Quality improvement in the US Veterans Health Administration.

The Veterans Health Administration, the largest government-operated health-care system in the United States, has been actively engaged in quality improvement activities since 1990. These activities have been implemented on both a system-wide and facility-specific basis. Some quality improvement efforts have been targeted to specific clinical services; others relate to the overall process of providing patient care. This paper provides an overview of three quality improvement activities in the Veterans Health Administration and considers the research and managerial issues they raise.

Contribution of locally and externally designed quality management activities to hospitals' efforts to improve patient care.

We examined the effects of quality management activities on efforts by hospitals to improve patient care. Our primary objective was to assess the relative contribution to these efforts of quality management activities designed by facility staff and those designed by external organizations. We asked chiefs of medicine, surgery, psychiatry, and ambulatory care at 47 randomly selected Department of Veterans Affairs hospitals to identify the 3 actions taken by their departments during the previous year that most improved patient care. The sources of information contributing to each action were subsequently identified through 2 independent procedures: a review of hospital documents and attributions by the department chiefs. Quality management activities contributed to 31% of 493 actions to improve care in the analysis of the department chiefs' attributions and to 26% of 446 actions in the analysis of the sources found in hospital documents. Four locally designed quality management activities contributed to more than twice as many actions to improve patient care as did 12 externally designed ones, suggesting that locally designed quality management activities have a greater effect on efforts to improve patient care than do externally designed ones.

Development of a quality improvement checklist for the Department of Veterans Affairs.

BACKGROUND: In 1991, the Department of Veterans Affairs developed an instrument to monitor various aspects of quality in Veterans Affairs hospitals. The instrument, the Quality Improvement Checklist, is composed of a series of clinical indicators or questions about administrative or clinical processes, structures, or outcomes. METHOD: For most questions, data are obtained by automated search of electronic patient data-bases maintained in each facility. Individual hospital data are collated and displayed in comparative format with those from other hospitals. Hospitals use the information to identify areas needing further study or improvement. CONCLUSION: Hospital directors and physicians are slowly accepting the usefulness of the instrument.

Usefulness of a discharge diagnosis of sepsis in detecting iatrogenic infection and quality of care problems.

To address the question of how often a diagnosis of sepsis in the discharge summary represents a condition present on hospital admission as opposed to an acquired condition, medical records from Veterans Affairs medical centers were reviewed. A random sample of discharged summaries coded for sepsis were obtained from five different hospitals. One hundred forty-one summaries involving 128 patients from 1989 were evaluated. Twenty-seven (18.7%) of the summaries were judged to be improperly coded. Of the remaining 114 summaries, 61 (53.5%) contained information supporting sepsis as an admission condition. Comparison of other clinical attributes of these summaries indicates that patients with sepsis on admission have some characteristics that are different from those of patients who acquire sepsis during care. These attributes include a history of chemotherapy, an overall shorter length of stay, and a lower death rate. Sepsis, as a discharge diagnosis, cannot be assumed to represent an iatrogenic condition or to be the result of poor care since more than half of the cases reviewed indicated that the condition was present at admission.

Studies of the permeability of isolated porcine peritoneum to nutrients: saccharides.

Isolated peritoneal membrane, freshly harvested from pigs, was studied in vitro to determine the permeability of the membrane to saccharide nutrients. Studies were performed with glucose and sucrose at various transmembrane gradients ranging from 150 to 600 mosm/liter (mmol/liter) and with polysaccharide at a 300 mosm/liter gradient. Findings indicate that flux of these nutrients across the isolated peritoneum is related to molecular weight and that sufficient kilocalories will traverse the membrane to provide for adequate carbohydrate nutrition (calculated to deliver more than 3000 kcal/day at gradients of 150 mosm/liter). Polysaccharide flux studies suggest that carbohydrate calories may be provided in the form of complex molecules and not only in the form of glucose. Studies of 1:1 serum and polysaccharide mixtures showed the conversion of polysaccharide to glucose by serum in vitro. When rats were given intraperitoneal polysaccharide their blood glucose levels rose promptly although they remained fasting, suggesting an in vivo conversion also occurs. These findings provide support for use of polysaccharides intraperitoneally as means to reduce the osmolarity of fluid administered for nutritional support; this would increase tolerance while still providing ample calories. The in vitro apparatus used in these studies provides a mechanism to study individual nutrients and yields highly reproducible results. These studies add further evidence that intraperitoneal nutrition is feasible.

Morning report. Role of the clinical librarian.

The educational value of morning report should be enhanced by thorough evaluation of the medical literature. We added a clinical medical librarian (CML) program to our morning report 2 1/2 years ago to provide rapid, complete access to reference material relevant to topics discussed in morning report. MEDLINE searches and references are made available on a same-day basis; cumulative lists of these are provided to the staff and house staff at bimonthly and yearly intervals. All house staff used the CML service to some degree and the majority found it to be of value in making patient care decisions. Since the inception of the CML program, the medical library has noted a more than twofold increase in the number of on-line reference searches and a similar increase in requests for searches by house staff. Patient care decisions have been improved through ready access to current medical literature, and the teaching program has been enhanced by the creation of the CML program as an integral part of morning report.

