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1.
Qual Saf Health Care ; 19(4): 279-83, 2010 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20630931

RESUMO

BACKGROUND: The diversity of quality improvement interventions (QIIs) has impeded the use of evidence review to advance quality improvement activities. An agreed-upon framework for identifying QII articles would facilitate evidence review and consensus around best practices. AIM: To adapt and test evidence review methods for identifying empirical QII evaluations that would be suitable for assessing QII effectiveness, impact or success. DESIGN: Literature search with measurement of multilevel inter-rater agreement and review of disagreement. METHODS: Ten journals (2005-2007) were searched electronically and the output was screened based on title and abstract. Three pairs of reviewers then independently rated 22 articles, randomly selected from the screened list. Kappa statistics and percentage agreement were assessed. 12 stakeholders in quality improvement, including QII experts and journal editors, rated and discussed publications about which reviewers disagreed. RESULTS: The level of agreement among reviewers for identifying empirical evaluations of QII development, implementation or results was 73% (with a paradoxically low kappa of 0.041). Discussion by raters and stakeholders regarding how to improve agreement focused on three controversial article selection issues: no data on patient health, provider behaviour or process of care outcomes; no evidence for adaptation of an intervention to a local context; and a design using only observational methods, as correlational analyses, with no comparison group. CONCLUSION: The level of reviewer agreement was only moderate. Reliable identification of relevant articles is an initial step in assessing published evidence. Advancement in quality improvement will depend on the theory- and consensus-based development and testing of a generalizable framework for identifying QII evaluations.


Assuntos
Bibliometria , Pesquisa Comparativa da Efetividade , Estudos de Avaliação como Assunto , Melhoria de Qualidade/tendências , Consenso , Medicina Baseada em Evidências , Humanos , Variações Dependentes do Observador , Publicações Periódicas como Assunto , Editoração/tendências , Estados Unidos
2.
Qual Saf Health Care ; 17(6): 403-8, 2008 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-19064654

RESUMO

BACKGROUND: Stakeholders in quality improvement agree on the need for augmenting and synthesising the scientific literature supporting it. The diversity of perspectives, approaches, and contexts critical to advancing quality improvement science, however, creates challenges. The paper explores the heterogeneity in clinical quality improvement intervention (QII) publications. METHODS: A preliminary classification framework was developed for QII articles, aiming for categories homogeneous enough to support coherent scientific discussion on QII reporting standards and facilitate systematic review. QII experts were asked to identify articles important to QII science. The framework was tested and revised by applying it to the article set. The final framework screened articles into (1) empirical literature on development and testing of QIIs; (2) QII stories, theories, and frameworks; (3) QII literature syntheses and meta-analyses; or (4) development and testing of QII-related tools. To achieve homogeneity, category (1) required division into (1a) development of QIIs; 1(b) history, documentation, or description of QIIs; or (1c) success, effectiveness or impact of QIIs. RESULTS: By discussing unique issues and established standards relevant to each category, QII stakeholders can advance QII practice and science, including the scope and conduct of systematic literature reviews.


Assuntos
Publicações/normas , Garantia da Qualidade dos Cuidados de Saúde
3.
Qual Saf Health Care ; 17 Suppl 1: i13-32, 2008 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-18836062

RESUMO

As the science of quality improvement in health care advances, the importance of sharing its accomplishments through the published literature increases. Current reporting of improvement work in health care varies widely in both content and quality. It is against this backdrop that a group of stakeholders from a variety of disciplines has created the Standards for QUality Improvement Reporting Excellence, which we refer to as the SQUIRE publication guidelines or SQUIRE statement. The SQUIRE statement consists of a checklist of 19 items that authors need to consider when writing articles that describe formal studies of quality improvement. Most of the items in the checklist are common to all scientific reporting, but virtually all of them have been modified to reflect the unique nature of medical improvement work. This "Explanation and Elaboration" document (E & E) is a companion to the SQUIRE statement. For each item in the SQUIRE guidelines the E & E document provides one or two examples from the published improvement literature, followed by an analysis of the ways in which the example expresses the intent of the guideline item. As with the E & E documents created to accompany other biomedical publication guidelines, the purpose of the SQUIRE E & E document is to assist authors along the path from completion of a quality improvement project to its publication. The SQUIRE statement itself, this E & E document, and additional information about reporting improvement work can be found at http://www.squire-statement.org.


