An English and Spanish Pediatric Asthma Symptom Scale

BACKGROUND

Pediatric asthma survey measures have not been adequately tested in non-English-speaking populations.

OBJECTIVES

To test the reliability and validity of an English and Spanish symptom scale to measure asthma control in children.

SUBJECTS

Parents (54% Spanish-speaking; 61% not high school graduates) of 234 children seen in the emergency department for an asthma exacerbation.

MEASURES

Parent report of frequency and perceived severity of child asthma symptoms during the beginning and after resolution of the exacerbation.

RESULTS

An 8-item scale composed of reports of cough, wheezing, shortness of breath, asthma attacks, chest pain, night symptoms, and overall perceived severity had very good psychometric properties in both English and Spanish. The reliability (Cronbach's alpha) of the scale ranged from 0.81 to 0.87 for both languages and time frames. In both languages, the validity of the scale was supported by responsiveness to changes in clinical status (lower symptom score after resolution of the exacerbation, P < 0.001) and by moderate to strong correlations (P < 0.001) with other asthma morbidity measures (parent report of child bother: r = 0.59-0.65; school days lost: r = 0.38-0.67; and activity days lost: r = 0.41-0.59). There were no statistically significant differences in the reliability or construct validity of the summary symptom scale by language, although Spanish speakers reported a lower frequency of some symptoms than did English speakers.

CONCLUSIONS

A reliable and valid 8-item scale can be used to measure control of asthma symptoms in Spanish-speaking populations of low literacy. Additional research to evaluate language equivalency of asthma measures is necessary.

Effect of variability in the interpretation of coronary angiograms on the appropriateness of use of coronary revascularization procedures

BACKGROUND

Evidence from numerous studies of coronary angiography show differences between observers' assessments of 15% to 45%. The implication of this variation is serious: If readings are erroneous, some patients will undergo revascularization procedures unnecessarily and others will be denied an essential treatment. We evaluated the variation in interpretation of angiograms and its potential effect on appropriateness of use of revascularization procedures.

METHODS AND RESULTS

Angiograms of 308 randomly selected patients previously studied for appropriateness of angiography, coronary artery bypass grafting (CABG), and percutaneous transluminal coronary angioplasty (PTCA) were interpreted by a blinded panel of 3 experienced angiographers and compared with the original interpretations. The potential effect on differences on the appropriateness of revascularization was assessed by use of the RAND criteria. Technical deficiencies were found in 52% of cases. Panel readings tended to show less significant disease (none in 16% of vessels previously read as showing significant disease), less severity of stenosis (43% lower, 6% higher), and lower extent of disease (23% less, 6% more). The classification of CABG changed from necessary/appropriate to uncertain/inappropriate for 17% to 33% of cases when individual ratings were replaced by panel readings.

CONCLUSIONS

The general level of technical quality of coronary angiography is unsatisfactory. Variation in the interpretation of angiograms was substantial in all measures and tended to be higher in individual than in panel readings. The effect was to lead to a potential overestimation of appropriateness of use of CABG by 17% and of PTCA by 10%. These findings indicate the need for increased attention to the technical quality of studies and an independent second reading for angiograms before recommending revascularization.

Appropriateness of referral of coronary angiography patients in Sweden. SECOR/SBU Project Group

OBJECTIVE

To evaluate the appropriateness of referral following coronary angiography in Sweden.

DESIGN

Prospective survey and review of medical records.

PATIENTS

Consecutive series of 2767 patients who underwent coronary angiography in Sweden between May 1994 and January 1995 and were considered for coronary revascularisation.

MAIN OUTCOME MEASURES

Percentage of patients referred for coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for indications that were judged necessary, appropriate, uncertain, and inappropriate by a multispecialty Swedish national expert panel using the RAND/University of California Los Angeles (UCLA) appropriateness method, and the percentage of patients referred for continued medical management who met necessity criteria for revascularisation.

RESULTS

Half the patients were referred for CABG, 25% for PTCA, and 25% for continued medical therapy. CABG was judged appropriate or necessary for 78% of patients, uncertain for 12% and inappropriate for 10%. For PTCA the figures were 32%, 30% and 38%, respectively. Two factors contributed to the high inappropriate rate. Many of these patients did not have "significant" coronary artery disease (although all had at least one stenosis > 50%) or they were treated with less than "optimal" medical therapy. While 96% of patients who met necessity criteria for revascularisation were appropriately referred for revascularisation, 4% were referred for continued medical therapy.

