The accuracy of clinician perceptions of "usual" blood pressure control.
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BACKGROUND: The term "clinical inertia" is used to describe the failure to manage a chronic condition aggressively enough to bring it under control. The underlying mechanisms for clinical inertia remain poorly understood. OBJECTIVE: To describe one potential mechanism for clinical inertia, seen through the lens of clinician responses to a computerized hypertension reminder. DESIGN: Cohort study. PARTICIPANTS: A total of 509 hypertensive patients from 2 primary care clinics in urban Veterans Health Administration (VA) Medical Centers. All patients had elevated blood pressure (BP) values that triggered a computerized reminder. Given a set of possible responses to the reminder, clinicians asserted at least once for each patient that medication adjustments were unnecessary because the BP was "usually well controlled". MEASUREMENTS: Using recent BP values from the electronic medical record, we assessed the accuracy of this assertion. RESULTS: In most instances (57%), recent BP values were not well controlled, with the systolic BP (56%) much more likely to be elevated than the diastolic BP (13%). Eighteen percent of recent systolic BP values were 160 mmHg or greater. CONCLUSIONS: When clinicians asserted that the BP was "usually well controlled", objective evidence frequently suggested otherwise. This observation provides insight into one potential mechanism underlying clinical inertia. (+info)
Extracting information from hospital records: what patients think about consent.
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BACKGROUND AND OBJECTIVE: There is increasing regulation and concern about the use of material from patients' records. Studies on patients' views have focused on primary care and on use of material for research. This study investigated patients' preferences about whether and how doctors should seek permission for use of specified items of anonymised information from their hospital records for clinical audit, teaching, national data collection and research. METHOD: A specially designed questionnaire sent to recently discharged patients under the care of medical and surgical specialists. RESULTS: 166/316 (53%) patients completed the questionnaires. The percentage of respondents who "definitely wanted" or "preferred" to be asked for permission for use of anonymised information was highest for medical history (21%) and reasons for treatment (20%). The purpose for which information was requested (eg, research, audit) made little difference to the overall percentages (range 10-12%). 21 (13%) patients "definitely wanted" to be asked for permission for use of some item or proposed use of information--most had no preference or preferred not to be asked. The most popular method for asking permission was signing a form while in hospital, rather than by specific requests later. CONCLUSIONS: Most hospital patients have no preference or prefer not to be asked permission for doctors to use information from their records. About 1 in 8 patients would like to be asked for permission, some even for clinical audit of outcomes--although a minority, this could compromise thorough clinical audit. Systems for obtaining permission when patients are admitted to hospital need to be considered. Resolution of uncertainties surrounding legislation on the use of information would be helpful to clinicians. (+info)
The impact of expressions of treatment efficacy and out-of-pocket expenses on patient and physician interest in osteoporosis treatment: implications for pay-for-performance programs.
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BACKGROUND: Clinical practice guidelines (CPGs) are increasingly used as the basis for pay-for-performance (P4P) programs. It is unclear how support for guidelines varies when treatment efficacy is expressed in varying mathematically equivalent ways. OBJECTIVES: To assess: (1) how patient and provider compliance with osteoporosis CPGs varies when pharmacotherapy efficacy is presented as relative risk reduction (RRR) versus absolute risk reduction (ARR) and (2) the impact of increasing out-of-pocket drug expenditures on acceptance of guideline concordant therapy. DESIGN: Cross-sectional survey of patients and physicians. SUBJECTS AND SETTING: Female patients age >50 years and providers drawn from academic and community outpatient clinics. MEASUREMENTS: Patient and provider acceptance of pharmacotherapy when treatment efficacy (reduction in hip fractures) was expressed alternatively in relative terms (35% RRR) versus absolute terms (1% ARR); acceptance of pharmacotherapy as patient drug copayment increased from 0% to 100% of the total drug costs. RESULTS: Compliance with CPGs fell significantly when the expression of treatment benefit was switched from RRR to ARR for both patients (86% vs 57% compliance; P < .001) and physicians (97% vs 56% compliance; P < .001). Increasing drug copayment from 0% to 10% of total drug cost decreased patient compliance with CPGs from 80% to 57% (P < .001) but did not impact physician compliance. With increasing levels of copay, both patient and provider interest in treatment decreased. LIMITATIONS: Respondents may not have fully understood the risks and benefits associated with osteoporosis and its treatment. CONCLUSION: Patient and provider interest in CPG-recommended treatment for osteoporosis is reduced when treatment benefit is expressed as ARR rather than RRR. In addition, minimal increases in drug copayment significantly decreased patient, but not provider, interest in osteoporosis treatment. Designers of P4P programs should consider details including expressions of treatment benefit and patients' out-of-pocket costs when developing measures to assess quality-of-care. (+info)
National audit of critical care resources in South Africa - research methodology.
