Screening intervals for diabetic retinopathy and incidence of visual loss: a systematic review

Screening for diabetic retinopathy can help to prevent this complication, but evidence regarding frequency of screening is uncertain. This paper systematically reviews the published literature on the relationship between screening intervals for diabetic retinopathy and the incidence of visual loss. The PubMed and EMBASE databases were searched until December 2012. Twenty five studies fulfilled the inclusion criteria, as these assessed the incidence/prevalence of sight-threatening diabetic retinopathy in relation to screening frequency. The included studies comprised 15 evaluations of real-world screening programmes, three studies modelling the natural history of diabetic retinopathy and seven cost-effectiveness studies. In evaluations of diabetic retinopathy screening programmes, the appropriate screening interval ranged from one to four years, in people with no retinopathy at baseline. Despite study heterogeneity, the overall tendency observed in these programmes was that 2-year screening intervals among people with no diabetic retinopathy at diagnosis were not associated with high incidence of sight-threatening diabetic retinopathy. The modelling studies (non-economic and economic) assessed a range of screening intervals (1-5 years). The aggregated evidence from both the natural history and cost-effectiveness models favors a screening interval >1 year, but ≤2 years. Such an interval would be appropriate, safe and cost-effective for people with no diabetic retinopathy at diagnosis, while screening intervals ≤1 year would be preferable for people with pre-existing diabetic retinopathy. A 2-year screening interval for people with no sight threatening diabetic retinopathy at diagnosis may be safely adopted. For patients with pre-existing diabetic retinopathy, a shorter interval ≤1 year is warranted.

Barriers to following dietary recommendations in Type 2 diabetes

AIMS

To evaluate barriers to following dietary recommendations in patients with Type 2 diabetes.

METHODS

We conducted focus groups and surveys in urban and suburban VA and academic medical centres. For the written survey, a self-administered questionnaire was mailed to a random sample of 446 patients with diabetes. For the focus groups, six groups of patients with diabetes (three urban, three suburban) were conducted, with 6-12 participants in each group. The focus groups explored barriers across various types of diabetes self-management; we extracted all comments relevant to barriers that limited patients' ability to follow a recommended diet.

RESULTS

The written survey measured the burden of diabetes therapies (on a seven-point rating scale). Moderate diet was seen as a greater burden than oral agents (median 1 vs. 0, P = 0.001), but less of a burden than insulin (median 1 vs. 4, P < 0.001). A strict diet aimed at weight loss was rated as being similarly burdensome to insulin (median 4 vs. 4, P = NS). Despite this, self-reported adherence was much higher for both pills and insulin than it was for a moderate diet. In the focus groups, the most commonly identified barrier was the cost (14/14 reviews), followed by small portion sizes (13/14 reviews), support and family issues (13/14 reviews), and quality of life and lifestyle issues (12/14 reviews). Patients in the urban site, who were predominantly African-American, noted greater difficulties communicating with their provider about diet and social circumstances, and also that the rigid schedule of a diabetes diet was problematic.

CONCLUSIONS

Barriers to adherence to dietary therapies are numerous, but some, such as cost, and in the urban setting, communication with providers, are potentially remediable. Interventions aimed at improving patients' ability to modify their diet need to specifically address these areas. Furthermore, treatment guidelines need to consider patients' preferences and barriers when setting goals for treatment.

Projections of demand and capacity for colonoscopy related to increasing rates of colorectal cancer screening in the United States

BACKGROUND

There is debate about the optimal colorectal cancer screening test, partly because of concerns about colonoscopy demand.

AIM

To quantify the demand for colonoscopy with different screening tests, and to estimate the ability of the United States health care system to meet demand.

METHODS

We used a previously published Markov model and the United States census data to estimate colonoscopy demand. We then used an endoscopic database to compare current rates of screening-related colonoscopy with those projected by the model, and to estimate the number of endoscopists needed to meet colonoscopy demand.

RESULTS

Annual demand for colonoscopy ranges from 2.21 to 7.96 million. Based on current practice patterns, demand exceeds current supply regardless of screening strategy. We estimate that an increase of at least 1360 gastroenterologists would be necessary to meet demand for colonoscopic screening undergone once at age 65, while colonoscopy every 10 years could require 32 700 more gastroenterologists. A system using dedicated endoscopists could meet demand with fewer endoscopists.

CONCLUSIONS

Colorectal cancer screening leads to demand for colonoscopy that outstrips supply. Systems to train dedicated screening endoscopists may be necessary in order to provide population-wide screening. The costs and feasibility of establishing this infrastructure should be studied further.

Which colon cancer screening test? A comparison of costs, effectiveness, and compliance

PURPOSE

Recent media reports have advocated the use of colonoscopy for colorectal cancer screening. However, colonoscopy is expensive compared with other screening modalities, such as fecal occult blood testing and flexible sigmoidoscopy. We sought to determine the cost effectiveness of different screening strategies for colorectal cancer at levels of compliance likely to be achieved in clinical practice.

METHODS

A Markov decision model was used to examine screening strategies, including fecal occult blood testing alone, fecal occult blood testing combined with flexible sigmoidoscopy, flexible sigmoidoscopy alone, and colonoscopy. The timing and frequency of screening was varied to assess optimal screening intervals. Sensitivity analyses were conducted to assess the factors that have the greatest effect on the cost effectiveness of screening.

RESULTS

All strategies are cost effective versus no screening, at less than $20,000 per life-year saved. Direct comparison suggests that the most effective strategies are twice-lifetime colonoscopy and flexible sigmoidoscopy combined with fecal occult blood testing. Assuming perfect compliance, flexible sigmoidoscopy combined with fecal occult blood testing is slightly more effective than twice-lifetime colonoscopy (at ages 50 and 60 years) but is substantially more expensive, with an incremental cost effectiveness of $390,000 per additional life-year saved. However, compliance with primary screening tests and colonoscopic follow-up for polyps affect screening decisions. Colonoscopy at ages 50 and 60 years is the preferred test regardless of compliance with the primary screening test. However, if follow-up colonoscopy for polyps is less than 75%, then even once-lifetime colonoscopy is preferred over most combinations of flexible sigmoidoscopy and fecal occult blood testing. Costs of colonoscopy and proportion of cancer arising from polyps also affect cost effectiveness.

CONCLUSIONS

Colonoscopic screening for colorectal cancer appears preferable to current screening recommendations. Screening recommendations should be tailored to the compliance levels achievable in different practice settings.

Avoiding pitfalls in chronic disease quality measurement: a case for the next generation of technical quality measures

The true utility of quality measurement lies in its ability to inspire quality improvement, with resultant enhancements in the processes and outcomes of care. Because quality measurement is expensive, it is difficult to justify using measures that are not likely to lead to important improvements in health. Many current measures of chronic disease technical quality, however, have one or more pitfalls that prevent them from motivating quality improvement reactions. These pitfalls include that: (1) measured processes of care lack strong links to outcomes; (2) actionable processes of care are not measured; (3) measures do not target those at highest risk; (4) measures do not allow for patient exceptions; and (5) intermediate outcome measures are not severity adjusted. To exemplify recent advancements and current pitfalls in chronic disease quality measurement, we examine the evolution of quality measures for diabetes mellitus and discuss the limitations of many currently used diabetes mellitus care measures. We then propose more clinically meaningful "tightly linked" measures that examine clinical processes directly linked to outcomes, target populations with specific diagnoses or intermediate disease outcomes that contribute to risk for poor downstream health outcomes, and explicitly incorporate exceptions. We believe that using more tightly linked measures in quality assessment will identify important quality of care problems and is more likely to produce improved outcomes for those with chronic diseases.

Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer

CONTEXT

Studies using physician implicit review have suggested that the number of deaths due to medical errors in US hospitals is extremely high. However, some have questioned the validity of these estimates.

OBJECTIVE

To examine the reliability of reviewer ratings of medical error and the implications of a death described as "preventable by better care" in terms of the probability of immediate and short-term survival if care had been optimal.

DESIGN

Retrospective implicit review of medical records from 1995-1996.

SETTING AND PARTICIPANTS

Fourteen board-certified, trained internists used a previously tested structured implicit review instrument to conduct 383 reviews of 111 hospital deaths at 7 Department of Veterans Affairs medical centers, oversampling for markers previously found to be associated with high rates of preventable deaths. Patients considered terminally ill who received comfort care only were excluded.

