Exemplar Hospital initiation trial to Enhance Treatment Engagement (EXHIT ENTRE): protocol for CTN-0098B a randomized implementation study to support hospitals in caring for patients with opioid use disorder

BACKGROUND

Hospitalizations involving opioid use disorder (OUD) are increasing. Medications for opioid use disorder (MOUD) reduce mortality and acute care utilization. Hospitalization is a reachable moment for initiating MOUD and arranging for ongoing MOUD engagement following hospital discharge. Despite existing quality metrics for MOUD initiation and engagement, few hospitals provide hospital based opioid treatment (HBOT). This protocol describes a cluster-randomized hybrid type-2 implementation study comparing low-intensity and high-intensity implementation support strategies to help community hospitals implement HBOT.

METHODS

Four state implementation hubs with expertise in initiating HBOT programs will provide implementation support to 24 community hospitals (6 hospitals/hub) interested in starting HBOT. Community hospitals will be randomized to 24-months of either a low-intensity intervention (distribution of an HBOT best-practice manual, a lecture series based on the manual, referral to publicly available resources, and on-demand technical assistance) or a high-intensity intervention (the low-intensity intervention plus funding for a hospital HBOT champion and regular practice facilitation sessions with an expert hub). The primary efficacy outcome, adapted from the National Committee on Quality Assurance, is the proportion of patients engaged in MOUD 34-days following hospital discharge. Secondary and exploratory outcomes include acute care utilization, non-fatal overdose, death, MOUD engagement at various time points, hospital length of stay, and discharges against medical advice. Primary, secondary, and exploratory outcomes will be derived from state Medicaid data. Implementation outcomes, barriers, and facilitators are assessed via longitudinal surveys, qualitative interviews, practice facilitation contact logs, and HBOT sustainability metrics. We hypothesize that the proportion of patients receiving care at hospitals randomized to the high-intensity arm will have greater MOUD engagement following hospital discharge.

DISCUSSION

Initiation of MOUD during hospitalization improves MOUD engagement post hospitalization. Few studies, however, have tested different implementation strategies on HBOT uptake, outcome, and sustainability and only one to date has tested implementation of a specific type of HBOT (addiction consultation services). This cluster-randomized study comparing different intensities of HBOT implementation support will inform hospitals and policymakers in identifying effective strategies for promoting HBOT dissemination and adoption in community hospitals.

TRIAL REGISTRATION

NCT04921787.

Integrating expert judgment in veterinary epidemiology: example guidance for disease freedom surveillance

Expert opinions supplement empirical data in many epidemiologic assessments. For veterinary disease freedom surveillance, where the geographic scope of concern is often broad, populations subject to change, decisions eminent and empirical data, expert opinion can be a critical component of the decision making process. However, opinion is by definition subjective and the manner in which opinion is sought can impact the quality and reliability of estimates. Group interaction can hinder or improve the estimation process, depending on its facilitation. Further, whether and how validation is conducted can limit or increase acceptance of the resulting model. While the utility of expert opinion is widely recognized in many fields, and the impact of its use or misuse implicit, standards for application to veterinary assessments are not readily available. This paper aims to foster discussion on this influential component of epidemiology, with disease freedom application as a focus. Benefits and concerns attributed to expert judgment and guidelines for its structured elicitation are described, borrowing insights from its long history of use in decision science fields and examples from recent veterinary assessments.

Differences in patient and clinic characteristics at CARE Act funded versus non-CARE Act funded HIV clinics

The Ryan White CARE Act supports comprehensive care to persons with HIV infection. With an annual budget of over $1 billion, it is the largest federally funded programme for HIV care in the USA. We analysed data from the HIV Costs and Services Utilization Study, a nationally representative sample of HIV patients. Patient data were collected in 1996-97 and clinic data were collected in 1998-99. We examined whether CARE Act funded clinics differed from other HIV clinics in (1) the characteristics of their patients, and (2) their organization, staffing, and services. We found that patients at CARE Act clinics were younger, less educated, poorer, and more likely to be female, non-white, unemployed, uninsured, and have heterosexual contact as an HIV risk factor, compared to patients at other HIV clinics. CARE Act clinics tended to specialize in HIV care, had more infectious disease specialists, had fewer total patients, and provided more support services (e.g. mental health, nutrition, case management, child care). These results are consistent with findings of other studies that were limited by non-probability samples or restricted geographical areas.

