Improving lipid evaluation and management in medicare patients hospitalized for acute myocardial infarction.

BACKGROUND: The control of low-density lipoprotein cholesterol (LDL-C) levels in patients with known coronary artery disease, particularly in those with acute myocardial infarction, has been shown to reduce the rates of disease progression, recurrent events, and mortality. OBJECTIVES: To evaluate and improve hospital-based processes for measuring and treating, when necessary, LDL-C levels above 3.36 mmol/L (>130 mg/dL) in patients with an acute myocardial infarction. DESIGN: A nonrandomized retrospective baseline study followed by a collaborative educational intervention with participating hospitals and a second nonrandomized postintervention study. PATIENTS: Four hundred six preintervention patients discharged from the hospital alive after a confirmed acute myocardial infarction in 1996, and 498 postintervention patients discharged from the hospital in 1999. INTERVENTIONS: Performance of lipid profiles on admission to the hospital and during hospitalization and drug and dietary interventions. RESULTS: The measurement of LDL-C level on admission to the hospital increased from 8% preintervention in 1996 to 32% postintervention in 1999. The measurement during hospitalization increased from 14% preintervention to 48% postintervention. Hospitals that initiated programs to ensure early lipid evaluations through preprinted orders and policy changes achieved an average patient LDL-C measurement rate of 70% in 1999. Hospitals lacking standard policies averaged only 23% at the same time. Of the patients with a measured LDL-C level greater than 3.36 mmol/L (>130 mg/dL) who were not undergoing drug therapy on admission to the hospital, 46% were given lipid-lowering agents by discharge from the hospital during the postintervention period. During this same period, only 11% of the patients were prescribed this therapy if they had either a lower measured level or no LDL-C measurement at all. CONCLUSION: Active hospital-based programs to ensure routine LDL-C measurements in patients admitted for acute myocardial infarction increased the use of appropriate lipid-lowering therapy in these high-risk individuals and could contribute to reducing the incidence of recurrent coronary artery disease.

The use of quality indicators for assessing radical prostatectomy specimens.

The information contained in pathology reports of radical prostatectomy specimens is critically important to treating physicians for selecting adjuvant therapy, evaluating therapy, estimating prognosis, and analyzing outcomes. This information is also of importance to patients and their families. In recent years, the Cancer Committee of the College of American Pathologists and the Association of Directors of Anatomic and Surgical Pathology developed suggested protocols for reporting the findings on radical prostatectomy specimens. The objectives of this study were to assess radical prostatectomy-specimen reports by using quality indicators derived from existing suggested protocols and to thereby assist pathologists in improving the quality of their reports on such specimens. A retrospective chart review of 554 cases for the second 6-month period of 1996 focused on 10 quality indicators: submission of a frozen section; location of the adenocarcinoma; proportion of the specimen involved by adenocarcinoma; perineural involvement; vascular involvement; seminal vesicle involvement; periprostatic fat status; number of nodes submitted; status of nodes; and prostate intraepithelial neoplasia (PIN). The findings of this study were shared with the pathology departments in all hospitals in New York State. In addition, the 113 hospitals from which the 554 cases were drawn were given their institution-specific data. Teleconferences were held with the 37 hospitals that accounted for 72.4% of all cases. These conferences included directors of pathology and laboratories and focused on the aggregate statewide findings. The presence of quality indicators in reports varied from a mean of 14.8% (periprostatic fat) to a mean of 85.9% (seminal vesicle involvement). For all hospitals, 4 indicators (proportion of the specimen involved by adenocarcinoma, vascular involvement, periprostatic fat status, and PIN) were included in fewer than 50% of cases. These 4 quality indicators and an additional 3 others (submission of a frozen section, perineural involvement, and the number of nodes submitted) were included in fewer than 70% of cases. Only 3 indicators (location of the adenocarcinoma, seminal vesicle involvement, and the status of nodes) were found in more than 70% of cases. Although the mean level of quality indicator inclusion ranged from 14.8% to 85.9% for all cases examined, the absolute range for any individual indicator was 0% to 100%. Thus, some hospitals included a given indicator 100% of the time; others never included it. This pattern held true for all 10 indicators. High-volume hospitals (10 or more cases) performed significantly better than low-volume hospitals (1-4 cases) on 5 indicators (P < .05), and better, but not significantly so, for an additional 2 indicators. Overall, the mean inclusion levels for all 10 indicators were 10% higher for high-volume hospitals compared with low-volume and medium-volume hospitals (5-9 cases). This study demonstrated wide variations in the inclusion of quality indicators by pathologists in their radical prostatectomy-pathology reports. Whereas some hospitals always include given indicators, others never mentioned them. These marked disparities point to the need for standardized reporting for radical prostatectomy specimens.

