Measuring the performance of individual physicians by collecting data from multiple health plans: the results of a two-state test.

Quality measurement and reporting have emerged as important tools that providers, health plans, and other stakeholders can use to identify gaps in quality and focus resources on improving care. Yet identifying, measuring, and evaluating the care that physicians and other health care providers deliver is complicated by limited data, privacy concerns, and the challenge of trying to compare data from diverse sources. This article describes an effort to pilot-test in Florida and Colorado a consistent approach to individual physician performance measurement using data compiled from multiple health plans. Our approach could be used as the basis for making comparable performance information available nationwide. Additional efforts are needed to address key issues, including ways to effectively engage providers in the use of performance information.

Factors associated with risk of surgical wound infections.

Surgical wound infections are the most common hospital-acquired infections among patients who undergo inpatient surgery. Risk of infection is a function of both patient susceptibility and exposure. The authors studied all discharges in Pennsylvania from October 1, 2004, through September 30, 2005, in which a circulatory (n= 65 940), neurological (n= 6706), or orthopedic (n = 107 825) procedure was performed using data from the Pennsylvania Health Care Cost Containment Council. They estimated the impact of patient-specific factors on risk of infection and compared the ability of these factors to predict infections relative to hospital effects. Results suggested that for all 3 types of procedures, patient-specific factors were a significant determinant of risk of surgical wound infection. However, prediction of infection was improved by 23% to 33% when hospital fixed effects were included. Although patient-specific factors had a statistically significant association with risk of infections, much of the risk of surgical wound infections is determined by hospital factors.

Behind, beneath, above, and beyond: the historical unconscious.

The unconscious is more than a collection of intrapsychic and interpersonal variables. On a broader level, it reflects a complex, historically woven tapestry of moral and ethical values, beliefs, and assumptions. A particular historical context provides an experiential and interpretive template that conditions the boundary between what is conscious and unconscious. Beyond the scope of explicitly inherited values, beliefs, and assumptions is what the historical unconscious comprises. It lingers at the very edge of our conscious experience, behind, beneath, above, and beyond everything that is spoken or unspoken, enacted or restrained, imagined or suppressed.