MAIN OUTCOME MEASURES

Reviewer estimates of whether deaths could have been prevented by optimal care (rated on a 5-point scale) and of the probability that patients would have lived to discharge or for 3 months or more if care had been optimal (rated from 0%-100%).

RESULTS

Similar to previous studies, almost a quarter (22.7%) of active-care patient deaths were rated as at least possibly preventable by optimal care, with 6.0% rated as probably or definitely preventable. Interrater reliability for these ratings was also similar to previous studies (0.34 for 2 reviewers). The reviewers' estimates of the percentage of patients who would have left the hospital alive had optimal care been provided was 6.0% (95% confidence interval [CI], 3.4%-8.6%). However, after considering 3-month prognosis and adjusting for the variability and skewness of reviewers' ratings, clinicians estimated that only 0.5% (95% CI, 0.3%-0.7%) of patients who died would have lived 3 months or more in good cognitive health if care had been optimal, representing roughly 1 patient per 10 000 admissions to the study hospitals.

CONCLUSIONS

Medical errors are a major concern regardless of patients' life expectancies, but our study suggests that previous interpretations of medical error statistics are probably misleading. Our data place the estimates of preventable deaths in context, pointing out the limitations of this means of identifying medical errors and assessing their potential implications for patient outcomes.

Who bounces back? Physiologic and other predictors of intensive care unit readmission

OBJECTIVE

To determine the influence of changes in acute physiology scores (APS) and other patient characteristics on predicting intensive care unit (ICU) readmission.

DESIGN

Secondary analysis of a prospective cohort study.

SETTING

Single large university medical intensive care unit.

PATIENTS

A total of 4,684 consecutive admissions from January 1, 1994, to April 1, 1998, to the medical ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The independent influence of patient characteristics, including daily APS, admission diagnosis, treatment status, and admission location, on ICU readmission was evaluated using logistic regression. After accounting for first ICU admission deaths, 3,310 patients were "at-risk" for ICU readmission and 317 were readmitted (9.6%). Hospital mortality was five times higher (43% vs. 8%; p < .0001), and length of stay was two times longer (16 +/- 16 vs. 32 +/- 28 days; p < .001) in readmitted patients. Mean discharge APS was significantly higher in the readmitted group compared with the not readmitted group (43 +/- 19 vs. 34 +/- 18; p > .01). Significant independent predictors of ICU readmission included discharge APS >40 (odds ratio [OR] 2.1; 95% confidence interval [CI] 1.6-2.7; p < .0001), admission to the ICU from a general medicine ward (Floor) (OR 1.9; 95% CI 1.4-2.6; p < .0001), and transfer to the ICU from other hospital (Transfer) (OR 1.7; 95% CI 1.3-2.3; p < .01). The overall model calibration and discrimination were (H-L chi2 = 3.8, df = 8; p = .85) and (receiver operating characteristic 0.67), respectively.

CONCLUSIONS

Patients readmitted to medical ICUs have significantly higher hospital lengths of stay and mortality. ICU readmissions may be more common among patients who respond poorly to treatment as measured by increased severity of illness at first ICU discharge and failure of prior therapy at another hospital or on a general medicine unit. Tertiary care ICUs may have higher than expected readmission rates and mortalities, even when accounting for severity of illness, if they care for significant numbers of transferred patients.

Where health and welfare meet: social deprivation among patients in the emergency department

CONTEXT

As a safety net provider for many disadvantaged Americans, the emergency department (ED) may be an efficient site not only for providing acute medical care, but also for addressing serious social needs.

OBJECTIVE

To characterize the social needs of ED patients, and to evaluate whether the most disadvantaged patients have connections with the health and welfare system outside the ED.

DESIGN

Cross-sectional survey conducted over 24 hours in the fall of 1997.

SETTING

Three EDs: an urban public teaching hospital, a suburban university hospital, and a semirural community hospital.

PARTICIPANTS

Consecutive patients presenting for care, including those transported by ambulance. The survey response rate was 91% (N = 300; urban = 115, suburban = 102, rural = 83).

MAIN OUTCOME MEASURE

Index of socioeconomic deprivation described by the US Census Bureau (based on food, housing, and utilities).

RESULTS

Of all ED patients, 31% reported one or more serious social deprivations. For example, 13% of urban patients reported not having enough food to eat, and 9% of rural patients reported disconnection of their gas or electricity (US population averages both less than 3%). While 40% of all patients had no consistent health care outside the ED (< or = 1 visit/year), those with higher levels of social deprivation had the least contact with the health care system outside the ED (P < .01). Although those with higher levels of deprivation were more likely to receive public assistance, still almost one-quarter of patients with high-level social deprivation were not receiving public aid.

CONCLUSION

Many ED patients suffer from fundamental social deprivations that threaten basic health. The most disadvantaged of these patients frequently lack contact with other medical care sites or public assistance networks. Community efforts to address serious social deprivation should include partnerships with the local ED.

Estimating the microvascular benefits of screening for type 2 diabetes mellitus

OBJECTIVE

To define the relative benefits of screening for diabetes and improved treatment programs and ways of improving the efficiency of screening for a population-based cohort derived from the Third National Health and Nutrition Examination Survey (NHANES III).

METHODS

A Markov decision model is used to estimate microvascular benefits of glucose control for four different screening and treatment scenarios, including either universal screening or improved glucose control of known diabetic subjects, neither, or both.

RESULTS

A population cohort of subjects with recent onset of diabetes (< 5 years) was derived from NHANES III (of whom close to half were unaware that they had diabetes). In this population-based cohort, the total benefit achievable by universal screening and improved treatment (limiting HbA1c to less than 9%) is a reduction of about 30,000 cases of blindness over the lifetime of the cohort. Screening alone results in 7% of this benefit, and improved treatment alone provides 65%. Screening a targeted group of patients with three or more risk factors for developing diabetes would reduce the number of required fasting glucose measurements needed by 82% and provide 50% of the total benefit of screening the entire population with a fasting glucose measurement.

CONCLUSIONS

Morbidity from type 2 diabetes can be most effectively reduced by developing ways to modestly improve the glycemic control of known diabetic subjects, particularly those with high A1c's and early onset of disease. Targeting can significantly reduce the number of persons who need to be screened with a fasting blood test while preserving a large component of the benefit of screening.

Report of the health care delivery work group: behavioral research related to the establishment of a chronic disease model for diabetes care

As one of four work groups for the November 1999 conference on Behavioral Science Research in Diabetes, sponsored by the National Institute on Diabetes and Digestive and Kidney Diseases, the health care delivery work group evaluated the status of research on quality of care, patient-provider interactions, and health care systems' innovations related to improved diabetes outcomes. In addition, we made recommendations for future research. In this article, which was developed and modified at the November conference by experts in health care delivery, diabetes and behavioral science, we summarize the literature on patient-provider interactions, diabetes care and self-management support among underserved and minority populations, and implementation of chronic care management systems for diabetes. We conclude that, although the quality of care provided to the vast majority of diabetic patients is problematic, this is principally not the fault of either individual patients or health care professionals. Rather, it is a systems issue emanating from the acute illness model of care, which still predominates. Examples of proactive population-based chronic care management programs incorporating behavioral principles are discussed. The article concludes by identifying barriers to the establishment of a chronic care model (e.g., lack of supportive policies, understanding of population-based management, and information systems) and priorities for future research in this area needed to overcome these barriers.

What is an error?

CONTEXT

Launched by the Institute of Medicine's report, "To Err is Human," the reduction of medical errors has become a top agenda item for virtually every part of the U.S. health care system.

OBJECTIVE

To identify existing definitions of error, to determine the major issues in measuring errors, and to present recommendations for how best to proceed.

DATA SOURCE

Medical literature on errors as well as the sociology and industrial psychology literature cited therein.

RESULTS

We have four principal observations. First, errors have been defined in terms of failed processes without any link to subsequent harm. Second, only a few studies have actually measured errors, and these have not described the reliability of the measurement. Third, no studies directly examine the relationship between errors and adverse events. Fourth, the value of pursuing latent system errors (a concept pertaining to small, often trivial structure and process problems that interact in complex ways to produce catastrophe) using case studies or root cause analysis has not been demonstrated in either the medical or nonmedical literature.

CONCLUSION

Medical error should be defined in terms of failed processes that are clearly linked to adverse outcomes. Efforts to reduce errors should be proportional to their impact on outcomes (preventable morbidity, mortality, and patient satisfaction) and the cost of preventing them. The error and the quality movements are analogous and require the same rigorous epidemiologic approach to establish which relationships are causal.

