Potential reduction in mortality rates using an intensivist model to manage intensive care units

CONTEXT

Because of evidence suggesting that outcomes are better in "intensivist-model" intensive care units (ICUs), the Leapfrog Group's hospital safety standards propose that ICUs be managed by critical care physicians (intensivists) who work exclusively in the ICU.

COUNT

Number of lives saved annually in the United States.

CALCULATION

Lives saved = (number of ICU admissions x in-hospital mortality rate of ICU patients) x reduction in mortality rates associated with the intensivist model.

DATA SOURCE

Reduction in mortality rate associated with intensivist-model ICUs was determined by performing a structured literature review from 1986 to the present using MEDLINE. Other variables were estimated from various data sources.

RESULTS

In the nine studies that met our selection criteria, relative reductions in mortality rates associated with intensivist-model ICUs ranged from 15% to 60%. On the basis of the most conservative estimate of effectiveness (15% reduction), full implementation of intensivist-model ICUs would save approximately 53,850 lives each year in the United States. CAUTIONS: Given the large number of ICU patients and their high baseline risks, even modest reductions in mortality rates would save many lives. Because of potential constraints related to the workforce and other resources, the feasibility of fully implementing intensivist-model ICUs nationwide is uncertain.

[Promoting reading and spelling in children with computer programs]

OBJECTIVES AND METHODS

Sixteen students trained their reading and spelling skills with the computer programmes Budenberg 1 and 2 and the Comles Package for 1000 minutes over a one-month period.

RESULTS

Following one month of computer training, reading test scores had improved for seven of the 16, and spelling test scores for three children whose basic performance had been poor. Three and a half months of school instruction later, the reading test scores had improved for nine children, while there was no effect upon the spelling scores for most of the students.

Crafting usable knowledge

Current emphasis on evaluating interventions does not address the problems of dissemination and utilization of these interventions, particularly in complex settings such as schools. Research on interventions is of value, but its generalizability to specific contexts is limited. Further, little is known about actual use of empirically supported interventions in practice settings. These concerns suggest the following: (a) There is a need to examine the dissemination process, including practitioner education and the development of a consumer information mindset by researchers; (b) guidance about selecting interventions would benefit from a systematic problem-solving orientation; and (c) research training and methodology need to be augmented with strategies and techniques suitable for developing an empirical approach to practice. These issues are addressed with specific examples drawn from school-based practice.

Quality assurance in hip arthroplasty

Documentation is key to quality assurance (QA): Data must be complete, plausible, and comparable, and then analyzed to implement corrective measures. Important factors are: qualification of care-providing staff, equipment and implants available (structural quality), effective scheduling of operations and therapy management (process quality), and patient status monitoring (outcome quality). The primary aim is to reveal deficits in process quality and develop and implement improvements in care. QA does not aim at exposing individual mistakes or flawed techniques; rather it is designed to analyze processes and treatments and implement specific solutions. An evaluation profile with the key quality indicators and a QA guideline is presented. A survey conducted in Germany, Austria, and Switzerland revealed: (1) up to 12-month waiting period for surgery in 6%, (2) only 40% written instructions, (3) data mostly written by hand, (4) differences in surgery planning and use of prosthesis passport, (6) inconsistent data analysis, (7) corrective measures rarely implemented.

The results of a randomized trial of a quality improvement intervention in the care of patients with heart failure. The MISCHF Study Investigators

PURPOSE

Quality improvement and disease management programs for heart failure have improved quality of care and patient outcomes at large tertiary care hospitals. The purpose of this study was to measure the effects of a regional, multihospital, collaborative quality improvement intervention on care and outcomes in heart failure in community hospitals.

PATIENTS AND METHODS

This randomized controlled study included 10 acute care community hospitals in upstate New York. After a baseline period, 5 hospitals were randomly assigned to receive a multifaceted quality improvement intervention (n = 762 patients during the baseline period; n = 840 patients postintervention), while 5 were assigned to a "usual care" control (n = 640 patients during the baseline period; n = 664 patients postintervention). Quality of care was determined using explicit criteria by reviewing the charts of consecutive patients hospitalized with the primary diagnosis of heart failure during the baseline period and again in the postintervention period. Clinical outcomes included hospital length of stay and charges, in-hospital and 6-month mortality, hospital readmission, and quality of life measured after discharge.