Assuntos
Editoração/normas , Qualidade da Assistência à Saúde , Pesquisa sobre Serviços de Saúde/normas
4.
Gen Hosp Psychiatry ; 23(5): 239-53, 2001.
Artigo em Inglês | MEDLINE | ID: mdl-11600165

RESUMO

It is difficult to evaluate the promise of primary care quality-improvement interventions for depression because published studies have evaluated diverse interventions by using different research designs in dissimilar populations. Preplanned meta-analysis provides an alternative to derive more precise and generalizable estimates of intervention effects; however, this approach requires the resolution of analytic challenges resulting from design differences that threaten internal and external validity. This paper describes the four-project Quality Improvement for Depression (QID) collaboration specifically designed for preplanned meta-analysis of intervention effects on outcomes. This paper summarizes the interventions the four projects tested, characterizes commonalities and heterogeneity in the research designs used to evaluate these interventions, and discusses the implications of this heterogeneity for preplanned meta-analysis.


Assuntos
Transtorno Depressivo/terapia , Equipe de Assistência ao Paciente , Gestão da Qualidade Total , Adulto , Estudos de Avaliação como Assunto , Feminino , Humanos , Masculino , Metanálise como Assunto , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Atenção Primária à Saúde , Ensaios Clínicos Controlados Aleatórios como Assunto , Reprodutibilidade dos Testes , Projetos de Pesquisa , Estados Unidos
5.
JAMA ; 286(11): 1325-30, 2001 Sep 19.
Artigo em Inglês | MEDLINE | ID: mdl-11560537

RESUMO

CONTEXT: Depression is a leading cause of disability worldwide, but treatment rates in primary care are low. OBJECTIVE: To determine the cost-effectiveness from a societal perspective of 2 quality improvement (QI) interventions to improve treatment of depression in primary care and their effects on patient employment. DESIGN: Group-level randomized controlled trial conducted June 1996 to July 1999. SETTING: Forty-six primary care clinics in 6 community-based managed care organizations. PARTICIPANTS: One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression. INTERVENTIONS: Matched practices were randomly assigned to provide usual care (n = 443 patients) or to 1 of 2 QI interventions offering training to practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication follow-up (QI-meds; n = 424 patients) or trained local psychotherapists (QI-therapy; n = 489). Practices could flexibly implement the interventions, which did not assign type of treatment. MAIN OUTCOME MEASURES: Total health care costs, costs per quality-adjusted life-year (QALY), days with depression burden, and employment over 24 months, compared between usual care and the 2 interventions. RESULTS: Relative to usual care, average health care costs increased $419 (11%) in QI-meds (P =.35) and $485 (13%) in QI-therapy (P =.28); estimated costs per QALY gained were between $15 331 and $36 467 for QI-meds and $9478 and $21 478 for QI-therapy; and patients had 25 (P =.19) and 47 (P =.01) fewer days with depression burden and were employed 17.9 (P =.07) and 20.9 (P =.03) more days during the study period. CONCLUSIONS: Societal cost-effectiveness of practice-initiated QI efforts for depression is comparable with that of accepted medical interventions. The intervention effects on employment may be of particular interest to employers and other stakeholders.


Assuntos
Transtorno Depressivo/economia , Transtorno Depressivo/terapia , Medicina de Família e Comunidade/economia , Medicina de Família e Comunidade/normas , Programas de Assistência Gerenciada/normas , Serviços de Saúde Mental/normas , Atenção Primária à Saúde/normas , Garantia da Qualidade dos Cuidados de Saúde/economia , Efeitos Psicossociais da Doença , Análise Custo-Benefício , Emprego , Custos de Cuidados de Saúde/estatística & dados numéricos , Pesquisa sobre Serviços de Saúde/métodos , Humanos , Programas de Assistência Gerenciada/economia , Serviços de Saúde Mental/economia , Avaliação de Processos e Resultados em Cuidados de Saúde , Atenção Primária à Saúde/economia , Anos de Vida Ajustados por Qualidade de Vida , Estados Unidos
6.
Arch Gen Psychiatry ; 58(7): 696-703, 2001 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-11448378