CHESS: ten years of research and development in consumer health informatics for broad populations, including the underserved

This paper reviews the research and development around a consumer health informatics system CHESS (The Comprehensive Health Enhancement Support System) developed and tested by the Center for Health Systems Research and Analysis at the University of Wisconsin. The review will place particular emphasis on what has been found with regard to the acceptance and use of such systems by high risk and underserved groups.

Impact of surgery and chemotherapy on the quality of life of younger women with breast carcinoma: a prospective study

BACKGROUND

Studies that prospectively and simultaneously evaluate, within the first year of diagnosis, the impact of surgery and chemotherapy on quality of life (QOL) of younger women (60 years or younger) with early stage breast carcinoma are limited.

METHODS

Quality of life of 103 women who had surgery (lumpectomy, 49; mastectomy, 54) approximately 1 month before the start of the study was evaluated at baseline and again after 5 months. Thirty-two women received chemotherapy during the study.

RESULTS

Over time, subjects reported improvement in body image and physical, emotional, and functional well-being (P < 0.001). They were less bothered by swollen/tender arms and worried less about risk of cancer to family members (P < 0.001). However, satisfaction with sex life, social support, and social/family well-being declined (P < 0.001). In the period closer to surgery, women with mastectomy reported poorer body image (P = 0.001) and worse functional (P = 0.08) and physical well-being (P = 0.10). Women with lumpectomy worried more about the effects of stress on their illness (P < 0.01) and had lower emotional well-being (P = 0.06). By 6 months after surgery, the two groups reported similar QOL scores. Chemotherapy had a negative impact on women's sexual functioning (P = 0.01) and their physical well-being (P = 0.09). Women who received chemotherapy also reported more shortness of breath (P = 0.07). Post hoc analysis showed that women with breast reconstruction had higher emotional well-being at baseline than those with lumpectomy (P = 0.001) and mastectomy alone (P < 0.01).

CONCLUSIONS

Younger women with breast carcinoma could experience a range of adjustment problems at various points in the treatment cycle. Interventions that would help reduce the negative impact of treatment on QOL need to be designed and integrated into routine clinical practice.

Impact of surgery and chemotherapy on the quality of life of younger women with breast carcinoma: a prospective study

BACKGROUND

Studies that prospectively and simultaneously evaluate, within the first year of diagnosis, the impact of surgery and chemotherapy on quality of life (QOL) of younger women (60 years or younger) with early stage breast carcinoma are limited.

METHODS

Quality of life of 103 women who had surgery (lumpectomy, 49; mastectomy, 54) approximately 1 month before the start of the study was evaluated at baseline and again after 5 months. Thirty-two women received chemotherapy during the study.

RESULTS

Over time, subjects reported improvement in body image and physical, emotional, and functional well-being (P < 0.001). They were less bothered by swollen/tender arms and worried less about risk of cancer to family members (P < 0.001). However, satisfaction with sex life, social support, and social/family well-being declined (P < 0.001). In the period closer to surgery, women with mastectomy reported poorer body image (P = 0.001) and worse functional (P = 0.08) and physical well-being (P = 0.10). Women with lumpectomy worried more about the effects of stress on their illness (P < 0.01) and had lower emotional well-being (P = 0.06). By 6 months after surgery, the two groups reported similar QOL scores. Chemotherapy had a negative impact on women's sexual functioning (P = 0.01) and their physical well-being (P = 0.09). Women who received chemotherapy also reported more shortness of breath (P = 0.07). Post hoc analysis showed that women with breast reconstruction had higher emotional well-being at baseline than those with lumpectomy (P = 0.001) and mastectomy alone (P < 0.01).

CONCLUSIONS

Younger women with breast carcinoma could experience a range of adjustment problems at various points in the treatment cycle. Interventions that would help reduce the negative impact of treatment on QOL need to be designed and integrated into routine clinical practice.

