Emergency room visit: a red-flag indicator for poor diabetes care.

AIM: To determine the association between emergency room (ER) admission and quality of diabetes care in the community. METHODS: In a nested case-control study of patients with Type 2 diabetes mellitus (DM) within a large health maintenance organization (HMO) in Israel, 919 patients who were admitted to one of West Jerusalem's ERs between 1 May and 30 June 2004 were compared with 1952 control subjects not admitted. Data on study covariates were retrieved from the HMO's computerized database and a subset of the study population was interviewed. Logistic regressions were conducted to estimate the odds ratios of being admitted according to different measures of quality of care, controlling for socio-demographic variables, co-morbidities and type of DM treatment. RESULTS: The main indices of quality of primary care that were inversely associated with visiting an ER during the study period included performance of a cholesterol test in the year prior to the index date [adjusted odds ratio (OR) 0.23, 95% confidence interval (CI) 0.19-0.29, P < 0.001], performance of glycated haemoglobin test (OR 0.26, 95% CI 0.24-0.29, P < 0.001), visiting an ophthalmologist (OR 0.47, 95% CI 0.32-0.68, P = 0.001), and recommendations to stop smoking (OR 0.10, 95% CI 0.05-0.21, P < 0.001). CONCLUSIONS: Admission to the ER can be used as an indicator for poor quality of diabetes care. There is an association between ER admission and poor quality of diabetes care.

Hospital campaign anti-bug 2000 as leverage for promoting continuous quality improvement.

The management of a 750-bed tertiary care university hospital that serves the Jerusalem area and nationwide referrals initiated a total overhaul of all its supporting systems. This program, with parallel contingency plans, ensured a smooth transition of all computer-dependent and other services into the year 2000. Because this extraordinary project proved successful, its outcomes are now being utilized as a unique impetus for implementation of hospital-wide continuous quality improvement programs. This paper reports how the established QI procedures, which were introduced also during the campaign, are now being activated from the baseline of those outcomes that have provided absolute efficacy in all hospital activities. The success of the campaign was achieved through the total involvement of all staff. This involvement was enhanced by the popular appeal of the dramatic deadline of the date 2000, as well as by focusing attention on personnel dynamics. Strategies for sustaining the momentum must be considered.

Preadmission screening of patients scheduled for hip and knee replacement: impact on length of stay.

OBJECTIVE: An evaluation of the impact of a social work preadmission program on length of stay (LOS) of orthopedic patients undergoing elective total hip or total knee replacement surgeries (under diagnosis-related groups [DRGs]) at the Hadassah Ein-Kerem Hospital in Jerusalem is Israel. INTERVENTION: The social work interventions included preadmission psychosocial evaluation and preliminary discharge planning, coordination of nursing and physiotherapy evaluations, ensuring completion of all medical tests prior to admission, and additional psychosocial follow-up during hospitalization to carry out the original discharge plan or prepare alternatives. PATIENTS: The intervention patients were divided into two groups in order to see changes over time: May through December 1994 (n = 48), and January through December 1995 (n = 81). The comparison groups included patients operated on at the same hospital during 1993 (n = 51) and during January through April 1994 (n = 21) and at the Hadassah Mount Scopus Hospital during the same time periods. Patients in the comparison groups received usual social work intervention, as necessary, only after hospitalization. RESULTS: Mean LOS was reduced significantly in the intervention patient groups, as compared to the preintervention patient groups in the same hospital, from 14.2 days (standard deviation [SD], 4.7) in 1993 and 14.7 (SD, 5.1) in January through April 1994 to 10.9 (SD, 3.0) in May through December 1994 and to 9.1 (SD, 2.8) in 1995 (P < .01). Length of stay also was reduced in the comparison hospital, but by 1995 was longer than in the intervention patients. No differences in LOS by gender, age, or marital status were found. Length of stay was significantly longer for those undergoing total hip replacement as compared to those undergoing total knee replacement in all the groups. CONCLUSIONS: Preadmission screening and case management by a social worker can contribute to the efforts to decrease LOS of orthopedic patients by early multidisciplinary evaluations, discharge planning, and coordination of services.

[Use of restraints in a general hospital--a picture of the situation].