RESUMO

BACKGROUND: This article addresses whether dissemination of short-term quality improvement (QI) interventions for depression to primary care practices improves patients' clinical outcomes and health-related quality of life (HRQOL) over 2 years, relative to usual care (UC). METHODS: The sample included 1299 patients with current depressive symptoms and 12-month, lifetime, or no depressive disorder from 46 primary care practices in 6 managed care organizations. Clinics were randomized to UC or 1 of 2 QI programs that included training local experts and nurse specialists to provide clinician and patient education, assessment, and treatment planning, plus either nurse care managers for medication follow-up (QI-meds) or access to trained psychotherapists (QI-therapy). Outcomes were assessed every 6 months for 2 years. RESULTS: For most outcomes, differences between intervention and UC patients were not sustained for the full 2 years. However, QI-therapy reduced overall poor outcomes compared with UC by about 8 percentage points throughout 2 years, and by 10 percentage points compared with QI-meds at 24 months. Both interventions improved patients' clinical and role outcomes, relative to UC, over 12 months (eg, a 10-11 and 6-7 percentage point difference in probable depression at 6 and 12 months, respectively). CONCLUSIONS: While most outcome improvements were not sustained over the full 2 study years, findings suggest that flexible dissemination of short-term, QI programs in managed primary care can improve patient outcomes well after program termination. Models that support integrated psychotherapy and medication-based treatment strategies in primary care have the potential for relatively long-term patient benefits.


Assuntos
Transtorno Depressivo/terapia , Atenção Primária à Saúde/organização & administração , Adulto , Antidepressivos/uso terapêutico , Terapia Cognitivo-Comportamental , Feminino , Nível de Saúde , Humanos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Planejamento de Assistência ao Paciente , Equipe de Assistência ao Paciente , Atenção Primária à Saúde/métodos , Psicoterapia/métodos , Qualidade de Vida
7.
J Gen Intern Med ; 15(12): 868-77, 2000 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-11119183

RESUMO

OBJECTIVE: We evaluated the effect of implementing quality improvement (QI) programs for depression, relative to usual care, on primary care clinicians' knowledge about treatment. DESIGN AND METHODS: Matched primary care clinics (46) from seven managed care organizations were randomized to usual care (mailed written guidelines only) versus one of two QI interventions. Self-report surveys assessed clinicians' knowledge of depression treatments prior to full implementation (June 1996 to March 1997) and 18 months later. We used an intent-to-treat analysis to examine intervention effects on change in knowledge, controlling for clinician and practice characteristics, and the nested design. PARTICIPANTS: One hundred eighty-one primary care clinicians. INTERVENTIONS: The interventions included institutional commitment to QI, training local experts, clinician education, and training nurses for patient assessment and education. One intervention had resources for nurse follow-up on medication use (QI-meds) and the other had reduced copayment for therapy from trained, local therapists (QI-therapy). RESULTS: Clinicians in the intervention group had greater increases compared with clinicians in the usual care group over 18 months in knowledge of psychotherapy (by 20% for QI-meds, P =.04 and by 33% for QI-therapy, P =.004), but there were no significant increases in medication knowledge. Significant increases in knowledge scores (P =.01) were demonstrated by QI-therapy clinicians but not clinicians in the QI-meds group. Clinicians were exposed to multiple intervention components. CONCLUSIONS: Dissemination of QI programs for depression in managed, primary care practices improved clinicians' treatment knowledge over 18 months, but breadth of learning was somewhat greater for a program that also included active collaboration with local therapists.


Assuntos
Depressão , Educação Médica Continuada , Programas de Assistência Gerenciada/normas , Atenção Primária à Saúde/normas , Gestão da Qualidade Total/métodos , Adulto , Antidepressivos/uso terapêutico , Competência Clínica , Depressão/diagnóstico , Depressão/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Psicoterapia , Encaminhamento e Consulta , Inquéritos e Questionários , Estados Unidos
8.
Med Care ; 38(11): 1074-91, 2000 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-11078049

RESUMO

BACKGROUND: Nurses' independent decisions about assessment, treatment, and nursing interventions for hospitalized patients are important determinants of quality of care. Physician peer implicit review of medical records has been central to Medicare quality management and is considered the gold standard for reviewing physician care, but peer implicit review of nursing processes of care has not received similar attention. OBJECTIVE: The objective of this study was to develop and evaluate nurse structured implicit review (SIR) methods. RESEARCH DESIGN: We developed SIR instruments for rating the quality of inpatient nursing care for congestive heart failure (CHF) and cerebrovascular accident (CVA). Nurse reviewers used the SIR form to rate a nationally representative sample of randomly selected medical records for each disease from 297 acute care hospitals in 5 states (collected by the RAND-HCFA Prospective Payment System study). SUBJECTS: The study subjects were elderly Medicare inpatients with CHF (n = 291) or CVA (n = 283). MEASURES: We developed and tested scales reflecting domains of nursing process, evaluated interrater and interitem reliability, and assessed the extent to which items and scales predicted overall ratings of the quality of nursing care. RESULTS: Interrater reliability for 14 of 16 scales (CHF) or 10 of 16 scales (CVA) was > or = 0.40. Interitem reliability was > 0.80 for all but 1 scale (both diseases). Functional Assessment, Physical Assessment, and Medication Tracking ratings were the strongest predictors of overall nursing quality ratings (P < 0.001 for each). CONCLUSIONS: Nurse peer review with SIR has adequate interrater and excellent scale reliabilities and can be a valuable tool for assessing nurse performance.