Automated computerized intensive care unit severity of illness measure in the Department of Veterans Affairs: preliminary results. SISVistA Investigators. Scrutiny of ICU Severity Veterans Health Sysyems Technology Architecture

OBJECTIVE

To evaluate the feasibility of an automated intensive care unit (ICU) risk adjustment tool (acronym: SISVistA) developed by selecting a subset of predictor variables from the Acute Physiology and Chronic Health Evaluation (APACHE) III available in the existing computerized database of the Department of Veterans Affairs (VA) healthcare system and modifying the APACHE diagnostic and comorbidity approach.

DESIGN

Retrospective cohort study.

SETTING

Six ICUs in three Ohio Veterans Affairs hospitals.

PATIENT SELECTION

The first ICU admission of all patients from February 1996 through July 1997.

OUTCOME MEASURE

Mortality at hospital discharge.

METHODS

The predictor variables, including age, comorbidity, diagnosis, admission source (direct or transfer), and laboratory results (from the +/- 24-hr period surrounding admission), were extracted from computerized VA databases, and APACHE III weights were applied using customized software. The weights of all laboratory variables were added and treated as a single variable in the model. A logistic regression model was fitted to predict the outcome and the model was validated using a boot-strapping technique (1,000 repetitions).

MAIN RESULTS

The analysis included all 4,651 eligible cases (442 deaths). The cohort was predominantly male (97.5%) and elderly (63.6 +/- 12.0 yrs). In multivariate analysis, significant predictors of hospital mortality included age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.04-1.09), comorbidity (OR, 1.11; 95% CI, 1.08-1.15), total laboratory score (OR, 1.07; 95% CI, 1.06-1.08), direct ICU admission (OR, 0.39; 95% CI, 0.31-0.49), and several broad ICU diagnostic categories. The SISVistA model had excellent discrimination and calibration (C statistic = 0.86, goodness-of-fit statistics; p > .20). The area under the receiver operating characteristic curve of the validated model was 0.86.

CONCLUSIONS

Using common data elements often found in hospital computer systems, SISVistA predicts hospital mortality among patients in Ohio VA ICUs. This preliminary study supports the development of an automated ICU risk prediction system on a more diverse population.

Department of Veterans Affairs' Quality Enhancement Research Initiative for Diabetes Mellitus

Diabetes is a common disease, which frequently leads to serious, high-cost complications. Estimates show that in fiscal year 1994 (FY94), 12.5% of outpatients in the Veterans Health Administration (VHA) received diabetes-specific medications, accounted for almost 25% of all VHA pharmacy costs, had a hospitalization rate 1.6 times that of veterans without diabetes, and made 3.6 million outpatient visits to VA clinics. Research demonstrates that much of the mortality and morbidity associated with diabetes can be prevented, and rigorous evidence-based guidelines have been developed. The short-term objectives of the Quality Enhancement Research Initiative for Diabetes Mellitus (QUERI-DM) are to (1) gather baseline information on how current VHA diabetes care differs from the VHA guidelines, (2) develop an efficient, validated system for monitoring key diabetes quality standards in the VHA, (3) evaluate the effectiveness of current approaches to diabetes care and the success of guideline implementation initiatives, and (4) initiate 2 to 4 large-scale quality improvement projects to enhance adherence to practice guidelines and evaluate their impact on patient outcomes, including quality of life.

Trends in domestic violence service and leadership: implications for an integrated shelter model

Domestic violence is a dangerous and prevalent social problem affecting up to 4 million women and countless children annually. Shelters offer safety and an opportunity for change during the crisis of family violence. These individuals also have the potential for retraumatization if leadership within the program recapitulates the abuse and coercion felt at home. This article reviews three related trends through the lens of power and control--domestic violence policy and service, models of leadership, and the study of traumatic stress disorders and recovery--and describes their implications for modern shelter service delivery.

Cost-utility analysis of screening intervals for diabetic retinopathy in patients with type 2 diabetes mellitus

CONTEXT

Annual eye screening for patients with diabetes mellitus is frequently proposed as a measure of quality of care. However, the benefit of annual vs less frequent screening intervals has not been well evaluated, especially for low-risk patients.

OBJECTIVE

To examine the marginal cost-effectiveness of various screening intervals for eye disease in patients with type 2 diabetes, stratified by age and level of glycemic control.

DESIGN

Markov cost-effectiveness model.

SETTING AND PARTICIPANTS

Hypothetical patients based on the US population of diabetic patients older than 40 years from the Third National Health and Nutrition Examination Survey.

MAIN OUTCOME MEASURES

Patient time spent blind, quality-adjusted life-years (QALYs), and costs of annual vs less frequent screening compared by age and level of hemoglobin A1c.

RESULTS

Retinal screening in patients with type 2 diabetes is an effective intervention; however, the risk reduction varies dramatically by age and level of glycemic control. On average, a high-risk patient who is aged 45 years and has a hemoglobin A1c level of 11% gains 21 days of sight when screened annually as opposed to every third year, while a low-risk patient who is aged 65 years and has a hemoglobin A1c level of 7% gains an average of 3 days of sight. The marginal cost-effectiveness of screening annually vs every other year also varies; patients in the high-risk group cost an additional $40530 per QALY gained, while those in the low-risk group cost an additional $211570 per QALY gained. In the US population, retinal screening annually vs every other year for patients with type 2 diabetes costs $107510 per QALY gained, while screening every other year vs every third year costs $49760 per QALY gained.

CONCLUSIONS

Annual retinal screening for all patients with type 2 diabetes without previously detected retinopathy may not be warranted on the basis of cost-effectiveness, and tailoring recommendations to individual circumstances may be preferable. Organizations evaluating quality of care should consider costs and benefits carefully before setting universal standards.

Discussion between reviewers does not improve reliability of peer review of hospital quality

OBJECTIVES

Peer review is used to make final judgments about quality of care in many quality assurance activities. To overcome the low reliability of peer review, discussion between several reviewers is often recommended to point out overlooked information or allow for reconsideration of opinions and thus improve reliability. The authors assessed the impact of discussion between 2 reviewers on the reliability of peer review.

METHODS

A group of 13 board-certified physicians completed a total of 741 structured implicit record reviews of 95 records for patients who experienced severe adverse events related to laboratory abnormalities while in the hospital (hypokalemia, hyperkalemia, renal failure, hyponatremia, and digoxin toxicity). They independently assessed the degree to which each adverse event was caused by medical care and the quality of the care leading up to the adverse event. Working in pairs, they then discussed differences of opinion, clarified factual discrepancies, and rerated the record. The authors compared the reliability of each measure before and after discussion, and between and within pairs of reviewers, using the intraclass correlation coefficient for continuous ratings and the kappa statistic for a dichotomized rating.

RESULTS

The assessment of whether the laboratory abnormality was iatrogenic had a reliability of 0.46 before discussion and 0.71 after discussion between paired reviewers, indicating considerably improved agreement between the members of a pair. However, across reviewer pairs, the reviewer reliability was 0.36 before discussion and 0.40 after discussion. Similarly, for the rating of overall quality of care, reliability of physician review went from 0.35 before discussion to 0.58 after discussion as assessed by pair. However, across pairs the reliability increased only from 0.14 to 0.17. Even for prediscussion ratings, reliability was substantially higher between 2 members of a pair than across pairs, suggesting that reviewers who work in pairs learn to be more consistent with each other even before discussion, but this consistency also did not improve overall reliability across pairs.

CONCLUSIONS

When 2 physicians discuss a record that they are reviewing, it substantially improves the agreement between those 2 physicians. However, this improvement is illusory, as discussion does not improve the overall reliability as assessed by examining the reliability between physicians who were part of different discussions. This finding may also have implications with regard to how disagreements are resolved on consensus panels, guideline committees, and reviews of literature quality for meta-analyses.

Are randomized controlled trials sufficient evidence to guide clinical practice in type II (non-insulin-dependent) diabetes mellitus?

Randomized controlled trials (RCTs) are often considered the standard for defining the practice of evidence-based medicine. Taken alone, they are, however, often insufficient to guide clinical care. Randomized controlled trials are clearly the best method to determine whether interventions are efficacious. They have, however, numerous limitations which make them difficult to carry out or limit applicability to routine clinical practice. Although observational studies also have inherent limitations, they provide data which can help to further explain the results of randomized controlled trials. The use of observational studies to frame randomized trials can allow better application of randomized controlled trial results to individual patients and can thus help to optimize delivery of care, inform clinical practice and determine the need for further such trials.