Effect of computer support on younger women with breast cancer

OBJECTIVE

Assess impact of a computer-based patient support system on quality of life in younger women with breast cancer, with particular emphasis on assisting the underserved.

DESIGN

Randomized controlled trial conducted between 1995 and 1998.

SETTING

Five sites: two teaching hospitals (Madison, Wis, and Chicago, Ill), two nonteaching hospitals (Chicago), and a cancer resource center (Indianapolis, Ill). The latter three sites treat many underserved patients.

PARTICIPANTS

Newly diagnosed breast cancer patients (N = 246) under age 60.

INTERVENTIONS

Experimental group received Comprehensive Health Enhancement Support System (CHESS), a home-based computer system providing information, decision-making, and emotional support.

MEASUREMENTS AND MAIN RESULTS

Pretest and two post-test surveys (at two- and five-month follow-up) measured aspects of participation in care, social/information support, and quality of life. At two-month follow-up, the CHESS group was significantly more competent at seeking information, more comfortable participating in care, and had greater confidence in doctor(s). At five-month follow-up, the CHESS group had significantly better social support and also greater information competence. In addition, experimental assignment interacted with several indicators of medical underservice (race, education, and lack of insurance), such that CHESS benefits were greater for the disadvantaged than the advantaged group.

CONCLUSIONS

Computer-based patient support systems such as CHESS may benefit patients by providing information and social support, and increasing their participation in health care. These benefits may be largest for currently underserved populations.

Increasing understanding of patient needs during and after hospitalization

BACKGROUND

The value of patient satisfaction surveys in health care improvement remains controversial. This study examined the value of alternative ways of identifying patient needs and estimating importance of those needs in improving the impact of satisfaction surveys.

METHODS

Ninety-one acute myocardial infarction (AMI) patients from three southeast U.S. community hospitals were surveyed in 1992. Critical incident and person-focused interviews were used to identify patient needs. Besides overall/global satisfaction with care, patients rated satisfaction with and importance of 12 care delivery and 18 information and support needs. Unmet need scores (importance minus satisfaction) were estimated. Derived importance scores were assessed by correlating global satisfaction with individual need satisfaction scores. A two-step process for identifying priority areas for improvement was proposed.

RESULTS

Patients identified and assigned greater scores to unmet needs for information and support needs (not included in typical satisfaction surveys) compared to typically assessed care delivery needs (p < 0.0001). Direct importance ratings differed substantially from those derived through correlation analyses (r = 0.28, p > 0.3 for care delivery needs and r = -0.17, p > 0.4 for information and support needs). Needs that received high importance and low satisfaction scores were all information and support needs.

DISCUSSION

Needs that patients consider very important are usually ignored in typical patient surveys. Derived approaches typically used to assess importance of need from satisfaction data may provide misleading results. If satisfaction surveys are to result in real performance improvement, a fresh examination of the content and importance assessment strategies, as proposed, is needed.

Experiences of women with breast cancer: exchanging social support over the CHESS computer network

Using an existential-phenomenological approach, this paper describes how women with breast cancer experience the giving and receiving of social support in a computer-mediated context. Women viewed their experiences with the computer-mediated support group as an additional and unique source of support in facing their illness. Anonymity within the support group fostered equalized participation and allowed women to communicate in ways that would have been more difficult in a face-to-face context. The asynchronous communication was a frustration to some participants, but some indicated that the format allowed for more thoughtful interaction. Motivations for seeking social support appeared to be a dynamic process, with a consistent progression from a position of receiving support to that of giving support. The primary benefits women received from participation in the group were communicating with other people who shared similar problems and helping others, which allowed them to change their focus from a preoccupation with their own sickness to thinking of others. Consistent with past research is the finding that women in this study expressed that social support is a multidimensional phenomenon and that their computer-mediated support group provided abundant emotional support, encouragement, and informational support. Excerpts from the phenomenological interviews are used to review and highlight key theoretical concepts from the research literatures on computer-mediated communication, social support, and the psychosocial needs of women with breast cancer.