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This article provides an in-depth description of the methodology that was followed and the quality control measures that were implemented during the audit of national critical care resources in South Africa. (+info)
National audit of critical care resources in South Africa - unit and bed distribution.
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OBJECTIVE: To determine the national distribution of intensive care unit (ICU)/high care (HC) units and beds. DESIGN AND SETTING: A descriptive, non-interventive, observational study design was used. An audit of all public and private sector ICU and high care units in South Africa was undertaken. RESULTS: A 100% sample was obtained; 23% of public and 84% of private hospitals have ICU/HC units. This translates to 1,783 public and 2,385 private beds. Only 18% of all beds were HC beds. The majority of units and beds (public and private) were located in three provinces: Gauteng, KwaZulu-Natal and the Western Cape. The Eastern Cape and Free State had less than 300 beds per province; the remaining four provinces had 100 or fewer beds per province. The public sector bed: population ratio in the Free State, Gauteng and Western Cape was less than 1:20,000. In the other provinces, the ratio ranged from 1:30,000 to 1:80,000. The majority of units are in level 3 hospitals. The ICU bed: total hospital bed ratio is 1.7% in the public sector compared with 8.9% in the private sector. The ratio is more when the comparison is made only in those hospitals that have ICU beds (3.9% v. 9.6% respectively). In the public and private sector 19.6% beds are dedicated to paediatric and neonatal patients with a similar disparity across all provinces. Most hospitals admit children to mixed medical surgical units. Of all ICU beds across all provinces 2.3% are commissioned but not being utilised. CONCLUSION: The most compelling conclusion from this study is the need for regionalisation of ICU services in SA. (+info)
National audit of critical care resources in South Africa - open versus closed intensive and high care units.
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OBJECTIVES: To evaluate the distribution and functioning of South African intensive care units (ICUs) and high care units (HCUs), in particular the extent to which units were 'closed units'. DESIGN AND SETTING: A descriptive, non-interventive, observational study design was used. An audit of all public and private sector ICUs and HCUs in South Africa was undertaken. RESULTS: A 100% sample was obtained. A total of 396 acute care public and 256 private hospitals were identified; 23% of public hospitals had ICUs and/or HCUs compared with 84% of private hospitals. In the public hospitals there were 210 units and 238 units in the private hospitals. Only 7% of public units and less than 1% of private units were 'ideal closed units'. A total number of 3,414 ICU and high care beds were identified; 71% of beds were in open units versus 29% in closed units. The distribution of ICU and ICU/high care beds comprised 64% in private sector and 36% (1,223) in public units. A total of 244,024 patients were admitted to all units in South Africa during 2002, of whom 63% were to private units and 37% to public sector units. CONCLUSION: In the face of already limited resources (financial and human) and given the emphasis on primary care medicine (with consequent limited capacity for further ICU development), it is crucial that existing facilities are maximally utilised. Like the USA we are not in a position to implement the Leapfrog recommendations and must modify our approach to dealing with South African realities. (+info)
National audit of critical care resources in South Africa - transfer of critically ill patients.
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OBJECTIVES: To establish the efficacy of the current system of referral of critical care patients: (i) from public hospitals with no ICU or HCU facilities to hospitals with appropriate facilities; and (ii) from public and private sector hospitals with ICU or HCU facilities to hospitals with appropriate facilities. DESIGN AND SETTING: A descriptive, non-interventive, observational study design was used. An audit of all public and private sector ICUs and HCUs in South Africa was undertaken. RESULTS: A 100% sample was obtained; 77% of public and 16% of private hospitals have no IC/HC units. Spread of hospitals was disproportionate across provinces. There was considerable variation (less than 1 hour - 6 hours) in time to collect between provinces and between public hospitals that have or do not have ICU/HCU facilities. In the private hospitals, the mean time to collect was less than an hour. In public hospitals without an ICU, the distance to an ICU was 100 km or less for approximately 50% of hospitals, and less than 10% of these hospitals were more than 300 km away. For hospitals with units (public and private), the distance to an appropriate hospital was 100 km or less for approximately 60% of units while for 10% of hospitals the distance was greater than 300 km. For public hospitals without units the majority of patients were transferred by non-ICU transport. In some instances both public and private hospitals transferred ICU patients from one ICU to another ICU in non-ICU transport. CONCLUSION: A combination of current resource constraints, the vast distances in some regions of the country and the historical disparities of health resource distribution represent a unique challenge which demands a novel approach to equitable health care appropriation. (+info)
Could clinical audit improve the diagnosis of pulmonary tuberculosis in Cuba, Peru and Bolivia?
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