Assuntos
Insuficiência Cardíaca/enfermagem , Auditoria de Enfermagem/métodos , Serviço Hospitalar de Enfermagem/normas , Garantia da Qualidade dos Cuidados de Saúde/métodos , Acidente Vascular Cerebral/enfermagem , Idoso , Idoso de 80 Anos ou mais , California , Feminino , Florida , Humanos , Indiana , Masculino , Pesquisa em Avaliação de Enfermagem , Processo de Enfermagem/normas , Variações Dependentes do Observador , Pennsylvania , Valor Preditivo dos Testes , Texas
9.
J Gen Intern Med ; 15(6): 381-8, 2000 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-10886472

RESUMO

OBJECTIVE: To determine patient and provider characteristics associated with increased risk of nondetection of mental health problems by primary care physicians. DESIGN: Cross-sectional patient and physician surveys conducted as part of the Medical Outcomes Study. PARTICIPANTS: We studied 19,309 patients and 349 internists and family physicians. MEASUREMENTS AND MAIN RESULTS: We counted "detection" of a mental health problem whenever physicians reported, in a postvisit survey, that they thought the patient had a mental health problem or that they had counseled or referred the patient for mental health. Key independent variables included patient self-reported demographic characteristics, health-related quality of life (HRQOL), depression diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders, and physician demographics and proclivity to provide counseling for depression. Logistic regression analysis, adjusted for HRQOL, revealed physicians were less likely to detect mental health problems in African Americans (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.46 to 0.86), men (OR, 0.64; 95% CI, 0.54 to 0.75), and patients younger than 35 years (OR, 0.61; 95% CI, 0.44 to 0.84), and more likely to detect them in patients with diabetes (OR, 1.4; 95% CI, 1.0 to 1.8) or hypertension (OR, 1.3; 95% CI, 1.1 to 1.6). In a model that included DSM-III diagnoses, odds of detection remained reduced for African Americans as well as for Hispanics (OR, 0.29; 95% CI, 0.11 to 0.71), and patients with more-severe DSM-III diagnoses were more likely to be detected. Physician proclivity toward providing counseling for depression influenced the likelihood of detection. CONCLUSIONS: Patients' race, gender, and coexisting medical conditions affected physician awareness of mental health problems. Strategies to improve detection of mental health problems among African Americans, Hispanics, and men should be explored and evaluated.


Assuntos
Transtornos Mentais/diagnóstico , Atenção Primária à Saúde , Asiático , Comorbidade , Estudos Transversais , Depressão/diagnóstico , Feminino , Hispânico ou Latino , Humanos , Modelos Logísticos , Masculino , Transtornos Mentais/epidemiologia , Transtornos Mentais/etnologia , Pessoa de Meia-Idade , Estados Unidos/epidemiologia
10.
Med Care ; 38(6 Suppl 1): I129-41, 2000 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-10843277

RESUMO

Basic science and health care research provide the evidence base for the scientific practice of medicine. Over the past 2 decades, as increasingly refined tools for improving health and health care have been developed, the health care community has attempted to bridge the gap between available tools and actual health care practices. This gap can be bridged only by influencing health care provider behavior. The VA Quality Enhancement Research Initiative (QUERI) is a program designed to systematically translate research findings into better health care practices, and thus better health outcomes for enrolled veterans. Integrating provider behavior research considerations and findings into each step of the QUERI process will enhance the effectiveness of the initiative. This article presents a provider behavior research framework for planning, implementing, and evaluating quality improvement interventions within QUERI.


