The effect of treatments on the shear modulus of human hair measured by the single fiber torsion pendulum.

Previous studies with the single fiber torsion pendulum have alluded to the ability of this device to selectively measure different regions of a fiber, namely, the core and the sheath. This selective ability of the torsion pendulum was explored further as a means of better understanding treatments effects. First, a substantial reduction in shear modulus was caused by simply abrading the hair fiber surface to remove the cuticle layer. In another experiment, bleaching was found to have a softening effect on the cuticle layer since the shear modulus was reduced significantly. Next, the fibers were subsequently treated with either Polyquaternium-10 or cetyl trimethylammonium bromide (CETAB) and measured again. The CETAB treatment resulted in an increase in the shear modulus indicating fortification of the cuticle layer. Polyquaternium-10 treatment increased the shear modulus slightly. These different effects are explained by the molecular sizes of these compounds-CETAB is a small molecule which can penetrate into the cuticle layer while Polyquaternium-10 is too large to do so. Lastly, the effect of moisture was evaluated by varying the humidity inside a chamber surrounding the sample mounted in the torsion pendulum. This showed a substantial inverse relationship between humidity level and shear modulus that was much more pronounced for bleached hair fibers than for untreated.

Use of intensive care units for patients with low severity of illness.

OBJECTIVE: To determine variations among hospitals in use of intensive care units (ICUs) for patients with low severity of illness. DESIGN: Retrospective cohort study. SETTING: Twenty-eight hospitals with 44 ICUs in a large metropolitan region. PATIENTS: Consecutive eligible patients (N=104,487) admitted to medical, surgical, neurological, or mixed medical-surgical ICUs from March 1, 1991, to March 31, 1995. OUTCOME MEASURES: The predicted risk of in-hospital death for each patient was assessed using a validated method that is based on age, ICU admission source, diagnosis, severe comorbid conditions, and abnormalities in 17 physiologic variables. Admissions were classified as low severity if the patient's predicted risk of death was less than 1%. In a subset of 12,929 consecutive patients, use of 19 specific interventions typically delivered in ICUs was examined. RESULTS: Twenty thousand four hundred fifty-one admissions (19.6%) were categorized as low severity, including 23.6% of postoperative and 16.9% of nonoperative admissions. Alcohol and other drug overdoses accounted for 40.2% of nonoperative low-severity admissions; laminectomy and carotid endarterectomy accounted for 52.3% of postoperative low-severity admissions. Mortality among patients with low-severity illness was 0.3%, and only 28.6% received an ICU-specific intervention during the first ICU day. Although mean ICU length of stay was shorter (P<.001) in low-severity admissions (2.2 vs 4.7 days in nonoperative and 2.4 vs 4.2 days in postoperative admissions), low-severity admissions accounted for 11.1% of total ICU bed days. Rates of low-severity admissions varied (P<.001) across hospitals, ranging from 5% to 27% for nonoperative and 9% to 68% for postoperative admissions. CONCLUSIONS: A large proportion of patients admitted to the ICU have a low probability of death and do not receive ICU-specific interventions. Rates of low-severity admissions varied among hospitals. The development and implementation of protocols to target ICU care to patients most likely to benefit may decrease the number of low-severity ICU admissions and improve the cost-effectiveness of ICU care.

Community-wide assessment of intensive care outcomes using a physiologically based prognostic measure: implications for critical care delivery from Cleveland Health Quality Choice.

STUDY OBJECTIVES: To examine the applicability of a previously developed intensive care prognostic measure to a community-based sample of hospitals, and assess variations in severity-adjusted mortality across a major metropolitan region. DESIGN: Retrospective cohort study. SETTING: Twenty-eight hospitals with 38 ICUs participating in a community-wide initiative to measure performance supported by the business community, hospitals, and physicians. PATIENTS: Included in the study were 116,340 consecutive eligible patients admitted to medical, surgical, neurologic, and mixed medical/surgical ICUs between March 1, 1991, and March 31, 1995. MAIN OUTCOME MEASURES: The risk of hospital mortality was assessed using a previous risk prediction equation that was developed in a national sample, and a reestimated logistic regression model fit to the current sample. The standardized mortality ratio (SMR) (actual/predicted mortality) was used to describe hospital performance. RESULTS: Although discrimination of the previous national risk equation in the current sample was high (receiver operating characteristic [ROC] curve area = 0.90), the equation systematically overestimated the risk of death and was not as well calibrated (Hosmer-Lemeshow statistic, 2407.6, 8 df, p < 0.001). The locally derived equation had similar discrimination (ROC curve area = 0.91), but had improved calibration across all ranges of severity (Hosmer-Lemeshow statistic = 13.5, 8 df, p = 0.10). Hospital SMRs ranged from 0.85 to 1.21, and four hospitals had SMRs that were higher or lower (p < 0.01) than 1.0. Variation in SMRs tended to be greatest during the first year of data collection. SMRs also tended to decline over the 4 years (1.06, 1.02, 0.98, and 0.94 in years 1 to 4, respectively), as did mean hospital length of stay (13.0, 12.4, 11.6, and 11.1 days in years 1 to 4; p < 0.001). However, excluding the increasing (p < 0.001) number of patients discharged to skilled nursing facilities attenuated much of the decline in standardized mortality over time. CONCLUSIONS: A previously validated physiologically based prognostic measure successfully stratified patients in a large community-based sample by their risk of death. However, such methods may require recalibration when applied to new samples and to reflect changes in practice over time. Moreover, although significant variations in hospital standardized mortality were observed, changing hospital discharge practices suggest that in-hospital mortality may no longer be an adequate measure of ICU performance. Community-wide efforts with broad-based support from business, hospitals, and physicians can be sustained over time to assess outcomes associated with ICU care. Such efforts may provide important information about variations in patient outcomes and changes in practice patterns over time. Future efforts should assess the impact of such community-wide initiatives on health-care purchasing and institutional quality improvement programs.

