Improvements in activities of daily living following functional hand surgery for treatment of lesions to the cervical spinal cord: self-assessment by patients.

STUDY DESIGN: Tetraplegic patients were tested for hand strength before and after hand surgery. They also answered questions about how they rated the results of surgery. OBJECTIVES: Presentation of the efficacy of reconstruction of hand raising, lateral grip, and cylindrical grip in the tetraplegic hand. SETTING: The study was conducted in the Werner Wicker Clinic, Bad Wildungen, Germany, from 1991 to 1998. METHODS: The results of reconstruction surgery performed on 23 tetraplegic hands, as reflected in lifting the hand (n=3), lateral grip (n=21), and cylindrical grip (n=14), are presented. In a follow-up study in 22 patients, their management of activities of daily living 34.1 months (9-51 months) after the surgery is compared with the preoperative situation. Subjective satisfaction levels were elicited for each of the 22 patients by means of a questionnaire. RESULTS: The gain in force corresponded to 893 g (150-1500 g) for cyclindrical grip and 488 g (100-1200 g) for lateral grip, while they were able to develop grade 4 force for lifting the hand. After the operation 28 aids/appliances that patients had formerly used regularly were no longer necessary. There were 75 separate activities listed in the questionnaire, and on average the 22 patients were able to perform 8.7 (0-20) more of these. Most patients (19) said they would advise others to have the operation and 18, that they would have the operation again. There were 12 complications in nine patients. CONCLUSION: Reconstructive surgery on the hands of tetraplegic patients leads to gains in both cylindrical grip and lateral grip force and to increased manual dexterity. Patient satisfaction with the procedure is high.

Data used to improve quality of health care.

Many factors are involved in improving the quality of health care. Using data to measure performance is an essential element. Whether the objective is to improve outcomes (e.g., reducing mortality among patients hospitalized with acute myocardial infarction) or to improve a process of care (e.g., increasing the rate of beta blocker administration at discharge in patients with acute myocardial infarction), data are central to assessing the quality of health care. Data help determine where opportunities for improvement exist and document the impact that system change interventions have made on the outcomes or processes of care for a clinical condition or topic. Measuring performance is critical to learning how your practice compares with best practices. If you haven't measured, you do not know. This article will focus specifically on the role and use of data to improve processes of health care for Medicare beneficiaries. Examples of projects and results are cited from the work of the Texas Medical Foundation, which is the Medicare peer review organization under the Health Care Financing Administration's Health Care Quality Improvement Program.

Aspirin administration for cardiac-related acute chest pain/angina: increased use in Medicare patients.

BACKGROUND: Coronary heart disease (CHD), the leading cause of death in the United States, accounted for approximately 490,000 deaths in 1993. Angina pectoris, a manifestation of CHD, accounted for 13,586 Medicare discharges in 1993 in Texas. A pilot project showed aspirin prophylaxis that reduces cardiovascular morbidity and mortality in individuals with acute angina is underused. Texas Medical Foundation collaborated with 10 acute-care facilities to improve aspirin prophylaxis. METHODS: Collaborators assessed processes of care and implemented clinical pathways to improve aspirin administration. Data were abstracted from medical records before and after pathway implementation to evaluate impact. RESULTS: Aspirin administration during hospital stay increased 10.8%, aspirin administration on discharge increased 11.7%, and average time from arrival to aspirin administration decreased 2.9 hours. CONCLUSIONS: Results suggest collaborator-implemented clinical pathways significantly improved care received by Medicare patients admitted for cardiac-related acute chest pain/angina. Data suggest room for further improvement.

Methodology of quality improvement projects for the Texas Medicare population.

The Texas Medical Foundation, the quality improvement organization for the state of Texas, develops local quality improvement projects for the Medicare population. These projects are developed as part of the Health Care Quality Improvement Program undertaken by the Health Care Financing Administration. The goal of a local quality improvement project is to collaborate with providers to identify and reduce the incidence of unintentional variations in the delivery of care that negatively impact outcomes. Two factors are critical to the success of a quality improvement project. First, as opposed to peer review that is based on implicit criteria, quality improvement must be based on explicit criteria. These criteria represent key steps in the delivery of care that have been shown to improve outcomes for a specific disease. Second, quality improvement must be performed in partnership with the health care community. As such, the health care community must play an integral role in the design and evaluation of a quality improvement project and in the design and implementation of the resulting quality improvement plan. Specifically, this article provides a historical perspective for the transition from peer review to quality improvement. It discusses key steps used in developing and implementing local quality improvement projects including topic selection, quality indicator development, collaborator recruitment, and measurement of performance/improvement. Two Texas Medical Foundation projects are described to highlight the current methodology and to illustrate the impact of quality improvement projects.

Implementing a clinical pathway for the treatment of Medicare patients with cardiac chest pain.

