Long-term effectiveness of disseminating quality improvement for depression in primary care.

BACKGROUND: This article addresses whether dissemination of short-term quality improvement (QI) interventions for depression to primary care practices improves patients' clinical outcomes and health-related quality of life (HRQOL) over 2 years, relative to usual care (UC). METHODS: The sample included 1299 patients with current depressive symptoms and 12-month, lifetime, or no depressive disorder from 46 primary care practices in 6 managed care organizations. Clinics were randomized to UC or 1 of 2 QI programs that included training local experts and nurse specialists to provide clinician and patient education, assessment, and treatment planning, plus either nurse care managers for medication follow-up (QI-meds) or access to trained psychotherapists (QI-therapy). Outcomes were assessed every 6 months for 2 years. RESULTS: For most outcomes, differences between intervention and UC patients were not sustained for the full 2 years. However, QI-therapy reduced overall poor outcomes compared with UC by about 8 percentage points throughout 2 years, and by 10 percentage points compared with QI-meds at 24 months. Both interventions improved patients' clinical and role outcomes, relative to UC, over 12 months (eg, a 10-11 and 6-7 percentage point difference in probable depression at 6 and 12 months, respectively). CONCLUSIONS: While most outcome improvements were not sustained over the full 2 study years, findings suggest that flexible dissemination of short-term, QI programs in managed primary care can improve patient outcomes well after program termination. Models that support integrated psychotherapy and medication-based treatment strategies in primary care have the potential for relatively long-term patient benefits.

What is the role of timing in the surgical and rehabilitative care of community-dwelling older persons with acute hip fracture?

OBJECTIVE: To determine the relationship of surgical repair of acute hip fracture within 2 days of hospital admission, followed by more than 5 sessions per week of physical and occupational therapy (PT/OT), to outcomes after acute hip fracture. DESIGN: Comparison of hip fracture outcomes via secondary analysis of data obtained by retrospective medical record review according to timing of surgical repair and frequency of PT/OT, adjusted for patient, medical care, and hospital characteristics. SAMPLE: The study included the medical records of 1880 elderly Medicare recipients admitted from the community to 284 acute care hospitals in 5 states during 1981 and 1982 or 1985 and 1986 with a primary diagnosis of acute hip fracture who underwent surgical repair and received PT/OT. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The postoperative day when ambulation first occurred, the length of hospital stay, and return to the community. RESULTS: Earlier surgical repair was associated with a shorter length of hospital stay (5 fewer days, P < .001) without a statistically significant increase in medical complications. High frequency PT/OT was associated with earlier ambulation (odds ratio [OR], 1.76; 95% confidence limits [CL], 1.50, 2.07). Patients who ambulated earlier [corrected] had shorter lengths of stay (6.5 fewer days, P < .001), were more likely to return to the community (OR, 1.45; 95% CL, 1.16, 1.81), and had better 6-month survival (OR, 2.8; 95% CL, 2.06, 3.88), and patients younger than 85 years had fewer in-hospital complications (11% vs 4%, P < .001). CONCLUSION: Surgical repair within the first 2 days of hospitalization and more than 5 PT/OT sessions per week were associated with better health outcomes in a nationally representative sample of elderly patients with hip fracture.

Helping practices reach primary care goals. Lessons from the literature.

We reviewed rigorous evaluations of programs to enhance the quality and economy of primary care. We identified 36 evaluations published from 1980 through 1992. We abstracted data on objectives, setting(s), patients and processes, outcomes, and costs of care. We identified successful programs, as well as significant gaps in our knowledge of how to improve aspects of care. In specific, computer reminders and social influence-based methods fostered preventive and economic care. Nurse implementation of prevention protocols increased their performance. Multidisciplinary teams improved access and economy. Regional organization of practices or telephone management improved access; regionalization also reduced emergency care. Improvements were not found in continuity, comprehensiveness, humanistic process, physical environment, or health outcomes. Primary care practices can implement several programs to continuously improve prevention and access, and to reduce costs and use of unnecessary services. Research documenting how to accomplish other major goals, including health outcome changes, in different practice types is needed.

Epidemiology of do-not-resuscitate orders. Disparity by age, diagnosis, gender, race, and functional impairment.

