Continuous quality improvement decreases length of stay and adverse events: a case study in an interventional cardiology program.
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A study was performed to assess the effectiveness of continuous quality improvement in achieving a better quality of care for patients undergoing coronary interventions. Increasing utilization of new coronary interventional devices has incurred a higher incidence of complications, prolonged hospital stay, and related costs. Using a clinical information system, we adopted continuous quality improvement to control the incidence of complications and postprocedural length of stay. Multiple regression analysis and a matched case-control study were performed to detect complications related to postprocedural length of stay and their causes among 342 patients. The results led to the modification of the postprocedural heparin anticoagulation protocol, which was followed by the introduction of a ticlopidine-based poststent anticoagulation regimen. Two sequential groups of patients (n = 261, n = 266) were selected to compare postprocedural length of stay and frequency of complications with those for the first group. Adjustments were made for patients and procedural characteristics through stratification and multiple regression methods. Blood transfusion was the most important predictor of prolonged hospital stay (partial R2 = 0.26, P < 0.01). A high level of postprocedural anticoagulation and intracoronary stent use were significantly associated with blood transfusion (P = 0.01, P = 0.02, respectively). The comparison among the three groups showed that heparin protocol change reduced only postprocedural length of stay (P < 0.001) for patients without stents, whereas the stent change in anticoagulation protocol significantly reduced both transfusion and hospital stay for patients with stents (P < 0.001, P < 0.05, respectively). Continuous quality improvement based on clinical information is promising to control both complications and hospital costs. Physician involvement is necessary throughout the process. (+info)
Pulmonary sarcoidosis: comparison of patients at a university and a municipal hospital.
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Charts and radiographs of sarcoidosis patients seen at a private university hospital and at a municipal hospital were reviewed to determine whether there was a difference in the severity of disease retrospectively. A standardized abstract form was used to identify and abstract information on new and continuing sarcoidosis patients seen at either Georgetown University Medical Center (GUMC) or District of Columbia General Hospital (DCGH) during a 2-year period. Because there were too few white sarcoidosis patients for comparison, analysis was done for African-American patients only. African-American patients at GUMC were slightly older, with a higher percentage of women. For GUMC patients, 76% had private insurance and 21% had public insurance, and for DCGH patients, one-half had public insurance and 29% had no insurance. Significantly fewer GUMC patients (7% versus 36%) reported moderate to severe dyspnea. Chest radiographs showed a larger percentage of patients with stage 1 disease at GUMC and more patients with stage 4 disease at DCGH. Spirometry showed more impairment of forced expired volume in one second (FEV1) in GUMC patients, but diffusing capacity of the lung for carbon monoxide (DLCO) values were significantly lower among DCGH patients. Less than 8% of GUMC patients showed disease progression compared with almost one-third of DCGH patients. These results demonstrate that substantially less severe pulmonary sarcoidosis was seen in African-American patients treated at a private, nonprofit university hospital compared with a municipal hospital. Factors that determine the use of municipal hospitals, such as limited financial access to care and sources of patients, may have played a major role in the differences seen. (+info)
Toward a redefinition of psychiatric emergency.
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OBJECTIVE: To compare three methods for rating legitimate use of psychiatric emergency services (PES) in order to develop criteria that can differentiate appropriate from inappropriate PES service requests. METHOD: Ratings of PES visits by treating physicians and ratings of the same visits made during review of medical records. STUDY DESIGN: Two previously used methods of identifying justified PES service use were compared with the treating physician's rating of the same: (1) hospitalization as visit outcome and (2) retrospective chart ratings of visit characteristics using traditional medico-surgical criteria for "emergent" illness episodes. DATA EXTRACTION METHODS: Data were extracted through use of a physician questionnaire, and medical and administrative record review. PRINCIPAL FINDINGS: Agreement between the methods ranged from 47.1 percent to 74.1 percent. A total of 21.7 percent of visits were rated as true health "emergencies" by the traditional definition, while 70.4 percent of visits were rated as "necessary" by treating physicians, and 21.0 percent resulted in hospitalization. Acuteness of behavioral dyscontrol and imminent dangerousness at the time of the visit were common characteristics of appropriate use by most combinations of the three methods of rating visits. CONCLUSIONS: The rating systems employed in similar recent studies produce widely varying percentages of visits so classified. However, it does appear likely that a minimum of 25-30 percent of visits are nonemergent and could be triaged to other, less costly treatment providers. Proposed criteria by which to identify "legitimate" psychiatric emergency room treatment requests includes only patient presentations with (a) acute behavioral dyscontrol or (b) imminent dangerousness to self or others. (+info)
Tuberculosis prevention project.
