Predicting non-elective hospital readmissions: a multi-site study. Department of Veterans Affairs Cooperative Study Group on Primary Care and Readmissions.

OBJECTIVE: To determine clinical and patient-centered factors predicting non-elective hospital readmissions. DESIGN: Secondary analysis from a randomized clinical trial. CLINICAL SETTING: Nine VA medical centers. PARTICIPANTS: Patients discharged from the medical service with diabetes mellitus, congestive heart failure, and/or chronic obstructive pulmonary disease (COPD). MAIN OUTCOME MEASUREMENT: Non-elective readmission within 90 days. RESULTS: Of 1378 patients discharged, 23.3% were readmitted. After controlling for hospital and intervention status, risk of readmission was increased if the patient had more hospitalizations and emergency room visits in the prior 6 months, higher blood urea nitrogen, lower mental health function, a diagnosis of COPD, and increased satisfaction with access to emergency care assessed on the index hospitalization. CONCLUSIONS: Both clinical and patient-centered factors identifiable at discharge are related to non-elective readmission. These factors identify high-risk patients and provide guidance for future interventions. The relationship of patient satisfaction measures to readmission deserves further study.

Database and informatics support for QUERI: current systems and future needs. Quality Enhancement Research Initiative.

OBJECTIVES: Our primary objective is to provide an overview of database and informatics support for the Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI). METHODS: We discuss the role of information technology resources in the QUERI process. We also review current VA information systems and specific databases in terms of strengths and weaknesses for addressing the QUERI goals. A synthesis of the issues and strategies for addressing specific data needs are presented by use of examples from 2 of the QUERI disease modules: Diabetes Mellitus and Human Immunodeficiency Virus. Finally, we discuss issues that need to be considered during development of new information systems to address the needs of clinical quality-improvement efforts. CONCLUSIONS: Quality enhancement in VA health care requires coordination and careful planning among clinical, administrative, research, policy, and information technology leaders to ensure that key clinical process and outcome measures are reliably collected in the VA information systems. As the QUERI progresses, data needs will probably shift from addressing data gaps to developing approaches for feedback and evaluation. Continued and enhanced cooperation among all VHA business processes is vital to the success of the QUERI.

Research as a key to promoting and sustaining innovative practice.

During the past decade, we have witnessed increasing emphasis on the integration of research and clinical care with the evolution of evidence-based practice and best practices. The principles underlying evidence-based medicine and best practices are fundamental to understanding the interdependence of research and innovation. These principles helped guide the US Department of Veterans Affairs (VA) Nursing Innovations Task Force to review and critique programs at VA health care facilities across the United States. This article reviews how the task force applied concepts and principles of evidence-based practice to identify innovative practices at VA health care facilities. Also described are task force recommendations to foster innovative practice through increased nursing research capacity, and strategies are suggested for applying these principles in other health care settings.

Using administrative databases for outcomes research: select examples from VA Health Services Research and Development.

The U.S. Department of Veterans Affairs (VA) operates and maintains one of the largest health care systems under a single management structure in the world. The coordination of administrative and clinical information on veterans served by the VA health care system is a daunting and critical function of the Department. This article provides an overview of VA Health Services Research and Development Service initiatives to assist researchers in using extant VA databases to study patient-centered health care outcomes. As examples, studies using the VA's Patient Treatment File (PTF) and the Beneficiary Identification and Records Locator System (BIRLS) Death File are described.

Prevalence of subacute patients in acute care: results of a study of VA hospitals.

Subacute care is a transitional level of care for medically stable patients who no longer require daily diagnostic/invasive care but require more intensive care than is typical in a skilled care facility. A Congressionally mandated study was undertaken to determine the number of VA patients with subacute needs being cared for in acute care. InterQual, Inc. subacute care criteria were retrospectively applied to 858 medical and surgical admissions from 43 VA hospitals. Over one-third contained at least one subacute day; with an average length of stay (LOS) of 12.7 days (SD = 12.4); of which 6.8 days were subacute. Patients with these admissions had significantly longer LOSs, were older, and were more likely to die or to be discharged to a nursing home. Diagnoses with subacute days included COPD, pneumonia, joint replacement, and cellulitis. Future studies should develop clinical pathways to prospectively manage admissions with subacute needs and then evaluate their effectiveness.