The total costs of illness: a metric for health care reform

Systems thinking is a fundamental element of quality management and should be a fundamental element of health care reform. An implication of systems thinking is that one aim of health care should be to minimize the total costs of illness, not simply the direct medical expenditures. If we are to continue to improve health care over time, we should measure its impact on the total costs of illness to the patient, family, employer, and society. Thus a system of measurement is needed that quantifies total costs of illness and also suggests how these constituencies can collaborate to improve processes and reduce total costs. This article introduces the total costs of illness concept, contrasts it with societal costs of illness, describes a measurement system we developed to quantify it, and describes a case study examining the total costs of back injury illness to employers. We found that medical expenditures accounted for less than half of the total costs of illness, the average total costs of illness varied by over 350 percent among employers, and a simple metric (days off work) explained 62.5 percent of the variance in total costs of illness.

Impact of a patient-centered, computer-based health information/support system

BACKGROUND

Consumer health information systems potentially improve a patient's quality of life and activate patient self-care.

OBJECTIVES

Test a computerized system (CHESS: Comprehensive Health Enhancement Support System), which, in this application, provided HIV-positive patients with information, decision support, and connections to experts and other patients. Would patients given in-home access to computers use the system, improve their quality of life, reduce health-risk behaviors, and use medical services more efficiently?

RESEARCH DESIGN

Randomized controlled trial: CHESS computers in experimental subjects' homes in Madison or Milwaukee, Wisconsin, for 3 or 6 months; controls received no intervention. Subjects were compensated for self-report surveys completed before, during, and after CHESS installation.

SUBJECTS

Of 204 HIV-positive patients recruited (90% male, 84% white, average education some college, and 65% experiencing HIV-related symptoms), 90% completed the study.

MEASURES

Self-reports of quality of life and frequency and duration of use of medical services.

RESULTS

CHESS was used daily with little difference between demographic subgroups. While CHESS was in the home, its users reported quality-of-life improvements: active life, negative emotions, cognitive function, social support, and participation in health care. They also reported spending less time during ambulatory care visits, making more phone calls to providers, and experiencing fewer and shorter hospitalizations.

CONCLUSIONS

A computer-based personal health support system can improve a patient's quality of life and promote more efficient use of health care.

Access to health information and support: a public highway or a private road?

Information and communication technologies may help reduce health disparities through their potential for promoting health, preventing disease, and supporting clinical care for all. Unfortunately, those who have preventable health problems and lack health insurance coverage are the least likely to have access to such technologies. Barriers to access include cost, geographic location, illiteracy, disability, and factors related to the capacity of people to use these technologies appropriately and effectively. A goal of universal access to health information and support is proposed to augment existing initiatives to improve the health of individuals and the public. Both public- and private-sector stakeholders, particularly government agencies and private corporations, will need to collaboratively reduce the gap between the health information "haves" and "have-nots." This will include supporting health information technology access in homes and public places, developing applications for the growing diversity of users, funding research on access-related issues, ensuring the quality of health information and support, enhancing literacy in health and technology, training health information intermediaries, and integrating the concept of universal access to health information and support into health planning processes.

The quality of interactive computer use among HIV-infected individuals

This study examined how HIV-infected individuals used an interactive health software package called CHESS (Comprehensive Health Enhancement Support System). CHESS packages information and support in a variety of ways; the research examined how a subset of users whose posttest scores in a larger randomized trial showed significant improvement in quality of life compared on use patterns of CHESS with those who did not improve. The evidence presented here points to the nature of CHESS use more than it does to the amount of CHESS use. Those whose quality of life improved were among the most involved in their use of CHESS information tools. That is, even though Discussion Group accounted for the majority of all CHESS uses and time spent with the system, total use and Discussion Group use appeared less important than use of the information tools, especially if that use was at least somewhat sustained and involved.

Incentives to promote quality improvement in long-term care

Long-term care acute care providers are using innovative, data-based approaches and information systems solutions to position themselves for the future. These approaches will significantly improve the ability of these providers to treat patients, justify their continued existence, and compete in the marketplace.