BACKGROUND: The relationship of do-not-resuscitate (DNR) orders to patient and hospital characteristics has not been well characterized. METHODS: This observational study of a nationally representative sample of 14,008 Medicare patients hospitalized with congestive heart failure, acute myocardial infarction, pneumonia, cerebrovascular accident, or hip fracture evaluated the relationship of DNR orders to patient sickness at admission, functional impairment, age, disease, race, gender, preadmission residence, insurance status, and hospital characteristics. RESULTS: Of the 14,008 patients, DNR orders were assigned to 11.6%. Patients with greater sickness at admission and functional impairment received more DNR orders (P < .001) but even among patients in the sickest quartile (with a 65% chance of death within 180 days), only 31% received DNR orders. The DNR orders were assigned more often to older patients after adjustment for sickness at admission and functional impairment (P < .001), and DNR order rates differed by diagnosis (P < .001). After adjustment for patient and hospital characteristics, DNR orders were assigned more often to women and patients with dementia or incontinence and were assigned less often to black patients, patients with Medicaid insurance, and patients in rural hospitals. CONCLUSIONS: Do-not-resuscitate orders are assigned more often to sicker patients but may be underused even among the most sick. Sickness at admission and functional impairment do not explain the increase in DNR orders with age or the disparity across diagnosis. Further evaluation is needed into whether variation in DNR order rates with age, diagnosis, race, gender, insurance status, and rural location represents differences in patient preferences or care compromising patient autonomy.

Value of functional status as a predictor of mortality: results of a prospective study.

PURPOSE: To assess the value of functional status questions in predicting mortality, we conducted a 4-year prospective longitudinal follow-up study of functionally impaired community-dwelling elderly persons. SUBJECTS AND METHODS: A total of 282 elderly (aged 64 years or older) patients of 76 community-based physicians who were UCLA clinical faculty members were assessed at baseline and at an average of 51 months later using scales from the Functional Status Questionnaire. RESULTS: By the end of the study, 24% of the sample had died. By means of a multivariate model, the following baseline characteristics were independently predictive of death: greater dysfunction on a scale of intermediate activities of daily living, male gender, living alone, white race, better quality of social interactions, and age. Initial baseline functional measures were also predictive of follow-up health status perceptions. CONCLUSION: The assessment of information on physical functioning and the quality of social interactions provides prognostic information regarding mortality. Furthermore, of the independent predictors of death identified in this sample, only functional impairment and living alone are remediable. Whether improving functional status can reduce the risk of mortality remains to be determined.

Evidence-based care for depression in managed primary care practices.

This paper evaluates whether externally designed, evidence-based interventions for improving care for depression can be locally implemented in managed care organizations. The interventions were carried out as part of a randomized trial involving forty-six practices within six diverse, nonacademic managed care plans. Based on evaluation of adherence to the intervention protocol, we determined that local practice leaders are able to implement predesigned interventions for improving depression care. Adherence rates for most key intervention activities were above 70 percent, and many were near 100 percent. Three intervention activities fell short of the goal of 70 percent implementation and should be targets for future improvement.

Does what nurses do affect clinical outcomes for hospitalized patients? A review of the literature.

OBJECTIVE: Through a review of the literature, to identify and describe (1) empirical studies of inpatient nursing care quality that evaluate links between nursing care processes and health-related patient outcomes, (2) nursing care processes for which process-outcome links have been established, and (3) important nursing care processes that have not yet been evaluated. DATA SOURCES/STUDY SETTING: Published empirical studies of inpatient nursing care quality that evaluated links between processes of nursing care and health-related patient outcomes. STUDY DESIGN/DATA COLLECTION/EXTRACTION METHODS: This literature review used a five-step article search and review method. PRINCIPAL FINDINGS: Of 257 data-based studies of nursing care quality identified, 135 investigated a process-outcome link but only 17 met study inclusion criteria. The literature provides evidence that the quality of nursing care processes affects health-related patient outcomes during and after hospitalization. Gaps in the literature that evaluates nursing quality are identified. CONCLUSIONS: Although some nursing care processes affect health-related patient outcomes, the full extent of nursing process-outcome links is relatively understudied. Further evaluation of the interrelationships between nursing care processes and outcomes is critical.