RESULTS

Patients had similar characteristics in the baseline and postintervention phases in the intervention and control groups. Using hospital-level analyses, the intervention had mixed effects on 5 quality-of-care markers that were not statistically significant. The mean of the average length of stay among hospitals decreased from 8.0 to 6.2 days in the intervention group, with a smaller decline in mean length of stay in the control group (7.7 to 7.0 days). The net effects of the intervention were nonsignificant changes in length of stay of -1.1 days (95% confidence interval [CI]: -2.9 to 0.7 days, P = 0.18) and in hospital charges of -$817 (95% CI: -$2560 to $926, P = 0.31). There were small and nonsignificant effects on mortality, hospital readmission, and quality of life.

CONCLUSIONS

The incremental effect of regional collaboration among peer community hospitals toward the goal of quality improvement was small and limited to a slightly, but not significantly, shorter length of stay.

Evidence-based medicine: a commentary on common criticisms

Discussions about evidence-based medicine engender both negative and positive reactions from clinicians and academics. Ways to achieve evidence-based practice are reviewed here and the most common criticisms described. The latter can be classified as "limitations universal to the practice of medicine," "limitations unique to evidence-based medicine" and "misperceptions of evidence-based medicine." Potential solutions to the true limitations of evidence-based medicine are discussed and areas for future work highlighted.

Clinicians' impact on the quality of substance use disorder treatment

Clinicians' impact on substance use disorder treatment has been much less studied than therapy and patient variables. Yet, in this selective review of literature, a growing body of empirical work on clinicians' impact highlights several key issues that have relevance both to clinical practice and future research. These issues include clinicians' effect on treatment retention and outcome, professional characteristics, recovery status, adherence to protocols, counter-transference, alliance, personality, beliefs about treatment, and professional practice issues. Specific recommendations are offered to help improve the quality of care clinicians provide. In particular, it is suggested that greater accountability for clinicians' performance be balanced with increased support for their very difficult role. Methodological issues in studying clinicians are also addressed.

Is a science of psychotherapy possible? Subjectivity problems

Two sorts of subjectivity problems are discussed. The 1st concerns the characterization of psychotherapy as an attempt to alter clients' meanings. The 2nd concerns the seemingly subjective nature of value judgments about psychotherapy outcomes. It is argued that despite initial appearances, neither of these problems poses an insuperable difficulty for transforming the discipline of psychotherapy into a genuine science.

Inadequate treatment of nosocomial infections is associated with certain empiric antibiotic choices

OBJECTIVE

The purpose of this study was to determine the impact of scheduled changes of antibiotic classes, used for the empirical treatment of suspected or documented Gram-negative bacterial infections, on the occurrence of inadequate antimicrobial treatment of nosocomial infections.

DESIGN

Prospective observational study.

SETTING

Medical (19-bed) and surgical (18-bed) intensive care units in an urban teaching hospital.

PATIENTS

A total of 3,668 patients requiring intensive care unit admission were prospectively evaluated during three consecutive time periods.

INTERVENTIONS

During each time period, one antibiotic class was selected for the empirical treatment of Gram-negative bacterial infections as follows: time period 1 (baseline period) (1,323 patients), ceftazidime; time period 2 (1,243 patients), ciprofloxacin; and time period 3 (1,102 patients), cefepime.

MEASUREMENTS AND MAIN RESULTS

The overall administration of inadequate antimicrobial treatment for nosocomial infections decreased during the course of the study (6.1%, 4.7%, and 4.5%; p = .15). This was primarily because of a statistically significant decrease in the administration of inadequate antibiotic treatment for Gram-negative bacterial infections (4.4%, 2.1%, and 1.6%; p < .001). There were no statistically significant differences in the overall hospital mortality rate among the three time periods (15.6%, 16.4%, and 16.2%; p = .828) despite a significant increase in severity of illness as measured with Acute Physiology and Chronic Health Evaluation (APACHE) II scores (15.3 +/- 7.6, 15.7 +/- 8.0, and 20.7 +/- 8.6; p < .001). The hospital mortality rate decreased significantly during time period 3 (20.6%) compared with time period 1 (28.4%; p < .001) and time period 2 (29.5%; p < .001) for patients with an APACHE II score > or = 15.

CONCLUSIONS

These data suggest that scheduled changes of antibiotic classes for the empirical treatment of Gram-negative bacterial infections can reduce the occurrence of inadequate antibiotic treatment for nosocomial infections. Reducing inadequate antibiotic administration may improve the outcomes of critically ill patients with APACHE II scores > or = 15.