Assuntos
Pesquisa sobre Serviços de Saúde/organização & administração , Modelos Organizacionais , Padrões de Prática Médica/organização & administração , Gestão da Qualidade Total/organização & administração , United States Department of Veterans Affairs/organização & administração , Benchmarking/organização & administração , Medicina Baseada em Evidências , Humanos , Serviços de Informação/organização & administração , Inovação Organizacional , Política Organizacional , Avaliação de Processos e Resultados em Cuidados de Saúde/organização & administração , Estados Unidos
11.
JAMA ; 283(2): 212-20, 2000 Jan 12.
Artigo em Inglês | MEDLINE | ID: mdl-10634337

RESUMO

CONTEXT: Care of patients with depression in managed primary care settings often fails to meet guideline standards, but the long-term impact of quality improvement (QI) programs for depression care in such settings is unknown. OBJECTIVE: To determine if QI programs in managed care practices for depressed primary care patients improve quality of care, health outcomes, and employment. DESIGN: Randomized controlled trial initiated from June 1996 to March 1997. SETTING: Forty-six primary care clinics in 6 US managed care organizations. PARTICIPANTS: Of 27332 consecutively screened patients, 1356 with current depressive symptoms and either 12-month, lifetime, or no depressive disorder were enrolled. INTERVENTIONS: Matched clinics were randomized to usual care (mailing of practice guidelines) or to 1 of 2 QI programs that involved institutional commitment to QI, training local experts and nurse specialists to provide clinician and patient education, identification of a pool of potentially depressed patients, and either nurses for medication follow-up or access to trained psychotherapists. MAIN OUTCOME MEASURES: Process of care (use of antidepressant medication, mental health specialty counseling visits, medical visits for mental health problems, any medical visits), health outcomes (probable depression and health-related quality of life [HRQOL]), and employment at baseline and at 6- and 12-month follow-up. RESULTS: Patients in QI (n = 913) and control (n = 443) clinics did not differ significantly at baseline in service use, HRQOL, or employment after nonresponse weighting. At 6 months, 50.9% of QI patients and 39.7% of controls had counseling or used antidepressant medication at an appropriate dosage (P<.001), with a similar pattern at 12 months (59.2% vs 50.1%; P = .006). There were no differences in probability of having any medical visit at any point (each P > or = .21). At 6 months, 47.5% of QI patients and 36.6% of controls had a medical visit for mental health problems (P = .001), and QI patients were more likely to see a mental health specialist at 6 months (39.8% vs 27.2%; P<.001) and at 12 months (29.1% vs 22.7%; P = .03). At 6 months, 39.9% of QI patients and 49.9% of controls still met criteria for probable depressive disorder (P = .001), with a similar pattern at 12 months (41.6% vs 51.2%; P = .005). Initially employed QI patients were more likely to be working at 12 months relative to controls (P = .05). CONCLUSIONS: When these managed primary care practices implemented QI programs that improve opportunities for depression treatment without mandating it, quality of care, mental health outcomes, and retention of employment of depressed patients improved over a year, while medical visits did not increase overall.


Assuntos
Transtorno Depressivo/terapia , Medicina de Família e Comunidade/normas , Programas de Assistência Gerenciada/normas , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Adulto , Feminino , Pesquisa sobre Serviços de Saúde/métodos , Humanos , Serviços de Informação , Masculino , Avaliação de Programas e Projetos de Saúde , Qualidade da Assistência à Saúde , Perfil de Impacto da Doença , Estados Unidos
12.
Health Serv Res ; 34(5 Pt 1): 1011-32, 1999 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-10591270

RESUMO

OBJECTIVE: Through a review of the literature, to identify and describe (1) empirical studies of inpatient nursing care quality that evaluate links between nursing care processes and health-related patient outcomes, (2) nursing care processes for which process-outcome links have been established, and (3) important nursing care processes that have not yet been evaluated. DATA SOURCES/STUDY SETTING: Published empirical studies of inpatient nursing care quality that evaluated links between processes of nursing care and health-related patient outcomes. STUDY DESIGN/DATA COLLECTION/EXTRACTION METHODS: This literature review used a five-step article search and review method. PRINCIPAL FINDINGS: Of 257 data-based studies of nursing care quality identified, 135 investigated a process-outcome link but only 17 met study inclusion criteria. The literature provides evidence that the quality of nursing care processes affects health-related patient outcomes during and after hospitalization. Gaps in the literature that evaluates nursing quality are identified. CONCLUSIONS: Although some nursing care processes affect health-related patient outcomes, the full extent of nursing process-outcome links is relatively understudied. Further evaluation of the interrelationships between nursing care processes and outcomes is critical.