The unreliability of individual physician "report cards" for assessing the costs and quality of care of a chronic disease

CONTEXT

Physician profiling is widely used by many health care systems, but little is known about the reliability of commonly used profiling systems.

OBJECTIVES

To determine the reliability of a set of physician performance measures for diabetes care, one of the most common conditions in medical practice, and to examine whether physicians could substantially improve their profiles by preferential patient selection.

DESIGN AND SETTING

Cohort study performed from 1990 to 1993 at 3 geographically and organizationally diverse sites, including a large staff-model health maintenance organization, an urban university teaching clinic, and a group of private-practice physicians in an urban area.

PARTICIPANTS

A total of 3642 patients with type 2 diabetes cared for by 232 different physicians.

MAIN OUTCOME MEASURES

Physician profiles for their patients' hospitalization and clinic visit rates, total laboratory resource utilization rate and level of glycemic control by average hemoglobin A1c level with and without detailed case-mix adjustment.

RESULTS

For profiles based on hospitalization rates, visit rates, laboratory utilization rates, and glycemic control, 4% or less of the overall variance was attributable to differences in physician practice and the reliability of the median physician's case-mix-adjusted profile was never better than 0.40. At this low level of physician effect, a physician would need to have more than 100 patients with diabetes in a panel for profiles to have a reliability of 0.80 or better (while more than 90% of all primary care physicians at the health maintenance organization had fewer than 60 patients with diabetes). For profiles of glycemic control, high outlier physicians could dramatically improve their physician profile simply by pruning from their panel the 1 to 3 patients with the highest hemoglobin A1c levels during the prior year. This advantage from gaming could not be prevented by even detailed case-mix adjustment.

CONCLUSIONS

Physician "report cards" for diabetes, one of the highest-prevalence conditions in medical practice, were unable to detect reliably true practice differences within the 3 sites studied. Use of individual physician profiles may foster an environment in which physicians can most easily avoid being penalized by avoiding or deselecting patients with high prior cost, poor adherence, or response to treatments.

The Michigan Hand Outcomes Questionnaire (MHQ): assessment of responsiveness to clinical change

Responsiveness is an important property of an outcomes questionnaire. It can be defined as the ability of an instrument to capture important changes in a patient's health status over time. The authors previously designed the Michigan Hand Outcomes Questionnaire (MHQ), a hand-specific outcomes instrument that contains six distinct scales: (1) overall hand function, (2) activities of daily living, (3) pain, (4) work performance, (5) aesthetics, and (6) patient satisfaction with hand function. In the first study, the authors demonstrated that the MHQ is a reliable and valid instrument for the hand. The purpose of this second study is to assess the responsiveness, or sensitivity, of the MHQ to clinical change in patient status. A total of 187 consecutive patients with chronic hand disorders completed a baseline MHQ prior to receiving treatment at a university plastic surgery clinic. Approximately 6 to 18 months after completing the first questionnaire, patients were sent a follow-up MHQ by mail. The second questionnaire was identical to the first, with the exception of one additional question added to each of the six MHQ scales. This additional question asked patients to rate the change in their hands since completing the last questionnaire using a seven-point response scale. Spearman's correlation coefficient was used to correlate the responses from patients' self-assessment questions with the actual score change (after score - before score). The response rate for the second administration was 49% (92 questionnaires returned)-a fairly good rate of return for mail surveys. There were no significant differences in gender, race, education, and income between responders and nonresponders. When patients' self-assessment of change was correlated with the change in the six scale scores over time, all six correlations were statistically significant, with p < 0.05. The correlations ranged from 0.25 for the aesthetics scale to 0.43 for the pain scale. The MHQ was responsive using patients' self-assessment of their clinical change. Future studies will evaluate the responsiveness of the MHQ compared with objective physiological measures such as grip strength, range of motion, and the Jebson-Taylor test. Additionally, research is underway to assess the responsiveness of the MHQ for specific procedures, including metacarpophalangeal arthroplasties for rheumatoid arthritis and microvascular toe-to-hand reconstructions.

Patients' desires and expectations for medical care: a challenge to improving patient satisfaction

Patients' desires and expectations for medical care warrant scrutiny because of their potential influence on health care use and patient satisfaction and their effects on patients' perceptions of quality of care. To determine if desires and expectations for selected elements of medical care and specialty referral differ between VA outpatients and non-VA outpatients, we conducted a cross-sectional survey of patients at a VA medical center site and 2 primary care sites of its university affiliate. Of 390 eligible patients at the VA medical center site, 270 (69%) consented to participate and returned completed self-administered questionnaires. At its university affiliate sites, 119 (73%) of the 162 eligible patients completed questionnaires. Overall, patient desire and expectation for elements of medical care and specialty referral were similar and high at all study sites. Desire ranged from 33% for a blood test to check for anemia to 80% for heart auscultation. Desire for specialty referral for hypothetical scenarios averaged 71% and 61% among VA Medical Center patients and university affiliate patients, respectively. Patient demographics and socioeconomic status were poor predictors of desire for care. These results suggest (a) that VA medical center outpatients' desires and expectations for preventive medical care are not significantly different from those of non-VA outpatients, (b) that desire is often high for both highly recommended care and care that is not generally recommended or is controversial, and (c) that high levels of desire are not limited to patients of higher levels of socioeconomic status. In an effort to improve satisfaction, it is important to examine ways in which to address patients' desires and expectations for medical care, even while faced with competing health care spending priorities.

2-W Ho:YAG laser intracavity pumped by a diode-pumped Tm:YAG laser

Efficient room-temperature operation of a Ho:YAG laser, intracavity pumped by a diode-bar-pumped Tm:YAG laser, is reported. At rod mount temperatures of 10 degrees C, for both the Tm:YAG and the Ho:YAG rods, we obtained 2.1 W of output at 2.097mum from the Ho:YAG laser for 9.2 W of diode power incident upon the Tm:YAG rod.

Initial emergency department diagnosis and return visits: risk versus perception

STUDY OBJECTIVES

To identify diagnostic predictors of return emergency department visits, and to compare actual and perceived associations between initial ED diagnosis and revisits to help identify target diagnoses for prevention strategies.

METHODS

This 2-part study involved a retrospective observational study and a health professional survey. The study population consisted of all patients with 2 or more visits to the University of Michigan ED within a 3-day period between July 1995 and June 1996 ("early-return visitors"). Billing records identified the initial diagnoses of subsequent return visitors. The prevalence of each initial diagnosis was determined in the general ED population (n=52,553), early-return population (n=1,422), and early-return population admitted to the hospital ("return-admit," n=313). Surveys were distributed to all ED health professionals to assess their perception of the diagnoses most likely to return within 3 days. Relative risk (RR) ratios and 95% confidence intervals (CIs) were calculated.

RESULTS

Dehydration was the most common diagnosis in the general, early-return, and return-admit populations (prevalence: 7%, 15%, 25%, respectively). Dehydration was also the diagnosis with the highest risk for both early return and subsequent admission on early return (RR [95% CI]: 2.3 [2.0-2.6], 1.8 [1.5-2.3], respectively). Nearly two thirds of health professionals, however, did not identify dehydration as a diagnosis at high risk for return, and almost half did not consider dehydration a high risk for admission.

CONCLUSION

Initial ED diagnosis may be a useful predictor of early ED return and admission. Patients with an initial diagnosis of dehydration are at particularly high risk for early return and admission, yet providers underestimate the risk in this very common group. Screening a return ED population for high-frequency diagnoses may reveal underrecognized target groups for specific prevention strategies.