BACKGROUND: A small urban hospital identified angina pectoris (DRG 140) as a high-cost and low-reimbursement DRG. Variation in the process of care for patients with cardiac chest pain was related to the timing of decisions on stress tests and whether inpatient GI workups were performed. Underutilization of aspirin was identified as a quality of care issue. In collaboration with Texas Medical Foundation (TMF), the Quality Improvement Organization (QIO) for Texas, this became the initial Health Care Quality Improvement Program (HCQIP) project and the first effort by the hospital at pathway development. INTERVENTION: A team effort lead by physicians, including other healthcare groups at the hospital, identified elements considered essential to providing ideal care for patients with cardiac chest pain, formulating these elements into a clinical pathway. RESULTS: Emergency room physicians, an essential stakeholder group, had not been included in the initial pathway development, which proved to be a critical factor to effective implementation. Pathway implementation was associated with increased administration of aspirin by 45.7% (p < 0.001), reduced length of stay by 1.0 days (p = 0.064), and reduced total charges by an average of $1710.20 (p = 0.039). DISCUSSION: These results suggest that process of care improvement, i.e., clinical pathway implementation, in collaboration with a QIO, contributed to reduced variation in the process of care. Participation by all stakeholders from the beginning in process of care improvement is essential.

Medical necessity for right heart catheterization.

Because there are no definitive guidelines for performing right heart catheterizations or controlled clinical trials demonstrating medical benefit, the value and necessity of performing routine right heart catheterizations for coronary artery disease have been questioned. This Texas Medical Foundation Health Care Quality Improvement Program project was designed to ensure medical necessity and proper documentation of right heart catheterization when performed as part of a bilateral procedure. Medicare claims data were used to identify Texas facilities where rates of bilateral catheterizations suggested that right heart catheterizations were being performed routinely. Five facilities were found to have rates of bilateral procedures exceeding 70%. Suggested guidelines for performing right heart catheterizations were prepared by the Texas Medical Association Committee on Cardiovascular Diseases. These guidelines, together with the facility's data on its rate of right heart catheterizations, were presented by the Texas Medical Foundation to the staff of each facility. They were asked to examine their individual facility's procedures for ensuring medical necessity and to develop and implement process improvement plans. Medicare claims data were analyzed to determine the rates of bilateral catheterizations before and after the plans were instituted. The statewide rate of bilateral procedures decreased from 27.2% to 21.3% (p < 0.005). Rate reductions for 4 facilities implementing improvement plans were statistically significant (p < 0.001): at the 1st facility, the rate decreased from 74.3% to 25.0%; at the 2nd, from 85.0% to 21.0%; at the 3rd, from 76.7% to 17.7%; and at the 4th facility, from 85.4% to 42.9%. The rate for the facility not implementing an improvement plan increased from 86.4% to 89.1%. Reductions in rates of bilateral procedures at the 4 facilities suggest that many procedures previously performed were routine and not medically indicated. Presentation of data and practice guidelines to facilities may have contributed to their ability to improve processes.

Morbidity pattern, health care utilization and per capita health expenditure in a rural population of Tamil Nadu.

BACKGROUND: Information on the existing morbidity pattern, pattern of health care utilization and the per capita health expenditure is essential to provide need-based health care delivery to a rural population. To obtain this information we performed a study in the K.V. Kuppam Block, North Arcot Ambedkar District, Tamil Nadu. METHODS: We did a cross-sectional study, interviewing respondents from 300 households, from 3 panchayats using a multistage sampling technique. Information relating to 1440 persons was collected. The morbidity data was obtained initially for the week prior to the day of interview, followed by one week to one month and then for two months to one year. RESULTS: During 1990-91, 825 of the 1440 persons (57.3%) did not have any illness. Sex had no bearing on the number of illnesses. Of the 60 children less than 2 years of age, 42 (70%) had one or two illnesses. The period prevalence of infective and parasitic diseases was found to be 21.9% with an average of 3 episodes. Services rendered by private practitioners (registered, non-registered and indigenous) were utilized by 59% of the households and 79% of the households had used allopathic treatment at some time. The average per capita per annum health expenditure was Rs 89.9 (Rs 449 per household). This increased significantly with increase in the household size (p < 0.001) and per capita income (p < 0.01). CONCLUSION: The health-seeking behaviour of this population can be changed if efficient services are rendered through government primary health centres and subcentres. This would allow the existing voluntary agency to withdraw without much change in the per capita health expenditure.

Adapting MCH strategies for the nineties.