Assuntos
Processo de Enfermagem , Recursos Humanos de Enfermagem Hospitalar , Avaliação de Processos e Resultados em Cuidados de Saúde , Humanos , Pesquisa em Enfermagem , Qualidade da Assistência à Saúde , Resultado do Tratamento
13.
Arch Fam Med ; 8(6): 529-36, 1999.
Artigo em Inglês | MEDLINE | ID: mdl-10575393

RESUMO

OBJECTIVE: To evaluate the process and quality of care for primary care patients with depression under managed care organizations. METHOD: Surveys of 1204 outpatients with depression at the time of and after a visit to 1 of 181 primary care clinicians from 46 primary care clinics in 7 managed care organizations. Patients had depressive symptoms in the previous 30 days, with or without a 12-month depressive disorder by diagnostic interview. Process indicators were depression counseling, mental health referral, or psychotropic medication management at index visit and the use of appropriate antidepressant medication during the last 6 months. RESULTS: Of patients with depressive disorder and recent symptoms, 29% to 43% reported a depression-specific process of care in the index visit, and 35% to 42% used antidepressant medication in appropriate dosages in the prior 6 months. Patients with depressive disorders rather than symptoms only and those with comorbid anxiety had higher rates of depression-specific processes and quality of care (P < .005). Recurrent depression, suicidal ideation, and alcohol abuse were not uniquely associated with such rates. Patients visiting for old problems or checkups received more depression-specific care than those with new problems or unscheduled visits. The 7 managed care organizations varied by a factor of 2-fold in rates of depression counseling and appropriate anti-depressant use. CONCLUSIONS: Rates of process and quality of care for depression as reported by patients are moderate to low in managed primary care practices. Such rates are higher for patients with more severe forms of depression or with comorbid anxiety, but not for those with severe but "silent" symptoms like suicide ideation. Visit context factors, such as whether the visit is scheduled, affect rates of depression-specific care. Rates of care for depression are highly variable among managed care organizations, emphasizing the need for process monitoring and quality improvement for depression at the organizational level.


Assuntos
Depressão/terapia , Programas de Assistência Gerenciada/normas , Serviços de Saúde Mental/normas , Atenção Primária à Saúde/normas , Qualidade da Assistência à Saúde , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores Socioeconômicos , Estados Unidos
14.
Health Aff (Millwood) ; 18(5): 89-105, 1999.
Artigo em Inglês | MEDLINE | ID: mdl-10495595

RESUMO

This paper evaluates whether externally designed, evidence-based interventions for improving care for depression can be locally implemented in managed care organizations. The interventions were carried out as part of a randomized trial involving forty-six practices within six diverse, nonacademic managed care plans. Based on evaluation of adherence to the intervention protocol, we determined that local practice leaders are able to implement predesigned interventions for improving depression care. Adherence rates for most key intervention activities were above 70 percent, and many were near 100 percent. Three intervention activities fell short of the goal of 70 percent implementation and should be targets for future improvement.


Assuntos
Transtorno Depressivo/terapia , Medicina Baseada em Evidências , Programas de Assistência Gerenciada , Equipe de Assistência ao Paciente , Transtorno Depressivo/diagnóstico , Humanos , Avaliação de Resultados em Cuidados de Saúde , Atenção Primária à Saúde , Garantia da Qualidade dos Cuidados de Saúde , Estados Unidos
15.
Med Care ; 37(8): 738-47, 1999 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-10448717

RESUMO

OBJECTIVE: This study assesses the effects of competing demands, such as poor health habits or new medical problems, on health-habit counseling during a primary care visit. METHODS: We surveyed a consecutive sample of 1,259 patients visiting primary care clinicians at an academic VA medical center. Before the visit, patients reported their health status, health habits, and sociodemographics; immediately after the visit, patients reported reasons for the visit and whether they had been counseled about specific health habits. We scored visit acuity ranging from visits for unscheduled walk-in care or new medical problems to scheduled visits for check-ups or old problems. We defined counseling "triggers" as clinical indications for counseling about particular health habits (e.g., smoking). We developed a logistic model predicting primary care provider counseling during a visit. RESULTS: Over two-thirds of patients (68.9%) received some health habit counseling. Controlling for other independent variables, patients with more triggers were more likely to report being counseled. Counseling rates went up as visit acuity went down; patients with the lowest visit acuity having 67% greater odds of being counseled than patients with the highest visit acuity. CONCLUSIONS: Physicians set priorities for health-habit counseling during a visit based on patients' health habit problems or triggers; whether the visit is scheduled or walk-in; and whether the patient has new or acute problems. Future research about primary care performance of health habit counseling should account for these patient and visit characteristics, and prevention-oriented health care organizations should ensure access to scheduled "check-up" visits.