Patient assessments of hospital maternity care: a useful tool for consumers?

OBJECTIVE: To examine three issues related to using patient assessments of care as a means to select hospitals and foster consumer choice-specifically, whether patient assessments (1) vary across hospitals, (2) are reproducible over time, and (3) are biased by case-mix differences. DATA SOURCES/STUDY SETTING: Surveys that were mailed to 27,674 randomly selected patients admitted to 18 hospitals in a large metropolitan region (Northeast Ohio) for labor and delivery in 1992-1994. We received completed surveys from 16,051 patients (58 percent response rate). STUDY DESIGN: Design was a repeated cross-sectional study. DATA COLLECTION: Surveys were mailed approximately 8 to 12 weeks after discharge. We used three previously validated scales evaluating patients' global assessments of care (three items)as well as assessments of physician (six items) and nursing (five items) care. Each scale had a possible range of 0 (poor care) to 100 (excellent care). PRINCIPAL FINDINGS: Patient assessments varied (p<.001) across hospitals for each scale. Mean hospital scores were higher or lower (p<.01) than the sample mean for seven or more hospitals during each year of data collection. However, within individual hospitals, mean scores were reproducible over the three years. In addition, relative hospital rankings were stable; Spearman correlation coefficients ranged from 0.85 to 0.96 when rankings during individual years were compared. Patient characteristics (age, race, education, insurance status, health status, type of delivery) explained only 2-3 percent of the variance in patient assessments, and adjusting scores for these factors had little effect on hospitals' scores. CONCLUSIONS: The findings indicate that patient assessments of care may be a sensitive measure for discriminating among hospitals. In addition, hospital scores are reproducible and not substantially affected by case-mix differences. If our findings regarding patient assessments are generalizable to other patient populations and delivery settings, these measures may be a useful tool for consumers in selecting hospitals or other healthcare providers.

Relationships between in-hospital and 30-day standardized hospital mortality: implications for profiling hospitals.

OBJECTIVE: To examine the relationship of in-hospital and 30-day mortality rates and the association between in-hospital mortality and hospital discharge practices. DATA SOURCES/STUDY SETTING: A secondary analysis of data for 13,834 patients with congestive heart failure who were admitted to 30 hospitals in northeast Ohio in 1992-1994. DESIGN: A retrospective cohort study was conducted. DATA COLLECTION: Demographic and clinical data were collected from patients' medical records and were used to develop multivariable models that estimated the risk of in-hospital and 30-day (post-admission) mortality. Standardized mortality ratios (SMRs) for in-hospital and 30-day mortality were determined by dividing observed death rates by predicted death rates. PRINCIPAL FINDINGS: In-hospital SMRs ranged from 0.54 to 1.42, and six hospitals were classified as statistical outliers (p <.05); 30-day SMRs ranged from 0.63 to 1.73, and seven hospitals were outliers. Although the correlation between in-hospital SMRs and 30-day SMRs was substantial (R = 0.78, p < .001), outlier status changed for seven of the 30 hospitals. Nonetheless, changes in outlier status reflected relatively small differences between in-hospital and 30-day SMRs. Rates of discharge to nursing homes or other inpatient facilities varied from 5.4 percent to 34.2 percent across hospitals. However, relationships between discharge rates to such facilities and in-hospital SMRs (R = 0.08; p = .65) and early post-discharge mortality rates (R = 0.23; p = .21) were not significant. CONCLUSIONS: SMRs based on in-hospital and 30-day mortality were relatively similar, although classification of hospitals as statistical outliers often differed. However, there was no evidence that in-hospital SMRs were biased by differences in post-discharge mortality or discharge practices.

Does length of hospital stay during labor and delivery influence patient satisfaction? Results from a regional study.