CONCLUSIONS

Using the RAND/UCLA appropriateness method and the definitions agreed to by the expert panel, which may be considered conservative today, it was found that 19% of Swedish patients were referred for coronary revascularisation judged inappropriate. Since some cardiovascular procedures evolve rapidly, the proportion of patients referred for inappropriate indications today remains unknown. Nevertheless, physicians should actively identify those patients who will and will not benefit from coronary revascularisation and ensure that they are appropriately treated.

Underuse and overuse of diagnostic testing for coronary artery disease in patients presenting with new-onset chest pain

PURPOSE

To determine the extent of overuse and underuse of diagnostic testing for coronary artery disease and whether the socioeconomic status, health insurance, gender, and race/ethnicity of a patient influences the use of diagnostic tests.

SUBJECTS AND METHODS

We identified patients who presented with new-onset chest pain not due to myocardial infarction at one of five Los Angeles-area hospital emergency departments between October 1994 and April 1996. Explicit criteria for diagnostic testing were developed using the RAND/University of California, Los Angeles, expert panel method. They were applied to data collected by medical record review and patient questionnaire.

RESULTS

Of the 356 patients, 181 met necessity criteria for diagnostic cardiac testing. Of these, 40 (22%) failed to receive necessary tests. Only 7 (3%) of the 215 patients who received some form of cardiac testing had tests that were judged to be inappropriate. Underuse was significantly more common in patients with only a high school education (30% vs 15% for those with some college, P = 0.02) and those without health insurance (34% vs 15% of insured patients, P = 0.01). In a multivariate logistic regression model, only the lack of a post-high school education was a significant predictor of underuse (odds ratio 2.2, 95% confidence interval 1.0 to 4.4).

CONCLUSION

Among patients with new-onset chest pain, underuse of diagnostic testing for coronary artery disease was much more common than overuse. Underuse was primarily associated with lower levels of patient education.

The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior

CONTEXT

Despite growing concern over the escalating antimicrobial resistance problem, physicians continue to inappropriately prescribe. It has been suggested that a major determinant of pediatrician antimicrobial prescribing behavior is the parental expectation that a prescription will be provided.

OBJECTIVES

To explore the extent to which parental previsit expectations and physician perceptions of those expectations are associated with inappropriate antimicrobial prescribing; and to explore the relationship between fulfillment of expectations and parental visit-specific satisfaction.

DESIGN

Previsit and postvisit survey of parents and postvisit survey of physicians.

SETTING

Two private pediatric practices, one community based and one university based.

PARTICIPANTS

Ten physicians (response rate = 77%), and a consecutive sample of 306 eligible parents (response rate = 86%) who were attending sick visits for their children between October 1996 and March 1997. Parents were screened for eligibility in the waiting rooms of the two practices and were invited to participate if they spoke and read English and their child was 2 to 10 years old, had a presenting complaint of ear pain, throat pain, cough, or congestion, was off antimicrobial therapy for the past 2 weeks, and was seeing one of the participating physicians.

MAIN OUTCOME MEASURES

Antimicrobial prescribing decision, probability of assigning a bacterial diagnosis, and parental visit-specific satisfaction.

RESULTS

Based on multivariate analysis, physicians' perceptions of parental expectations for antimicrobials was the only significant predictor of prescribing antimicrobials for conditions of presumed viral etiology; when physicians thought a parent wanted an antimicrobial, they prescribed them 62% of the time versus 7% of the time when they did not think the parent wanted antimicrobials. However, physician antimicrobial prescribing behavior was not associated with actual parental expectations for receiving antimicrobials. In addition, when physicians thought the parent wanted an antimicrobial, they were also significantly more likely to give a bacterial diagnosis (70% of the time versus 31% of the time). Failure to meet parental expectations regarding communication events during the visit was the only significant predictor of parental satisfaction. Failure to provide expected antimicrobials did not affect satisfaction.

CONCLUSIONS

The antibiotic resistance epidemic should lead to immediate replication of this study in a larger more generalizable population. If inaccurate physician perceptions of parent desires for antimicrobials for viral infections are confirmed, then an intervention to change the way physicians acquire this set of perceptions should be undertaken.

Underuse of cardiac procedures: do women, ethnic minorities, and the uninsured fail to receive needed revascularization?

