Effect of practice variation on resource utilization in infants hospitalized for viral lower respiratory illness.

OBJECTIVE: Hospital care for children with viral lower respiratory illness (VLRI) is highly variable, and its relationship to severity and impact on outcome is unclear. Using the Pediatric Comprehensive Severity Index, we analyzed the correlation of institutional practice variation with severity and resource utilization in 10 children's medical centers. METHODS: Demographics, clinical information, laboratory results, interventions, and outcomes were extracted from the charts of consecutive infants with VLRI from 10 children's medical centers. Pediatric Component of the Comprehensive Severity Index scoring was performed at admission and at maximum during hospitalization. The correlation of patient variables, interventions, and resource utilization at the patient level was compared with their correlation at the aggregate institutional level. RESULTS: Of 601 patients, 1 died, 6 were discharged to home health care, 4 were discharged to rehabilitative care, and 2 were discharged to chronic nursing care. Individual patient admission severity score correlated positively with patient hospital costs (r = 0.48), but institutional average patient severity was negatively correlated with average institutional costs (r = -0.26). Maximal severity score correlated well with costs (r = 0.66) and length of stay (LOS; r = 0.64) at the patient level but poorly at the institutional level (r = 0.07 costs; r = 0.40 LOS). The institutional intensity of therapy was negatively correlated with admission severity (r = -0.03) but strongly correlated with costs (r = 0.84) and LOS (r = 0.83). CONCLUSIONS: Institutional differences in care practices for children with VLRI were not explained by differences in patient severity and did not affect the children's recovery but correlated significantly with hospital costs and LOS.

Newness of drugs and use of HMO services by asthma patients.

OBJECTIVE: To define newness of drug technology and show associations between two measures of newness and health service utilization. METHODS: Healthcare use and changes in severity at each office visit were assessed for 1309 asthma patients from six health maintenance organizations (HMOs) during 1992. The age of each drug product, derived by subtracting its Food and Drug Administration (FDA) approval date from January 1, 1992, was used to construct two newness measures: the average age of all asthma drugs and, separately, all non-asthma drugs a patient used during the year and the percentages of a patient's asthma drugs from each of four time intervals of asthma drug breakthroughs. Service utilization variables included all primary care provider (PCP) visits, total prescription costs, emergency department (ED) visits, and hospitalizations. RESULTS: Using either measure of drug newness, multivariate analyses showed an association between greater use of newer asthma drugs and lower overall drug costs and fewer PCP visits. A trend was found between greater use of newer asthma drugs and fewer hospitalizations and ED visits. Newer non-asthma medications were associated with fewer ED visits. CONCLUSIONS: After controlling for patient and site variables, greater use of newer asthma drugs was associated with significantly lower drug costs and fewer PCP visits; associations with hospitalization rates and ED visits, although lower, were not significant.

Quality, clinical practice improvement, and the episode of care.

To improve routine clinical practice, we must measure patients treated in routine practice (effectiveness research), not in specially controlled circumstances (efficacy research). We describe a new study methodology, Clinical Practice Improvement (CPI), designed to develop data-driven, analytically-based protocols to achieve desirable outcomes at the lowest essential cost over the continuum of care. Measurement in CPI encompasses a comprehensive view of care management: patient characteristics, process steps, and outcomes. All three classes of data are considered simultaneously, providing a basis for meaningful analyses of significant associations between processes and outcomes. We present an example of a CPI pediatric asthma study.

[Clinical practice improvement--clinical practice quality improvement of local health care processes]. / Clinical Practice Improvement--Qualitätsverbesserung lokaler medizinischer Versorgungsprozesse.

Clinical Practice Improvement (CPI) is a methodological approach to develop analytically-based protocols to achieve desirable outcomes at the lowest essential cost over the continuum of local care processes. Several elements of the CPI approach make it attractive to clinicians: First, it is a scientific bottom-up approach that places accountability for practice improvement and outcomes with local clinicians. Clinicians are not told to blindly follow a guideline or protocol developed by others, but instead collect data on outcomes, on treatments, and on patient signs and symptoms that support practice change. CPI supports caregivers in making their own decisions about optimal care on the basis of objective statistical evidence gathered in the routine, everyday practice of medicine. Second, CPI measurement encompasses a comprehensive view of the care management process: patient characteristics, process steps, and outcomes. All three classes of data are considered simultaneously. This comprehensive measurement framework provides a basis for meaningful analyses of significant associations, as well as relationships between process and outcome. Third, the CPI methodology focuses on deployment and application. There is a continual emphasis on factors that can be implemented to improve outcomes and the process to achieve these results. This focus on implementation guides who is involved in the design, what data are collected, what questions are answered during analyses, and who designs the protocols or improvements in practice.