[Laparoscopic nephrectomy in geriatric patients: comparison with conventional nephrectomy]

INTRODUCTION

We report our experience with laparoscopic nephrectomy in comparison to open nephrectomy in geriatric patients. The laparoscopic technique is presented and the results are discussed with respect to the data from the current literature.

MATERIAL AND METHODS

Since 1993, a total of 249 patient have undergone a nephrectomy for benign renal disease. In 131 patients a laparoscopic nephrectomy (in most cases via a transperitoneal approach) was performed and in 118 patients an open nephrectomy via a flank incision. Clinical parameters were compared between both groups as well as with respect to different age groups.

RESULTS

There were no differences in terms of operative results (operative time, pre- and postoperative hemoglobin) between the laparoscopy group and open nephrectomy group as well as among the different age groups. Patients in the laparoscopy group demonstrated significant advantages with respect to blood loss, transfusion rate, analgesic consumption, hospital stay, and convalescence. These advantages were not related to patient age. The complication rate was comparable for both groups; however, both groups showed an elevation of the complication rate in the age groups 75 to 84 years. The mortality rate within the first 30 days after nephrectomy was 1.7% in the open nephrectomy group.

CONCLUSIONS

The laparoscopic nephrectomy offers comparable operative results (with less blood loss and a lower transfusion rate) when compared to open nephrectomy. In terms of postoperative parameters, patients in the laparoscopy group have significant advantages. Especially geriatric patients benefit from these advantages and, therefore, the laparoscopic approach should be the preferred technique for a nephrectomy in these patients.

Co-occurring mental and substance use disorders: promising approaches and research issues

This paper surveys the mental health and drug user treatment literature, identifying promising approaches and research issues in the treatment of co-occurring mental illness and substance use disorders. The prevalence and classification of co-occurring disorders are briefly reviewed, and selected treatment models currently in use are described. Three models are cited as representing particularly promising approaches--comprehensive integrated treatment, assertive community treatment, and the modified therapeutic community--and best practices are summarized. This paper proposes a research agenda focused on relevant emerging treatment issues.

Client-case manager racial matching in a program for homeless persons with serious mental illness

OBJECTIVE

This study evaluated the relationship between client-case manager racial matching and both service use and clinical outcomes in a case management program for homeless persons with serious mental illness.

METHODS

The study focused on 1,785 clients from the first cohorts that entered the Center for Mental Health Services' Access to Community Care and Effective Services and Supports (ACCESS) program, a five-year demonstration program for homeless persons with mental illness established at 18 sites between 1994 and 1996. A series of two-way analyses of variance was used to assess the effect of client and case manager race and their interaction on changes in outcomes and service use over a 12-month period.

RESULTS

Although African Americans had more severe problems on several measures and higher levels of service use at baseline, no differences in service use at 12 months or in the changes in client outcomes as measured by nine variables were associated with the different pairings of African-American and white clients and case managers. White clients had a greater reduction in psychotic symptoms than did African-American clients, regardless of client- case manager racial pairing. No differences were found between white and African-American clients on the amount of services received over time.

CONCLUSIONS

This study found virtually no evidence of a relationship between client race, case manager race, or client-case manager racial matching on either outcomes or service use.

Emergency evaluation and intervention with female victims of rape and other violence

Given the high prevalence of crime within the general population and the increased rates of victimization among those seeking medical care, professionals who work in emergency departments, primary care medical facilities, or mental health settings need to be prepared to address physical and psychological problems related to sexual and physical assault. In this paper, interpersonal violence prevalence studies are reviewed in terms of study design and findings for sexual assault and physical assault. Common injuries following both forms of assault are documented, followed by a review of long-term medical outcomes. In addition to a review of physical health outcomes, primary psychological effects of violence are also reviewed. Strategies with which to screen for interpersonal violence in the medical setting are offered, and issues related to mandatory reporting are summarized. Interventions for assault victims that can be implemented in the medical setting are outlined, and a new hospital-based treatment for victims of rape is described.