BACKGROUND

Women, ethnic minorities, and uninsured persons receive fewer cardiac procedures than affluent white male patients do, but rates of use are crude indicators of quality. The important question is, Do women, minorities, and the uninsured fail to receive cardiac procedures when they need them?

OBJECTIVE

To measure receipt of necessary coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA) overall; by patient sex, ethnicity, and payer status; and by availability of on-site revascularization.

DESIGN

Retrospective, randomized medical record review.

SETTING

13 of the 24 hospitals in New York City that provide coronary angiography.

PATIENTS

631 patients who had coronary angiography in 1992 and met the RAND expert panel criteria for necessary revascularization.

MEASUREMENTS

The percentage of patients who had CABG surgery or PTCA was measured, as were variations in use rates by sex, ethnic group, insurance status, and availability of on-site revascularization. Clinical and laboratory data were retrieved from medical records to identify patients who met the panel criteria for necessary revascularization. Receipt of revascularization was determined from state reports, medical records, and information provided by cardiologists.

RESULTS

Overall, 74% (95% CI, 71% to 77%) of patients who met the panel criteria for necessary revascularization had CABG surgery or PTCA (underuse rate, 26%). No differences were found in use rates by patient sex, ethnic group, or payer status, but hospitals that provided on-site revascularization had higher use rates (76% [CI, 74% to 79%]) than hospitals that did not provide it (59% [CI, 56% to 65%]) (P < 0.01). In hospitals that did not provide on-site revascularization, uninsured patients were less likely to have revascularization recommended to them (52% [CI, 32% to 78%]); rates of recommendation for patients with private insurance, Medicare, and Medicaid were 82%, 91%, and 75%, respectively (P = 0.026).

CONCLUSIONS

Although revascularization procedures are substantially underused, no variations in rate of use by sex, ethnic group, or payer status were seen among patients treated in hospitals that provide CABG surgery and PTCA. However, underuse was significantly greater in hospitals that do not provide these procedures, particularly among uninsured persons.

Elevated asthma morbidity in Puerto Rican children: a review of possible risk and prognostic factors

Latino children represent a significant proportion of all US children, and asthma is the most common chronic illness affecting them. Previous research has revealed surprising differences in health among Latino children with asthma of varying countries of family origin. For instance, Puerto Rican children have a higher prevalence of asthma than Mexican American or Cuban American children. In addition, there are important differences in family structure and socioeconomic status among these Latino populations: Cuban Americans have higher levels of education and family income than Mexican-Americans and Puerto Ricans; mainland Puerto Rican children have the highest proportion of households led by a single mother. Our review of past research documents differences in asthma outcomes among Latino children and identifies the possible genetic, environmental, and health care factors associated with these differences. Based on this review, we propose research studies designed to differentiate between mutable and immutable risk and prognostic factors. We also propose that the sociocultural milieus of Latino subgroups of different ethnic and geographic origin are associated with varying patterns of risk factors that in turn lead to different morbidity patterns. Our analysis provides a blue-print for future research, policy development, and the evaluation of multifactorial interventions involving the collaboration of multiple social sectors, such as health care, public health, education, and public and private agencies.

Differences between child and parent reports of symptoms among Latino children with asthma

OBJECTIVES

To determine, in a population of predominantly Latino children with asthma 6 to 18 years old, whether parent and child reports of asthma symptoms with exercise differ and to evaluate the validity of child and parent reports of symptoms.

DESIGN

Data obtained from child and parent interviews; pulmonary function tests (forced vital capacity, forced expiratory volume in 1 second, forced expiratory flow25-75, peak expiratory flow), and observation of symptoms after exercise.

SETTING

Three summer camps for minority children with asthma in Los Angeles County.

PARTICIPANTS

A total of 97 children with asthma (78% Latino, 12% non-Latino White, 9% Other; 6 to 18 years of age) and their parents.

INTERVENTION(S)

None.

PRIMARY OUTCOME MEASURES

Child and parent reports of cough and wheezing with exercise and pulmonary function tests before and after exercise. While at camp, children underwent spirometry after completing the self-administered survey. The pulmonary function tests were conducted and interpreted according to the pediatric specifications for spirometry, and results >80% of predicted, adjusted for gender, age, height, and race, were considered normal. Six peak expiratory flow rates (PEFR) by peak flow meter also were recorded by trained research assistants immediately before spirometry, and values >80% of predicted based on height were considered normal. To observe child symptoms with exercise, children participated in a relay running race of 200 feet followed by a swimming race of 300 feet. Research assistants measured heart rate and 6 PEFRs using ASSESS portable peak flow meters immediately before and after each exercise. A positive exercise challenge was defined as a 15% reduction in mean PEFR and/or observed asthma symptoms (cough, wheezing, chest pain, asthma attack).