Reliability and validity testing of the Michigan Hand Outcomes Questionnaire

In this study, psychometric principles were used to develop an outcomes questionnaire capable of measuring health state domains important to patients with hand disorders. These domains were hypothesized to include (1) overall hand function, (2) activities of daily living (ADL), (3) pain, (4) work performance, (5) aesthetics, and (6) patient satisfaction with hand function. An initial pool of 100 questions was pilot-tested for clarity in 20 patients; following factor analysis, the number of questions was reduced to a 37-item Michigan Hand Outcomes Questionnaire (MHQ). The MHQ, along with the Short Form-12, a generic health status outcomes questionnaire, was then administered to 200 consecutive patients at a university-based hand surgery clinic and was subjected to reliability and validity testing. The mean time required to complete the questionnaire was 10 minutes (range, 7-20 minutes). Factor analysis supported the 6 hypothesized scales. Test-retest reliability using Spearman's correlation demonstrated substantial agreement, ranging from 0.81 for the aesthetics scale to 0.97 for the ADL scale. In testing for internal consistency, Cronbach's alphas ranged from 0.86 for the pain scale to 0.97 for the ADL scale (values >0.7 for Cronbach's alpha are considered a good internal consistency). Correlation between scales gave evidence of construct validity. In comparing similar scales in the MHQ and the Short Form-12, a moderate correlation (range, 0.54-0.79) for the ADL, work performance, and pain scales was found. In evaluating the discriminate validity of the aesthetics scale, a significant difference (p = .0012) was found between the aesthetics scores for patients with carpal tunnel syndrome and patients with rheumatoid arthritis. The MHQ is a reliable and valid instrument for measuring hand outcomes. It can be used in a clinic setting with minimal burden to patients. The questions in the MHQ have undergone rigorous psychometric testing, and the MHQ is a promising instrument for evaluation of outcomes following hand surgery.

Patients' desires and expectations for medical care in primary care clinics

To explore whether patients' desires for and expectations of medical care differ between the United States and Canada, we surveyed 652 patients and 105 physicians at primary care sites in Michigan and Ontario. Patient desires were similar at both sites, but expectations were higher in Michigan. Michigan physicians gave higher estimates of patient desire than physicians in Ontario. Physicians at both sites, however, similarly underestimated patients' desires. These between-site differences in expectation may reflect differences both in general cultural factors and in patient exposure to different clinical policies within the medical systems.

Type II (beta) errors in the hand literature: the importance of power

When a study concludes that there is no difference between 2 treatments ("negative studies"), it is essential to determine whether the study has sufficient power to find a clinically significant difference. Insufficient power precludes an adequate assessment of therapeutic efficacy and may result in a type II error, an erroneous conclusion that the null hypothesis is correct. In evaluating 39 studies that highlighted negative findings in The Journal of Hand Surgery, we found that 32 (82%) papers had a power of less than .80 to detect a 25% treatment effect and, when the treatment effect was increased to 50%, more than one half of the studies still had a power of 0.80. These "negative studies" frequently have inadequate statistical power to support their conclusions. These findings have important implications for researchers, editors, and readers.

Estimated benefits of glycemic control in microvascular complications in type 2 diabetes

BACKGROUND

The benefits of intensive glycemic control in patients with type 2 diabetes are not well quantified. It is therefore not clear which patients will benefit most from aggressive glycemic control.

OBJECTIVE

To evaluate the efficacy of glycemic control in type 2 diabetes.

DESIGN

Markov decision model.

PATIENTS

Diabetic patients at a health maintenance organization.

MAIN OUTCOME MEASURES

Risks for developing blindness and end-stage renal disease; number of patients and patient-years needed to treat to prevent complications.

RESULTS

For a patient in whom diabetes developed before 50 years of age, reducing hemoglobin A1c levels from 9% to 7% results in an estimated 2.3-percentage point decrease (from 2.6% to 0.3%) in lifetime risk for blindness due to retinopathy. The same change in a patient with diabetes onset at 65 years of age would be expected to decrease the risk for blindness by 0.5 percentage points (from 0.5% to < 0.1%). However, the Markov model predicts substantially greater benefit when moving from poor to moderate glycemic control than when moving from moderate to almost-normal glycemic control. Targeting less than 20% of the patients at one health maintenance organization for intensified therapy may prevent more than 80% of the preventable patient-time spent blind. The risks for end-stage renal disease and the risk reduction provided by improved glycemic control are lower than those for blindness.

CONCLUSIONS

This probability model, based on extrapolation from the experience with type 1 diabetes, suggests that patients with early onset of type 2 diabetes will accrue substantial benefit from almost-normal glycemic control. In patients with later onset, moderate glycemic control prevents most end-stage complications caused by microvascular disease. These results have important implications for informing patients and allocating health care resources.

Validating quality indicators for hospital care

BACKGROUND

Many of the indicators used to monitor the quality of hospital care are resource intensive and ineffective. Furthermore, current efforts to develop new indicators for report cards are generally directed at the evaluation of health plans and are not constructed to help providers (physician groups, hospitals, and health plans that contract to provide care to patients) find and fix problems with the quality of care at their organizations.

FOUR QUESTIONS

Before using an indicator, four questions should be posed: (1) When cases identified by the indicator are examined, can one find a set of definable and preventable processes of care known to lead to a bad outcome? (2) Can a review instrument be created that will allow providers to identify which process problems are present? (3) Are there substantially more process problems in those cases identified by the indicator than in those cases not identified by the indicator, and can the sensitivity and specificity of the indicator be defined? and (4) Is the indicator primarily useful for quality improvement efforts by a provider, or is it also useful as an external measure of quality across providers? A FOUR-STEP FRAMEWORK: Four corresponding steps comprise an efficient validation method to produce indicators that detect deficiencies in an important process-outcome continuum, help produce the tools to find the deficiencies, document the efficiency of using the indicator to search for process problems, and define the appropriate use of the indicator. Use of such validated indicators, and the information about their utility, would allow providers to optimize the impact of money spent on quality improvement efforts.

Identifying poor-quality hospitals. Can hospital mortality rates detect quality problems for medical diagnoses?

OBJECTIVES

Many groups involved in health care are very interested in using external quality indices, such as risk-adjusted mortality rates, to examine hospital quality. The authors evaluated the feasibility of using mortality rates for medical diagnoses to identify poor-quality hospitals.

METHODS

The Monte Carlo simulation model was used to examine whether mortality rates could distinguish 172 average-quality hospitals from 19 poor-quality hospitals (5% versus 25% of deaths being preventable, respectively), using the largest diagnosis-related groups (DRGs) for cardiac, gastrointestinal, cerebrovascular, and pulmonary diseases as well as an aggregate of all medical DRGs. Discharge counts and observed death rates for all 191 Michigan hospitals were obtained from the Michigan Inpatient Database. Positive predictive value (PPV), sensitivity, and area under the receiver operating characteristic curve were calculated for mortality outlier status as an indicator of poor-quality hospitals. Sensitivity analysis was performed under varying assumptions about the time period of evaluation, quality differences between hospitals, and unmeasured variability in hospital casemix.

RESULTS

For individual DRG groups, mortality rates were a poor measure of quality, even using the optimistic assumption of perfect casemix adjustment. For acute myocardial infarction, high mortality rate outlier status (using 2 years of data and a 0.05 probability cutoff) had a PPV of only 24%, thus, more than three fourths of those labeled poor-quality hospitals (high mortality rate outliers) actually would have average quality. If we aggregate all medical DRGs and continue to assume very large quality differences and perfect casemix adjustment, the sensitivity for detecting poor-quality hospitals is 35% and PPV is 52%. Even for this extreme case, the PPV is very sensitive to introduction of small amounts of unmeasured casemix differences between hospitals.

CONCLUSION

Although they may be useful for some surgical diagnoses, DRG-specific hospital mortality rates probably cannot accurately detect poor-quality outliers for medical diagnoses. Even collapsing to all medical DRGs, hospital mortality rates seem unlikely to be accurate predictors of poor quality, and punitive measures based on high mortality rates frequently would penalize good or average hospitals.

Comparing the hospitalizations of transfer and non-transfer patients in an academic medical center

BACKGROUND

By accepting and caring for patients transferred from other institutions, academic medical centers have been able to develop comprehensive training and research programs. Whether academic institutions can continue to do this in the future is questionable. To the extent that transfer patients are more complex and severely ill than non-transfer patients, they are likely to consume more resources, and in managed care payment systems, they could place accepting hospitals in financial jeopardy.

METHOD

Between July 1989 and December 1993, the internal medicine, surgery, and pediatrics services of the 880-bed University Hospital of the University of Michigan accepted 8,740 patients from other hospitals. The hospitalizations of these patients were compared with those of the 76,047 non-transfer patients on these services. The statistical methods used were Student's t-test, chi-square, Cochran-Mantel-Haenszel chi-square, and analysis of variance.