Predictors of mammography use among women veterans.

We examined mammography use patterns of women veterans and explored Veterans Administration (VA) health care use and military experience as predictors of mammography use by this population. We conducted a national telephone survey of women veterans. A sample of 397 women veterans was selected from all military discharges from 1971 through 1994. A 3 x 2 stratification scheme was used: three age groups (35-49, 50-64, > or = 65 years old) and two VA user groups indicating whether (VA user) or not (VA nonuser) they received any health care from a VA Medical Center in the last 5 years. The response rate was 75% (297 of 397). Analyses included bivariate techniques and weighted logistic regression. We found that women veterans told to have a mammogram by a health care professional were more than five times more likely to have ever had a mammogram (OR 5.41, CI 4.63-6.32) and nearly twice as likely to have had a mammogram within the past 2 years (OR 1.81, CI 1.57-2.09) as those who were not told to do so, controlling for age, race, VA user status, and length of military service. Regular VA users were more likely to have had a mammogram ever and within the past 2 years, controlling for other factors. Mammography use was not necessarily at a VA medical center. Interventions that promote better provider-patient communication and target older women veterans may have the most potential benefit. Whether VA health care is filling an important gap in access to mammography for older women veterans is an important policy question and warrants further research.

An evaluation of the Weber classification of ankle fractures.

This retrospective study over a 3 year follow-up was designed to establish the significance of the Weber classification of ankle fractures with regards to functional and radiographic outcome. One hundred and seven patients were available for follow-up, of which 88 ankles could be classified with the Weber system. Medial malleolar fractures alone and pilon fractures could not be classified with this system. A correlation was found between the type of Weber fracture and the overall ankle score. This held true for unimalleolar fractures alone. More complex bimalleolar and trimalleolar fractures did not follow this convention. Logistical regression analysis was used to evaluate other predictors of outcome. Bimalleolar and trimalleolar fractures were statistically significant predictors of a poorer outcome (P = 0.033, P = 0.021). The initial degree of displacement was also determined to be a predictor of outcome (P = 0.0133) as was the operative reduction (P = 0.0113). Using linear regression, older age (> 62 years) was also established as a predictor of a poorer outcome (P < 0.05). The Weber classification was found to be a predictor of outcome in unimalleloar ankle fractures and not for multimalleolar fractures. We have identified further predictors of a poorer outcome in ankle fractures as the degree of initial injury, the number of malleoli fractured and older age. These factors were found to have greater significance in predicting outcome than the level of fibular fracture alone. We have identified a deficiency of the Weber system in excluding these criteria and have addressed this by modifying the existing system to include the number of malleoli involved, thus providing a more useful prognostic tool.

Towards filmless and distance radiology.

To many people radiology is synonymous with films. For 20 years or so, however, it has been possible to capture digitally data traditionally displayed on film, and that was true from the beginning of computed tomography and magnetic resonance imaging too. There is more to picture archiving and communication systems (PACS) than the economies of filmlessness and the ability to modify images. To realise the full potential of PACS requires huge and expensively equipped networks linking the radiology department, hospital wards, outpatient clinics, laboratories, family doctors' clinics, and so on, permitting simultaneous consultations on different sites and almost instant reporting from specialist radiologists at a distance. The data sets that need to be transferred are huge but some of the technical obstacles are now being overcome and the past few years have seen some hospitals move to a filmless state. The more common pattern, though, will be a piecemeal approach. PACS and teleradiology certainly provide a quicker imaging service. How soon a total PACS will save money for a hospital operating budget is less clear.

Is universal neonatal hemoglobinopathy screening cost-effective?