RESULTS

Of the children, 18% reported never having a cough when they exercised, 46% reported having it occasionally when they exercised, and 36% reported having it quite often or always when they exercised. For wheezing, 20% of children reported never having wheezing when they exercised, 35% having it occasionally when they exercised, and 45% having it quite often or always when they exercised. Parents reported fewer symptoms than did their children. Of the parents, 34% reported that their children did not have cough with exercise, 37% reported few to some days, and 29% reported most days or every day. Forty-seven percent of parents reported that their child did not wheeze with exercise in the last 2 months, 35% reported wheezing on a few days to some days, and 17% reported wheezing most days to every day. Parent and child reports of cough or wheezing after exercise correlated mildly with each other (parent/child cough r = 0. 23; kappa = 0.03; parent/child wheezing r = 0.21; kappa = 0.14). Children were more likely to report cough: 59 of 71 (83%) of children versus 44 of 71 (62%) of parents. The 22 children who reported cough when their parents did not account for most of the disagreement between parents and children. Children were more likely than were their parents to report wheezing; 55 of 69 (80%) children versus 36 of 69 (52%) parents reported that the child wheezed. The 24 children who reported wheezing when their parents did not account for most of the disagreement between parents and children. Forty-seven percent of the children had a value <80% of predicted for at least one of the four spirometry tests; 29% of mean baseline PEFRs were <80% of predicted. Overall, 86% of the children met one or more of the following: any percent of predicted pulmonary function tests <80% or any symptom or PEFR reduction of 15% after exercise, or other occurrence of nonexercise symptoms during camp. Almost all child reports of cough and wheezing correlated significantly with the criterion validity criteria. For example, child reports of wheezing were, as expected, correlated negatively with the percent of predicted FEV1 (r = -0.28) and correlated positive

How good is the quality of health care in the United States?

Studies over the past decade show that some people are receiving more care than they need, and some are receiving less. Simple averages from a number of studies indicate that 50 percent of people received recommended preventive care; 70 percent, recommended acute care; 30 percent, contraindicated acute care; 60 percent, recommended chronic care; and 20 percent, contraindicated chronic care. These studies strongly suggest that the care delivered in the United States often does not meet professional standards. Efforts to measure quality and report routinely on the results to the public at large would allow more definitive assessments of the status of the nation's health care and would enable us to single out the areas in need of improvement.

Costs attributable to osteoarthritis

OBJECTIVE

To estimate charges attributable to osteoarthritis (OA) in a managed care organization.

METHODS

Longitudinal study based on insurance claims incurred and filed between 1991 and 1993 in a national managed care organization. Patients with claims for OA were randomly sampled to yield 20,000 study subjects. Charges per person-year were determined for these patients and compared to those of comparison subjects matched for age, sex, and insurance plan without claims for OA.

RESULTS

Total charges per patient-year adjusted to 1993 dollars for patients with OA <65 and > or =65 years of age were $5,294 and $5,704, respectively, while charges for controls were $2,467 and $3,741, respectively. Thus, charges due to OA were $2,827 and $1,963, accounting for 5% of total plan charges.

CONCLUSION

Patients with symptomatic OA incur charges for medical care at about twice the rate of plan enrollees without claims for OA and account for a substantial proportion of total charges in a managed care plan.

Visual function impairments in relation to gender, age, and visual acuity in patients who undergo cataract surgery

PURPOSE

This study aimed to determine the relationship between visual function impairment in 776 patients who had extracapsular cataract extraction with posterior chamber intraocular lens implantation and gender, age, preoperative visual acuity (VA) of both the operative and the contralateral eye, and presence of other ocular disease in the operative eye.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

1139 patients whose medical records were abstracted and who had cataract surgery performed at 1 of 10 participating academic medical centers in 1990.

MAIN OUTCOME MEASURE

In the 776 patients who had explicit statements about impairment of visual function documented in their medical records, univariate and multivariable logistic analyses were used to assess the above relationship.