RESULTS

The hospitalizations of the transfer patients were more complex and resource-use intensive. The transfer patients were more likely (p<.0000) to be length-of-stay outliers as defined by Medicare standards (28% vs 10%) and to suffer in-hospital death (9.4% vs 2.5%). After case-mix adjustment and exclusion of length-of-stay outliers, transfer patients on the three services (surgery, medicine, and pediatrics) remained in the hospital 1.62, 1.15, and 0.84 days longer (p<.0001) than non-transfer patients. Ancillary-service resource use was assessed using a relative-value-unit (RVU) scale based on direct-cost dollars. The transfer patients' case-mix-adjusted resource use exceeded that of the non-transfer patients by 1,155,850 and 957 RVUs for surgery, pediatrics, and medicine (p<.0001). Although the transfer patients were more likely to have Medicaid insurance, the differences in lengths of stay and use of ancillary services persisted throughout all insurance groups. Indeed, transfer status, compared with age, sex, and insurance status, was the best predictor of high resource use.

CONCLUSION

The transfer patients stayed longer and consumed more hospital resources than did the non-transfer patients. Age, sex, case-mix, and insurance status did not account for these differences. To limit the financial liability that transfer patients pose, academic medical centers could be forced to abandon their traditional role of caring for such patients. The consequences of this possibility should be explored.

Do the criteria of resident selection committees predict residents' performances?

PURPOSE

To further the understanding of what factors residency selection committees consider when rating candidates and how well these ratings predict residents' performances.

METHOD

The authors analyzed the application and residency files of 123 physicians who completed the internal medicine residency at the University of Michigan from 1989 through 1992; they also reviewed all 308 applications for 1993-94. Applications to the residency were reviewed by an intern selection committee (ISC) and given scores ranging from 0 (best) to 450 (worst). Multivariate analyses were used to evaluate the influences on ISC scores of seven factors: gender, internal medicine clerkship grade, number of honors in non-medicine clerkships, Alpha Omega Alpha (AOA) status, number of publications, score on the National Board of Medical Examiners (NBME) Part I examination, and medical school reputation. Each resident's performance was evaluated using the final overall evaluation score submitted by the program to the American Board of Internal Medicine.

RESULTS

The most significant predictors of ISC score were internal medicine clerkship grade, AOA status, medical school reputation, and NBME I score (all four at p < .01; R2 = .66 for the full model of seven factors). The residents' final evaluation scores were moderately correlated with ISC scores at the time of application (r = -.52). In a multivariate analysis, the final scores were significantly associated only with internal medicine clerkship honors (p < .01) and graduation from the University of Michigan Medical School (p < .05), and there was a trend associating them with junior-year AOA election.

CONCLUSION

The findings suggest that the intern selection committee overemphasized the predictive value of AOA election in the senior year, NBME I scores, and medical school reputation.

Measuring attending physician performance in a general medicine outpatient clinic

OBJECTIVE

To determine which aspects of outpatient attending physician performance (e.g., clinical ability, teaching ability, interpersonal conduct) were measurable and separable by resident report.

DESIGN

Self-administered evaluation form.

SETTING

University internal medicine resident continuity clinic.

PARTICIPANTS

All residents with their continuity clinic at the university hospital evaluated the two attendings who staffed their clinic for the academic years of 1990-1991, 1991-1992, and 1992-1993 (average of 85 total residents per year). The overall response rate was 74%.

ANALYSIS

Exploratory analyses were conducted on a preliminary evaluation form in the first two years of the study (236 evaluations of 20 different clinic attendings) and confirmatory analyses using factor analysis and generalizability analysis were performed on the third year's data (142 evaluations of 15 different clinic attendings). Analysis of variance was used to evaluate factors associated with evaluation scores.

RESULTS

Analyses demonstrated that the residents did not distinguish between the attendings' clinical and teaching abilities, resulting in a single four-item scale that was named the Clinical/Teaching Excellence Scale, measured on a five-point scale from poor to outstanding (Cronbach's alpha = 0.92). A large amount of the variance for this scale score was associated with attending identity (adjusted R2 = 46%). However, two alternative approaches to evaluating the performance of the attending (preference for him or her to the "average" attending and perceived impact of the attending on residents' clinical skills) did not provide useful information independent of the Clinical/Teaching Excellence Scale. The ratings of three separate conduct scales [availability in clinic (Availability Scale), treating residents and patients with respect (Respect Scale), and time efficiency in staffing cases (Slow Staffing Scale)] were separable from each other and from the rating of clinical/teaching excellence. For the Clinical/Teaching Excellent Scale, as few as four evaluations produced good interrater reliability and eight evaluations produced excellent reliability (reliability coefficients were 0.70 and 0.84, respectively).

CONCLUSIONS

Although this evaluation instrument for measuring clinic attending performance must be considered preliminary, this study suggests that relatively few attending evaluations are required to reliably profile an individual attending's performance, that attending identity is associated with a large amount of the scale score variation, and that special issues of attending performance more relevant to the outpatient setting than the inpatient setting (availability in clinic and sensitivity to time efficiency) should be considered when evaluating clinic attending performance.

The integrated inpatient management model. Lessons for managed care

The Integrated Inpatient Management Model was a 2.5-year controlled prospective trial of using a clinical information system to direct and monitor physician and hospital practice on general medicine services of an 880-bed university hospital. For the over 2,000 admissions on both a control service and the intervention service, the mean length of stay (LOS) decreased when compared with historic norms (0.68 and 0.95 days respectively; P < 0.01 for both). This difference in mean LOS represents a savings of 580 hospital days for the intervention over the control service; (95% confidence interval, 300 to 1420 days). There also was a trend for the intervention service to have fewer LOS outliers than expected (P = 0.14). Ancillary service use decreased by 17% on both control and intervention services (a trend that disappeared after the study was terminated), while other internal medicine services experienced a 29% increase in this measure of resource use. The intervention service experienced fewer preventable deaths (P = 0.04), but there were no differences in global quality of care measures, readmission and mortality rates, and patient satisfaction. This use of a clinical information system is a prototype for the systems that will be needed for all forms of managed care.

Can early re-admission rates accurately detect poor-quality hospitals?

There is widespread interest in using external quality measures, such as early re-admission rates (ERRs), to evaluate hospital quality. To evaluate the feasibility of using ERRs to identify poor-quality hospitals, a Monte Carlo simulation model was developed that describes the predictive power of ERRs for the 190 hospitals in Michigan using different assumptions concerning the distribution and variability of quality problems, the number of years of data aggregated, and unmeasured case-mix differences. The ability of ERRs to distinguish 171 average-quality hospitals from 19 poor-quality hospitals (assigned to have 5% vs. 15% premature discharges) was evaluated. First, the largest diagnosis-related groups (DRGs) were studied to determine if they included cardiac, gastrointestinal, pulmonary, and neurologic diseases. Despite using the highly optimistic assumptions that premature discharges are readmitted 50% more frequently than appropriately timed discharges and that no ERR variation was caused by unmeasured case-mix differences between hospitals, the results were poor. For example, for DRG 127 (heart failure), high ERR outlier status (using a .05 probability cutoff) had a positive predictive value of only 36%, meaning that approximately two thirds of hospitals labeled "poor-quality" (high ERR outliers) were false-positive results. Next, we repeated the simulation with sample sizes aggregated for all medical DRGs. The positive predictive value was 72%, but was very sensitive to ERR variability due to non-quality-related factors (e.g., unmeasured case mix). The positive predictive value decreases to 45% if unmeasured case mix accounts for even 10% of observed hospital ERR variation. The circumstances under which DRG-specific ERRs would be useful to detect poor-quality hospitals are unlikely to occur. Even collapsing to all medical DRGs, ERRs are likely to be accurate predictors only if quality differences are quite large and if unmeasured case-mix differences account for a small amount of interhospital variation in ERRs.

Measuring physician attitudes toward cost, uncertainty, malpractice, and utilization review

OBJECTIVE

To develop a reliable measure of physician attitudes postulated to influence resource utilization.

DESIGN

Statements related to attitudes that may influence resource use were culled from the literature and informal discussions with physicians.

SETTING

Academic medical center.

PARTICIPANTS

All faculty and housestaff in internal medicine, pediatrics, family medicine, and surgery at an academic medical center were surveyed. The response rate was 59% (n = 428).

RESULTS

Exploratory factor analysis of all internal medicine surveys revealed four prominent domains. These closely corresponded with our a-priori hypothesized domains and were interpreted as cost-consciousness, discomfort with uncertainty, fear of malpractice, and annoyance with utilization review. A replication of the analysis using 25 survey items and conducted on the remainder of the data (surgeons, pediatricians, and family practitioners) revealed a similar four-factor solution. Scales were constructed for each of the four domains. Cronbach's alpha ranged from 0.66 to 0.88. Discomfort from uncertainty and fear of malpractice were moderately correlated (r = 0.42); other scale-scale correlations were modest. Of the four attitude measures, only cost-consciousness was associated with lower self-estimates of resource use. Both annoyance with utilization review and fear of malpractice increased as the proportion of time spent in patient care increased.

