Quality improvement activity directed at the national level: examples from the Health Care Financing Administration.

Quality improvement projects coordinated by the Health Care Financing Administration (HCFA) are currently underway to improve the care provided to Medicare beneficiaries. We describe five national quality improvement projects, the End Stage Renal Disease Core Indicators Project, the National Anemia Cooperative Project, the Ambulatory Care Quality Improvement Project, and the Cooperative Cardiovascular Project. We outline the types of intervention strategies employed and compare the approaches used for fee-for-service sites and for managed care plans.

Effects of restricting levothyroxine dosage strength availability.

We conducted a prospective, randomized, controlled trial to assess whether hospital formulary restrictions involving limiting dosage strengths of levothyroxine affect physicians' ability to manage patients effectively and provide pharmacy cost savings in a tertiary care federal government research hospital. Thirty-three endocrinologists were randomly assigned to prescribe levothyroxine from a restrictive (dosage strengths of 25, 50, 100, 125, and 150 micrograms) or a nonrestrictive (dosage strengths of 25, 50, 75, 100, 112, 125, 150, 175, 200, and 300 micrograms) formulary through a central computer system. Their 241 respective outpatients' laboratory results and drug compliance were outcome measures. Achievement of treatment objectives was measured by thyroid function tests (free and total thyroxine, total triiodothyronine, thyrotropin), number of clinic visits, and compliance (survey method). Additional measures were drug distribution patterns, drug costs, and pharmacy inventory costs. Restriction of levothyroxine's dosage strength did not significantly alter therapeutic outcomes. However, the restricted formulary was associated with more complex dosing regimens, and resulted in no significant cost savings. It is not known whether such restriction would adversely affect the care of patients of nonspecialists. Prospective studies are required to verify presumed cost-containment measures before such measures are adopted for widespread application.

Knowledge about hypoglycemia in young women with type I diabetes and their supportive others.

Hypoglycemia is a common stressful occurrence for people with type I diabetes, is disruptive to daily activities, and is a source of embarrassment, fear, and anxiety. Adequate knowledge about hypoglycemia is needed to recognize, treat, and prevent this condition. Families and friends also need adequate knowledge about hypoglycemia to provide helpful support. In this study, the Hypoglycemia Knowledge Questionnaire was used to measure knowledge about hypoglycemia in a convenience sample of 94 young women with type I diabetes and 94 supportive others. Knowledge about hypoglycemia was significantly higher for the young women with diabetes than for their supportive others, although knowledge deficits were evident for the young women on selected questionnaire items. Because normalization of blood glucose is associated with an increased risk of hypoglycemia, comprehensive evaluation of knowledge about hypoglycemia is critical to self-care. Additional studies are needed to validate the reliability and evaluate the usefulness of the Hypoglycemia Knowledge Questionnaire in clinical and research applications.

Automated therapeutic drug monitoring in an ambulatory care endocrine clinic.

OBJECTIVE: To develop and implement an automated therapeutic drug monitoring system for accessing data from endocrine clinic patients who had been prescribed insulin, oral hypoglycemic agents (OHA), or levothyroxine. DATA SOURCES: We designed a computer system to retrieve clinical data from the Medical Information System (MIS), a centralized hospital computer system, and import this information directly into a Macintosh personal computer. Physician entry of prescriptions for insulin, OHA, or levothyroxine into MIS formed the basis for a computer program to retrieve daily diagnostic and prescription information, demographics, and laboratory analyses, including blood glucose and glycosylated hemoglobin for insulin and OHA orders and free and total thyroxine, total triiodothyronine, and thyroid stimulating hormone for levothyroxine orders. The information was imported into a database program (4th Dimension). RESULTS: The system identifies laboratory values outside of predetermined therapeutic ranges, maintains an up-to-date patient profile, and edits and generates reports. Preliminary experience suggests that automation eliminates 75-90 percent of the time required to manually collect the same information, and improves the accuracy, comprehensiveness, and utility of reports. CONCLUSIONS: Automated therapeutic drug monitoring minimizes the time required to collect clinical data, alerts clinicians to potential problems, and provides a means to assess overall therapeutic management. Our methodology can be used to evaluate other medications in a variety of general or specialty clinics.

Perceived and actual level of knowledge of diabetes mellitus among nurses.

The purpose of this study was to survey staff nurses on their perceived and actual level of knowledge of diabetes mellitus. A convenience sample of 184 professional staff nurses from both inpatient and outpatient settings of a large research-teaching hospital was surveyed. The Diabetes Self-Report Tool (Cronbach's alpha = .91) was used to assess staff nurses' perceptions of knowledge of diabetes mellitus. The Diabetes: Basic Knowledge Test (DBKT; Cronbach's alpha = .79) was used to measure the actual level of knowledge of diabetes mellitus. The data were analyzed with Pearson's correlation coefficients. A moderately low negative correlation (r = -.36, P less than .001) indicated that the staff nurses' perceived knowledge of diabetes mellitus was inversely related to actual knowledge. Subjects were found to have a mean score of 64% on the DBKT. Study findings raise questions as to the adequacy of staff nurse knowledge of diabetes and the ability of staff nurses to assess themselves for knowledge deficits.