RESULTS

The most severe visual functional deficit that justified the cataract operation varied in relation to gender, age, and VA. On bivariate analysis, men were more likely to have impairment with employment, driving, and glare, whereas women were more likely to have impairment with activities of daily living and recreational activities. Significant findings between visual impairment and the independent variables from the logistic regression models included: (1) employment limitation and male gender (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.08-3.40); (2) employment limitation and younger age (OR, 0.12; 95% CI, 0.050-0.28 for ages 70-79); (3) recreational impairment and older age (OR, 2.77; 95% CI, 1.64-4.70 for ages 80+); (4) impairment in performing activities of daily living and female gender (OR, 0.72; 95% CI, 0.53-0.98 for male gender); (5) impairment in performing activities of daily living and worse VA in the operative eye (OR, 5.13; 95% CI, 2.93-9.00 for VA < 20/100); (6) glare-associated impairment and younger age (OR, 0.40; 95% CI, 0.24-0.69 for age 80+); and (7) glare-associated impairment and better VA (OR, 0.16; 95% CI, 0.067-0.38 for VA < 20/100).

CONCLUSION

When deciding whether to perform cataract surgery, functional impairment must be considered in relation to the age and the gender of the patient, for the type of functional impairment varies in association with age and gender.

The smoking gun: do clinicians follow guidelines on firearm safety counseling?

OBJECTIVES

To describe clinicians' behavior regarding firearm safety counseling practices, develop a model to predict current counseling behavior, and identify resources that might positively influence willingness to counsel according to medical guidelines.

DESIGN

Four hundred sixty-five primary care Los Angeles County, California, pediatricians, family physicians, and pediatric nurse practitioners who serve families with children aged 5 years and younger received mailed questionnaires; 325 (70%) responded.

MAIN OUTCOME MEASURE

Clinician self-reported behavior.

RESULTS

Of the respondents, 80% stated that they should counsel on firearm safety; only 38% do so. Of those clinicians who currently counsel, only 20% counsel more than 10% of their patient families. Firearm safety counseling behavior is positively associated with a clinician being 49 years or younger (odds ratio [OR]=2.19, P=.02); a perception that counseling is beneficial (OR=2.62, P=.02); and household handgun ownership (OR=2.47, P=.02). Clinician households that report gun ownership counsel differently than those clinicians who report not possessing a household gun. There are no significant differences in the rates of counseling across specialties and crime area types. Forty-one percent of clinicians report that patient education handouts would increase their likelihood of counseling.

CONCLUSIONS

In Los Angeles County gaps exist between clinicians' views of the benefits of counseling families with young children regarding firearm safety and their actual behavior. Guidelines and handouts are available from major medical organizations. Research should focus on how to get practitioners to use available materials, enabling them to better adhere to guidelines.

Performance of panel-based criteria to evaluate the appropriateness of colonoscopy: a prospective study

BACKGROUND

Prospective data describing the appropriateness of use of colonoscopy based on detailed panel-based clinical criteria are not available.

METHODS

In a cohort of 553 consecutive patients referred for colonoscopy to two university-based Swiss outpatient clinics, the percentage of patients who underwent colonoscopy for appropriate, equivocal, and inappropriate indications and the relationship between appropriateness of use and the presence of relevant endoscopic lesions was prospectively assessed. This assessment was based on criteria of the American Society for Gastrointestinal Endoscopy and explicit American and Swiss criteria developed in 1994 by a formal panel process using the RAND/UCLA appropriateness method.

RESULTS

The procedures were rated appropriate or equivocal in 72.2% by criteria of the American Society for Gastrointestinal Endoscopy, in 68.5% by explicit American criteria, and in 74.4% by explicit Swiss criteria (not statistically significant, NS). Inappropriate use (overuse) of colonoscopy was found in 27.8%, 31.5%, and 25.6%, respectively (NS). The proportion of appropriate procedures was higher with increasing age. Almost all reasons for using colonoscopy could be assessed by the two explicit criteria sets, whereas 28.4% of reasons for using colonoscopy could not be evaluated by the criteria of the American Society for Gastrointestinal Endoscopy (p < 0.0001). The probability of finding a relevant endoscopic lesion was distinctly higher in the procedures rated appropriate or equivocal than in procedures judged inappropriate.

CONCLUSIONS

The rate of inappropriate use of colonoscopy is substantial in Switzerland. Explicit criteria allow assessment of almost all indications encountered in clinical practice. In this study, all sets of appropriateness criteria significantly enhanced the probability of finding a relevant endoscopic lesion during colonoscopy.