CONCLUSIONS

Although various physician attitudes and beliefs have been hypothesized to influence health services resource use, reliable and valid measures for most of these have not been developed. The authors developed a 19-item survey instrument designed to measure these attitudes reliably. The four scales developed in this study may help identify physician attitudes that are important determinants of physician decision making and help foster a better understanding of physicians' reactions and acculturation to different practice environments.

Do attending or resident physician practice styles account for variations in hospital resource use?

Prospective payment has created incentives for hospitals to identify physicians who are responsible for high or excessive rates of resource use. However, at teaching hospitals it is unclear whether individual attending or resident physicians account for a substantial portion of the observed variations in hospital resource use. To explore this issue, case-mix adjusted hospital length of stay and ancillary resource use at a university teaching hospital for 7,667 consecutive discharges on general medicine wards and 7,566 discharges on medical subspecialty wards were evaluated. After controlling for case mix and patient characteristics (patients' age, sex, marital status, insurance status, and ward service), only 2% of the length of stay variance (log transformed) was attributable to the attending physician on general medicine wards (P = 0.06) and 1% on subspecialty medicine wards (P < 0.01). For total ancillary resource use, about 2% of the variance was attributable to general medicine and subspecialty ward attendings. Similar associations were found for resident physicians, although the overlap of attending and resident physicians' month-long rotations prevented critical appraisal of their independent contributions to resource use. Furthermore, labeling attending physicians as high or low hospital resource utilizers based on data from one month of attending duty (mean admissions = 33 +/- 7) would be scarcely better than randomly classifying them (kappas ranged from -0.05 for length of stay on subspecialty services to 0.18 for pharmacy use on general medicine services). In conclusion, in this university teaching hospital, attendings and residents account or a small, although statistically significant, amount of the variation in hospital resource use. It would be impractical for the hospital to reliably profile the resource use intensity of individual physicians.

Effects of horizontal whole-body vibration on reading

Text from a newspaper was read by seated subjects (8 male, 8 female) during exposure to fore-and-aft and lateral whole-body vibration. With narrow-band random vibration at frequencies between 0.5 Hz and 10 Hz and with vibration magnitudes between 0.63 m s(-2) rms and 1.25 m s(-2) rms, reading speed was measured and subject ratings of reading speed were obtained. During exposure to fore-and-aft vibration, the subjects' ratings suggested that reading speed was significantly reduced at frequencies between 1.25 Hz and 6.3 Hz, with greater impairment at higher magnitudes of vibration. Maximum interference with reading was reported at 4 Hz. Measures of reading speed showed that subjects consistently overestimated their reduction in reading speed. Lateral vibration produced similar results, but the effect was less than that with fore-and-aft vibration.

The integrated inpatient management model's clinical management information system

The rising cost of health care has increased the call for cost control. The pressing need to control cost, coupled with the increase in managed care and prospective payment, has placed new urgency on administrators and clinicians to work collaboratively in providing efficient and effective care. We have developed the Integrated Inpatient Management Model (IIMM) to assist in this collaborative effort. We describe the IIMM's clinical information system that provides decision support to both administrators and clinicians. This clinical information system is the information backbone for the development and monitoring of practice guidelines or critical pathways. An integrated information system of this type is essential if hospitals are to prosper during the next decade.

Gender and hospital resource use. Unexpected differences

Several recent studies have explored gender differences in medical care that are not attributable to clinical characteristics. At an 880-bed teaching hospital between July 1987 and June 1990, we studied the importance of gender on two measures of hospital care: length of stay and ancillary service use. The latter was measured on a relative value unit (RVU) scale, based on an estimation of direct cost dollars. Neither mean age nor in-hospital mortality differed between the 9,102 women and 10,285 men. After case-mix adjustment, women stayed in the hospital 0.22 days longer than men (p = 0.01) but consumed 67 fewer RVUs (p = 0.01). This RVU difference dissolved when intensive care unit (ICU) stays were eliminated; men were 1.13 times more likely (95% confidence interval 1.07 to 1.19) to be placed in the ICU. Being married shortened length of stay and women were less likely to be married (51% vs. 68%; p < 0.001), but even within marital status subgroups women remained in the hospital longer than men. Whether this longer length of stay and less technologically intensive care for women reflects a difference in illness severity or physician gender bias requires further study.

An evaluation of generic screens for poor quality of hospital care on a general medicine service

In this study, 675 general medicine admissions at a university teaching hospital were reviewed to evaluate six potential generic quality screens: 1) in-hospital death; 2) 28-day early readmission; 3) low patient satisfaction; 4) worsening severity of illness (as determined by an increase in Laboratory Acute Physiology and Chronic Health Evaluation APACHE-L); and 5) deviations from expected hospital length of stay; and 6) expected ancillary resource use. The quality of care for a stratified random sample of admissions were evaluated using structured implicit review (inter-rate reliability, Kappa = 0.5). Patients who died in-hospital were substantially more likely than those who were discharged alive to be rated as having had substandard care (30% vs. 10%; P < 0.001). In contrast, cases who had subsequent early readmissions did not have poorer quality ratings. Similarly, lower patient satisfaction was not associated with poorer ratings of technical process of care. Cases with lower-than-expected ancillary resource use (case-mix adjusted for diagnosis-related group) were more likely to be rated as having received substandard care than those with higher-than-expected resource use (16% vs. 6%; P < 0.05), and there was a similar trend for cases with shorter than expected length of stays. Associations between worsening severity of illness, as determined by APACHE-L scores, and quality were confounded because such patients were more likely to have died in-hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluating the care of general medicine inpatients: how good is implicit review?

OBJECTIVE

Peer review often consists of implicit evaluations by physician reviewers of the quality and appropriateness of care. This study evaluated the ability of implicit review to measure reliably various aspects of care on a general medicine inpatient service.

DESIGN

Retrospective review of patients' charts, using structured implicit review, of a stratified random sample of consecutive admissions to a general medicine ward.

SETTING

A university teaching hospital.

PATIENTS

Twelve internists were trained in structured implicit review and reviewed 675 patient admissions (with 20% duplicate reviews for a total of 846 reviews).

RESULTS

Although inter-rater reliabilities for assessments of overall quality of care and preventable deaths (kappa = 0.5) were adequate for aggregate comparisons (for example, comparing mean ratings on two hospital wards), they were inadequate for reliable evaluations of single patients using one or two reviewers. Reviewers' agreement about most focused quality problems (for example, timeliness of diagnostic evaluation and clinical readiness at time of discharge) and about the appropriateness of hospital ancillary resource use was poor (kappa < or = 0.2). For most focused implicit measures, bias due to specific reviewers who were systematically more harsh or lenient (particularly for evaluation of resource-use appropriateness) accounted for much of the variation in reviewers' assessments, but this was not a substantial problem for the measure of overall quality. Reviewers rarely reported being unable to evaluate the quality of care because of deficiencies in documentation in the patient's chart.

CONCLUSION

For assessment of overall quality and preventable deaths of general medicine inpatients, implicit review by peers had moderate degrees of reliability, but for most other specific aspects of care, physician reviewers could not agree. Implicit review was particularly unreliable at evaluating the appropriateness of hospital resource use and the patient's readiness for discharge, two areas where this type of review is often used.

Data and the internal medicine houseofficer: alumni's views of the educational value of a residency program's research requirement

The authors surveyed 112 recent alumni and 92 current residents (70% responded) at a residency program that requires original research. Most alumni felt that the research project was a valuable learning experience, particularly in improving their abilities to critically review the medical literature. Almost a third felt that it had influenced their career choices (academic medicine vs private practice). The overall learning value of no other residency program component was rated significantly higher than that of the research project. While 65% of current residents supported making the senior resident research project optional, 64% of alumni opposed this change (p < 0.0001). These results support requiring formal oral presentations and encouraging original research projects as a part of residency training.

Coming to terms with the era of AIDS: attitudes of physicians in U.S. residency programs

PURPOSE

To examine factors associated with residents' willingness to provide care to persons with AIDS.

PATIENTS AND METHODS

Survey of all senior residents in internal medicine and family medicine in ten geographically representative states in early 1989.