Evaluation of the VA's Pilot Program in Institutional Reorganization Toward Primary and Ambulatory Care: Part II, A study of organizational stresses and dynamics.

BACKGROUND: Many academically affiliated hospitals are moving from an inpatient, subspecialty orientation in their patient care and educational programs toward a greater emphasis on ambulatory and primary care. Few studies have focused on the organizational, staffing, and management issues involved in implementing these changes. METHOD: The authors carried out a qualitative evaluation of the process of change in an academic Department of Veterans Affairs hospital during implementation of a major ambulatory primary care program. They interviewed four top managers individually and 59 top and middle managers, house officers, and patients in focus groups in the spring of 1992, nine months after implementation of the key components of the program. Four raters independently evaluated written transcripts of focus-group sessions and identified themes. RESULTS: The main problems identified were difficulty with administrative integration between inpatient and outpatient services; need for training, retraining, and orientation; tensions due to changes in roles and organizational culture; and inefficiency due to the need for frequent negotiations in daily work life. These four problems reflected tensions associated with new demands imposed by matrix management, changing job descriptions, policies and procedures, and changing patterns of communication and record keeping. CONCLUSION: During the process of implementation of a primary care focus throughout a medical center, extra demands upon staff are inevitable and should be anticipated and planned for. Twelve key factors for successful organizational change are discussed.

Evaluation of the VA's Pilot Program in Institutional Reorganization toward Primary and Ambulatory Care: Part I, Changes in process and outcomes of care.

PURPOSE: To evaluate the impact of the reorganization of an academic Veterans Affairs medical center toward primary and ambulatory care--including the implementation of a medical-center-wide interdisciplinary firm system and ambulatory care training program--on the quality of primary ambulatory care. METHOD: Randomly selected male veterans visiting the Veterans Affairs Medical Center in Sepulveda, California, were surveyed in 1992, early in the implementation of the program, and in 1993, after the program had been fully implemented. Two surveys were used: one before the veterans saw their primary care providers (practice-based survey) and the other immediately after patient visits (visit-based survey). Survey-participant data were then linked to computerized utilization and mortality data. Survey topics were mapped to the medical center's strategic plan and goals for ambulatory care, and focused on patients' reports about the care they had received in terms of continuity, access, preventive care, and other aspects of the biopsychosocial model of care. Administrative computer data were then used to evaluate effects on medical center workload. Statistical analyses included analysis of variance, analysis of covariance, chi-square, and logistic regression. RESULTS: For practice-based comparisons, complete data were available for 1,262 veterans in 1992 and 1,373 in 1993. For visit-based comparisons, complete data were available for 1,407 veterans in 1992 and 643 in 1993. Results included statistically significant improvements in continuity of care and detection of depression as well as increased rates of preventive care counseling (smoking and exercise). The proportion of veterans reporting being seen by physicians increased, as did the proportion of patients seen for check-ups rather than for acute problems. Fewer patients were seen in subspecialty clinics than in general medicine clinics. Patient satisfaction increased, hospitalizations decreased, and death rates decreased. Alcohol counseling and access to care for acute symptoms declined. Workload shifted from subspecialists to generalists and from inpatient care to outpatient care. CONCLUSION: The institutional reorganization toward primary and ambulatory care succeeded in substantially improving the quality of ambulatory care, reflecting improvements in the system of care and of health care provider training in ambulatory care.

The Quality Improvement for Depression collaboration: general analytic strategies for a coordinated study of quality improvement in depression care.

It is difficult to evaluate the promise of primary care quality-improvement interventions for depression because published studies have evaluated diverse interventions by using different research designs in dissimilar populations. Preplanned meta-analysis provides an alternative to derive more precise and generalizable estimates of intervention effects; however, this approach requires the resolution of analytic challenges resulting from design differences that threaten internal and external validity. This paper describes the four-project Quality Improvement for Depression (QID) collaboration specifically designed for preplanned meta-analysis of intervention effects on outcomes. This paper summarizes the interventions the four projects tested, characterizes commonalities and heterogeneity in the research designs used to evaluate these interventions, and discusses the implications of this heterogeneity for preplanned meta-analysis.