28 in-patient units were surveyed during a 5-day period to determine the extent of the use of physical restraints in hospitalized patients. Information was gathered on the characteristics of restrained patients and indications for use and removal of restraints, patterns and means of restraints, monitoring, and written notations. 31 different patients (6% of those surveyed) were restrained in 13 units during the 5 days of the survey, an average of 15 (3%) daily. Characteristics of restrained patients were: age 70 and over requiring emergency hospitalization, reduced level of consciousness, limitation of mobility, incontinence, history of 2 or more chronic diseases, requiring multiple drugs, and use of multiple medical devices. Bilateral, soft hand restraints were most often used to prevent patients from removing tubes. Nurses initiated the decision to apply or remove restraints, which were usually removed as the patients' condition improved. Written policies were lacking regarding monitoring and follow-up of restrained patients. Clearly written policies and increased staff awareness of potential hazards may reduce the use of restraints and the length of time they are employed.

A methodology model for quality management in a general hospital.

A reappraisal is made of the relevance of industrial modes of quality management to the issues of medical care. Analysis of the nature of medical care, which differentiates it from the supplier-client relationships of industry, presents the main intrinsic characteristics, which create problems in application of the industrial quality management approaches to medical care. Several examples are the complexity of the relationship between the medical action and the result obtained, the client's nonacceptance of economic profitability as a value in his medical care, and customer satisfaction biased by variable standards of knowledge. The real problems unique to hospitals are addressed, and a methodology model for their quality management is offered. Included is a sample of indicator vectors, measurements of quality care, cost of medical care, quality of service, and human resources. These are based on the trilogy of planning quality, quality control, and improving quality. The conclusions confirm the inadequacy of industrial quality management approaches for medical institutions and recommend investment in formulation of appropriate concepts.

Report of a continuous quality improvement program in a tertiary-care medical center.

OBJECTIVE/DESIGN: Changes in the health system in Israel have led to an increasingly competitive environment, decentralization, and economic constraints. We evaluated the use of a continuous quality improvement (CQI) program. SETTING: Three medical departments and three administrative wings in a 700-bed, tertiary-care, teaching hospital in Jerusalem. INTERVENTION: The program was planned as a short-term pilot project for long-term extension throughout the institution. The objectives were improved institutional efficiency and provision for change. The program was implemented through departmental improvement teams under a hospital management team and a steering committee, guided by an outside consultant firm. RESULTS: The Orthopedics Department experienced a 3-day reduction in patient length of stay (P<.008). The Emergency Room experienced a significant reduction in time to discharge through reduced waiting times for consulting physicians (P<.007) and for blood tests (P<.001). The Office of Patient Admissions streamlined procedures for admission and discharge, accomplished physical restructuring, and installed a telephone hot line. In Medical Records, a significant improvement in records availability was realized. In Outpatient Clinics, reductions in waiting times were realized, but were not statistically significant. The Supply Division showed savings on monthly orders and increased efficiency, with 95% of orders completed promptly and accurately. CONCLUSIONS: Several factors were identified as essential to the success of the program, including staff cooperation and commitment. We conclude that the CQI program was a useful tool to help our tertiary-care medical center adjust to changes in the Israeli healthcare system. It also served as a valid vehicle for maintaining and furthering optimal quality of care.

Analysis of direct cost of standard compared with intensive insulin treatment of insulin-dependent diabetes mellitus and cost of complications.

Insulin-dependent diabetes mellitus (type 1) is accompanied by long-term complications: retinopathy, nephropathy, neuropathy, as well as macrovascular complications. We compared the direct cost of standard insulin treatment in type 1 patients with that of intensified treatment as well as the direct cost of their complications during the two treatment modes for 35 years' duration of disease. According to our model calculations, the direct cost of basic intensified insulin treatment is $3300 per year, about three times more than that of the standard insulin treatment. However, for the period of 35 years, the cost of complications associated with intensified insulin treatment is lower, while the total cost of intensified treatment, over 35 years, is higher than that of the standard treatment. Thus, looking from the health provider point of view and relating only to economic analysis, intensified insulin treatment encompassing all type 1 patients is not cost-beneficial. Therefore, the decision to adopt this type of therapy should be based on the combination of medical, ethical, political, and economical principles, and applied to selected, well motivated, and prepared patient groups, in whom compliance to intensified treatment would be expected to prevent or delay the onset of complications. According to cost analysis, nephropathy is the most common and severest complication, and intensive treatment promises to be most effective in this group of patients.

Patients' complaints as a management tool for continuous quality improvement.