Early and sufficient feeding reduces length of stay and charges in surgical patients.

BACKGROUND: The role of perioperative nutrition in surgical patients remains controversial. We performed a Clinical Practice Improvement (CPI) study that, while controlling for severity of illness, explored the relationship between the timing and amount of parenteral or enteral nutrition, with two outcomes: length of stay (LOS) and total charges in patients undergoing open intestinal operations. MATERIALS AND METHODS: A CPI study was conducted at eight hospitals to determine which process steps were associated with shorter LOS and lower charges. Hospital charts were abstracted for over 800 components of detailed patient, process, and outcome measures. Severity of illness was measured multiple times during the stay using the Comprehensive Severity Index, a disease-specific physiologic severity measurement instrument. Data on 1007 patients undergoing intestinal operations, 183 of whom received nutritional support, were then analyzed using multiple regression procedures. Early (within 48 h of surgery) and sufficient (60% of protein and calorie goals) nutrition, patient variables, and a severity of illness measure were included as independent variables and LOS and hospital charges were used as dependent variables. RESULTS: Mean patient age was 58 years. After controlling for severity of illness, patients who received early and sufficient nutrition had significantly shorter LOS (11.9 days) and lower charges ($34,602) than patients who received early (13.3; $36,452), sufficient (14.6, $39,883), or neither early nor sufficient (14.8, $38,578) (P < or = 0.0001 for early and sufficient versus all other groups). CONCLUSIONS: CPI methodology provides a detailed view of the actual relationship between the timing and the amount of nutrition with LOS and hospital charge outcomes.

Severity assessment in children hospitalized with bronchiolitis using the pediatric component of the Comprehensive Severity Index.

OBJECTIVE: Practice variation in the management of children hospitalized with bronchiolitis may result in significant differences in resource utilization. Determination of cost-effective care requires an objective means of adjusting for severity. We examined the correlation of the pediatric component of the Comprehensive Severity Index (CSI) with resource utilization in children hospitalized with bronchiolitis at ten children's medical centers. DESIGN: Demographics, clinical findings, laboratory results, interventions, and outcomes were retrospectively extracted from the charts of 804 consecutive children with International Classification of Disease, Ninth Revision codes for bronchiolitis from 10 children's medical centers. Comorbidities of prematurity, heart disease, and a prior history of wheezing or hospitalization, and the viral etiology of the illness were specifically examined. CSI scoring was performed at admission and maximum and correlated with patient variables and measures of resource utilization (hospital costs, length of stay, pediatric intensive care unit admission, and intubation). The performance of CSI relative to the Pediatric Risk of Mortality III was also evaluated. SETTING: Ten tertiary children's medical centers. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One child died and >99% of children returned to their baseline state of health. Admission CSI was comparable to the aggregate of all patient variables in its correlation with hospital costs (r2 = 0.23 vs. r2 = 0.24, respectively) and lengths of stay (r2 = 0.23 vs. r2 = 0.24, respectively). Maximum CSI had the highest correlation coefficient with hospital costs (r2 = 0.42) and lengths of stay (r2 = 0.41), whereas the correlation of admission Pediatric Risk of Mortality III scores with costs was r2 = 0.12 and with lengths of stay was r2 = 0.07. CSI scores also correlated well with measures of resource utilization in subgroups of bronchiolitis patients with comorbidities or other risk factors for severe disease. CONCLUSIONS: CSI scores correlate well with resource use in pediatric patients hospitalized with bronchiolitis. This severity scoring system may be useful in assessing the cost-effectiveness of their care.

Results of a collaborative quality improvement program on outcomes and costs in a tertiary critical care unit.

