Hospital readmissions as a measure of quality of health care: advantages and limitations.

We reviewed the recent literature on hospital readmissions and found that most of them are believed to be caused by patient frailty and progression of chronic disease. However, from 9% to 48% of all readmissions have been judged to be preventable because they were associated with indicators of substandard care during the index hospitalization, such as poor resolution of the main problem, unstable therapy at discharge, and inadequate postdischarge care. Furthermore, randomized prospective trials have shown that 12% to 75% of all readmissions can be prevented by patient education, predischarge assessment, and domiciliary aftercare. We conclude that most readmissions seem to be caused by unmodifiable causes, and that, pending an agreed-on method to adjust for confounders, global readmission rates are not a useful indicator of quality of care. However, high readmission rates of patients with defined conditions, such as diabetes and bronchial asthma, may identify quality-of-care problems. A focus on the specific needs of such patients may lead to the creation of more responsive health care systems for the chronically ill.

HCFA documentation guidelines and the need for discrete data: a golden opportunity for applied health informatics.

BACKGROUND: The medical community is shocked by the complexity of the documentation now required to support the Medicare billing codes. This situation represents an opportunity for Electronic Medical Records that use discrete data to become a central factor at the point of care by fulfilling these stringent documentation specifications. METHODS: This empirical study explores whether a discrete data EMR has the ability to generate automatically a report describing what billing code is consistent with the documentation recorded. We tested this hypothesis on HBOC Pathways SMR by attempting to create algorithms that reflected the HCFA guidelines. We validated this process using historical records from the Cleveland Clinic. RESULTS: All the data elements required by HCFA were available as discrete data. Using algorithms, the billing code consistent with the documentation of the health care encounter could be automatically generated. CONCLUSIONS: EMRs using discrete data can substantially reduce the burden placed on health care providers by HCFA's new documentation guidelines. This benefit creates a window of opportunity for health informatics to become an integral tool in the provision of health care. Using EMRs for billing purposes can help achieve the loftier goal of using EMRs for quality improvement.

What is adequate health care and how can quality of care be improved?

Attempts to improve patient care, its increasing cost and the aggressive malpractice environment have highlighted the need for standards of professional accountability. However, current measures of quality of care have mostly been met with skepticism by the medical community. These measures have been criticized for their uncertain validity and for focusing on secondary aspects of service that measure what is minimally acceptable. The objective of this essay is to review quality improvement methods that have been reported to be feasible, effective and acceptable by practicing physicians. The successful implementation of these methods seems to be related to their being nonintrusive, nonthreatening, and based on agreed upon standards of care. We believe that these three features are essential for a continuous quality improvement process in health care.

Configuring for the World Wide Web: recommendations for dermatologists.

Physicians have become increasingly interested in obtaining the hardware, software, and connection necessary to take advantage of the educational and practice material available on the World Wide Web (WWW) (i.e., on the Internet). The related ongoing development of unique on-line resources promises to provide a compelling force for change in the way in which information is accessed and medicine is practiced. WWW applications created for dermatologists often include high-quality images, and proper viewing is critical to use this information. Because images tend to be large files, and dermatology resources tend to have from several up to hundreds of images, the speed of transfer and display and the quality of the display are important factors to consider. This study was an evaluation of some of the current options in the hardware, software, and Internet connections to determine desirable configurations for accessing image-rich, on-line dermatology WWW applications.

Physician malpractice: does the past predict the future?

OBJECTIVE: To assess whether there is a population of physicians who have consistently poor malpractice claims experiences over time. DESIGN: Retrospective cohort study. POPULATION: 12,730 physicians insured in New Jersey from 1977 to 1991. MAIN OUTCOME MEASURES: After adjusting for specialty, the physicians were grouped according to who had the highest, very high, and high rates of malpractice claims, approximating 1%, 5%, and 10% respectively, of the insured population. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated comparing the physicians in these high-risk categories with the other physicians. RESULTS: Of the 55 physicians who had the highest malpractice claims rates during the first four years, two (3.6%) were in the highest group during the subsequent three years (OR 2.8; 95% CI 0.7 to 10.8), five (9.1%) were in the very high group (OR 2.0; 95% CI 0.7 to 5.3), and 11 (20%) were in the high group (OR 2.3; 95% CI 1.1 to 4.6). Of the 260 physicians in the very high group during the first four years, 11 (4.2%) were in the highest group during the subsequent three years (OR 3.6; 95% CI 1.8 to 6.4), 26 (10.0%) were in the very high group (OR 2.3; 95% CI 1.5 to 3.6), and 46 (17.7%) were in the high group (OR 2.0; 95% CI 1.4 to 2.8). Of the 947 physicians in the high group during the first four years, 24 (2.5%) were in the highest group during the subsequent three years (OR 2.3; 95% CI 1.4 to 3.7), 62 (6.6%) were in the very high group (OR 1.5; 95% CI 1.1 to 1.9), and 118 (12.5%) were in the high group (OR 1.3; 95% CI 1.1 to 1.6). Similar results were found when using awards as the outcome. CONCLUSIONS: Most physicians who have high malpractice rates during their first four years improve over time. Physicians who have high rates of malpractice during one period should not be subjected to disciplinary action. However, carefully evaluating physicians who consistently have high rates of malpractice during two periods may represent an effective strategy for identifying problem physicians.