OBJECTIVE: To examine the relationship between patients' satisfaction with hospital obstetric care, length of stay, and patients' perceived appropriateness of the length of stay. STUDY DESIGN: A cross-sectional study. PATIENTS AND METHODS: We surveyed 27,789 women (a 58% response rate) discharged after labor and delivery from 18 hospitals in a large metropolitan region from 1992 through 1994. Patient satisfaction was assessed using the Patient Judgment System, a previously validated instrument. Our analysis focused on four scales evaluating specific aspects of care (physician care, nursing care, provision of information, and preparation for discharge) and two single-item indicators of satisfaction (overall quality and willingness to return to the hospital). RESULTS: Patients with shorter lengths of stay were more likely (P < 0.001) to perceive their stays as "too short." In addition, the six measures of satisfaction were lower (P < 0.001) in patients who perceived their stays as too short. However, the hypothesized lower satisfaction in patients with shorter stays was not observed; differences in satisfaction according to length of stay were small and of questionable practical significance. CONCLUSION: The findings suggest that patients' satisfaction with obstetric care may not depend on the absolute duration of stay but rather on whether patients perceive the length of stay to be adequate. The results are timely because of recent legislation that mandates minimum hospital stays for labor and delivery.

Declines in hospital mortality associated with a regional initiative to measure hospital performance.

To determine changes in hospital mortality that occurred in association with the dissemination of data by a regional initiative to profile hospital performance, we conducted a retrospective cohort study of patients admitted before and subsequent to dissemination of comparative data in 1992. The analysis included 101,060 consecutive eligible discharges from 30 hospitals in Northeast Ohio with eight diagnoses: acute myocardial infarction, congestive heart failure (CHF), obstructive airway disease, gastrointestinal hemorrhage, pneumonia, stroke, coronary artery bypass surgery, and lower bowel resection. Baseline (1991, N = 35,629) mortality rates were compared to rates during three subsequent periods (July-December 1992, N = 20,392; January-June 1993, N = 23,070; and July-December 1993, N = 21,969). Mortality rates were risk-adjusted using validated multivariable models based on data abstracted from patient's medical records. For all conditions, risk-adjusted mortality declined from a baseline rate of 7.5% to rates of 6.8%, 6.8%, and 6.5%, respectively, during the three subsequent periods. Using weighted linear regression analysis to estimate trends across periods, declines in mortality rates were significant for CHF (0.50% per period; P = 0.002) and pneumonia (0.38% per period; P = 0.03). We conclude that hospital mortality declined in association with the dissemination of comparative data. Although changes in hospital care were not directly examined, the results suggest that initiatives to examine provider performance may have a beneficial impact on quality of care.

Critical appraisal of the DRG system. Problem areas for DRG reimbursement in the U.S.A.

This Prospective Payment System (PPS) utilising Diagnosis Related Groups (DRGs) which was introduced for the reimbursement of acute care hospitals for Medicare patients in the U.S., was adopted primarily to control the rapidly rising costs of health care and, as an initial effort to retain the solvency of the Nation's Medicare Hospital Insurance Trust Fund. It is this factor, an overall decrease of health care dollars to health care providers and not the DRG system, which has generated the most criticism and concern. The DRG system, as a method to accomplish control of the expenditure of health care dollars and the method of implementation of this system in the United States, also generates criticism and concern from health care providers. One thing is certain, health care providers in the United States have seen just the beginning of what promises to be a rapidly changing environment driven by the need to control costs. The challenge will be to provide quality health care in a price competitive environment. This paper attempts to explore some of the criticisms and concerns of health care providers that result from the threat to reduce health care dollars and the methodology implemented to accomplish that objective.

Executive roundtable II. Talking about quality.

In the last issue of Healthcare Executive, we introduced the first in a two-part series on quality in healthcare. The series, which is predicated on a five-hour roundtable discussion among eight healthcare leaders, was moderated by Thomas C. Dolan, Ph.D., FACHE, CAE, ACHE's president and chief executive officer, and jointly sponsored by ACHE and the Bayer Quality Network, an educational forum for sharing innovative and effective continuous quality improvement methods with healthcare executives. In Part I, participants spoke about current issues as they relate to quality. They discussed the reliability of existing quality data and expressed a need for more practical indicators and measurement systems. The consumer mindset was discussed, as leaders debated the value of customer satisfaction surveys and ways to create more realistic consumer expectations. In terms of employers and third parties, participants suggested tailoring quality information and presenting it in a simplified fashion. Finally, leaders emphasized the need for better performance information, as well as the use of outcomes data for both educational and quality improvement purposes. In Part II, the dialogue remains compelling. Participants cover new ground as they talk about the role of accreditors in regulating quality, of governance teams and senior management in creating an organizational culture to support quality, and of physicians in attracting both business partners and patients based on quality. Following is the second in our two-part series.