Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey.

CONTEXT: Inappropriate medication use is a major patient safety concern, especially for the elderly population. Using explicit criteria, prior studies have found that 23.5% and 17.5% of the US community-dwelling elderly population used at least 1 of 20 potentially inappropriate medications in 1987 and 1992, respectively. OBJECTIVES: To determine the prevalence of potentially inappropriate medication use in community-dwelling elderly persons in 1996, to assess trends over 10 years, categorize inappropriate medication use according to explicit criteria, and to examine risk factors for inappropriate medication use. DESIGN, SETTING, AND PARTICIPANTS: Respondents aged 65 years or older (n = 2455) to the 1996 Medical Expenditure Panel Survey, a nationally representative survey of the US noninstitutionalized population were included. A 7-member expert panel was convened to categorize inappropriate medications. MAIN OUTCOME MEASURE: Prevalence of use of 33 potentially inappropriate medications. RESULTS: In 1996, 21.3% (95% confidence interval [CI], 19.5%-23.1%) of community-dwelling elderly patients in the United States received at least 1 of 33 potentially inappropriate medications. Using the expert panel's classifications, about 2.6% of elderly patients (95% CI, 2.0%-3.2%) used at least 1 of the 11 medications that should always be avoided by elderly patients; 9.1% (95% CI, 7.9%-10.3%) used at least 1 of the 8 that would rarely be appropriate; and 13.3% (95% CI, 11.7%-14.9%) used at least 1 of the 14 medications that have some indications but are often misused. Use of some inappropriate medications declined between 1987 and 1996. Persons with poor health and more prescriptions had a significantly higher risk of inappropriate medication use. CONCLUSIONS: Overall inappropriate medication use in elderly patients remains a serious problem. Despite challenges in using explicit criteria for assessing inappropriate medications for elderly patients, such criteria can be applied to population-based surveys to identify opportunities to improve quality of care and patient safety. Enhancements of existing data sources to include dosage, duration, and indication may augment national improvement and monitoring efforts.

Optimal methods for guideline implementation: conclusions from Leeds Castle meeting.

BACKGROUND: Quality problems in medical care are not a new finding. Variations in medical practice as well as actual medical errors have been pointed out for many decades. The current movement to write practice guidelines to attempt to correct these deviations from recommended medical practice has not solved the problem. OBJECTIVE: In order to gain greater acceptance of these guidelines and to change the behavior of health care providers, the science of guideline implementation must be understood better. RESEARCH DESIGN: A group of experts who have studied the problem of implementation in Europe and the United States was convened. This meeting summary enumerates the implementation methods studied to date, reviews the theories of behavioral change, and makes recommendation for effecting better implementation guidelines. RESULTS: A research agenda was proposed to further our knowledge of effective evidence-based implementation.

The forgotten component of the quality triad: can we still learn something from "structure"?

BACKGROUND: Quality assessment was founded on structural measures, such as accreditation status of facilities, credentialing of providers, and type of provider. Recent efforts in measures development have focused on processes and outcomes because research has suggested that structural measures are not strong markers of the quality of care at the health plan or provider levels. Nevertheless, the literature on the quality of health care contains a number of examples illustrating the potential application of structural measures to the assessment of quality. The continued development of measures of structure-which would at least measure aspects of the physical environment, working conditions, organizational culture, and provider satisfaction--may be helpful because generalizing from studies of process and outcome requires specification of the conditions under which these linkages are found. A ROAD MAP FOR MEASURES DEVELOPMENT: The Leapfrog Group of large purchasers has promoted the application of three patient safety "leaps" that are, in essence, structural measures: the use of computerized physician order entry, the selective referral of patients to high-volume providers for certain procedures, and the availability of board-certified critical care specialists in intensive care units. Structural measures, like process and outcomes measures, face the same challenges of standardization, reliability, validity, and portability. Field testing of potential measures will be required to examine the feasibility and added value of these measures in real-world settings. CONCLUSION: Research to date suggests that a new cadre of structural measures of health care quality, which have largely been overlooked in the recent measures development boom, have the potential to fill in important gaps in our ability to assess quality.

Labor epidurals improve outcomes for babies of mothers at high risk for unscheduled cesarean section.