Referrals by general internists and internal medicine trainees in an academic medicine practice.

Patient referral from generalists to specialists is a critical clinic care process that has received relatively little scrutiny, especially in academic settings. This study describes the frequency with which patients enrolled in a prepaid health plan were referred to specialists by general internal medicine faculty members, general internal medicine track residents, and other internal medicine residents; the types of clinicians they were referred to; and the types of diagnoses with which they presented to their primary care physicians. Requested referrals for all 2,113 enrolled prepaid health plan patients during a 1-year period (1992-1993) were identified by computer search of the practice's administrative database. The plan was a full-risk contract without carve-out benefits. We assessed the referral request rate for the practice and the mean referral rate per physician. We also determined the percentage of patients with diagnoses based on the International Classification of Diseases, 9th revision, who were referred to specialists. The practice's referral request rate per 100 patient office visits for all referral types was 19.8. Primary care track residents referred at a higher rate than did nonprimary care track residents (mean 23.7 vs. 12.1; P < .001). The highest referral rate (2.0/100 visits) was to dermatology. Almost as many (1.7/100 visits) referrals were to other "expert" generalists within the practice. The condition most frequently associated with referral to a specialist was depression (42%). Most referrals were associated with common ambulatory care diagnoses that are often considered to be within the scope of generalist practice. To improve medical education about referrals, a better understanding of when and why faculty and trainees refer and don't refer is needed, so that better models for appropriate referral can be developed.

Information content and clarity of radiologists' reports for chest radiography.

RATIONALE AND OBJECTIVES: We systematically characterized the information provided by chest radiography reports on a nationally representative sample of 822 elderly patients hospitalized in 297 acute-care hospitals in five states who had an admission diagnosis of congestive heart failure, acute myocardial infarction, or pneumonia. METHODS: We studied the content of radiography reports, including mention of the type or adequacy of radiography; the presence or absence of a prior radiograph; comments about bones, the aorta, the mediastinum, and pleura and notation of the laterality of findings; and the presence of diagnosis. Two physicians reviewed each patient's report, and a third assigned the final rating when they disagreed. RESULTS: Our analysis found wide variation in content of chest radiography reports, extensive variation in terms used to identify the presence or absence of abnormal findings, and a large degree of uncertainty in what was found. CONCLUSION: With most hospitals introducing new information systems in response to technological advances and the need to generate more formal hospitalwide reports, the time is right to improve the quality of chest radiography reporting.

The validity of a nursing assessment and monitoring of signs and symptoms scale in ICU and non-ICU patients.

PURPOSE: This study examined the validity of medical-record-based nursing assessment and monitoring of signs and symptoms (nursing surveillance) in predicting patients who were admitted to ICUs and those admitted to non-ICUs. The association of this assessment and monitoring with differences in an intermediate patient outcome, instability at discharge, was also explored. Patients admitted to either setting with a diagnosis of acute myocardial infarction, cerebrovascular accident, congestive heart failure, or pneumonia, were included in the study. METHOD: A secondary analysis was carried out using a subset of data originally collected for a quality-of-care study. Data from the medical records of 11,246 patients (52% female, 48% male) with a mean age of 76.4 years were used in the present study. RESULTS: ICU patients (n = 3969) were found to have a longer length of stay and to be sicker on admission than non-ICU patients (n = 7277). Overall, patients in the ICU received significantly higher nursing assessment and monitoring of signs and symptoms scores than non-ICU patients. Nursing assessment and monitoring of signs and symptoms scores were lower for patients discharged with greater instability for three of the four diseases (cerebrovascular accidents, congestive heart failure, and pneumonia).

Identifying quality improvement intervention evaluations: is consensus achievable?