Controlled comparison of hemodialysis and peritoneal dialysis: Veterans Administration multicenter study.

We measured mortality and morbidity among 114 patients assigned randomly to home hemodialysis (HD) and home intermittent peritoneal dialysis (IPD). Data were collected during the time of home training and for 12 months after initiation of home dialysis. Training time was shorter for the IPD than for the HD patients (P less than 0.001) with median time 1.8 months for IPD and 3.9 months for HD. Switching to the alternative mode of treatment was more frequent for the IPD group (29/59 vs. 5/55, P less than 0.001). Survival time was not different, perhaps because of the modality change. More IPD patients were hospitalized in the first 6 months (20 for IPD vs. 9 for HD, P = 0.02), but they had fewer troublesome cardiovascular events in the first year (0 vs. 12, P less than 0.001). The HD patients maintained better nutritional status as reflected in body weight and arm muscle circumference and possibly in urea appearance rate. Thus, these data suggest that for most patients, IPD is a less satisfactory form of therapy than HD, but certain advantages of IPD did emerge. Applications of this information to the currently more popular mode of CAPD await further study.

Malnutrition in the hospitalized geriatric patient.

The nutritional status of 59 consecutive geriatric male patients admitted to the medical service of a Veterans Administration Hospital was evaluated and compared with that of 93 younger patients admitted during the period. Protein-calorie malnutrition was diagnosed in 61 per cent of patients aged 65 or older compared with 28 per cent of patients younger than 65. The death rate and the incidence of infection were higher in the malnourished geriatric patients, however, there was no increase in the incidences of these abnormal findings compared with well-nourished patients udder the age of 65. The presence of malnutrition on admission, regardless of age, predicted a significant increase in the risk of infection or death during the hospital course.

Malnutrition and hospital prognosis in the alcoholic patient.

The nutritional status of 65 alcoholic patients admitted to the Medical Service of a Veterans Administration Hospital was evaluated and compared to that 87 nonalcoholic patients admitted during the same period of time. There was no statistical difference in the prevalence of malnutrition in the alcoholic population (36.9%) when compared to the nonalcoholic population (43.7%). The death rate and incidence of infection were similar in both populations as was the prevalence of anemia, depressed total lymphocyte count, and skin test anergy. Malnutrition, however, correlated with an increased death rate and incidence of infection, regardless of whether the patient was an alcoholic or not.

Methods for assessing nutritional status of patients with renal failure.

Since wasting and malnutrition are common problems in patients with renal failure, it is important to develop techniques for the longitudinal assessment of nutritional status. This paper reviews available methods for assessing the nutritional status; their possible limitations when applied to uremic patients are discussed. If carefully done, dietary intake can be estimated by recall interviews augmented with dietary diaries. Also, in a stable patient with chronic renal failure, the serum urea nitrogen (N)/creatinine ratio and the rate of urea N appearance reflect dietary protein intake. A comparison of N intake and urea N appearance will give an estimate of N balance. Anthropometric parameters such as the relationship between height and weight, thickness of subcutaneous skinfolds, and midarm muscle circumference are simple methods for evaluating body composition. Other methods for assessing body composition, such as densitometry and total body potassium, may not be readily applicable in patients with renal failure. More traditional biochemical estimates of nutritional status such as serum protein, albumin, transferrin, and selected serum complement determinations show that abnormalities are common among uremic patients. Certain anthropometric and biochemical measurements of nutritional status are abnormal in chronically uremic patients who appear to be particularly robust; thus, factors other than altered nutritional intake may lead to abnormal parameters in such patients. Serial monitoring of selected nutritional parameters in the same individual may improve the sensitivity of these measurements to detect changes. Standards for measuring nutritional status are needed for patients with renal failure so that realistic goals can be established optimal body nutriture.

Fludrocortisone therapy for hypercalcemia.

A patient with mild hypercalcemia associated with adenocarcinoma of the lung was treated with fludrocortisone, a synthetic mineralocorticoid. Hypercalcemia resolved during therapy in conjunction with sodium retention and increased weight. Volume expansion and weight gain were highly correlated with decreases in the serum calcium level. Augmented urinary calcium excretion was documented in the first week of therapy and is the likely mechanism for the observed lowering of serum calcium levels. Long-term fludrocortisone therapy was not associated with signs of hyperaldosteronism and appears to be an effective means of controlling mild hypercalcemia.

Measurement of peritoneal clearances in self-dialysis patients.