Concurrent improvements in ambulatory cardiac catheterization practices following inpatient interventions.

Questions have been increasingly raised about the value of performing right heart catheterization. A preliminary analysis done in 1992 revealed significant interhospital variation in the frequency of the procedure among Medicare Part A and Medicaid patients in New York State, and it also suggested that the procedure was being performed routinely in some hospitals. In 1993, IPRO initiated a cooperative health care quality improvement program involving the state's 53 catheterization laboratories. As a result of this educational intervention, the rate of bilateral catheterization among Medicare Part A patients fell from 89/100,000 beneficiaries in 1992 to 65/100,000 in 1996, and the overall percentage of catheterized Medicare patients undergoing bilateral catheterization fell from 30.5% in 1992 to 17.4%. A major question was whether a corresponding decrease had occurred among ambulatory patients (Medicare Part B). To determine the answer, the Medicare Part B database was analyzed for the identical period of time. It was found that the percentage of ambulatory Medicare patients who underwent bilateral catheterization at the 53 laboratories fell from 37.6% in 1992 to 17.0% in 1996, paralleling the decline observed among inpatients. The results of this quality improvement study show that an educational intervention directed at inpatient practice patterns can have a similar impact on outpatient patterns.

Laparoscopic and open cholecystectomy in New York State: mortality, complications, and choice of procedure.

BACKGROUND: With the advent of laparoscopic cholecystectomy patient outcomes and choice of procedure (laparoscopic vs open) are of vital interest. The purpose of this study was to examine the mortality and complication rates for patients undergoing laparoscopic and open cholecystectomy in New York State and to test for differences among hospital peer groups and regions of the state in the tendency to use the laparoscopic approach. METHODS: A population-based, retrospective cohort study of laparoscopic and open cholecystectomy was conducted in which data were analyzed on all 30,968 patients who underwent cholecystectomy as a principal procedure in New York State in 1996. RESULTS: A total of 78.7% of the 30,968 patients who underwent cholecystectomy as a principal procedure in New York State in 1996 underwent laparoscopic cholecystectomy. The mortality rate was lower for laparoscopic cholecystectomy than for the open procedure (0.23% vs 1.90%, P < .0001) and remained significantly lower after patient characteristics related to patient survival (odds ratio 0.34, P < .0001) were controlled for. The prevalence rate of the 8 most common complications among cholecystectomy patients was also much lower among patients undergoing laparoscopic cholecystectomy. Patients undergoing cholecystectomy in public hospitals, Bronx County, and Kings County were found to be significantly less likely to have laparoscopic procedures, and patients undergoing cholecystectomy on Long Island were found to be significantly more likely to have laparoscopic procedures than were other patients in the state. CONCLUSIONS: There are reasonably large differences among hospitals, hospital groups, and regions of the state in the type of cholecystectomy used, even after adjustment for differences in patient comorbidities and indications for type of procedure.

Impact of an educational program on bilateral heart catheterization practice patterns.

The value and necessity of performing right heart catheterizations for coronary artery disease have been increasingly questioned. Preliminary analyses of the procedure among Medicare and Medicaid patients in New York State revealed significant inter-hospital variations in the frequencies with which such catheterizations were performed. These data suggested that right heart catheterizations (RHC) were being performed routinely. Medicare and Medicaid claims data for bilateral catheterizations were analyzed before and after an educational intervention program involving the state's 53 catheterization laboratories. The educational intervention was multifaceted and consisted of disseminating suggested guidelines established with the assistance of the New York State Chapter of the American College of Cardiology, the Committee on Cardiovascular Disease of the Medical Society of the State of New York, and the Cardiac Advisory Council of the New York State Department of Health. Posteducational intervention assessments were made over a 4-year period. The baseline data for 1992 demonstrated that 10 (18.4%) laboratories had performed RHC routinely (70-100%) on Medicare and Medicaid patients undergoing catheterization. In contrast, 34 (64.2%) laboratories performed RHC in less than 20% of their Medicare cases, whereas 39 (73.5%) did so among Medicaid cases. Eighteen (34%) laboratories performed RHC in less than 10% of Medicare cases. These data indicated that there was significant inter-hospital variation in the frequency with which RHC was performed. Beginning in 1993, ongoing educational meetings and conferences were held with all laboratories, but especially with the 10 that were at the high end of the RHC performance level. As a result of this ongoing intervention, the rate of RHC among Medicare patients fell from 89/100,000 in 1992 to 65/100,000 beneficiaries in 1996. From another perspective, the percentage of catheterized Medicare patients undergoing RHC fell from 30.5% in 1992 to 17.4% in 1996. The decline among the 10 laboratories was even more dramatic; the percentage of catheterized Medicare patients undergoing RHC fell from 89.1% in 1992 to 31.6% in 1996. The parallel drop for Medicaid patients over the same time period was from 92.8 to 32.7%. The results of the study indicate that many previously performed RHC in patients with coronary artery disease were routine and not medically indicated. The dramatic decreases in RHC documented in this study over a 4-year period demonstrate the success of quality improvement efforts jointly undertaken by providers and a peer review organization.