OBJECTIVE: To determine whether and where universal neonatal screening for hemoglobinopathies, chiefly sickle-cell disease, could be performed at socially acceptable costs. METHODS: We made projections of the cost-effectiveness of nonuniversal and universal sickle-cell disease screening throughout the United States. We then compared the cost-effectiveness of universal sickle-cell disease screening with that of universal phenylketonuria screening. Finally, we asked if "high-cost" states, that is, those in which the cost of finding a case of sickle-cell disease exceeded one half the cost of finding a case of phenylketonuria, could enhance their cost-effectiveness by joining demographically complementary states in screening cooperatives. RESULTS: If all states conducted independent screening and if the value of finding a case of sickle-cell disease were no more than one half that of finding a case of phenylketonuria, seven of the 19 states that do not currently conduct universal screening for hemoglobinopathies would begin to do so, but six of the 34 that currently do so would stop. Of the six that would stop, three have already formed a screening cooperative, reducing their projected average costs for finding either sickle-cell disease or phenylketonuria or both; the other three could similarly improve cost-effectiveness through cooperative arrangements. Nineteen states realize economies of scale in six cooperative groups; more could do so. CONCLUSION: Universal neonatal hemoglobinopathy screening can be made available at socially acceptable costs to the citizens of demographically various states.

The quality of breast cancer care in local communities: implications for health care reform.

Despite many advances in the treatment of breast cancer during the last decade, many breast cancer patients still do not receive appropriate treatment. The year 2000 cancer control objectives for the nation require a 50% decrease in breast cancer mortality. This goal cannot be achieved unless appropriate care is provided to all women with breast cancer. This study examines the role of patient characteristics, health insurance, physician characteristics, competition and local environment factors on the quality of care provided by physicians to breast cancer patients. Developed from a theoretical model of physician behavior, an empirical model was tested to demonstrate how these factors affect the quality of care provided for two specific breast cancer practice patterns: 1) whether a two-step surgical technique was performed and, 2) whether postmastectomy rehabilitation and/or education was provided. Data from the National Cancer Institute Community Cancer Care Evaluation, from 1985-1986 were used and included information about the inpatient and outpatient care provided to 3,972 women with local or regional stage breast cancer from local communities across the United States. Multivariable regression results indicate older patients were significantly less likely to receive appropriate care for both surgical and rehabilitation practice patterns studied: patients 80 years and older were two to three times less likely to receive appropriate care. However, effects for other variables differed for the two practice patterns studied: competition had a significant positive impact on surgical care (Odds ratio (OR) = 1.37, P < 0.01), but a negative impact on rehabilitation care (OR = 0.76, P < 0.01), and only having Medicaid coverage had a significant positive impact on whether rehabilitation care was provided (OR 1.93, P < 0.03), but no effect for whether a two-step procedure was performed. The results from this study have implications for program design and policy initiatives aimed at assuring equity in access to treatment for older women. Moreover, the differential effects of competition on these breast cancer practice patterns may have implications for health care reform efforts that rely exclusively on competitive models without performance-based incentives to ensure appropriate care.

Predicting the performance of a strategic alliance: an analysis of the Community Clinical Oncology Program.

OBJECTIVE: This study is designed to examine the effects of environment and structure of the Community Clinical Oncology Program (CCOP) on performance as measured by patient accrual to National Cancer Institute (NCI)-approved treatment protocols. DATA SOURCES/STUDY SETTING: Data and analysis are part of a larger evaluation of the NCI Community Clinical Oncology Program during its second funding cycle, June 1987-May 1990. Data, taken from primary and secondary sources, included a survey of selected informants in CCOPs and research bases, CCOP grant applications, CCOP annual progress reports, and site visits to a subsample of CCOPs (N = 20) and research bases (N = 5). Accrual data were obtained from NCI records. STUDY DESIGN: Analysis involved three complementary sets of factors: the local health care resources environment available to the CCOP, the larger policy environment as reflected by the relationship of the CCOP to selected research bases and the NCI, and the operational structure of the CCOP itself. A hierarchical model examined the separate and cumulative effects of local and policy environment and structure on performance. PRINCIPAL FINDINGS: Other things equal, the primary predictors of treatment accrual were: (1) the larger policy environment, as measured by the attendance of nurses at research base meetings; and (2) operational structure, as measured by the number and character of components within participating CCOPs and the number of hours per week worked by data managers. These factors explained 73 percent of the total variance in accrual performance. CONCLUSIONS: Findings suggest criteria for selecting the types of organizations to participate in the alliance, as well as for establishing guidelines for managing such alliances. A future challenge is to determine the extent to which factors predicting accrual to cancer treatment clinical trials are equally important as predictors of accrual to cancer prevention and control trials.