CONTEXT: Epidural placement for labor in the general population of laboring women is associated with increased incidence of operative deliveries, prolongation of labor, and may be associated with an increased cesarean section rate. The risks and benefits associated with epidural placement for labor in the subpopulation of mothers at high risk for cesarean section have not been studied. OBJECTIVE: To determine if a population of mothers and babies at high risk for cesarean section will have improved outcomes with labor epidural placement. DESIGN: A decision and cost analysis examining epidural placement for labor on a population of women who are at high risk for unscheduled cesarean section and may benefit from scheduled cesarean section as determined by threshold analysis was performed. Outcomes and probabilities were determined through analysis of the Department of Defense's 1996 National Quality Management Program (NQMP) Birth Product Line data set containing more than 7000 deliveries. Outcomes were defined using variables comprised of all documented conditions that occurred during the peripartum and neonatal hospitalizations. The 1997 NQMP data set was used to validate the results. SETTING: Military Treatment Facilities throughout the United States and abroad and civilian facilities in the United States providing care to military dependents. PATIENT POPULATION: Active duty and dependent pregnant women and babies. RESULTS: About 8% of mothers in this patient population were found to be at high risk for cesarean section. The decision and cost analyses showed that babies of the high risk mothers who received epidurals for labor had better clinical outcomes (p<0.05) and the procedure was cost neutral (p=0.23). The procedure did not increase the frequency of cesarean section, and there was no effect on maternal outcomes scores. These results were confirmed by the validation study. CONCLUSIONS: There is a sizable subpopulation of women at high risk for cesarean section whose babies may have better outcomes with epidural placement with no sacrifice in maternal outcomes or costs.

Patient Safety Indicators: using administrative data to identify potential patient safety concerns.

OBJECTIVE: To develop Patient Safety Indicators (PSI) to identify potential in-hospital patient safety problems for the purpose of quality improvement. DATA SOURCE/STUDY DESIGN: The data source was 2,400,000 discharge records in the 1997 New York State Inpatient Database. PSI algorithms were developed using systematic literature reviews of indicators and hand searches of the ICD-9-CM code book. The prevalence of PSI events and associations between PSI events and patient-level and hospital-level characteristics, length of stay, in-hospital mortality, and hospital charges were examined. PRINCIPAL FINDINGS: PSIs were developed for 12 distinct clinical situations and an overall summary measure. The 1997 event rates per 10,000 discharges varied from 1.1 for foreign bodies left during procedure to 84.7 for birth traumas. Discharge records with PSI events had twofold to threefold longer hospital stays, twofold to 20-fold higher rates of in-hospital mortality, and twofold to eightfold higher total charges than records without PSI events. Multivariate logistic regression revealed that PSI events were primarily associated with increasing age (p < .001), hospitals performing more inpatient surgery (p < .001), and hospitals with higher percentage of beds in intensive care units (p < .001). CONCLUSIONS: The PSIs provide an efficient and user-friendly tool to identify potential inhospital patient safety problems for targeted institution-level quality improvement efforts. Until better error-reporting systems are developed the PSIs can serve to shed light on the problem of medical errors not limited solely to mortality because of errors.

Effect of lovastatin on cardiovascular resource utilization and costs in the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS). AFCAPS/TexCAPS Research Group.

This cost-consequences analysis of the Air Force/Texas Coronary Atherosclerosis Prevention Study compares the costs of lovastatin treatment with the costs of cardiovascular hospitalizations and procedures. The cost of lovastatin treatment was defined as the average retail price and the cost of drug safety monitoring and adverse experiences. Costs were determined by actual rates of hospitalizations and procedures. Within a trial, lovastatin treatment cost approximately $4,654/patient. Lovastatin treatment significantly reduced the cumulative rate of cardiovascular hospitalizations and procedures (p = 0.002). Over the duration of the study, the cumulative number of cardiovascular hospitalizations and related therapeutic procedures was significantly reduced by 29%. The time to first cardiovascular-related hospitalization or procedure was significantly extended by lovastatin (p = 0.002). Lovastatin reduced the frequency of cardiovascular hospitalization (28%), and cardiovascular therapeutic (32%) and diagnostic procedures (23%). Among therapeutic procedures, treatment reduced coronary artery bypass graft surgery by 19% and percutaneous transluminal coronary angioplasty by 37%. Total cardiovascular-related hospital days were reduced by 26% (p = 0.025). The between-group offset in direct medical costs was $524, which resulted in a 11% cost offset of lovastatin therapy over the mean study duration of 5.2 years. Lovastatin provides meaningful reductions in cardiovascular-related resource utilization and reductions in direct cardiovascular-related costs associated with the onset of coronary disease.