Radical prostatectomy specimens among Medicare patients in New York State: a review of pathologists' reports.

CONTEXT: Gross and microscopic pathologic examinations of radical prostatectomy specimens should result in reports that contain comprehensive information. Such information is important for facilitating adjuvant therapy decisions, assessing treatment interventions, providing patients and their families with estimates of prognosis, and in analyzing clinical outcomes. An important element of the information in radical prostatectomy specimen reports is the tumor status of margins, which is essential for staging. OBJECTIVES: The purposes of this study were to analyze the gross and microscopic examinations documented in a sample of radical prostatectomy reports and, by doing so, to determine the comprehensiveness of these reports. METHODS: The pathology reports from 414 charts of male Medicare patients aged 70 years and older who underwent radical prostatectomy in the 3-year period between 1991 and 1993 in New York State were examined. This group included all patients 75 years and older and a random sample of the 1266 patients aged 70 to 74 years who had undergone the procedure during the 3-year time frame. A protocol was used for recording general information from each pathology report as well as data relevant to gross and microscopic examinations. RESULTS: The results of this study demonstrated an absence of uniformity in reporting protocols, as well as documentation problems in those protocols used. Important information concerning both the gross and microscopic examinations was frequently absent. An important finding of the study was the high level (94.9%) of reporting on the microscopic status of prostate gland margins, which permitted an accurate assessment of margin positivity. Among those cases for which margin status was reported, 54% were found to be tumor positive. This is a significant finding in that it has implications for TNM staging. Such patients have an increased risk of disease progression and have been shown to have the same 5-year mortality rate as patients who have not been treated surgically. CONCLUSIONS: The study demonstrated a lack of uniformity in the pathology protocols used to describe radical prostatectomy specimens and the frequent absence of important gross and microscopic information. The results of this study also demonstrated a high rate (54%) of margin positivity among elderly men undergoing radical prostatectomy. Based on the results of this study, there is a need for closer attention to the issue of margin positivity. There is also a need for considering the usefulness of standardized reporting that includes elements with proven, putative, or prognostic value.

Radical prostatectomy: lower rates among African-American men.

This study compares radical prostatectomy rates by race among male Medicare patients in New York. A retrospective analysis was conducted of all radical prostatectomies performed on hospitalized male Medicare beneficiaries for the period 1991 through 1993. Basic trend data also were analyzed for 1990. Pattern analysis was conducted on the 4154 procedures performed between 1990 and 1993. The rate of radical prostatectomy rose dramatically during the 3-year period from 1990 to 1992 among New York's 1.1 million male Medicare beneficiaries. The rates rose for both African Americans and whites. However, the annual rates of radical prostatectomy for African Americans were significantly below those for whites. Lower rates of radical prostatectomies were observed for African Americans in all age groups except the < 65-year-old group. However, the total number of radical prostatectomies in this age group were small in number. An important finding was the lower annual rates of radical prostatectomy for African Americans in the 65- to 69-year-old age group. During the period under study, prostate cancer among Medicare patients in New York rose by 33.8% for African Americans and 26.5% for whites. Significantly, local disease was found at the time of diagnosis in 70% of whites but in only 55% of African Americans. These data reflect later stage at diagnosis among African-American males. These results indicate that despite higher national rates for prostate cancer, male African-American Medicare patients in New York have reduced access to radical prostatectomy as a treatment modality. This is especially of importance in the < 70-year-old group in whom most authorities consider the procedure appropriate. The reasons for this reduced access are discussed as are the measures needed to remedy the underlying inequities in health care.

A Third World international health elective for U.S. medical students. The 16-year experience of the State University of New York, Health Science Center at Brooklyn.