Assuntos
Aconselhamento/estatística & dados numéricos , Hábitos , Comportamentos Relacionados com a Saúde , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Idoso , California , Estudos de Coortes , Humanos , Funções Verossimilhança , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Razão de Chances , Inquéritos e Questionários , Estados Unidos , United States Department of Veterans Affairs
16.
J Gen Intern Med ; 14(1): 39-48, 1999 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-9893090

RESUMO

OBJECTIVE: To compare primary care providers' depression-related knowledge, attitudes, and practices and to understand how these reports vary for providers in staff or group-model managed care organizations (MCOs) compared with network-model MCOs including independent practice associations and preferred provider organizations. DESIGN: Survey of primary care providers' depression-related practices in 1996. SETTING AND PARTICIPANTS: We surveyed 410 providers, from 80 outpatient clinics, in 11 MCOs participating in four studies designed to improve the quality of depression care in primary care. MEASUREMENTS AND MAIN RESULTS: We measured knowledge based on depression guidelines, attitudes (beliefs about burden, skill, and barriers) related to depression, and reported behavior. Providers in both types of MCO are equally knowledgeable about treating depression (better knowledge of pharmacologic than psychotherapeutic treatments) and perceive equivalent skills in treating depression. However, compared with network-model providers, staff/group-model providers have stronger beliefs that treating depression is burdensome to their practice. While more staff/group-model providers reported time limitations as a barrier to optimal depression treatment, more network-model providers reported limited access to mental health specialty referral as a barrier. Accordingly, these staff/group-model providers are more likely to treat patients with major depression through referral (51% vs 38%) or to assess but not treat (17% vs 7%), and network-model providers are more likely to prescribe antidepressants (57% vs 6%) as first-line treatment. CONCLUSIONS: Whereas the providers from staff/group-model MCOs had greater access to and relied more on referral, the providers from network-model organizations were more likely to treat depression themselves. Given varying attitudes and behaviors, improving primary care for the treatment of depression will require unique strategies beyond enhancing technical knowledge for the two types of MCOs.


Assuntos
Depressão/terapia , Conhecimentos, Atitudes e Prática em Saúde , Programas de Assistência Gerenciada/organização & administração , Padrões de Prática Médica , Atenção Primária à Saúde , Distribuição de Qui-Quadrado , Humanos , Modelos Organizacionais , Garantia da Qualidade dos Cuidados de Saúde , Análise de Regressão , Estatísticas não Paramétricas , Inquéritos e Questionários
18.
Am J Manag Care ; 3(11): 1679-87, 1997 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-10178466

RESUMO

Patient referral from generalists to specialists is a critical clinic care process that has received relatively little scrutiny, especially in academic settings. This study describes the frequency with which patients enrolled in a prepaid health plan were referred to specialists by general internal medicine faculty members, general internal medicine track residents, and other internal medicine residents; the types of clinicians they were referred to; and the types of diagnoses with which they presented to their primary care physicians. Requested referrals for all 2,113 enrolled prepaid health plan patients during a 1-year period (1992-1993) were identified by computer search of the practice's administrative database. The plan was a full-risk contract without carve-out benefits. We assessed the referral request rate for the practice and the mean referral rate per physician. We also determined the percentage of patients with diagnoses based on the International Classification of Diseases, 9th revision, who were referred to specialists. The practice's referral request rate per 100 patient office visits for all referral types was 19.8. Primary care track residents referred at a higher rate than did nonprimary care track residents (mean 23.7 vs. 12.1; P < .001). The highest referral rate (2.0/100 visits) was to dermatology. Almost as many (1.7/100 visits) referrals were to other "expert" generalists within the practice. The condition most frequently associated with referral to a specialist was depression (42%). Most referrals were associated with common ambulatory care diagnoses that are often considered to be within the scope of generalist practice. To improve medical education about referrals, a better understanding of when and why faculty and trainees refer and don't refer is needed, so that better models for appropriate referral can be developed.