Twelve chronic peritoneal dialysis patients were studied on 20 occasions to measure peritoneal clearances of creatinine, urea, uric acid, and potassium. Two clearance techniques were employed, the classical type using timed collections and a midpoint blood specimen and an experimental type using calculated dialysate flow and predialysis peritoneal fluid solute concentrations. Comparison of the two techniques demonstrated a close correlation between simultaneously measured clearances and also for repeat measurements in the same patient. The new technique is simple and reproducible, does not require blood sampling, and can be performed in the home by patients treated by self-dialysis using automated peritoneal dialysis equipment. The new technique will allow more frequent monitoring of peritoneal permeance in self-dialysis patients, and necessary adjustments in treatment time can be prescribed without requiring hospitalization.

Effect of parathyroidectomy on anemia in chronic renal failure.

Fourteen patients with chronic renal failure underwent parathyroidectomy. Postoperatively, seven patients exhibited a rise in hematocrit reading, but seven others did not. Responders had more severe bone disease and lower initial hematocrit values than did nonresponders. Marrow fibrosis was slightly more prominent in responders. Current concepts of marrow erythropoietic inhibition in renal failure suggest a toxic serum factor as the cause. This report fails to support parathyroid hormone as the toxic agent directly responsible for marrow inhibition. Rather, parathyroid hormone may contribute to anemia in renal failure by causing marrow fibrosis, a process sometimes reversible by successful therapy of hyperparathyroidism.

Vasopressin-resistant nephrogenic diabetes insipidus. A result of amphotericin B therapy.

Polyuria and polydipsia developed in two cases during amphotericin B therapy for deep mycoses. Neither patient could concentrate his urine in response to water deprivation or exogenous vasopressin. Other causes of vasopressin-resistant nephrogenic diabetes insipidus were not present. Three months after amphotericin B therapy had been discontinued, concentrating ability improved toward normal. A third patient was further observed and demonstrated normal diluting capacity but impaired free-water reabsorption, suggesting a distal tubular defect consistent with nephrogenic diabetes insipidus. Four months after discontinuing therapy, renal concentrating ability was normal. Amphotericin B can induce a reversible form of nephrogenic diabetes insipidus.

Videotape aids informed consent decision.

Obtaining informed consent for clinical investigations represents a major legal, ethical, and moral consideration in human experimentation. Mechanisms for informing the patient vary widely, and usually no system exists to confirm the degree of information retained by the patient. A Veterans Administration Cooperative Study, begun in 1975, has used a videotape information package in addition to a standard written consent form to ensure uniformity. Each presentation was followed by a questionnaire to assess the amount of material learned before attempting randomization. Repeated showings were occasionally necessary and did not affect the rate of randomization. A videotape presentation, especially in cooperative studies, ensures uniformity, makes allowance for varying educational levels of patients, and provides documentation of the degree of informed consent.

Bilateral angiomyolipomas and renal cell carcinoma in polycystic kidney.

A case is presented of a twenty-eight-year-old man in whom renal failure developed at age twenty-four from polycystic kidney disease known to be present since childhood. He also had cutaneous manifestations of the tuberous sclerosis complex. Intrarenal hemorrhage led to bilateral nephrectomy. Microscopic examination disclosed typical polycystic disease and multiple angiomyolipomas in each kidney. In addition several renal cell carcinomas of oncocytic, papillary, and clear cell type were found. Review of the literature disclosed the uncommon coexistence of any two of these lesions and did not uncover any reported case of the simultaneous existence of all three.

Asymptomatic Bartter's syndrome.

A 63-year-old man had asymptomatic Bartter's syndrome, discovered during evaluation for hypokalemia. Elevated plasma renin and aldosterone levels, angiotension resistance, and elevated urinary prostaglandin excretion were noted. Tubular function studies implicated the proximal tubule as the site of a mild sodium reabsorption defect, and renal wasting of potassium and magnesium were also noted. Indomethacin therapy lowered the urinary prostaglandin excretion and the renin and aldosterone levels but did not correct the hypokalemia. Spironolactone therapy resulted in normalization of serum potassium but not serum magnesium levels. Bartter's syndrome may result from various causes but renal wasting of sodium, potassium and/or magnesium probably exist in all cases. Unexplained, asymptomatic hypokalemia in any age group may be due to Bartter's syndrome.

Distal renal tubular acidosis in selective hypoaldosteronism.

Renal mechanisms for metabolic acidosis in selective hypoaldosteronism were investigated in a patient with marked renal insufficiency. Studies demonstrated a distal hydrogen ion secretory defect. Control of elevated serum potassium levels did not normalize urinary acid excretion, but systemic acidosis was improved. Mineralocorticoid therapy normalized serum potassium without increasing urinary potassium. Hyperkalemia did not directly affect renal acid handling, and extrarenal mechanisms for potassium excretion are suggested. Measurement of rectal mucosal potential difference suggests this test may be of value in detecting a wide range of abnormalities in aldosterone metabolism.