Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure.

PURPOSE: To assess the effects of an intervention involving dissemination of treatment recommendations to primary care physicians treating outpatients with acute myocardial infarction or heart failure. METHODS: The study comprised 509 patients with myocardial infarction and 323 patients with heart failure who were discharged from hospital. The primary care physicians caring for these patients were assigned randomly to either the intervention or control group; the intervention group was mailed practice guidelines immediately after patient discharge, and patients were cited by name. During a 6-month assessment period, the records of primary care physicians (and cardiologists, if any) were reviewed to assess mean conformance with the guidelines, using seven measures of care for myocardial infarction and eight measures of care for heart failure. RESULTS: After adjusting for demographic and clinical characteristics of patients, and the number of eligible measures per patient, we observed no effect of the intervention on care of patients with myocardial infarction (odds ratio [OR] = 0.98; 95% confidence interval [CI]: 0.81 to 1.17) or heart failure (OR = 1.25; 95% CI: 0.96 to 1.59). However, there was a higher likelihood of conformance with measures for patients with infarction (OR = 1.56; 95% CI: 1.29 to 1.87) or heart failure (OR = 1.71; 95% CI: 1.29 to 2.23) who had also been seen by a cardiologist during the 6-month assessment period. CONCLUSION: Mailing treatment recommendations did not improve the quality of care of recently discharged patients with myocardial infarction or heart failure. However, efforts to include cardiologists in the care of these patients might be worthwhile.

Process measures for the assessment and improvement of quality of care for schizophrenia.

The development of process measures for the assessment and improvement of care for schizophrenia is at an early stage. As part of a national inventory of mental health quality measures, we identified 42 process measures developed to assess the quality of schizophrenia care. A greater proportion of measures assessed pharmacotherapy than assessed psychosocial interventions or other clinical processes, such as assessment, continuity, or coordination. Twenty-five measures (60%) were based on research evidence linking measure conformance with improved patient outcomes, while 17 (40%) were based on clinical consensus or opinion. Only 12 measures (29%) were fully operationalized. Few were tested for validity or reliability. A number of demonstration projects currently under way should expand the pool of well-developed and tested measures. Further research and consensus development will be needed to identify common measurement priorities, reduce the data collection burden, enhance the interpretability of results, and allow for comparisons of clinical practice across facilities and health care systems.

Discrepancies between explicit and implicit review: physician and nurse assessments of complications and quality.

OBJECTIVE: To identify and characterize discrepancies between explicit and implicit medical record review of complications and quality of care. SETTING: Forty-two acute-care hospitals in California and Connecticut in 1994. STUDY DESIGN: In a retrospective chart review of 1,025 Medicare beneficiaries age >65, we compared explicit (nurse) and implicit (physician) reviews of complications and quality in individual cases. To understand discrepancies, we calculated the kappa statistic and examined physicians' comments. DATA COLLECTION: With Medicare discharge abstracts, we used the Complications Screening Program to identify and then select a stratified random sample of cases flagged for 1 of 15 surgical complications, 5 medical complications, and unflagged controls. Peer Review Organization nurses and physicians performed chart reviews. PRINCIPAL FINDINGS: Agreement about complications was fair (kappa = 0.36) among surgical and was moderate (kappa = 0.59) among medical cases. In discordant cases, physicians said that complications were insignificant, attributable to a related diagnosis, or present on admission. Agreement about quality was poor among surgical and medical cases (kappa = 0.00 and 0.13, respectively). In discordant cases, physicians said that quality problems were unavoidable, small lapses in otherwise satisfactory care, present on admission, or resulted in no adverse outcome. CONCLUSIONS: We identified many discrepancies between explicit and implicit review of complications and quality. Physician reviewers may not consider process problems that are ubiquitous in hospitals to represent substandard quality.

National Institute of Child Health and Human Development (NICHD) conference on kernicterus: a population perspective on prevention of kernicterus.

This paper reviews barriers to the prevention of kernicterus. Reports of kernicterus cases persist. We do not know why kernicterus continues to occur or how best to prevent it. We need evidence for key recommendations that make clinical guidelines usable by practitioners caring for newborns, especially for practitioners providing ambulatory care in the first week of life. Data on prevalence and incidence, mortality and morbidity are essential for launching a kernicterus public health campaign. Modeling cost-effectiveness requires data on costs and benefits of alternative strategies for managing hyperbilirubinemia and preventing kernicterus and on parental preferences concerning follow-up in the first days of life. Understanding how existing patterns of care obstruct preventive care involves exploration of the roles of clinicians, health-care organizations, parents, and payers and purchasers of health care. Lastly, discovering how to motivate change in existing practices can provide the guidance needed to prevent kernicterus in the US.