Assuntos
Centros Médicos Acadêmicos/estatística & dados numéricos , Prática de Grupo Pré-Paga/estatística & dados numéricos , Medicina Interna , Medicina , Encaminhamento e Consulta/estatística & dados numéricos , Especialização , Centros Médicos Acadêmicos/organização & administração , California , Capitação , Serviços Contratados , Doença/classificação , Humanos , Medicina Interna/educação , Medicina Interna/estatística & dados numéricos , Internato e Residência , Medicina/estatística & dados numéricos , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/estatística & dados numéricos
19.
Arch Intern Med ; 157(5): 513-20, 1997 Mar 10.
Artigo em Inglês | MEDLINE | ID: mdl-9066455

RESUMO

OBJECTIVE: To determine the relationship of surgical repair of acute hip fracture within 2 days of hospital admission, followed by more than 5 sessions per week of physical and occupational therapy (PT/OT), to outcomes after acute hip fracture. DESIGN: Comparison of hip fracture outcomes via secondary analysis of data obtained by retrospective medical record review according to timing of surgical repair and frequency of PT/OT, adjusted for patient, medical care, and hospital characteristics. SAMPLE: The study included the medical records of 1880 elderly Medicare recipients admitted from the community to 284 acute care hospitals in 5 states during 1981 and 1982 or 1985 and 1986 with a primary diagnosis of acute hip fracture who underwent surgical repair and received PT/OT. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The postoperative day when ambulation first occurred, the length of hospital stay, and return to the community. RESULTS: Earlier surgical repair was associated with a shorter length of hospital stay (5 fewer days, P < .001) without a statistically significant increase in medical complications. High frequency PT/OT was associated with earlier ambulation (odds ratio [OR], 1.76; 95% confidence limits [CL], 1.50, 2.07). Patients who ambulated earlier [corrected] had shorter lengths of stay (6.5 fewer days, P < .001), were more likely to return to the community (OR, 1.45; 95% CL, 1.16, 1.81), and had better 6-month survival (OR, 2.8; 95% CL, 2.06, 3.88), and patients younger than 85 years had fewer in-hospital complications (11% vs 4%, P < .001). CONCLUSION: Surgical repair within the first 2 days of hospitalization and more than 5 PT/OT sessions per week were associated with better health outcomes in a nationally representative sample of elderly patients with hip fracture.


Assuntos
Fraturas do Quadril/reabilitação , Fraturas do Quadril/cirurgia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Deambulação Precoce , Feminino , Fixação Interna de Fraturas/mortalidade , Fraturas do Quadril/complicações , Fraturas do Quadril/mortalidade , Humanos , Tempo de Internação , Masculino , Prontuários Médicos , Análise Multivariada , Terapia Ocupacional , Razão de Chances , Modalidades de Fisioterapia , Características de Residência , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
20.
Stroke ; 28(1): 19-25, 1997 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-8996482

RESUMO

BACKGROUND AND PURPOSE: We undertook this study to ascertain whether elderly black and white patients who are hospitalized for stroke utilize inpatient physical and occupational therapy (PT/OT) services differently, adjusting for characteristics associated with use of these services. METHODS: We retrospectively reviewed medical records regarding the care received by a nationally representative sample of 2497 black and white Medicare patients, aged 65 years of older, who were hospitalized at any of 297 acute-care hospitals located in 30 communities within five states. RESULTS: Compared with whites, black stroke patients were younger and more likely to have Medicaid coverage, have an ischemic stroke, and have a motor deficit noted at the time of admission. There was no difference in either sex or level of consciousness on admission. Overall, a larger proportion of black stroke patients used inpatient PT/OT at some point during the hospitalization (66.3% versus 55.8%; P < .01). However, after adjustment for characteristics associated with use of PT/OT, there was no racial difference in either the likelihood of inpatient PT/OT use (adjusted relative risk, 1.06; 95% confidence limits, 0.89 to 1.27; P = .42) or time to initial contact (median: blacks, 6.6 days; whites, 7.4 days; P = .42). Adjusted analyses also indicated a similarity between the racial groups in the number of inpatient PT/OT days overall or as a proportion of the hospital stay. CONCLUSIONS: Elderly black and white stroke patients who have Medicare coverage have similar patterns of use of inpatient PT/OT services.


Assuntos
Negro ou Afro-Americano , Transtornos Cerebrovasculares/reabilitação , Pacientes Internados , Terapia Ocupacional/estatística & dados numéricos , Modalidades de Fisioterapia/estatística & dados numéricos , População Branca , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , População Negra , Estudos de Coortes , Feminino , Humanos , Masculino , Medicaid , Prontuários Médicos , Medicare , Estudos Retrospectivos , Fatores Sexuais , Estados Unidos
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