The workforce in otolaryngology-head and neck surgery: moving into the next millennium.

OBJECTIVE: The goal was to examine the current scope of otolaryngologists' practices, their geographic distribution, and the roles otolaryngologists and other specialists play in caring for patients with otolaryngic and related conditions of the head and neck. STUDY DESIGN: A large national survey and administrative claims databases were examined to develop practice profiles and compile a physician supply for otolaryngology. A focus group of otolaryngologists provided information to model future scenarios. RESULTS: The current and predicted workforce supply and demographics are at a satisfactory level and are decreasing as a proportion of the increasing population. Empiric data analysis supports the diverse nature of an otolaryngologist's practice and the unique role for otolaryngologists that is not shared by many other providers. Together with the focus group results, the study points to areas for which more background and training are warranted. CONCLUSIONS: This study represents a first step in a process to form coherent workforce recommendations for the field of otolaryngology.

Complications from cardiac catheterization: analysis of a military database.

BACKGROUND: Cardiac catheterization is a common procedure in the United States. Our purpose was to assess possible risk factors for complications from cardiac catheterization. METHODS: The Civilian External Peer Review Program database, which contains data on 3,494 cardiac catheterizations performed at 28 military facilities from 1987 to 1989, provided the patient population for this study. Of 360 abstracted clinical elements, 27 were selected by a panel of internists and cardiologists for evaluation as potential risk factors and were analyzed using logistic regression. Complications were analyzed within three categories: major (myocardial infarction, cerebral vascular accident, or death within 24 hours of catheterization); minor (hemorrhage requiring transfusion, pseudoaneurysm, fistula, or femoral thrombosis); and any. RESULTS: The mean age of the 3,494 patients was 56 years, and 75% of them were male; 85% were white, 10% were African-American, and 5% were other races. Complication rates were as follows: death (N = 13), 3.7/1,000; cerebral vascular accident (N = 16), 4.1/1,000; myocardial infarction (N = 22), 5.6/1,000; hemorrhage (N = 20), 5.1/1,000; fistula (N = 7), 0.3/1,000; and thrombosis (N = 15), 3.8/1,000. These were categorized as 59 major, 71 minor, or 122 any complications. Complications were more likely in patients with hypertension (odds ratio, 1.8; 95% confidence interval, 1.05-3.18), peripheral vascular disease (odds ratio, 2.9; 95% confidence interval, 1.1-8.7), age greater than 60 years (odds ratio, 2.1; 95% confidence interval, 1.2-3.8), and those undergoing angioplasty (odds ratio, 6.0; 95% confidence interval, 2.9-12.2). CONCLUSIONS: Hypertension, age greater than 60 years, peripheral vascular disease, and procedures either nonelective or involving angioplasty all independently increased the risk of complications. There was a "dose-response" relationship between risk and number of risk factors. The risk of a complication may be greater than 10% in patients with more than three risk factors.

Differences between generalists and specialists in characteristics of patients receiving gastrointestinal procedures.

BACKGROUND: As a result of market forces and maturing technology, generalists are currently providing services, such as colonoscopy, that in the past were deemed the realm of specialists. OBJECTIVE: To determine whether there were differences in patient characteristics, procedure complexity, and clinical indications when gastrointestinal endoscopic procedures were provided by generalists versus specialists. DESIGN: Retrospective cohort study. PATIENTS: A random 5% sample of aged Medicare beneficiaries who underwent rigid and flexible sigmoidoscopy, colonoscopy, and esophagogastroduodenoscopy (EGD) performed by specialists (gastroenterologists, general surgeons, and colorectal surgeons) or generalists (general practitioners, family practitioners, and general internists). MEASUREMENTS: Characteristics of patients, indications for the procedure, procedural complexity, and place of service were compared between generalists and specialists using descriptive statistics and logistic regression. MAIN RESULTS: Our sample population had 167,347 gastrointestinal endoscopies. Generalists performed 7.7% of the 57, 221 colonoscopies, 8.7% of the 62,469 EGDs, 42.7% of the 38,261 flexible sigmoidoscopies, and 35.2% of the 9,396 rigid sigmoidoscopies. Age and gender of patients were similar between generalists and specialists, but white patients were more likely to receive complex endoscopy from specialists. After adjusting for patient differences in age, race, and gender, generalists were more likely to have provided a simple diagnostic procedure (odds ratio [OR] 4.2; 95% confidence interval [95% CI] 4.0, 4.4), perform the procedure for examination and screening purposes (OR 4.9; 95% CI, 4. 3 to 5.6), and provide these procedures in rural areas (OR 1.5; 95% CI 1.4 to 1.6). CONCLUSIONS: Although generalists perform the full spectrum of gastrointestinal endoscopies, their procedures are often of lower complexity and less likely to have been performed for investigating severe morbidities.