Common ground: a framework for selecting core quality measures for mental health and substance abuse care.

There is widespread interest throughout the mental health system in routine quality assessment to facilitate quality improvement, oversight, purchasing, and consumer choice. In the absence of agreement on a limited number of meaningful and feasible quality measures, delivery systems, payers, managed care organizations, regulators, and accreditors have each implemented unique measures and specifications. The resulting heterogeneity among measures has increased the burden on providers, limited the comparability of results, and hindered efforts to focus limited resources on further development of the most promising measures. Policy makers have initiated efforts for stakeholders to reach consensus on a core set of measures for common use, but barriers to progress remain, including differences in stakeholder needs and trade-offs between prioritizing desirable attributes of measures and representing the mental health system broadly. The authors present a framework for the selection of a core set of measures, clarify divergent perspectives, and make recommendations for further development of core quality measures for mental health care.

The changing face of race: risk factors for neonatal hyperbilirubinemia.

OBJECTIVES: Race is a predictor of health outcomes and risk for some clinical conditions, for example, mother's race predicts risk for hyperbilirubinemia in newborns, with blacks at lowest risk. Little is known about the correlation of race as recorded in medical records with self-reported race. Also, use of maternal race to predict newborn risk for hyperbilirubinemia has not been tested for multiracial mothers and newborns. We sought to examine how maternal race documented in medical records correlates with self-reported race and to examine the correlation between mothers' and newborns' race in the context of risk for neonatal hyperbilirubinemia, focusing on multiracial mothers and newborns. DESIGN: A cohort study with 3021 newborns at > or =35 weeks gestation discharged from normal nursery between January 2001 and October 2002 with a telephone survey of their mothers within 6 months of birth. SETTING: The study was conducted in the Neonatology Department of Henry Ford Hospital. PATIENTS: There were 1773 mothers (58%) with incorrect telephone numbers. Of 1248 mothers contacted, 866 (69%) completed the interview. OUTCOME MEASURES: We measured mother's race in hospital database and mother's reported race for herself, her newborn, and the father, allowing < or =5 responses for each. RESULTS: Of mothers documented in the medical record as white, 64% self-reported as white. Among mothers recorded as black, 70% self-reported as black. Mothers identified 93 newborns as > or =2 races with primary race matching both parents for 41%, father for 25%, mother for 23%, and neither parent for 11%. Of 70 newborns whose parents were not the same race, mothers identified 45 (64%) as > or =2 races. CONCLUSIONS: There is incomplete overlap between racial identification in medical records versus self-report. Given 1 choice, mothers of multiracial infants overselect black in their newborns' ancestry. Because black race is the lowest risk category for neonatal hyperbilirubinemia, this may lead to underestimating their risk.

Physician assistants as providers of surgically induced abortion services.

OBJECTIVES: We compared complication rates after surgical abortions performed by physician assistants with rates after abortions performed by physicians. METHODS: A 2-year prospective cohort study of women undergoing surgically induced abortion was conducted. Ninety-one percent of eligible women (1363) were enrolled. RESULTS: Total complication rates were 22.0 per 1000 procedures (95% confidence interval [CI] = 11.9, 39.2) performed by physician assistants and 23.3 per 1000 procedures (95% CI = 14.5, 36.8) performed by physicians (P =.88). The most common complication that occurred during physician assistant-performed procedures was incomplete abortion; during physician-performed procedures the most common complication was infection not requiring hospitalization. A history of pelvic inflammatory disease was associated with an increased risk of total complications (odds ratio = 2.1; 95% CI = 1.1, 4.1). CONCLUSIONS: Surgical abortion services provided by experienced physician assistants were comparable in safety and efficacy to those provided by physicians.

Quality measures for children's health care.