OBJECTIVE: To demonstrate that by using the knowledge and skills of the primary care provider and by applying statistical and scientific principles of quality improvement, outcomes can be improved and costs significantly reduced. DESIGN: A before and after quasi-experimentally designed trial using historical controls plus an analysis of costs in areas not influenced by intensive care unit (ICU) practice to control for possible secular changes. SETTING: A tertiary ICU. PATIENTS: All patients admitted to the above-mentioned ICU from January 1, 1991, through December 31, 1995. INTERVENTIONS: a) A focused program that applied statistical and scientific quality improvement processes to the practice of intensive care. b) An organized effort to modify the culture, thinking, and behavior of the personnel who practice in the ICU. MEASUREMENTS: Severity of illness, ICU and hospital lengths of stay, ICU and hospital mortality rates, total hospital costs as analyzed by the cost center, and measures of improvement in specific areas of care. MAIN RESULTS: Significant improvement in glucose control, use of enteral feeding, antibiotic use, adult respiratory distress syndrome survival, laboratory use, blood gases use, radiograph use, and appropriate use of sedation. A severity adjusted total hospital cost reduction of $2,580,981 in 1991 dollars when comparing 1995 with the control year of 1991, with 87% of the reduction in those cost centers directly influenced by the intervention. CONCLUSIONS: A focused quality improvement program in the ICU can have a beneficial impact on care and simultaneously reduce costs.

Continuity of care: is it cost effective?

OBJECTIVE: To examine the association between the degree of healthcare provider continuity and healthcare utilization and costs. STUDY DESIGN: A longitudinal, prospective, observational study. PATIENTS AND METHODS: Data on patients with arthritis, asthma, epigastric pain/peptic ulcer disease, hypertension, and otitis media were collected at each of 6 health maintenance organizations (HMOs). Outcome variables included the number of prescriptions for the target disease and the cost, total number of prescriptions and the cost, the number of outpatient visits, and the number of hospital admissions. Disease-specific severity of illness, type of visit, and provider information were obtained at each encounter. HMO profit status, visit copay, gatekeeper strictness, formulary limitations, use of multisource (generic) drugs, gender, number of months in the study, age, and severity of illness were controlled in the analyses. RESULTS: There were 12,997 patients followed for more than 99,000 outpatient visits, 1000 hospitalizations, and more than 240,000 prescriptions. Increasing the number of primary or specialty care providers a patient encountered during the study generally was associated with increased utilization and costs when HMO and patient characteristics were controlled. The number of specialty care providers also increased as the number of primary care providers increased. The incremental increase in pharmacy costs per patient per year with each additional provider ranged between $19 in subjects with otitis media to $58 in subjects with hypertension. CONCLUSIONS: Continuity of care was associated with a reduction in resource utilization and costs. As healthcare delivery systems are designed, care continuity should be promoted.

Cataract surgery with ciliary sulcus fixation of intraocular lenses in patients with uveitis.

PURPOSE: To describe intentional placement of intraocular lens haptics in the ciliary sulcus of patients with uveitis who are at high risk for postoperative posterior synechiae and lens dislocation. METHODS: We reviewed our experience with 16 eyes of 12 patients with uveitis who underwent cataract surgery with ciliary sulcus fixation of intraocular lenses. Patients were followed for a median of 16.5 months (range, 9 to 44 months) after surgery. We evaluated eyes for surgical technique and the following preoperative and postoperative factors: best-corrected visual acuity, intraocular pressure, anterior chamber cells, and posterior synechiae. The following additional postoperative factors were sought: lens dislocation, lens edge capture, and evidence of pigment dispersion. RESULTS: Posterior synechiae were present in 13 eyes before surgery; postoperative posterior synechiae developed in only three of these eyes. These adhesions resulted in lens edge capture in one eye and limited lens decentration in another. Scant pigment was present on the lens optic or in the anterior chamber, suggesting pigment dispersion, in four eyes. We found no evidence of consistently increased anterior segment inflammation or intraocular pressure after surgery when compared with preoperative levels for this group of patients. Postoperative posterior synechiae were seen more often in eyes that had can-opener anterior capsulotomy than in eyes that had continuous, curvilinear capsulorhexis (P = .036). CONCLUSIONS: Ciliary sulcus fixation allows the intraocular lens to serve as a physical barrier between the iris and the lens capsule remnants. This technique may be useful for reducing the risk of postoperative posterior synechiae in patients with uveitis without increasing the risk of other postoperative problems.

Calf-thigh sequential pneumatic compression compared with plantar venous pneumatic compression to prevent deep-vein thrombosis after non-lower extremity trauma.