The Department of Preventive Medicine and Community Health at the State University of New York, Health Science Center at Brooklyn (SUNY, HSCB) instituted an eight-week third world international health elective for fourth year medical students in 1980. Since that time, ninety students have participated. The purposes of this elective are to provide fourth year medical students with an opportunity to observe and study the structure and functions of a health care delivery system in a third world country, to provide medical service, and to have a cross-cultural experience. The emphasis in this elective is on public health, preventive medicine, and primary care. There is a high level of student competition for this elective, with 46.9% of applicants having been accepted over a fifteen-year period. Although women comprise 40% of the average medical school class, they represent 50% of participants in this elective program. The percentage of African-American and Hispanic students has been 20%. These two minority groups represented from 8% to 10% of the student body during the period under study. Careful screening, including an examination of academic records and personal interviews, has resulted in the selection of highly motivated, adaptable, and dedicated students who have performed well at overseas sites. Student satisfaction levels with this elective are extremely high, with most rating it the best experience of their medical school years. Students undergo extensive preparation prior to going overseas. This covers issues related to individual health and safety, travel and lodging, and the nature of the host country culture, health care system, and assignment site. Our students are especially experienced at cross-cultural understanding because of the unusual diversity of the patients they treat in Brooklyn, and the ethnic diversity of local hospital staffs and the medical school class. This Brooklyn experience in cross-cultural understanding has been cited by many participants as having been the best preparation for functioning in a foreign culture. The Alumni Fund of the College of Medicine has strongly and consistently supported this elective both with philosophical commitment and financial grants to help defray travel costs. This type of support is unusual among medical schools in New York City. Overseas preceptors have willingly given of their time and institutional resources to make these experiences available and meaningful for students.

The effects of regionalization on clinical outcomes for a high risk surgical procedure: a study of the Whipple procedure in New York State.

The purpose of this study was to analyze the effects on clinical outcomes of regionalization for a high risk surgical procedure, pancreaticoduodenectomy (the Whipple procedure). Claims data were examined for all Medicare patients undergoing the procedure in New York State for the 4-year period 1991-1994. Outcomes were analyzed for two regional hospitals and for 115 other hospitals that performed the procedure. In-hospital mortality and length of stay were significantly less at the two high volume regional hospitals when compared with the remaining low volume hospitals. In-hospital mortality rates at all hospitals generally decreased as the number of procedures increased. The results of this study demonstrate that there is significant value in regionalization for even relatively lower volume high risk surgical procedures.

Trends in radical prostatectomy in New York State.

The purpose of this study was to examine trends in radical prostatectomy in New York State for the period 1991-1993. A retrospective analysis was conducted of all radical prostatectomies performed on hospitalized male Medicare beneficiaries in New York State for the period 1991-1993. Basic trend data were also analyzed for 1990. Pattern analysis was conducted on the 4,154 procedures performed between 1990-1993. In depth hospital chart review was conducted of the 220 cases of radical prostatectomy performed in patients 75 years of age and over between 1991 and 1993 and of a random sample of 263 of 1,266 patients 70-74 years of age. A total of 452 hospital charts were examined for a broad range of information, including family history and therapeutic preferences, preoperative work-up, staging, intraoperative and postoperative transfusions, postoperative complications, and mortality. The rate of radical prostatectomy dramatically rose among New York State male Medicare beneficiaries between 1990 and 1992 and remained at a high plateau in 1993. Pattern analysis revealed a tripling of the procedure rate among those 70-74 years of age and a doubling of the rate in those 75 years of age and older. It was also found that a high proportion of radical prostatectomies in men 70 years of age and older were performed by relatively few hospitals. Although rates of radical prostatectomy rose in New York State during the period under study, these rates were lower than those reported several years earlier in other parts of the country. This may reflect an overall conservative approach to the management of prostate cancer, especially among older men, on the part of New York's urologic community. The overall postoperative complication rate was 18.5% and the mortality rate 1.3%. These rates are similar to those found in other series. Prostate cancer in older men usually has a protracted course. Radical prostatectomy in such men is associated with operative risks, and significant immediate and long-term complications. In addition, the procedure provides only marginal benefit of 10 years because of competing mortality in older men. The results of this study show a need for provider and patient focused educational efforts to reduce the numbers of radical prostatectomies in older men where the benefits are marginal compared to operative risks and significant immediate and long term complications.

IPRO's Health Care Quality Improvement Program.

IPRO is a peer-review organization in New York State that functions under a contract with the Health Care Financing Administration (HCFA) of the U.S. Department of Health and Human Services for assuring quality of care for Medicare patients. In 1993, IPRO initiated its Health Care Quality Improvement Program (HCQIP). The purpose of this program is to develop information on patterns of care and outcomes, to share this with health care providers, and in so doing effect measurable improvements in care and outcomes. In order to achieve improvements in the quality of care, IPRO has initiated a series of cooperative projects which combine pattern analysis and feedback. These cooperative projects cover a broad range of medical care issues and areas. They have demonstrated that IPRO, providers, and physicians can collaborate to establish and implement efforts to achieve the ultimate goal of improved quality of care for Medicare beneficiaries.