysis adequacy, peritoneal dialysis adequacy, vascular access, and anemia. More than 11,000 publications were identified, of which 1,500 were considered relevant and were subjected to structured review. Draft guidelines, with supporting rationales of their evidentiary basis, were subjected to a three-stage public and organizational review process. The final guidelines were issued in the fall of 1997. Because the potential benefit of guidelines depends on their implementation, planning for the implementation of NKF-DOQI was begun simultaneously with its review process. A 3-year implementation plan, with specific priorities and estimated costs, was developed and set into action by the end of 1997. The main objectives of the rather diverse and multifaceted plan of action are translating the NKF-DOQI Guidelines into clinical practice, building on what has been accomplished, and continued evaluation and review of the Guidelines.

Defining quality of care for children and adolescents with type 1 diabetes

Recent years have seen an increase in awareness of the need to improve the quality of diabetes care for children and adolescents, as detailed in the Declaration of Kos, for example. This paper addresses some quality-of-care principles and evaluates specific examples of current management. The meaning of the terms quality of care, evidence-based medicine and cost-containment are examined, and the features central to the development and evaluation of quality health care (structure, process and outcome) are explored. The practical aspects of diabetes care are reviewed in terms of the causes and prevention of early mortality, ambulatory vs inpatient care, the value of measuring HbA1c, other metabolic control criteria (including the effect of patient selection, cultural, socioeconomic and biological differences) and clinical practice guidelines. It is concluded that a multidisciplinary team provides the optimum context for diabetes management and that care must be family centred and multidimensional (i.e. not focusing on HbA 1c levels alone). The task of improving diabetes care is massive and operates at all levels (individual, family, healthcare providers, national and international bodies), but offers significant improvements in quality and cost-effectiveness.

What do health authorities think of population based health outcome indicators?

OBJECTIVES

To determine the role of population based indicators of health outcome in local health outcome assessments; the constraints of using such indicators; how they could be made more useful; and whether health authorities had developed their own indicators of health outcome.

DESIGN

A structured telephone interview with representatives of 91 of the 100 English health authorities.

RESULTS

Interviewees, asked to give details on two clinical areas in which population health outcome assessments had been of most value, nominated 147 examples in over 30 clinical areas. They chose 50 (34%) of the examples because of an outlying national indicator, and 20 (14%) because of local variations in a national indicator. The main perceived constraints in the use of population based indicators of health outcome were: data validity and timeliness; the attributability of these health outcomes to the quality of health care; the difficulties of changing clinical behavior; and organisational change within health authorities. To make these indicators more useful interviewees wanted an increased use of process indicators as proxies for health outcome, indicator trend data, and indicator comparisons of districts with similar population structures. Some recent publications have started to consider some of these issues. 27 (30%) health authorities had developed their own indicators, mostly provider based process indicators. 10 of these used their own indicators to manage the performance of local provider units.

CONCLUSIONS

Population based indicators of health outcome had an important role in prompting districts to undertake population health outcome assessments. Health authorities also used these indicators to examine local variations in health outcome. They helped to highlight areas for further investigation, initiated data validation, and enabled the monitoring of changes to services. Comparative population based indicators of health outcome may have an increasing part to play in assessing the performance of health authorities.

[Quality-of-care assessment in a university hospital pediatric clinic]

This study focuses on the Pediatric Clinic of the UNICAMP University Hospital, teaching and care facility belonging to the Brazilian National Health System, providing secondary and tertiary health care for children aged 0 to 18 years. A total of 221 questionnaires were applied with users of the general pediatric out patient services and one of the specialties, allowing for comparison of various medical care indicators. Users were found to be quite knowledgeable about their health conditions and satisfied with the care received, despite a weak link in the physician-patient relationship. 43.4% reported problems related to the services, while only 17.6% made suggestions to improve them. Waiting time was found to be quite long. Users of specialized services differed from general care patients with regard to several indicators.

[Evolutionary quality assurance. A new concept for improving process and outcome quality]

BACKGROUND

The concept evolutionary quality assurance is a new, non-mandatory, open peer review process for in-patients settings.

METHOD

Ten medical charts (with radiographs) from participating hospitals were randomly chosen and assessed using a prespecified questionnaire (total 134). Individual inadequacies had to be justified on a case by case level. Reviewer and reviewee are known by names, allowing subsequent discussions on content between reviewer and reviewee prior to a final judgement. The final analysis was performed anonymously and communicated to the participants after completion of the process. Patients had to give their consent to the review process. The report, however, is not part of the medical patient file, so that access is not warranted. For the first cycle, all lung clinics and departments throughout Germany were asked to participate. 35 chest hospital (approximately 50%) agreed to participate.

RESULTS

Data analysis revealed that almost all detected inadequacies were apparent, i.e. discussions on the discordant interpretation of diagnostic and therapeutic strategies rarely occurred (0.25%). Final analysis of the evaluation performance of reviewers judged less than 5% and 14% judged more than 30% of all quality inadequacies.

CONCLUSIONS

The quality assurance process is comparably cheap and can be implemented without delay, because standards for reference values are not required. The structure allows adaptation in all areas of clinical medicine.

Factors determining angiotensin-converting enzyme inhibitor underutilization in heart failure in a community setting

BACKGROUND

Angiotensin-converting enzyme (ACE) inhibitors were underprescribed for patients with congestive heart failure (CHF) treated in the community setting in the early 1990s despite convincing evidence of benefit.

HYPOTHESIS

We postulated that (1) the prevalence of ACE inhibitor use has increased, and (2) prescribing biases have narrowed, as community physicians have gained additional clinical experience with these drugs for treatment of CHF.

METHODS

We examined rates of ACE inhibitor use among 1,150 patients with CHF hospitalized at 10 community hospitals in 1995, evaluated determinants of ACE inhibitor prescription, and compared the results with survey data gathered among similar patients during 1992.

RESULTS

Compared with 1992, ACE inhibitor use prior to hospital admission was increased among all patients (42 vs. 33%, p < 0.001) and the subset with a history of CHF (53 vs. 39%, p < 0.0005). Angiotensin-converting enzyme inhibitor prescription at hospital discharge also increased among all survivors (64 vs. 51%, p < 0.00005) and the subset eligible for ACE inhibitor treatment based on clinical trial criteria (77 vs. 66%, p = 0.04). Multivariate analysis suggested no change in the prescribing biases previously observed; ACE inhibitor use was related to lower ejection fraction, lower serum creatinine, documentation of left ventricular systolic function, younger patient age, prescription of any diuretic drug, and nonprescription of alternate vasodilators and calcium blockers. In multivariate analyses, physician specialty did not predict ACE inhibitor use.

CONCLUSIONS

Angiotensin-converting enzyme inhibitor use among patients with CHF is increasing but remains below the 80-90% rates of drug tolerance documented in randomized clinical trials. This discrepancy is partially explained by the prevalence of renal impairment and "diastolic" heart failure in the community setting. However, age bias, use of alternative vasodilators, and substandard quality of care may also play a role.