CHESS (Comprehensive Health Enhancement Support System): an interactive computer system for women with breast cancer piloted with an underserved population

The Comprehensive Health Enhancement Support System (CHESS) is an interactive computer system containing information, social support, and problem-solving tools. It was developed with intensive input from potential users through needs-assessment surveys and field testing. CHESS had previously been used by women in the middle and upper socioeconomic classes with high school and college education. This article reports on the results of a pilot study involving eight African-American women with breast cancer from impoverished neighborhoods in Chicago. CHESS was very well received; was extensively used; and produced feelings of acceptance, motivation, understanding, and relief.

The comprehensive health enhancement support system

This article describes the process of using needs assessment data to develop an interactive information technology specifically designed to support patients in a health-related crisis. The Comprehensive Health Enhancement Support System (CHESS) is an interactive information, social support, and problem-solving system that was developed by a team at the University of Wisconsin. This article looks at the program developed for breast cancer patients and their families.

Removing the assumption of conditional independence from Bayesian decision models by using artificial neural networks: some practical techniques and a case study

The article describes how artificial neural networks with special designs can be applied to approximate a subjective Bayesian decision model without the assumption of conditional independence. New techniques are proposed to resolve some of the practical difficulties during the processes of problem structuring, knowledge elicitation, quantitative modeling, and model interpretation. A Bayesian model considering the conditional dependencies to predict a teenager's marijuana use was constructed by experts using these techniques, and compared to another conventional Bayesian model which assumed conditional independence. The new approach without the assumption of conditional independence had predictive power (r = 0.7) in the test of linearity compared to the conventional approach (r = 0.58) on a data set (n = 129). Its receiver operating characteristic curve dominated the alternative approach within the range (true positive fraction > 0.7) that we were interested in. The interpretations of the possible conditional dependencies provided by the artificial neural network after the training process were consistent with the expert's descriptions.

Predicting adolescent problem use of marijuana: development and testing of a Bayesian model

This paper reports on the development and testing of a risk assessment index for problem marijuana use designed to guide teenagers through an extensive computer-based support system intended to help them improve marijuana-related behaviors. Bayesian decision theory, used as the basis of the index development process, offers the advantage of building the index on subjective judgments of experts and does not require a large empirical data base. The index was found to predict an independent panel's ratings of teenager risk, and predict the marijuana use of 10th graders using self-reports of their profiles in the 7th grade. Implications for future risk assessment developments are discussed.

Assessing the needs of breast cancer patients and their families

Patient needs have long been elicited only through the use of customer satisfaction surveys, which unfortunately are not designed to obtain the in-depth information needed to guide the improvement of health care services. Through the use of the integrative group process and the help of many patients and hospital staffs, we developed a needs assessment survey for women with breast cancer. This article outlines this process and the results and discusses how we used these results to create a computer program designed to help women with breast cancer and their families.

CHESS: An interactive computer system for women with breast cancer piloted with an under-served population

The Comprehensive Health Enhancement Support System (CHESS) is an interactive computer system containing information, social support and problem solving tools. It was developed with intensive input from potential users through needs-assessment surveys and field testing. CHESS had previously been used by women in the middle and upper socio-economic classes with high school and college education. This article reports on the results of a pilot study involving eight African-American women with breast cancer from impoverished neighborhoods in the city of Chicago. CHESS was very well received, extensively used and produced feelings of acceptance, motivation, understanding and relief.

The use and impact of a computer-based support system for people living with AIDS and HIV infection

CHESS (the Comprehensive Health Enhancement Support System) is an interactive, computer-based system to support people facing AIDS/HIV Infection and other health-related crises or concerns. CHESS provides information, referral to service providers, support in making tough decisions and networking to experts and others facing the same concerns. CHESS is designed to improve access to health and human services for people who would otherwise face psychological, social, economic or geographic barriers to receiving services. CHESS has been evaluated in a random-assignment study with over 200 men and women living with AIDS and HIV infection. When CHESS was placed in subjects' homes for 3-6 months, use of CHESS was extremely heavy, with the average subject using CHESS 138 times for 39 hours. Compared with a control group which did not receive CHESS, subjects who used CHESS reported significantly higher quality of life in several dimensions, including social support and cognitive functioning. Users also reported significant reductions in some types of health care costs, especially inpatient services (hospitalizations). All segments of the study population used and benefited from CHESS, including women, minorities and those subjects with lower levels of education. Thus, CHESS appears to be an effective means of delivering education and support to the diverse populations which are affected by AIDS and HIV infection.