Continuous quality improvement focuses on the customer and, therefore, requires attention to customers' feedback as a vital input. Customers' feedback in general hospitals includes utilization statistics of various services, patient satisfaction surveys and patients' complaints. The role of complaint data as a management tool, and particularly as applied to quality improvement, has received little attention in the literature. As a quality control tool, complaints are investigated on the individual, unit and organizational levels. Repeated complaints about the same units, procedures or individuals, are especially important for quality review. The role of the hospital administration is to draw on the human, technological and procedural resources at its disposal, along a solution time interval (immediate, short and long term), in designing its policy for quality improvement. Presents three examples of policy changes. The aggregate of complaint data serves, in addition, for follow-up of the effect of changes introduced by policy decisions.

Cost analysis of in vitro fertilization.

In vitro fertilization (IVF) has become a routine tool in the arsenal of infertility treatments. Assisted reproductive techniques are expensive, as reflected by the current "take home baby" rate of about 15% per cycle, implying the need for repeated attempts until success is achieved. Israel, today is facing a major change in its health care system, including the necessity to define a national package of health care benefits. The issue of infertility and whether its treatment should be part of the "health basket" is in dispute. Therefore an exact cost analysis of IVF is important. Since the cost of an IVF cycle varies dramatically between countries, we sought an exact breakdown of the different components of the costs involved in an IVF cycle and in achieving an IVF child in Israel. The key question is not how much we spend on IVF cycles but what is the cost of a successful outcome, i.e., a healthy child. This study intends to answer this question, and to give the policy makers, at various levels of the health care system, a crucial tool for their decision-making process. The cost analysis includes direct and indirect costs. The direct costs are divided into fixed costs (labor, equipment, maintenance, depreciation, and overhead) and variable costs (laboratory tests, chemicals, disposable supplies, medications, and loss of working days by the couples). The indirect costs are the costs of premature IVF babies, hospitalization of the IVF pregnant women in a high risk unit, and the cost of complications of the procedure. According to our economic analysis, an IVF cycle in Israel costs $2,560, of which fixed costs are about 50%. The cost of a "take home baby" is $19,267, including direct and indirect costs.

[Program for operating teams for quality improvement of hospital services].

In mid-1992, improvement of quality of service was set as a major goal in the framework of a 5-year plan at this hospital. This subject was selected in preparation for a new era in health care emerging in the world in general, and in Israel in particular. 6 problematic departments with high potential for improvement were chosen for the first stage of implementing a total quality management program (TQM). The goal was to gain experience through the implementation of TQM in a few medical and nonmedical departments in preparation for implementing TQM in the entire hospital. This process is ongoing and the first conclusions and perspectives are now being studied by all involved.

Cost containment: the Middle East. Israel.

The Israeli Health Service was established with the intent of providing an equal standard of care to the entire Israeli population. The Health Service has dealt with changes over the years, including the governing of large populations of Judea, Samaria, and Gaza. In 1990, mass immigration brought 500,000 more individuals to Israel, putting an additional burden on medical services. ICUs in Israel began to emerge after the Six Day War in 1967. The government's Ministry of Health has approved a limited amount of ICU beds. Beyond this set amount, hospital directors decide whether to establish additional ICU beds, weighing departmental pressures from within the hospital to create beds against the knowledge that the hospital will not be reimbursed more than the per diem rate of an ordinary hospital bed ($US 265). Hospital directors and administrators, knowing that the average daily cost of an ICU bed is close to $US 800, turn to their supporting organization to finance the uncontrollable deficit, seek aid from the Ministry of Health to make the per diem rates or diagnosis-related group reimbursements more realistic, and/or implement hospital policies aimed at cutting costs and personnel.

The direct cost of type 1 diabetes mellitus in Israel.

Estimates of the cost of Type 1 (insulin-dependent) diabetes mellitus should take into account the development of various complications. In this study, we calculated separately the basic direct costs of a Type 1 diabetic patient over a span of 35 years of living with the disease, and on average, the cost of complications which developed during this period of time. Assessment of costs showed that there is a difference between the cost of treating the disease itself, which decreases over the years, and the cost of treating its complications, which increases. The cost of treating one patient over the 35-year period amounted to about 247,000 pounds in 1993 prices, and in terms of discount value, to about 104,000 pounds. These costs are significant in planning the health expenditure and the investment of resources for prevention of the disease, and in selecting proper methods of treatment of complications.

Administrative behavior of directors in hospitals: the Israeli case.

This article presents research findings on the behavior of directors in hospitals in Israel. According to the findings, hospital directors devote most of their time to internal organization processes and less time to the management of the external organizational environment. The findings also reveal that the orientation of these directors is toward centralization of authority and concentration of the decision-making process.