BACKGROUND: The ability to measure and improve the quality of children's health care is of national importance. Despite the existence of numerous health care quality measures, the collective ability of measures to assess children's health care quality is unclear. A review of existing health care quality measures for children is timely for both assessing the current state of quality measures for children and identifying areas requiring additional research and development. OBJECTIVES: To identify and collect current health care quality measures for child health and then to systematically categorize and classify measures and identify gaps in child health care quality measures requiring additional development. DESIGN/METHODS: We first identified child health care quality instruments with assistance from staff at the Agency for Healthcare Research and Quality, experts in the field, the Computerized Needs-oriented Quality Measurement Evaluation System, the Child and Adolescent Health Measurement Initiative, and a medical literature review. From these instruments, we then selected clinical performance measures applicable to children (aged 0-18 years). We categorized the individual measures into the Institute of Medicine's framework for the National Health Care Quality Report. The framework includes health care quality domains (patient safety, effectiveness, patient-centeredness, and timeliness) and patient-perspective domains (staying healthy, getting better, living with illness, and end-of-life care). We then determined the balance of the measures (how well they assess care for all children versus children with special health care needs) and their comprehensiveness (how well the measures apply to the developmental range of children). Finally, we analyzed the ability of the measures to assess equity in care. RESULTS: We identified 19 measure sets, and 396 individual measures were used to assess children's health care quality. The distribution of measures in the health care quality domains was: safety, 14.4%; effectiveness, 59.1%; patient-centeredness, 32.1%; and timeliness, 33.3%. The distribution of measures in the patient-perspective domains was: staying healthy, 24%; getting better, 40.2%; living with illness, 17.4%; end of life, 0%; and multidimensional, 23.5% (measures were multidimensional if they applied to >1 domain). Most of the measures were meant for use in the general pediatric population (81.1%), with a significant proportion designed for children with special health care needs (18.9%). The majority (>or=79%) of the measures could be applied to children across all age groups. However, there were relatively few measures designed specifically for each developmental stage. Regarding the use of measures to study equity in health care, 6 of the measure sets have been used in previous studies of equity. All the survey measure sets contain items that identify patients at risk for poor outcomes, and 4 are available in languages other than English. However, only 1 survey (Consumer Assessment of Health Plans) has undergone studies of cross-cultural validation. Among the measure sets based on administrative data, 3 included infant mortality, a well-known measure of health disparity. CONCLUSIONS: There are several instruments designed to measure health care quality for children. Despite this, we found relatively few measures for assessing patient safety and living with illness and none for end-of-life care. Few measures are designed for specific age categories among children. Although equity is an overarching concern in health care quality, the application of current measures to assess disparities has been limited. These areas need additional research and development for a more complete assessment of health care quality for children.

Barriers to first-week follow-up of newborns: findings from parent and clinician focus groups.

BACKGROUND: Monitoring newborns within the first week is critical to assess the adequacy of feeding and weight gain and to identify instances of hyperbilirubinemia. As systems of maternal and newborn care have become increasingly fragmented, infants are at increased risk of poor outcomes because of poor follow-up. Structured focus groups were conducted in June--July 2001 to provide information about the barriers to timely newborn follow-up and strategies to address them. METHODS: One focus group for physicians and one for nurses were held at the Henry Ford Health System, Detroit, and two focus groups of parents were recruited by Blue Cross Blue Shield of Texas, Dallas. RESULTS: Barriers were identified in communication and information, systems and processes of care, and parental knowledge and education. Concerns raised by clinicians and parents were consistent and complementary. Some organizations have begun implementing some of the suggested strategies to achieve timely follow-up. DISCUSSION: Implementing the AAP guideline and improving safe care in the first week of newborn life will require attention to linkages and transitions between these various microsystems.

Management of hyperbilirubinemia in newborns: measuring performance by using a benchmarking model.

BACKGROUND: Accreditors hold hospitals accountable for harm from serious newborn hyperbilirubinemia, yet standards for evaluating performance in prevention are lacking. OBJECTIVE: We confirmed prognostic variables for newborn hyperbilirubinemia and developed a benchmarking model for self-evaluation of hyperbilirubinemia management. METHODS: We conducted a 3-year prospective cohort study in the Henry Ford Health System (HFHS) on 5507 healthy newborns of >or=35 weeks' gestational age. HFHS follows a rigorous protocol for hyperbilirubinemia management. Defining hyperbilirubinemia as age-specific levels of total serum bilirubin exceeding American Academy of Pediatrics criteria for considering phototherapy and severe hyperbilirubinemia as total serum bilirubin >or=20 mg/dL, we used logistic and Poisson regressions to determine predictors and estimate parameters for a benchmarking model. We compared incidence rates for severe hyperbilirubinemia from HFHS to aggregate data from 11 hospitals reported to have less rigorous management. RESULTS: Newborns were 52.9% black, 14.4% white, 24.3% Latino, and 2.4% Asian; 30% were exclusively and 28% partially breastfed. Regression analyses revealed associations for hyperbilirubinemia and severe hyperbilirubinemia with black mothers (negative) and exclusive or partial breastfeeding and younger gestational age (positive). Male newborns and older mothers were also associated with severe hyperbilirubinemia. For all 5 variables, we found a lower risk for severe hyperbilirubinemia at HFHS than in the comparison hospital group. To compare hospitals, we developed a benchmarking model for incidence of hyperbilirubinemia adjusting for race, feeding method, and gestational age. CONCLUSIONS: Hospitals with access to newborns' inpatient and postdischarge data can use our benchmarking model to compare their management of hyperbilirubinemia with a reference population that received rigorous care.