Measuring quality of care in psychiatric emergencies: construction and evaluation of a Bayesian index

OBJECTIVE

This study was conducted to determine whether an index for measuring quality of care for psychiatric emergencies is reliable and valid.

DATA SOURCES/STUDY SETTING

The study used primary data collected over a 12-month period from two urban hospitals in the Northeast. One had 700 inpatient beds, an inpatient psychiatric unit, and community mental health personnel located in the emergency department. The other had 300 beds but none of the other hospital's features.

STUDY DESIGN

The index was developed by a panel of experts in emergency psychiatry using a subjective Bayesian statistical methodology and was evaluated in terms of its ability to: (1) predict a second panel's judgments of quality; (2) predict a specific quality-related patient outcome, i.e., compliance with follow-up recommendations; (3) provide a reliable measurement procedure; and (4) detect variations in patterns of emergency department practices.

DATA COLLECTION/EXTRACTION METHODS

Data were collected on 2,231 randomly selected emergency psychiatric patients (psychiatric diagnosis, alcohol abuse, nonverbal patients experiencing a psychiatric emergency, and patients with somatic complaints such as life crisis) treated in the emergency departments of the two hospitals.

PRINCIPAL FINDINGS

The index predicted physician judgments of quality, was reliable, exhibited sufficient variation in scores, and was strongly associated with patient compliance.

CONCLUSIONS

The study demonstrated that a subjective Bayesian model can be used to develop a reliable and valid index for measuring quality of care, with potential for practical application in management of health services.

Will HIV-positive people use an interactive computer system for information and support? A study of CHESS in two communities

A study of use of an interactive computer system (CHESS--Comprehensive Health Enhancement Support System) by HIV-Positive people was conducted in Madison and Milwaukee during Fall 1992 and Winter 1993. Computers were placed in homes, and use monitored by the computer. Results showed that the system was used heavily by both samples, and that gender (women used it more) age, (younger used it more), living arrangements (those living alone used it more), and need for health care information (those who felt the most need used it more) but not education predicted use of CHESS. The authors argue that heavy CHESS use by a wide variety of HIV-positive people suggests that the computer can overcome "information poor" barriers in health information campaigns.

Lessons learned from an early attempt to implement CQI principles in a regulatory system

This article describes the Quality Assurance Project (1978-1982), which was developed as a demonstration project by a Wisconsin research team and was intended to implement and evaluate new methods for carrying out the regulatory roles of facility and resident assessment in Wisconsin nursing homes. The new method included (1) a screening process to distribute efforts between sanctioning and process improvement, (2) role changes that would move surveyors beyond problem identification toward education and consultation, and (3) a resident review process based on efforts to find systems-level problems. For the first three years of the project (reported here) certain principles were followed, many of which were similar to those of continuous quality improvement (CQI). Although this is an imperfect example of CQI implementation in a regulatory organization, it contains important lessons that may be helpful in integrating the CQI philosophy into other external review efforts.

CHESS: a computer-based system for providing information, referrals, decision support and social support to people facing medical and other health-related crises

CHESS (the Comprehensive Health Enhancement Support System) is an interactive, computer-based system to support people facing health-related crises or concerns. CHESS provides information, referral to service providers, support in making tough decisions and networking to experts and others facing the same concerns. CHESS will improve access to health and human services for people who would otherwise face psychological, social, economic or geographic barriers to receiving services. CHESS has developed programs in five specific topic areas: Academic Crisis, Adult Children of Alcoholics, AIDS/HIV Infection, Breast Cancer and Sexual Assault. The lessons learned, and the structures developed, will serve as a model for future implementation of CHESS programs in a broad range of other topic areas. CHESS is designed around three major desired outcomes: 1) improving the emotional health status of users; 2) increasing the cost-effective use of health and human services; and 3) reducing the incidence of risk-taking behaviors that can lead to injury or illness. Pilot-testing and initial analysis of controlled evaluation data has shown that CHESS is extensively used, is useful and easy-to-use, and produces positive emotional outcomes. Further evaluation in continuing.