Assessing disease prevalence from inaccurate test results: teaching an old dog new tricks.

Estimates of disease prevalence are needed for the interpretation of test results as well as for public health decisions. Assessing prevalence may be difficult if a definitive test is unavailable, impractical, or expensive. A formula derived from Bayes' theorem can calculate the prevalence of disease in a population by incorporating test results with a knowledge of the sensitivity and specificity of a test. This paper reviews this formula and provides examples evaluating the prevalence of HIV disease, the usefulness of ventilation-perfusion scans in diagnosing pulmonary embolism, and settings where screening tests should not be applied. These examples demonstrate that precise yet inexpensive estimates of disease prevalence are possible by enhancing the usefulness of an inaccurate test.

Does physician performance explain interspecialty differences in malpractice claim rates?

Physician specialty has been consistently associated with different malpractice claim rates, with neurosurgery, orthopedics, and obstetrics and gynecology having the highest rates. Whether these differences reflect physician performance or other aspects of patient care that are unique for each specialty is unclear. A retrospective cohort study was performed including 12,829 physicians involved in 8,221 closed cases from 1977 to 1991. For each case an assessment was made whether the plaintiff received an award and whether the physician care of the patient was indefensible. An award was made to the plaintiff in 42% of cases. Physician care was considered indefensible in 23% of the cases. The specialties with the highest award rates were anesthesiology (58.3%), obstetrics and gynecology (47.5%), and radiology (43.0%). Neurosurgery had the lowest rate of award (30.2%). The specialties with the highest indefensibility rates were radiology (36%), obstetrics and gynecology (27%), and anesthesiology (27%). Neurosurgery had the lowest indefensibility rate (10%). These results were unchanged after controlling for physician age, degree, site of training, certification status, and severity of patient injury. In conclusion, differences in award rate and indefensibility are present, but not large enough to explain the large variation in specialty claim rates. This suggests that the variation in malpractice rates results from factors other than a meaningful difference in physician performance.

Physician demographics and the risk of medical malpractice.

PURPOSE: This study was undertaken to clarify which, if any, physician demographic characteristics are associated with an increased rate of medical malpractice claims. METHODS: We analyzed the malpractice experience of 9,250 physicians insured for at least 2 years from 1977 to 1987 in the state of New Jersey. After adjusting for years at risk, physician claims per year was categorized into low, medium, and high. RESULTS: Male physicians were three times as likely to be in the high-claims group as female physicians, even after adjusting for other demographic variables (relative risk, 3.1; 99% confidence interval, 2.2 to 4.4). Specialty was strongly associated with claims rate, with neurosurgery, orthopedics, and obstetrics/gynecology having 7 to 12 times the number of claims per year as psychiatry, the specialty with the fewest claims. The rate of claims varied with age (p < 0.001) and peaked at approximately age 40. No association was evident between claims rate and a physician's site of training or type of degree. CONCLUSION: Male physicians are three times as likely to be in a high-claims category as female physicians. We suspect that the most likely explanation for this finding is that women interact more effectively with patients. Understanding the reasons for the variation in claim rates between physicians may lead to the development of methods to reduce the overall rate of malpractice claims.

The influence of standard of care and severity of injury on the resolution of medical malpractice claims.