BACKGROUND: The diversity of quality improvement interventions (QIIs) has impeded the use of evidence review to advance quality improvement activities. An agreed-upon framework for identifying QII articles would facilitate evidence review and consensus around best practices. AIM: To adapt and test evidence review methods for identifying empirical QII evaluations that would be suitable for assessing QII effectiveness, impact or success. DESIGN: Literature search with measurement of multilevel inter-rater agreement and review of disagreement. METHODS: Ten journals (2005-2007) were searched electronically and the output was screened based on title and abstract. Three pairs of reviewers then independently rated 22 articles, randomly selected from the screened list. Kappa statistics and percentage agreement were assessed. 12 stakeholders in quality improvement, including QII experts and journal editors, rated and discussed publications about which reviewers disagreed. RESULTS: The level of agreement among reviewers for identifying empirical evaluations of QII development, implementation or results was 73% (with a paradoxically low kappa of 0.041). Discussion by raters and stakeholders regarding how to improve agreement focused on three controversial article selection issues: no data on patient health, provider behaviour or process of care outcomes; no evidence for adaptation of an intervention to a local context; and a design using only observational methods, as correlational analyses, with no comparison group. CONCLUSION: The level of reviewer agreement was only moderate. Reliable identification of relevant articles is an initial step in assessing published evidence. Advancement in quality improvement will depend on the theory- and consensus-based development and testing of a generalizable framework for identifying QII evaluations.

Finding order in heterogeneity: types of quality-improvement intervention publications.

BACKGROUND: Stakeholders in quality improvement agree on the need for augmenting and synthesising the scientific literature supporting it. The diversity of perspectives, approaches, and contexts critical to advancing quality improvement science, however, creates challenges. The paper explores the heterogeneity in clinical quality improvement intervention (QII) publications. METHODS: A preliminary classification framework was developed for QII articles, aiming for categories homogeneous enough to support coherent scientific discussion on QII reporting standards and facilitate systematic review. QII experts were asked to identify articles important to QII science. The framework was tested and revised by applying it to the article set. The final framework screened articles into (1) empirical literature on development and testing of QIIs; (2) QII stories, theories, and frameworks; (3) QII literature syntheses and meta-analyses; or (4) development and testing of QII-related tools. To achieve homogeneity, category (1) required division into (1a) development of QIIs; 1(b) history, documentation, or description of QIIs; or (1c) success, effectiveness or impact of QIIs. RESULTS: By discussing unique issues and established standards relevant to each category, QII stakeholders can advance QII practice and science, including the scope and conduct of systematic literature reviews.

The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration.

As the science of quality improvement in health care advances, the importance of sharing its accomplishments through the published literature increases. Current reporting of improvement work in health care varies widely in both content and quality. It is against this backdrop that a group of stakeholders from a variety of disciplines has created the Standards for QUality Improvement Reporting Excellence, which we refer to as the SQUIRE publication guidelines or SQUIRE statement. The SQUIRE statement consists of a checklist of 19 items that authors need to consider when writing articles that describe formal studies of quality improvement. Most of the items in the checklist are common to all scientific reporting, but virtually all of them have been modified to reflect the unique nature of medical improvement work. This "Explanation and Elaboration" document (E & E) is a companion to the SQUIRE statement. For each item in the SQUIRE guidelines the E & E document provides one or two examples from the published improvement literature, followed by an analysis of the ways in which the example expresses the intent of the guideline item. As with the E & E documents created to accompany other biomedical publication guidelines, the purpose of the SQUIRE E & E document is to assist authors along the path from completion of a quality improvement project to its publication. The SQUIRE statement itself, this E & E document, and additional information about reporting improvement work can be found at http://www.squire-statement.org.

In pursuit of the abnormal serum alkaline phosphatase: a clinical dilemma.

The serum alkaline phosphatase (ALP) is often included among the tests used for case-finding among ambulatory patients. To determine the positive predictive value of the ALP, test results for all adults screened by a health maintenance organization between March and December 1969 were obtained by computer. The authors reviewed the charts of all 661 patients with abnormal tests whose primary source of medical care was at this facility. Complete two-year follow-up data were available for 91% of these patients. There were 56 patients (9%) with a diagnosis that could have explained an abnormal ALP. Of those cases in which ALP would have been clinically useful all but one could have been diagnosed by a simple, noninvasive workup, and in that one case, no management change would have occurred. The authors conclude that in the absence of a small number of specific indications, extensive testing need not be performed to evaluate an isolated abnormal ALP obtained from a screening examination.