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This article reports the findings from a clinical study that examined the impact of health education and counseling on the decision of a patient infected with tuberculosis (TB) to complete a regimen of isoniazid (INH) chemoprophylaxis for 6 months to prevent TB. Forty patients were divided into two groups; both groups were administered a questionnaire to collect demographic data and medical history. One group received additional health education and counseling independent of clinic staff, and the other group only received health education and counseling from clinic staff. The proportion of patients in the first group who completed INH for 6 months (63.6%) was significantly greater than the proportion of patients in the second group (11.1%). These findings suggest that health education and counseling did make an impact on the decision of a patient infected with TB to conform with a rational choice when provided with information and a supportive relationship about the consequences of TB infection. (+info)
Hospitalists as teachers.
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OBJECTIVE: To compare evaluations of teaching effectiveness among hospitalist, general medicine, and subspecialist attendings on general medicine wards. DESIGN: Cross-sectional. SETTING: A large, inner-city, public teaching hospital. PARTICIPANTS: A total of 423 medical students and house staff evaluating 63 attending physicians. MEASUREMENTS AND MAIN RESULTS: We measured teaching effectiveness with the McGill Clinical Tutor Evaluation (CTE), a validated 25-item survey, and reviewed additional written comments. The response rate was 81%. On a 150-point composite measure, hospitalists' mean score (134.5 [95% confidence interval (CI), 130.2 to 138.8]) exceeded that of subspecialists (126.3 [95% CI, 120.4 to 132.1]), P =.03. General medicine attendings (135.0 [95% CI, 131.2 to 138.8]) were also rated higher than subspecialists, P =.01. Physicians who graduated from medical school in the 1990s received higher scores (136.0 [95% CI, 133.0 to 139.1]) than did more distant graduates (129.1 [95% CI, 125.1 to 133.1]), P =.006. These trends persisted after adjusting for covariates, but only year of graduation remained statistically significant, P =.05. Qualitative analysis of written remarks revealed that trainees valued faculty who were enthusiastic teachers, practiced evidence-based medicine, were involved in patient care, and developed a good rapport with patients and other team members. These characteristics were most often noted for hospitalist and general medicine attendings. CONCLUSIONS: On general medicine wards, medical students and residents considered hospitalists and general medicine attendings to be more effective teachers than subspecialists. This effect may be related to the preferred faculty members exhibiting specific characteristics and behaviors highly valued by trainees, such as enthusiasm for teaching and use of evidence-based medicine. (+info)
Economic impact of standard antibiotic therapy combined with amikacin, in clinical unit, Lodz, poland--part I.
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The study "Alexander" on bacterial resistance to antibiotics conducted in Poland revealed high sensitivity of bacterial strains to simple and cheap antibiotics. In Poland pharmacoeconomic studies on the safety, effectiveness and costs of treatment are rare. Development of therapeutic standards in bacterial infections on the basis of pharmacoeconomic analyses and clinical studies determining effectiveness and safety of therapy allows for more rational pharmacotherapy. The following problems were investigated: is the treatment of serious bacterial infections with cheap standard antibiotics [SAT] or other antibiotics therapy [OAT] combined with amikacin safe and effective? What are the direct costs? How can reduction in costs be achieved? Prospective, randomized, single-blind study was performed in the group of 152 patients, admitted from 1 January to 31 July 2000, treated with amikacin combined with aminopenicillin/amoxicillin [SAT] versus other antibiotic therapy [OAT]. The economic evaluation was done by estimation of direct cost of treatment in patients with risk factors of nephrotoxicity [NT] and therapeutic drug monitoring [TDM] versus without TDM. The statistical significance was evaluated. This study revealed that effectiveness of the SAT versus OAT combined with amikacin in serious infections is high, 80% vs. 87%, respectively. Amikacin used in high once daily dose [HODD] in combined therapy with SAT or OAT was more safe in patients with risk of nephrotoxicity and TDM (21%) vs without TDM (10%) than used in conventional therapy [CT] 40% vs 19% [p < 05]. Evaluation of the absolute risk of nephrotoxicity increase in patients with TDM was 0.16 vs 0.34 Absolute Risk Increase (ARI) 0.18, Relative Risk Reduction (RRR): 0.53; 95% Confidence Interval (Cl): 0.87-2.82. The number needed to tread (NNT): 5.43; reduction of the risk of nephrotoxicity in patients without TDM treated with HODD was 0.19 vs 0.09, Absolute Risk Reduction (ARR): 0.09; RRR: 0.47; 95% CI: 0.74-1.34; NNT: 11.1; reduction of the risk of nephrotoxicity in patients with TDM treated with amikacin HODD was 0.21 vs 0.40, ARR: 0.19; RRR: 0.48; 95% CI 0.68-1.74; NNT: 5.3; Direct costs of the treatment with SAT vs OAT combined with amikacin are low [EU 78.30 vs EU 145.16] in the Clinical Unit of Lodz, compared with other countries. Out of EU 530 for the hospitalization of one patient, 86% constituted "hotel costs". Omitting TDM in patients without risk factors can significantly decrease costs by EU 66 860 per 1000 patients. Introduction of safe and cheap standard in the treatment of bacterial infections in clinical unit, shortening hospitalization by 5 days and limiting the number of patients requiring TDM service allows for a decrease in direct cost of about EU 235410 per 1000 patients/year. (+info)
Economic impact of standard antibiotic therapy combined with amikacin, in clinical unit, Lodz, Poland--part II.