PIP: Brief overview was given for strategies in maternal and child health (MCH) in India that were used in the 1980s and adapted for the 1990s in the following areas: perinatal outcomes, empowerment of women, immunization, oral rehydration, adolescent girls, anthropometric measurement, health education, management, and coordination with nongovernmental organizations (NGOs). In order to assure a healthy baby weighing 2.5 kg, monitoring of maternal health is occurring. Iron and folic acid and tetanus toxoid vaccine are provided to pregnant mothers, and fetal growth is monitored. Training of traditional birth attendants and multipurpose health workers will contribute to clean deliveries and referral of complicated pregnancies. During the 1990s, women's health in addition to maternal health has received attention. The empowerment of women to care for themselves, to learn how to mix oral rehydration packets (ORS) at home, and to receive the knowledge and skills were deemed more important than the 1980s focus on the delivery system and inputs of MCH. An excellent cold chain for delivery of vaccines has been put in place, which provides the vehicle for the 1990s to maintain high vaccine coverage. The emphasis on oral rehydration in the 1990s will be on teaching mothers about the importance of ORS treatment of diarrhea. During the 1990s, educating the adolescent girl before she becomes married and pregnant will be the focus. Greater emphasis will be placed on stunting or height for age measurements, as a measure of long term nutritional change; age weight for height for measurement of wasting; and maternal nutritional monitoring of arm circumference. Sustained health education, more media exposure to disease conditions and treatment, and social marketing in health will be better coordinated and more cost effective. Accountability for manpower, materials, and money will be in place within management. Management will focus on motivation and training, and other, newer management concepts. Government will begin to work with NGOs, including cost sharing and a favorable attitude toward NGO contributions. In general, all programs will have greater community participation and improvement in method and strategies.^ieng

Evaluation of effectiveness of good growth monitoring in south Indian villages.

We conducted a community intervention trial in 12 villages in Tamil Nadu, India to evaluate the benefits of growth monitoring. The villages were divided into 6 "growth-monitoring package" of intervention villages (GMP) and 6 "non-growth-monitoring package" of intervention villages (NGM). A functioning primary health care system was in place in all 12 villages implemented a set of interventions including health and nutritional education. About 550 children under the age of 60 months were studied over 4 years in GMP villages and a similar number of children in NGM villages. The interventions were identical in the two sets of villages except for the use of growth charts in education in the 6 GMP villages. The nutrition worker in the NGM villages had the same contact time as in the GMP villages but advised mothers without the benefit of growth charts. The research team, independently of the nutrition worker, did anthropometric studies on children in all villages every 4 to 5 months. Comparisons were done by calculating monthly gains in stature, and weight, and the significance of differences observed was adjusted for age and sex. After 30 months of interventions, similar improvements in growth were seen in GMP and NGM children. The interventions seemed to have improved the nutritional status of young children in both groups of villages. In view of the lack of additional benefit from growth monitoring over other educational interventions, we question its use as part of child survival programmes in India.

Maternal risk factors associated with low birth weight.

Maternal factors comprising of social, obstetric and anthropometric are found to influence LBW. The present study had found association between obstetric risk factors like age of the mother, parity and gravida with LBW. Similar association was also observed between maternal height, and maternal weight with LBW. However, social factors were not found to be associated with LBW. This could probably be due to RUHSA's intervention which requires a further inquiry.

PIP: Low birth weight (LBW) is one of the major causes of high mortality and morbidity rates, and may indicate that a baby did not remain in utero long enough or that it did not develop well enough. A multifactorial interrelationship exists between the environment in which pregnant mothers live and the growth of the fetus. A primary health care intervention program has been implemented by the RUSHA Department of Christian Medical College and Hospital since 1977 in the rural villages of K.V. Kuppam block of Tamil Nadu in southern India. Adopting a case-control approach with mothers who delivered LBW babies as the cases and mothers who delivered normal birth weight (NBW) infants as the controls, the authors investigated the association between maternal factors and birth weight. Birth weight monitoring records for 1990-91 yielded relevant information for 53 LBW and 49 NBW mothers. Analysis found a definite association between maternal factors and birth weight. Specifically, mothers under 20 years old, mothers residing in tiled houses rather than in terraced or thatched houses, primigravid mothers, primipara mothers, mothers shorter than 150 cm, and mothers weighing less than 45 kilograms delivered more LBW babies. Social factors were not, however, found to be associated with LBW. This may be due to RUSHA's intervention which requires a further inquiry

Basal metabolic rate of Indian men: no evidence of metabolic adaptation to a low plane of nutrition.

Basal metabolic rate (BMR) was measured in 58 men of a rural Indian population who had low body weight and body fat stores. Comparisons of subgroups of subjects of different socio-economic status and different nutritional status showed no evidence of differences in BMR when corrected for differences in body weight and body fat content. This suggests that metabolic adaptation did not account for differences in absolute BMR between subgroups of this population. The BMR values agreed well with values predicted by equations based on BMR measurements in Asian men of higher body weight, but were below values predicted by the new FAO/WHO/UNU prediction equations by an average of 12.1 per cent (P less than 0.0001). This overprediction could be a reflection of allometric or climatic influences on BMR rather than evidence for metabolic adaptation to a low plane of energy nutrition.