Predictive ability of acute physiology and chronic health evaluation II scoring applied to human immunodeficiency virus-positive patients.

OBJECTIVE: To evaluate the predictive ability of the Acute Physiology and Chronic Health Evaluation II (APACHE II) prognostic scoring system when applied to human immunodeficiency virus (HIV) seropositive patients in the medical intensive care unit (ICU). DESIGN: A retrospective chart review. SETTING: An urban university hospital serving the local community population and also functioning as a tertiary care referral center. PATIENTS: All HIV-positive patients who were discharged from the Yale-New Haven Hospital medical ICU between October 1, 1986 and September 30, 1991. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: APACHE II scoring significantly underestimated the mortality rate in our patient population (n = 161) (35.5% estimated vs. 44.1% observed, p < .025). When patients were evaluated according to total lymphocyte count, APACHE II scores accurately predicted the mortality rate of all patients with a total lymphocyte count of > or = 201 cells/mm3 (n = 112) (32.6% estimated vs. 33.0% observed). However, APACHE II scoring significantly underestimated the mortality rate in the group of patients with a total lymphocyte count of < or = 200 cells/mm3 (n = 36) (44.2% expected vs. 61.1% observed, p < .05), particularly those patients with pneumonia or sepsis (n = 14) (50.5% expected vs. 85.7% observed, p < .01). CONCLUSION: APACHE II scoring significantly underestimates mortality risk in HIV-positive patients admitted to the medical ICU with a total lymphocyte count of < or = 200 cells/mm3. This finding is particularly true regarding patients admitted due to pneumonia or sepsis.

The postoperative incidence of small bowel obstruction following standard, open appendectomy and cholecystectomy: a six-year retrospective cohort study at Yale-New Haven Hospital.

The incidence of postoperative small bowel obstruction (SBO) after standard, open appendectomy and cholecystectomy was calculated during a six-year period at a university medical center hospital, which is the larger of two local, community hospitals. A cohort of 567 patients who underwent either a standard, open appendectomy or cholecystectomy from 1 October 1985 through 30 September 1986 was assembled. Of these patients, 182 (32.1%) were readmitted to the hospital prior to 1 October 1991 and thereby received follow-up. The time-related incidence of readmission to the hospital with a specific diagnosis of SBO as estimated by the Kaplan-Meier method was tabulated. This analysis revealed the following incidence rates of postoperative SBO: 10.7% following appendectomy during 64 months of follow-up (n = 41) and 6.4% following cholecystectomy during 67 months (n = 141). The Kaplan-Meier product-limit incidence of postoperative SBO was significantly different for standard appendectomy versus standard cholecystectomy (Breslow-Cox P value < 0.0277). This implies that the anatomical position and/or the likelihood of perioperative infection associated with open, abdominal surgery plays a significant role in subsequent adhesion formation and development of SBO. These data may be compared to laparoscopic techniques in future studies.

Surveillance for quality assessment: III. The critical assessment of quality indicators.

Increased attention to healthcare quality issues by insurers, the public and providers has created the desire for quantitative indicators of high quality care. Attributes of quality indicators, including primary and secondary definitions, predictive accuracy and potential to define avoidable problems in care, have been discussed in an effort to allow the reader to critique suggested quality indicators as they appear through legislation and the literature. A continuous feedback process between reviewers and reviewees in the quality assessment process is mandatory to optimize the performance of quality indicators.

Analytic strategies in hospital epidemiology: cross-sectional studies.

Prevalence studies have long been a cornerstone of chronic disease epidemiology and infectious hospital epidemiology. However, application of cross-sectional techniques to non-infectious areas of hospital epidemiology has been limited to large scale period prevalence studies of mortality. The architecture of cross-sectional studies was reviewed in detail, highlighting the descriptive power of such studies and acknowledging problems in proving causation as opposed to association. An application of cross-sectional methodology in evaluating blood product use, which takes advantage of the descriptive strengths of the method and availability of information concerning indications for blood use, was outlined. The cross-sectional method should be as useful a tool in evaluating non-communicable disease quality of care as it has been in infectious disease-related hospital epidemiology.

Utilization review and management: a brief analysis of a growth industry.

Current evidence concerning the prevalence of inappropriate care indicates that there is an opportunity for significant utilization and cost reductions. Although the efficacy of some methods of utilization control has been demonstrated, the clinical impact and safety of these techniques are unclear. Although financial incentives have been successful in nonhealth industries, there is no evidence that fiscal rewards will eliminate inappropriate use rather than necessary care. Both short- and long-term quality assurance monitors should be combined with any utilization control method promoting "appropriate" use of inpatient beds and hospital services.

Mortality rates as a quality indicator: a simple answer to a complex question.

Clinical, administrative, and information issues have been reviewed that may impact on the sensitivity of mortality rates as a quality indicator. It is clear that current technology cannot necessarily identify high-risk institutions through the use of abstracted discharge data. Furthermore, even if this screening capability is improved, verification of quality problems still requires detailed chart review. Quality of health care delivery will continue to be scrutinized by various groups, only some familiar with clinical risk adjustment and the actual process of care. In order to promote the accuracy and fairness of the review process, objective, outcome-based criteria for high-quality care must be developed for many clinical situations, and clinicians must continue to be involved in quality assessment.

Preadmission screening of Medicare patients. The clinical impact of reimbursement disapproval.

The clinical impact of a statewide Medicare preadmission certification program was assessed with a retrospective survey of Connecticut physicians. In a three-month period, only 100 (0.37%) of 28,450 Medicare admission requests were disapproved for reimbursement. Following disapproval, 22 patients were admitted immediately, 44 received outpatient care, and eight additional outpatients were not evaluated or treated. The remaining 26 patients subsequently were admitted with preadmission approval due to changed clinical condition or failed outpatient plan. Although some patients had minor problems that their physicians believed would have been avoided by immediate admission, no severe morbidity resulted from admission delay. Many physicians expressed concern about preadmission certification program-related patient anxiety and inconvenience. Although this limited survey provides preliminary evidence that preadmission certification programs can be implemented without major deleterious short-term medical effects, continued monitoring of physicians and patients involved in disapproved admissions is necessary to evaluate potential medical and psychosocial problems.

Along the data-information continuum: pitfalls and opportunities.

Opportunities and problems in hospital information have been reviewed. At this juncture, it is clear that problems exist in much of the data that administrators and regulators accept as valid. This is due in part to the lack of attention to clinical information systems compared with financial and other management systems. At individual institutions, opportunities exist not only to upgrade the quality of data collected, but also to enhance the integration of these data to provide better clinical information. If this process can occur in an environment of cooperation between larger teaching institutions, larger clinically sophisticated databases can be constructed to better evaluate medical practice and clinical care.