Cost-effective syphilis screening in military recruit applicants.

A cost-effectiveness analysis of syphilis screening was performed. Strategies included no screening, universal testing at military entrance processing stations, universal testing at basic training centers, and contracting centralized screening. Probabilities derived from data retained on recruit applicants from 1989 through 1991 (N = 1,588,143) and from the published literature were used. Cost estimates were derived from costs incurred by the military and costs projected from implementing new strategies. Sensitivity analyses were performed. Modifying the existing contract for human immunodeficiency virus screening to include syphilis screening would maximize the effectiveness of screening at a cost to the Department of Defense of $9.52 per additional year of service received. The no-screening option was significantly more cost-saving than the current method of testing. Syphilis is rare and treatable, and individuals with syphilis will be identified by other means in many cases. Syphilis screening of recruit applicants at the military entrance processing stations should cease, saving the military $2,541,000 per year.

Validity of the Department of Defense Standard Inpatient Data Record for quality management and health services research.

OBJECTIVE: To assess the validity of the Department of Defense's Standard Inpatient Data Record (SIDR) for health services research and quality measurement. SUBJECTS: Patients whose inpatient charts were abstracted through the Civilian External Peer Review Program's studies of acute myocardial infarction (N = 1,432) and 1993 review of the birth product line (N = 9,705). METHODS: Separate databases of professionally abstracted (the clinical data set) and hospital-reported (the administrative SIDR data set) diagnoses and procedures were compared for each patient, and the sensitivity and specificity of the SIDR for elements in the Civilian External Peer Review Program's clinical "gold standard" data set were calculated. Agreement beyond chance was examined with kappa statistics. RESULTS: The clinical data set's principal procedure was found as a SIDR principal or secondary procedure in 92.5% of cases. Sensitivities of the SIDR data for common diagnoses in the clinical data ranged from 64% (viral infection) to 97% (diabetes), with kappa statistics ranging from 0.55 to 0.96. Procedural sensitivities ranged from 77% (echocardiography) to 99% (cesarean section), with kappa statistics ranging from 0.7 to 1.0. CONCLUSIONS: Our analyses indicate that the Department of Defense's SIDR is a reliable source of administrative data that compares favorably with traditional civilian quality management and health services research data sources, such as those from the Health Care Financing Administration and large insurers.

Modeling the future workforce of obstetrics and gynecology.

OBJECTIVE: To examine the current supply and distribution of obstetrician-gynecologists and project future supply under various scenarios. METHODS: A discrete actuarial supply model was developed, and practice patterns were analyzed. Supply projections under different scenarios, distributions, and practice profiles were examined. RESULTS: Women are expected to become the majority of practitioners by 2014. Continuation of current residency output will result in slow to no growth in obstetrician-gynecologist-to-female population ratios over the next 20 years. A minor (10%) reduction in specialty training would slow specialty growth over the next decade, followed by a slight reduction in supply. Services provided chiefly involve ambulatory reproductive health care, pregnancy, and surgical correction of conditions specific to the female genitourinary system. Even though the proportion of deliveries performed by midwives has increased and family practitioners have maintained their share, obstetrician-gynecologists provide the vast majority of obstetric care and virtually all services for perinatal complications. Generalist services represent relatively minor aspects of their practices. Care of the aged female population is highly fragmented among specialties; more than 50% of all aged Medicare beneficiaries who saw an obstetrician-gynecologist at least once failed to receive a majority of services from any one physician specialty. CONCLUSION: On the basis of trends in patient demographics and care patterns, obstetrician-gynecologists must resolve whether to provide more generalist office-based care, especially to the rapidly growing older female population, or to invest more intensively in surgical specialty care. The specialty's unique contributions to women's health should influence this decision.