Evaluating productivity in clinical research programs: the National Cancer Institute's (NCI) Community Clinical Oncology Program (CCOP).

This paper outlines an approach to studying productivity in clinical research programs that incorporates environmental, organizational, provider, and patient specific factors in the model of production process. We describe how this approach has been applied to the National Cancer Institute's (NCI) Community Clinical Oncology Programs (CCOPs). Next, a practical evaluative model of the productive process in CCOPs is outlined and its use in evaluation and monitoring performance in CCOPs is discussed. Each level of the model is described and a number of factors potentially affecting each level are explored. Finally, we discuss the strengths and weaknesses of this approach and show how management can use it to study and improve the productivity of clinical research programs.

Performance in quasi-firms: an example from the Community Clinical Oncology Program.

In this analysis, the authors examined the effects of different sets of process, structure, and environmental variables on the performance of the CCOP as a quasi-firm. Specifically, they distinguished between internal organizational processes, structural, and size characteristics of the CCOP and the organizational environment created by prior NCI program experience and the relationship within the quasi-firm. The analysis revealed that these sets of organizational and environmental characteristics have differential effects on treatment accrual. The strongest predictors are those associated with the quasi-firm relationship between the CCOP and its chosen research bases. Any definitive policy implications for the design of organizational network relationships--especially the CCOPs--will require further analysis. Particular attention needs to be given to the longitudinal nature of the relationships and the ability of these organizational and environmental factors to affect other aspects of performance. Several points have been made within this initial assessment. First, the structural character of the CCOP and its relationship to its organizational environment are important factors affecting accrual performance. The subtleties of this multivariate model are not as important as simply demonstrating that the various internal and external characteristics of these organizations as quasi-firms simultaneously affect their ability to accrue patients to clinical trials. Secondly, the importance of research base relations, and particularly the significant role of nurses, needs to be emphasized. While CCOPs were originally designed as a network of physicians and hospitals, it appears that an infrastructure of professionally active nurses working within a larger organizational environment is critical to success--at least as defined by accrual to treatment protocols. Finally, the failure of prior experience with other NCI community programs to affect CCOP accrual performance suggests that such experience does not assure "organizational learning" that may enhance performance. This suggests that CCOPs can be designated de novo to maximize performance without necessarily having to undergo a developmental or experiential phase involving community cancer programs to be effective. However, the authors suspect that another method of characterizing experience may produce different results. Further analyses of these data will test these results against other measures of CCOP performance. Specifically, attention will be given to whether this same set of characteristics is predictive of accrual to cancer control research protocols. Similarly, these same organizational characteristics may or may not be associated with other dimensions of CCOP performance such as changes in physician practice patterns and/or levels of institutionalization of the CCOP within its local community.(ABSTRACT TRUNCATED AT 400 WORDS)

Digital videofluorography: a new direction in diagnostic imaging.

Accurate information about digital technology is often difficult to obtain because of unrealistic expectations. The development of the digital department is complex and must not be understated. However, we have attempted to show that if a truly committed hospital immediately accepts DVF, this will result in reduced capital and operational costs, as well as lower radiation doses to the patient and operator. We believe this will happen because every major X-ray manufacturer is demonstrating and offering DVF systems, all of which are based on the technology described in this paper. These systems can either be totally integrated into fluoroscopic facilities or be purchased as add-on components to established units. In any event, a modern fluoroscopic facility can cost several hundred thousand dollars, and must last 10 to 15 years. It seems prudent to acquire quality and digital capability so that these units will be adequate in the year 2000 and beyond.

Clinical comparison of analog and digital 100 mm photofluorography.

Many of the problems associated with digital acquisition of clinical images from x-ray intensifier/television systems have been eliminated by the use of a pulsed progressive readout from a 1024 line television camera into a 1024 x 1024 pixel image store, the whole arrangement triggered by the circuitry of a 100 mm camera. By means of a beam splitter, this study demonstrates a clinical comparability between 100 mm and digital images under identical conditions. In addition, radiation dose levels can be reduced by tailoring exposures to individual patients and their clinical needs. Several clinical cases are presented to illustrate the interchangeability of the new digital modality for fluoroscopic examination with an ordinary sized x-ray image intensifier.