The Quality Assessment Index (QAI) for measuring nursing home quality

There have been few detailed evaluations of measures of quality of care in nursing homes. This is unfortunate because it has meant that much research on factors affecting nursing home quality has used measures of questionable reliability and validity. Moreover, some measures currently in use have been developed using methodologies not based on solid conceptual grounds, offering little reason to expect them to have much internal or external validity. In this article we suggest characteristics that should be present in measures of nursing home quality, propose a methodology for the development of such measures, propose a specific nursing home quality measure (the Quality Assessment Index or QAI), and report the results of several tests of its validity and reliability.

Quality assurance for psychiatric emergencies. An analysis of assessment and feedback methodologies

Improvement in the quality of evaluation and treatment of behavioral emergencies presenting to hospital emergency rooms requires a multicomponent assessment of resources, clinician performance, and outcome. The authors present a summary of data and conclusions derived from index-based assessment of quality of care in over 2000 psychiatric emergencies. The study revealed that emergency room physicians rendered high-quality medical care, but were deficient in crucial aspects of psychiatric evaluation and treatment including evaluation of dangerousness and substance abuse and provision of appropriate follow-up care. A positive association was observed between quality of care and compliance with referral. Subsequent review with the staff pointed to issues such as staffing, emergency room and community resources, and adequacy of documentation as significant influences on quality of care, as assessed by the chart-audit, index approach. A pilot study demonstrated uniform improvement of quality scores in a small group of physicians receiving written and oral feedback about their performance. The use of focused quality assessment studies that examine both structural and process factors, and their correlation with outcome, is discussed in light of the information obtained from the previously described study. A feedback methodology that emphasizes an interactive process to identify deficiencies in care and to explore their causes and remedies is presented.

Impacting quality in health care: the role of the health systems engineer

Total Quality Management (TQM) is just beginning to influence hospital operations. The health systems engineer (HSE) is uniquely qualified and in an opportune position to expedite the implementation of TQM in hospitals. We discuss how we envision the HSE's roles as technical facilitator, measurer, and modeler in supporting the principles of quality improvement in the hospital. In the process, we suggest that the HSE can be much more valuable in helping the hospital reduce costs by improving quality rather than monitoring productivity. As a result, HSEs will expand their role in the hospital, better utilize their skills and training, and increase their effectiveness.

Suicide risk prediction by computer interview: a prospective study

A computer interview program that uses a subjective Bayesian probability model to assess suicide risk was evaluated. Predictions made by clinicians for 52 patients were compared with predictions made by the computer for the same patients. The computer was significantly (p = .001) better at predicting attempters, and clinicians were significantly (p = .01) better at predicting nonattempters. An analysis of receiver operating characteristic curves showed that the computer had better overall discrimination, but the difference was nonsignificant.

How to construct a subjective index

We present a method of constructing quantitative indices, which is based on the subjective opinions of a panel of experts, and discuss how a Bayesian probability model and panel opinions can be used together to produce an index. Among the advantages of the method are its face validity and ease of construction. Research shows that when expert opinions are solicited according to certain guidelines, subjective methods may be as accurate as the more objective ones. Guidelines along with a brief report of a recent application are also discussed.

Weight loss and body temperature changes in breast-fed and bottle-fed neonates

Among 1138 newborns in a Level II nursery, breast-fed and formula-fed infants were comparable in terms of sex, mode of delivery, gestational age, birth weight, and birth temperature. Breast-fed neonates subsequently lost more weight and a greater percentage of their birth weight (mean, 7.4% vs. 4.9%) than did formula-fed infants. Loss of more than 10 percent of birth weight was associated with short gestation and low birth weight and with breast feeding. Birth weight loss of greater than or equal to 3 percent was associated with a risk of fever (greater than or equal to 37.5 degrees C) among breast-fed and formula-fed infants, but there was no gradient of increasing risk of fever with increasing percentage weight loss beyond 3 percent. After weight loss and other significant variables were adjusted for in a multivariate analysis, breast feeding was not independently predictive of fever. Although breast feeding may be associated with weight loss, it is not prudent to assume that this is the cause of fever in a breast-fed neonate.