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The study "Alexander" on bacterial resistance to antibiotics conducted in Poland revealed high sensitivity of bacterial strains to simple and cheap antibiotics. In Poland pharmacoeconomic studies on the safety, effectiveness and costs of treatment are rare. Development of therapeutic standards in bacterial infections on the basis of pharmacoeconomic analyses and clinical studies determining effectiveness and safety of therapy allows for more rational pharmacotherapy. The following problems were investigated: is the treatment of serious bacterial infections with cheap standard antibiotics [SAT] or other antibiotics therapy [OAT] combined with amikacin safe and effective? What are the direct costs? How can reduction in costs be achieved? Prospective, randomized, single-blind study was performed in the group of 152 patients, admitted from 1 January to 31 July 2000, treated with amikacin combined with aminopenicillin/amoxicillin [SAT] versus other antibiotic therapy [OAT]. The economic evaluation was done by estimation of direct cost of treatment in patients with risk factors of nephrotoxicity [NT] and therapeutic drug monitoring [TDM] versus without TDM. The statistical significance was evaluated. This study revealed that effectiveness of the SAT versus OAT combined with amikacin in serious infections is high, 80% vs. 87%, respectively. Amikacin used in high once daily dose [HODD] in combined therapy with SAT or OAT was more safe in patients with risk of nephrotoxicity and TDM (21%) vs without TDM (10%) than used in conventional therapy [CT] 40% vs 19% [p < 05]. Evaluation of the absolute risk of nephrotoxicity increase in patients with TDM was 0.16 vs 0.34 Absolute Risk Increase (ARI) 0.18, Relative Risk Reduction (RRR): 0.53; 95% Confidence Interval (CI): 0.87-2.82. The number needed to tread (NNT): 5.43; reduction of the risk of nephrotoxicity in patients without TDM treated with HODD was 0.19 vs 0.09, Absolute Risk Reduction (ARR): 0.09; RRR: 0.47; 95% CI: 0.74-1.34; NNT: 11.1; reduction of the risk of nephrotoxicity in patients with TDM treated with amikacin HODD was 0.21 vs 0.40, ARR: 0.19; RRR: 0.48; 95% CI: 0.68-1.74; NNT: 5.3; Direct costs of the treatment with SAT vs OAT combined with amikacin are low [EU 78.30 vs EU 145.16] in the Clinical Unit of Lodz, compared with other countries. Out of EU 530 for the hospitalization of one patient, 86% constituted "hotel costs". Omitting TDM in patients without risk factors can significantly decrease costs by EU 66 860 per 1000 patients. Introduction of safe and cheap standard in the treatment of bacterial infections in clinical unit, shortening hospitalization by 5 days and limiting the number of patients requiring TDM service allows for a decrease in direct cost of about EU 235410 per 1000 patients/year. (+info)
Evaluation of an intervention to increase screening colonoscopy in an urban public hospital setting.
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Only 50% of New Yorkers aged 50 and over reported ever being screened for colorectal cancer by any modality according to a recent household survey. The objective of this investigation was to assess the impact of a hospital-based intervention aimed at eliminating health care system barriers to timely colorectal cancer screening at Lincoln Medical Center, a large, urban public hospital in one of the nation's poorest census tracts. We conducted a retrospective analysis of all colonoscopies performed over an 11-month period, during which a multi-pronged intervention to increase the number of screening colonoscopies took place. Two "patient navigators" were hired during the study period to provide continuity for colonoscopy patients. A Direct Endoscopic Referral System (DERS) was also implemented. Enhancements to the gastrointestinal (GI) suite were also made to improve operational efficiency. Immediately following the introduction of the patient navigators, there was a dramatic and sustained decline in the broken appointment rates for both screening and diagnostic colonoscopy (from 67% in May of 2003 to 5% in June of 2003). The likelihood of keeping the appointment for colonoscopy after the patient navigator intervention increased by nearly 3-fold (relative risk = 2.6, 95% CI 2.2-3.0). The rate of screening colonoscopies increased from 56.8 per month to 119 per month. The screening colonoscopy coverage provided by this facility among persons aged 50 and over in surrounding Zip codes increased from 5.2 to 15.6% (RR 3.0, 95% CI 1.9-4.7). Efforts to increase the number of screening colonoscopies were highly successful, due in large part to the influence of patient navigators, a streamlined referral system, and GI suite enhancements. These findings suggest that there are significant health-care system barriers to colonoscopy that, when addressed, could have a significant impact on screening colonoscopy rates in the general population. (+info)