Quality improvement for methadone maintenance treatment

Negative community attitudes toward heroin addicts and toward methadone treatment are the major obstacles to providing good treatment. Negative attitudes find expression in inappropriate and constricting regulation of treatment, and in inadequate resources to support programs. They contribute to the ambivalence of patients in treatment. They find expression in a variety of staff behaviors in anxiety and defensiveness about treatment, in staff ambivalence about the value of methadone, and in extreme cases, in cynical and suboptimal treatment practices. These issues are not merely theoretical barriers to quality, but have contributed to serious problems in the quality and effectiveness of treatment. Neither regulations, nor wise prescriptions as to how treatment should be delivered, is an adequate response to these problems. A systematic approach to dealing with these issues is highly desirable. External, peer-based quality improvement provides an appropriate form of accountability, while enhancing the sense of professionalism of clinical staff. Although conventional approaches to quality assurance do not ensure the delivery of good care, benchmarking approaches based on monitoring outcomes can be used to review and improve treatment.

Implications of recent research for program quality in cocaine dependence treatment

Great strides have been made in recent years regarding the development and evaluation of treatments for cocaine dependence. In particular, several behavioral strategies have been developed with demonstrated effectiveness for diverse populations of cocaine-dependent individuals. These include contingency management, cognitive behavioral treatments, and manualized individual disease model approaches. In addition, large-scale client surveys have identified several correlates of good outcome in the treatment of cocaine dependence, including retention in treatment, increasing compliance, providing services and treatments that address the patient's comorbid psychosocial problems, and encouraging involvement in self-help groups. Finally, greater adoption by treatment providers of strategies commonly used in treatment efficacy research might also contribute to improved treatment quality.

The relationship between the quality of drug user treatment and program completion: understanding the perceptions of women in a prison-based program

To determine why some women offenders complete prison-based drug user treatment and others leave early, clients' (N = 101) perceptions of various aspects of the quality of the treatment experience were compared. Analyses of both quantitative and qualitative data indicate that clients who completed the program had a more favorable perception of staff and felt empowered by the experience in treatment. Most of the clients who left early did so because of conflicts or disagreements with the program's rules. We discuss how a supportive approach to personal development may enhance client perceptions of program quality and increase retention rates.

Assisted reproductive technology in the United States: 1997 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry

OBJECTIVE

To summarize the procedures and outcomes of assisted reproductive technology (ART) initiated in the United States in 1997.

DESIGN

Data were collected electronically by using Society for Assisted Reproductive Technology Clinical Outcome Reporting System software and were submitted to the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry.

PARTICIPANT(S)

335 programs submitted data on procedures performed in 1997. Data were collated after November 1998 so that the outcome of all pregnancies established would be known.

MAIN OUTCOME MEASURE(S)

Incidence of clinical pregnancy, ectopic pregnancy, abortion, stillbirth, delivery, and structural and functional abnormalities.

RESULT(S)

Programs reported initiating 73,069 cycles of ART treatment. Of these, 51,344 cycles involved IVF (with and without micromanipulation), with a delivery rate per retrieval of 27.9%; 1,943 were cycles of GIFT, with a delivery rate per retrieval of 30.0%; and 1,104 were cycles of zygote intrafallopian transfer, with a delivery rate per retrieval of 28.0%. The following additional ART procedures were also initiated: 4,616 donor oocyte cycles, with a delivery rate per transfer of 40.0%; 10,181 frozen embryo transfer procedures, with a delivery rate per transfer of 18.8%; 1,584 frozen embryo transfers using donated oocytes, with a delivery rate per transfer of 22.2%; and 600 cycles using a host uterus, with a delivery rate per transfer of 34.6%. Furthermore, 1,173 cycles were reported as combinations or more than one treatment type, 40 cycles as research, 258 as embryo banking, and 226 as other (unclassified) cycle types. As a result of all procedures, 17,311 deliveries resulting in 25,059 babies were reported.

CONCLUSION(S)

In 1997, more programs reported ART treatment and the number of reported cycles increased significantly (10.9%) compared with 1996. In comparable cycle types, the overall success rate (deliveries per retrieval) increased by 1.8%, which represents an increase of 6.9% compared with the success rate for 1996.

Conceptualizing and assessing treatment structure and process in community-based drug dependency treatment programs

Having established the effectiveness of drug dependency treatment, the next generation of research will necessitate a focus on treatment structure and process and the systems within which programs operate. As a foundation for a process conceptualization, we constructed a grounded theory definition of treatment consisting of core elements and related comprehensive services. We then presented the multilevel conceptual framework that guided the Drug Abuse Treatment Outcome Study (DATOS) treatment structure and process study design and instrumentation, anchored by supporting empirical literature. The framework emphasizes seven critical levels of process measurement that future research should consider in order to avoid potential spurious findings.