A decision theoretic methodology for severity index development

Severity indices are a key element in evaluation of health programs. But the methodologies used in development of such indices are rarely clearly defined. Moreover, there have been no tests of transportability of the index development methodologies that do exist, so there is no guarantee that panels of physicians convened by different facilitators would produce indices with similar performance characteristics. This paper describes a replicable index development strategy, a heart disease severity index developed by using that methodology, and a test of that methodology's transportability.

Evaluation of a sampling approach. Nursing home reimbursement and level of care determination

Under existing federal regulations, it is mandated that the care of all nursing home residents be reviewed annually. A four-year demonstration project in Wisconsin tested a sampling approach to nursing home resident review. The rationale for the sampling approach is that one can more effectively identify pervasive problems with resident care by an in-depth examination of a sample of residents than by cursory assessment of all residents. If problems are identified in the sample, all residents can then be reviewed. However, reimbursement for nursing home care is also influenced by level of care and given that nursing home inspectors review the appropriateness of level of care, the issue arises as to what impact a sampling approach would have on reimbursement. This evaluation compares the changes in reimbursement owing to resident review under the sampling and federally mandated, 100% review methods. The results indicate that reviewing a sample of nursing home residents may offer similar reductions in nursing home reimbursement as a 100% resident review--but at a lower cost.

Assessment of level of care: implications of interrater reliability on health policy

In Wisconsin, level-of-care assessments are used to set Medicaid reimbursement and determine nursing home eligibility. This study examined three methods of assessing level of care: 1) the Wisconsin quality assurance project (QAP) method, based on observations of patients, patient records, and staff interviews; 2) the Wisconsin standard (STD) method, based primarily on a clinical record review; and, 3) an adaptation of New York's "DMS-I," a checklist with numerical weights used to set level of care. Results address interrater reliability, the agreement between assessments by research teams and actual levels of care set by the State, and the implications that agreement has for reimbursement.

An evaluation of multiple trauma severity indices created by different index development strategies

Evaluation of the effectiveness of emergency trauma care systems is complicated by the need to adjust for the widely variable case mix found in trauma patient populations. Several strategies have been advanced to construct the severity indices that can control for these population differences. This article describes a validity and reliability comparison of trauma severity indices developed under three different approaches: 1) use of a multi-attribute utility (MAU) model; 2) an actuarial approach relying on empirical data bases; and 3) an "ad hoc" approach. Seven criteria were identified to serve as standards of comparison for four different indices. The study's findings indicate that the index developed using the MAU theory approach associates most closely with physician judgments of trauma severity. When correlated with a morbidity outcome measure, the MAU-based index shows higher levels of agreement than the other indices. The index development approach based on the principles of MAU theory has several advantages and it appears to be a powerful tool in the creation of effective severity indices.

Measuring the quality of care in nursing homes: a pilot study in Wisconsin

The traditional method of evaluating nursing homes, which relies on State and Federal regulations, does not ensure quality care for nursing home residents. This fact led the Wisconsin State Department of Health and Social Services to fund a project for the development of a system that would permit rapid and reliable assessment of the quality of care given by nursing homes, permit the identification of specific problem areas, and suggest whether more in-depth investigation was needed. A corner-stone in that system was to be a screening instrument that would quickly determine where the care delivery system in a nursing home was breaking down so that resources could be focused on these problem areas.Eleven quality of care criteria to be used in the screening instrument were drawn up by a panel of experts. The instrument itself was then tested in nine Wisconsin nursing homes. Five teams of people with nursing home expertise (two persons per team) used the screening instrument to evaluate each of the homes. Another team, visiting the same homes, used a second screening instrument based on State and Federal regulations to evaluate the homes. Finally, without relying on any survey instrument, all of the teams did a general assessment of the homes. The purpose of this general assessment was to ascertain if a "common wisdom" exists among experts in the field. The results of the teams' evaluations using both instruments were compared with each other, as well as with the results of the general assessments and the results of the most recent standard survey. This analysis showed that there was a significant amount of inter-team reliability among the teams using the new screening model and, also, that the new screening model correlated well with the general assessments.The model is being tested further in a 2-year study of 170 nursing homes in urban and rural parts of Wisconsin.