RESULTS

Preferring not to care for persons with AIDS was less common in the western United States and more common among those with more conservative politics, men physicians, Asian physicians, and foreign medical graduates. Multivariate analysis revealed scores on six attitudinal scales (homophobia, dislike of intravenous drug users, professional responsibility, fear of AIDS, futility of providing AIDS care, and clinical difficulty of AIDS care) to be strong independent predictors of willingness to care for persons with AIDS (adjusted R2 = 0.42). The authors postulated a model in which these six fundamental attitudes functioned as intervening variables between demographic characteristics and expressed willingness to provide AIDS care. Regression results supported the hypothesis that the associations between demographic characteristics and willingness to provide AIDS care were mediated via these attitudes. However, having had ambulatory experience in AIDS care during residency was associated with future intentions to provide such care, independent of negative attitudes.

CONCLUSIONS

Physician willingness to care for persons with AIDS is inversely related to fear of acquiring AIDS, viewing treatment as futile or difficult, dislike of certain risk groups, and a lower sense of professional responsibility. These results identify concerns and stresses that should be addressed by residency programs, and emphasize the need for attention to the ethics and ideals of the profession in medical education.

Residents' experiences in, and attitudes toward, the care of persons with AIDS in Canada, France, and the United States

OBJECTIVE

To evaluate resident physicians' experiences in, and attitudes toward, the care of persons with the acquired immunodeficiency syndrome (AIDS) in Canada, France, and the United States.

DESIGN

Cross-sectional survey, using a self-administered, mailed questionnaire to residents in 10 American states, three French regions, and all 10 Canadian provinces, with follow-up surveys of nonresponders in France and the United States.

SUBJECTS

Systematic samples of residents in the last year of internal medicine or family medicine residencies prior to subspecialization or entry into medical practice.

RESULTS

While the majority of residents had provided inpatient and outpatient care to persons with AIDS, most believed that their training in ambulatory care of persons with AIDS had been deficient. The rate of blood-contaminated needle-sticks from human immunodeficiency virus-infected patients ranged from 4% for internal medicine residents in Canada to 14% in the United States (P less than .05). The majority recognized an ethical obligation to treat AIDS, but 4% in France, 14% in Canada, and 23% in the United States indicated that they would not care for persons with AIDS if they had a choice (P less than .001). A substantial minority of US physicians reported that a patient of theirs had been refused care by a medical specialist (19%) or a surgeon (39%), but less than 10% of French physicians reported such refusals (P less than .001).

CONCLUSION

Concerns about caring for AIDS patients were common and many physicians reported that patients were refused care. While most residents acknowledged an obligation to treat human immunodeficiency virus infection, many did not, and viewpoints varied considerably across the countries studied. The lower level of reluctance to treat AIDS patients in France and Canada makes it clear that the higher rate in the United States is far from optimal and needs to be addressed.

APACHE-L: a new severity of illness adjuster for inpatient medical care

A principal concern regarding Medicare's diagnosis-related group (DRG)-based prospective payment system is whether hospitals caring for more severely ill patients may be undercompensated for the services they provide. Research on possible inequities in hospital payment has been hampered by the absence of an objective, easily obtained, and valid measure of patients' severity of illness. Because laboratory data are objective and computerized in most of our nation's hospitals, a system utilizing such data, if shown to discriminate between patients of differing expected resource use, could prove most helpful in examining possible inequities in prospective payment system hospital payment. At a major teaching hospital, data were used from length of stay inlier patients in the 10 most frequent medical DRGs in the U.S. to develop and evaluate a severity of illness system called APACHE-L. APACHE-L uses the laboratory component of the original APACHE score. Whereas DRGs explained 20% of the variation in length of stay for the top ten DRGs, APACHE-L explained up to an additional 14% of the variation. For ancillary resource use, DRGs explained 10% of the variance, and APACHE-L explained up to an additional 15%. Diagnosis-related group-specific analyses demonstrated that the amount of resource use variance explained by APACHE-L varied widely depending on the DRG (from R2 = .00 for DRG 410, chemotherapy; to R2 = .38 for DRG 320, kidney and urinary tract infections, age greater than 17 years with complications or comorbidities). The APACHE-L score, which is objective and readily available in our nation's hospitals, shows considerable promise as a severity of illness adjuster for a subset of DRGs.

Choosing between apples and apples: physicians' choices of prescription drugs that have similar side effects and efficacies

OBJECTIVE

To examine physician choices of commonly used medications having similar side effects and efficacies, and to evaluate factors that may affect these choices.

DESIGN/SETTING

Cross-sectional survey conducted in winter 1989-1990.

PARTICIPANTS

263 physicians at a university teaching hospital (response rate = 71%).

MEASUREMENTS AND MAIN RESULTS

Physicians rated patient compliance, cost to patient, and patient preference as the three most influential factors in their selection of a particular agent from a class of similar drugs. Housestaff were less likely than faculty to consider cost to patient as a "very important" factor (33% vs. 60%; p less than 0.05), and only 11% of all physicians felt that cost to third-party payer was very important. Physicians reported that their choices of particular nonsteroidal anti-inflammatory drugs (NSAIDs), histamine-2 (H2) blockers, and inhaled beta-agonists were mainly determined by which drugs enhanced compliance or were used by others (the "traditional choice"); cost to patient was a less important influence in these instances. All physician subgroups were inaccurate in predicting the approximate prices of their first- and second-choice agents. For example, only 28% of those selecting naproxen as their preferred NSAID were within $10 of the range of the prices of a one-month supply, and 14% were within $10 for cimetidine.

CONCLUSION

Although this group of physicians reported considering drug costs to be important when choosing between similar drugs, they acknowledged that cost was relatively unimportant in several specific instances studied and their knowledge of the absolute and relative prices of drugs they commonly prescribed was deficient.

The U.S. and Canadian health care systems: views of resident physicians

OBJECTIVE

To evaluate U.S. and Canadian resident physicians' views about their health care systems.

DESIGN

Self-administered questionnaire survey in 1989.

PARTICIPANTS

Senior family medicine and internal medicine residents in Canada and in ten geographically representative American states.

MAIN RESULTS

American and Canadian residents had similar levels of professional satisfaction and almost universally agreed on the ethical obligation to provide care to persons of all social circumstances, but U.S. residents were more likely to perceive a serious access problem in their country (75% compared with 18%) and to think that current controls on the medical profession interfere with patient care (81% compared with 58%; P less than 0.001). In addition, U.S. residents were more likely than Canadian residents to believe that primary care salaries were too low (78% compared with 38%) and that salaries of medical subspecialists (57% compared with 17%) and surgeons (85% compared with 28%) were too high. In general, residents preferred their own country's predominant health care system. Whereas 87% of U.S. physicians supported private fee-for-service health care, 85% of Canadian physicians supported government-funded national health insurance. Nonetheless, 42% of U.S. physicians supported and only 17% strongly opposed national health insurance as an alternative approach. About two thirds of respondents from both countries opposed a salaried national health service.

CONCLUSIONS

American residents perceived greater problems with access, overall intrusions into medical practice, and fee disparities than did their Canadian counterparts. They preferred private fee-for-service health care, but few strongly opposed government-funded national health insurance as an alternative approach to the health care needs of the United States.

Regular source of ambulatory care and access to health services

BACKGROUND

To examine why people lack a regular source of ambulatory care (RSAC) and explore whether this commonly used access measure accurately identifies population subgroups at risk for barriers to continuity care.

METHODS

Using data from a 1986 national telephone survey, we performed a content analysis of subjects' verbatim reports as to why they lacked an RSAC (n = 5,748).

RESULTS

The 16.4 percent of respondents who lacked an RSAC gave the following reasons: 1) financial problems, 8 percent; 2) local resource inaccessibility, 5 percent; 3) not wanting a regular source of ambulatory care, 61 percent; and 4) transitory loss of their regular source of ambulatory care, 18 percent. However, some sociodemographic subgroups reported substantially more problems with access barriers, and these disparities were often not detected by the global measure, RSAC. The poor were not more likely than the non-poor to lack an RSAC (odds ratio [OR] = 0.8; 95% confidence interval, [0.6, 1.1]), but were much more likely to lack an RSAC for financial reasons (OR = 5.2 [2.6, 10.6]). Similarly, rural respondents were not more likely than urban dwellers to lack an RSAC, but were more likely to lack an RSAC because of local resource inaccessibility (OR = 5.8 [2.8, 11.9]).

CONCLUSIONS

We conclude that the global measure, RSAC, is not an accurate indicator of whether population subgroups have access barriers to obtaining a source of continuity care.