OBJECTIVE: To explore how frequently physicians lose medical malpractice cases despite providing standard care and to assess whether severity of patient injury influences the frequency of plaintiff payment. DESIGN: Retrospective cohort study. SETTING: Physicians from the state of New Jersey insured by one insurance company from 1977 to 1992. PARTICIPANTS: A total of 12,829 physicians involved in 8231 closed malpractice cases. MEASUREMENTS: Physician care and claim severity were prospectively determined by the insurance company using a standard process. RESULTS: Physician care was considered defensible in 62% of the cases and indefensible in 25% of the cases, in almost half of which the physician admitted error. In the remaining 13% of cases, it was unclear whether physician care was defensible. The plaintiff received a payment in 43% of all cases. Payment was made 21% of the time if physician care was considered defensible, 91% if considered indefensible, and 59% if considered unclear. The severity of the injury was classified as low, medium, or high in 28%, 47%, and 25% of the cases, respectively. Severity of injury had a small but significant association (P < 0.001) with the frequency of plaintiff payment (low severity, 39%; medium severity, 43%; and high severity, 47%). The severity of injury was not associated with the payment rate in cases resolved by a jury (low severity, 23%; medium severity, 25%; and high severity, 23%). CONCLUSIONS: In malpractice cases, physicians provide care that is usually defensible. The defensibility of the case and not the severity of patient injury predominantly influences whether any payment is made. Even in cases that require a jury verdict, the severity of patient injury has little effect on whether any payment is made. Our findings suggest that unjustified payments are probably uncommon.

The risks of blood transfusion: the relative influence of acquired immunodeficiency syndrome and non-A, non-B hepatitis.

PURPOSE: The acquired immunodeficiency syndrome epidemic has greatly increased concern about the risk of blood transfusion. Many transfusions are now autologous, and when these are not available, both physicians and patients are more likely to question the advisability of transfusion. We evaluate the risk of preoperative blood transfusion and the contribution of human immunodeficiency virus (HIV) infection to that risk. METHODS: We used decision analysis to characterize the risk associated with HIV infection in days of life lost. The contributions to risk of acute transfusion reaction, hepatitis B, and non-A, non-B hepatitis are also estimated. Sensitivity analyses show the implications for transfusion risk of recent information about HIV infection in the blood supply and a new test for hepatitis C. RESULTS: The analysis shows that the contribution of HIV infection to the risk of death from transfusion, expressed in days of life expectancy lost, has become extremely small over the last several years. Currently, HIV infection accounts for less than 1% of the risk of death, while non-A, non-B hepatitis accounts for 97% to 98%. Further reductions in the risk of HIV infection, even to zero, will make relatively little difference in the safety of transfusion. The analysis also shows that the remaining risk from transfusion should decrease sharply, by more than two thirds, with the adoption of the test for hepatitis C. CONCLUSIONS: Efforts to improve the safety of blood should focus on reducing the risk of non-A, non-B hepatitis. The remaining risk of HIV infection is very small.

The impact of the night float system on internal medicine residency programs.

OBJECTIVE: To study the design, method of implementation, perceived benefits, and problems associated with a night float system. DESIGN: Self-administered questionnaire completed by program directors, which included both structured and open-ended questions. The answers reflect resident and student opinions as well as those of the program directors, since program directors regularly obtain feedback from these groups. SETTING/PARTICIPANTS: The 442 accredited internal medicine residency programs listed in the 1988-89 Directory of Graduate Medical Education Programs. RESULTS: Of the 442 programs, 79% responded, and 30% had experience with a night float system. The most frequent methods for initiating a night float system included: decreasing elective time (42.3%), hiring more residents (26.9%), creating a non-teaching service (12.5%), and reallocating housestaff time (9.6%). Positive effects cited include decreased fatigue, improved housestaff morale, improved recruiting, and better attitude toward internal medicine training. The quality of medical care was considered the same or better by most programs using it. The most commonly cited problems were decreased continuity of care, inadequate teaching of the night float team, and miscommunication. CONCLUSION: Residency programs using a night float system usually observe a positive effect on housestaff morale, recruitment, and working hours and no detrimental effect on the quality of patient care. Miscommunication and inadequate learning experience for the night float team are important potential problems. This survey suggests that the night float represents one solution to reducing resident working hours.

Gastrointestinal bleeding from the nonsteroidal anti-inflammatory drugs.

Nonsteroidal anti-inflammatory drugs (NSAIDs) represent a remarkably frequently used class of drugs. The major motivation for the use of these drugs is the known gastrointestinal (GI) toxicity of aspirin. From premarketing studies it was known that NSAIDs could cause subclinical GI bleeding, but there were no controlled studies of the association between NSAID use and clinically apparent upper GI bleeding. In part because of the frequent use of these drugs and in part because of the potential seriousness of this adverse reaction, this association has been the subject of a considerable amount of postmarketing pharmacoepidemiology research. Despite this, many questions remain unanswered. This paper reviews the existing data on GI bleeding from NSAIDs and provides suggestions for future studies which could address some of the deficiencies in the data.