OBJECTIVE: To compare the effectiveness of calf-thigh sequential pneumatic compression devices with the effectiveness of plantar venous intermittent pneumatic compression devices in prevention of venous thrombosis after major trauma. SUBJECTS AND METHODS: We evaluated 181 consecutive patients after major trauma without lower extremity injuries that precluded the use of pneumatic compression devices. We randomly assigned 149 patients to either calf-thigh sequential pneumatic compression or plantar venous pneumatic compression. After blinding the observers to the method of prophylaxis against deep-vein thrombosis, we performed bilateral compression ultrasonography on or before day 8 after randomization. RESULTS: Among 149 randomized patients, 62 who received calf-thigh sequential pneumatic compression and 62 who received plantar venous intermittent pneumatic compression devices completed the trial. Thirteen patients randomized to plantar venous intermittent pneumatic compression (21.0%) and 4 patients randomized to calf-thigh sequential pneumatic compression (6.5%) had deep-vein thrombosis (p = 0.009). Seven of 13 patients with deep-vein thrombosis after prophylaxis with plantar venous intermittent pneumatic compression had bilateral deep-vein thromboses, whereas all 4 patients with deep-vein thrombosis after prophylaxis with calf-thigh sequential pneumatic compression had unilateral deep-vein thrombosis. CONCLUSION: Calf-thigh sequential pneumatic compression prevents deep-vein thrombosis more effectively than plantar venous intermittent pneumatic compression after major trauma without lower extremity injuries.

Formulary limitations and the elderly: results from the Managed Care Outcomes Project.

OBJECTIVE: To examine whether restrictive formularies are associated with differences in healthcare resource utilization, including number of office visits, prescriptions, and hospitalizations, and whether this association varies by age. STUDY DESIGN: Cross-sectional, longitudinal study. PATIENTS AND METHODS: Patients enrolled in one of six health maintenance organizations in six different states, three in the eastern and three in the western United States, were eligible for the study. Data from between 1309 and 3938 patients were available for analysis for each of the five diseases studied, for a total of 12,997 patients across all study diseases. Healthcare utilization by patients in the study included more than 99,000 office visits, 1000 hospitalizations, and 240,000 prescriptions. We used severity-adjusted prescription counts, prescription costs, office visit counts, and measures of inpatient hospital utilization to assess the effects of formulary limitations. RESULTS: We found positive, significant associations between the independent variable formulary limitations in drug class and the dependent variables measuring resource utilization. These associations were sometimes significantly greater for elderly patients after controlling for severity of illness and other variables. CONCLUSIONS: Common strategies for decreasing drug expenditures may be associated with higher severity-adjusted resource utilization. In specific areas, this association is more pronounced in the elderly.

Overcoming obstacles to effective treatment: use of clinical practice improvement methodology.

Clinical practice improvement (CPI) is a method for examining the steps of a care process to determine how to achieve the best medical outcomes at the least necessary cost over the continuum of a patient's care. This methodology includes tracking of medical care process factors (management strategies, interventions, medications), patient factors (physiologic severity of illness and psychosocial deviations at each visit), and outcomes and furnishes information that presents distinct advantages over information furnished by outcomes research or clinical trials in the designing of management protocols. The Managed Care Outcomes Project, a large-scale CPI study, examined the effects of health maintenance organization (HMO) cost-containment strategies on patient outcome and utilization of care. Approximately 13,000 patients with otitis media, arthritis, hypertension, asthma, or ulcer disease were analyzed; since all patient diagnoses and medication use were captured in the CPI model, my colleagues and I were able to assess factors in psychiatric illness diagnosis, treatment, and outcome. Among the findings were the following: (1) the majority of patients receiving psychiatric drugs do not have a specific psychiatric diagnosis; (2) a significant proportion of patients with a specific diagnosis of major depression do not receive antidepressant medication; (3) cost-containment strategies appeared to markedly limit psychiatric referral and frequency of visits and use of serotonin selective reuptake inhibitor treatment; and (4) severity of the primary illness in the study population was markedly increased in patients with a psychiatric diagnosis. Further analysis of data from this study may help to determine which processes of care for depression were associated with better outcomes.

A comparison of the accuracy and reproducibility of digital three-dimensional coronary artery reconstructions using edge detection or videodensitometry.

Global quantitative three-dimensional measurements of coronary arteries may be helpful in determining the functional significance of various forms of coronary pathology. A computerized system has been developed that is capable of performing 3-D reconstruction of digitized images obtained from multiple coronary angiographic views using either automated edge detection (AED) or videodensitometric (VD) techniques. To compare the accuracy and reproducibility of measurements obtained from this system using either technique, stationary and moving coronary aluminum 3-D phantoms, each with 13 branches (diameter 0.58-6.35 mm, length 21.5-64.5 mm), were imaged and reconstructed 10 separate times each. Individual branch lengths and diameters were calculated and compared to each other and to known values. Diameter measurements were compared using either AED or VD. Intraclass correlation coefficients between observed values (ICC) for vessel length were r = 0.89 for the stationary and r = 0.97 for the moving phantom. ICCs for vessel diameter were r = 0.93 (AED) and r = 0.95 (VD) for the stationary and r = 0.98 (AED) and r = 0.97 (VD) for the moving phantom. Mean differences (+/-SD) between true and observed values [MDTO(+/-SD)] for vessel length were -1.0 +/- 3.9 mm for the stationary and -3.5 +/- 3.2 mm for the moving phantom. MDTO(+/-SD) for vessel diameter were -0.10 +/- 0.52 mm (AED) and +0.03 +/- 0.30 mm (VD) for the stationary and -0.21 +/- 0. 44 mm (AED) and -0.12 +/- 0.33 (VD) for the moving phantom. We conclude that the quantitative accuracy and reproducibility of measurements obtained by computerized 3-D reconstruction of coronary model phantoms is of high enough quality to warrant further clinical evaluation. VD appears to be more accurate than AED for measuring vessel diameter.

Lessons from evaluating an automated patient severity index.

OBJECTIVE: To report lessons learned from evaluation of an automated interface between a hospital clinical information system and a severity of illness index. DESIGN: A system was developed to convert coded electronic patient findings from the HELP System at LDS Hospital into the attributes used by the Computerized Severity Index (CSI) to calculate a severity of illness score. Performance was assessed by comparing the automated CSI score with the manual CSI score (from paper chart review) and by evaluating changes introduced by augmenting the manual CSI score with verified patient data discovered by the automated CSI method. MEASUREMENTS: The strengths and weaknesses of each method are presented. RESULTS: The automated CSI score matched the manual CSI score in 61% of the cases. Sources of errors were analyzed. When the automated score was in error, two-thirds of the time it was due to the lack of codes in the HELP system representing CSI concepts; one-third of the time it was due to nurses not using established HELP system codes. Surprisingly, significant problems were also discovered in the manual system, making it difficult to define a "gold standard". CONCLUSIONS: Automated computerized severity indices have great potential for future applicability once their performance exceeds that of the time-consuming manual chart review method. Neither automated nor manual methods are adequate at the present time. This area remains a fertile ground for future research.

A cohort analysis of pre-menopausal women with dysfunctional uterine bleeding.

OBJECTIVE: To examine the clinical and cost outcomes of patients with dysfunctional uterine bleeding (DUB) who are treated with hysterectomy or not. DESIGN: A retrospective analysis of DUB patients over 30 months of treatment after initial diagnosis. SETTING: Patients with DUB from an HMO with over 200,000 enrollees. PARTICIPANTS: Study patients, all women with an initial diagnosis of DUB, were divided into two cohorts. Cohort 1 was women who had a hysterectomy (not for cancer); Cohort 2 was women who did not have a hysterectomy. MAIN OUTCOME MEASURES: Visit counts and costs, prescription counts and costs, hospital costs, and procedure counts. RESULTS: Hysterectomy patients in our dataset tend to have more prescriptions, higher prescription costs, more visits overall, higher visit costs, higher hospitalization costs, and higher total costs per member per month (PMPM) than non-hysterectomy patients. After surgery, the hysterectomy patients' costs and utilization PMPM are higher than those for the non-hysterectomy patients. CONCLUSIONS: There is wide variation in the treatment of patients with DUB. Clinical practice improvement studies are needed to determine the appropriate treatments based on patient characteristics to achieve better outcomes for lower costs.

The clinical practice improvement (CPI) model and how it is used to examine the availability of pharmaceuticals and the utilisation of ambulatory healthcare services in HMOs. Results from the Managed Care Outcomes Project (MCOP).

Many American healthcare facilities have come to understand that quality controls cost. Clinical practice improvement (CPI) is a methodology that creates a clinical laboratory, built into the everyday practice setting, to find and test best practices. A CPI study is an analysis of the content and timing of individual steps in a medical care process aimed at producing better clinical outcomes for the least necessary cost over the continuum of a patient's care. Statistical regression analyses are used to determine whether and how much a particular step actually improves medical outcomes. Systematic determination of individual process steps that improve medical outcomes is the best way to develop demonstrably better care and practice. Combining CPI methodology and a data monitor creates a dynamic environment in which all patient encounters potentially contribute to improving the process of care. We describe a recent multisite study: the Managed Care Outcomes Project (MCOP). The MCOP study design permits us to compare the effects of various pharmaceutical treatments on resource utilisation in actual practice in managed-care organisations. The MCOP database is an important resource for developing information required to design systems-based disease management programmes.