Measuring the quality of outpatient treatment for schizophrenia

BACKGROUND

Consumers and policy makers are increasingly interested in measuring treatment quality. We developed a standardized approach to measuring the quality of outpatient care for schizophrenia and used it to evaluate routine care.

METHODS

We randomly sampled 224 patients in treatment for schizophrenia at 2 public mental health clinics. Appropriate medication management was defined according to criteria derived from national treatment recommendations, and focused on recent management of symptoms and side effects. Adequate psychosocial care was defined as the recent provision of case management or family management to patients for whom it is indicated. Care was evaluated using patient interviews and medical records abstractions.

RESULTS

Although patients at the 2 clinics had similar illnesses, the treatment they received was quite different. In total, 84 (38%) of patients received poor-quality medication management, and 117 (52%) had inadequate psychosocial care. Clinics differed in the proportion of patients receiving poor-quality medication management not attributable to patient factors (28% vs 16%). The clinic with better-quality medication management provided case management to fewer severely ill patients (48% vs 81%). More than half of the cases of poor care would not have been detected if we had used only medical records data.

CONCLUSIONS

At these clinics, many schizophrenic patients were receiving poor-quality care and most poor care was likely due to factors that can be modified. One approach to improving care begins by developing systems that monitor quality. These systems may require improved medical records and patient-reported symptoms and side effects.

The UCLA Prostate Cancer Index: development, reliability, and validity of a health-related quality of life measure

OBJECTIVES

The need for accurate measures of health-related quality of life (HRQOL) in men treated for prostate cancer is of paramount importance because patients may survive for many years after their diagnosis. Hence, interest has increased in choosing treatments that optimize both the quality and quantity of life in patients with this disease. This study sought to develop and evaluate a self-administered, multiitem, disease-specific instrument to capture the health concerns central to the quality of life of men treated for early stage prostate cancer.

METHODS

After focus group analysis and pilot testing, the instrument was tested with a large retrospective, cross-sectional survey. Exploratory factor analysis and multitrait scaling analysis were used to facilitate the formation of six scales containing 20 disease-targeted items that address impairment in the urinary, bowel, and sexual domains. The psychometric properties of the new scales were assessed by measuring test-retest reliability, internal consistency reliability, and construct validity. Performance on the new scales was compared with scores on other established cancer-related health-related quality of life instruments. Two hundred fifty-five long-term survivors of prostate cancer treatment and 273 age-matched and ZIP code-matched comparison subjects without prostate cancer from a large managed care population in California were studied. Mean age was 72.7 years. In addition to the new scales, the RAND 36-Item Health Survey (SF-36) was used as a generic core measure, and a cancer-related health-related quality of life instrument (the Cancer Rehabilitation System-Short Form) was used to provide construct validity.

RESULTS

For the new scales, test-retest reliability ranged from 0.66 to 0.93, and internal consistency ranged from 0.65 to 0.93. Disease-targeted measures of function and bother in the three domains correlated substantially with one another. Scale scores correlated well with related, established scales. Men undergoing prostatectomy or pelvic irradiation demonstrated the expected differences in performance on the disease-specific health-related quality of life scales when compared with each other or with comparison subjects. Age was inversely related to sexual and bowel function.

CONCLUSIONS

The UCLA Prostate Cancer Index performed well in this population of older men with and without prostate cancer. It demonstrated good psychometric properties and appeared to be well understood and easily completed. The high response among patients suggests that these men especially are interested in addressing both the general and disease-specific concerns that impact their daily quality of life.

Congruence between decisions to initiate chiropractic spinal manipulation for low back pain and appropriateness criteria in North America

BACKGROUND

Recent U.S. practice guidelines recommend spinal manipulation for some patients with low back pain. If followed, these guidelines are likely to increase the number of persons referred for chiropractic care. Concerns have been raised about the appropriate use of chiropractic care, but systematic data are lacking.

OBJECTIVE

To determine the appropriateness of chiropractors' decisions to use spinal manipulation for patients with low back pain.

DESIGN

Retrospective review of chiropractic office records against preset criteria for appropriateness that were developed from a systematic review of the literature and a nine-member panel of chiropractic and medical specialists. Appropriateness criteria reflect the expected balance between risk and benefit.

SETTING

131 of 185 (71%) chiropractic offices randomly sampled from sites in the United States and Canada.

PATIENTS

10 randomly selected records of patients presenting with low back pain from each office (1310 patients total).

MEASUREMENTS

Sociodemographic data on patients and chiropractors; use of health care services by patients; assessment of the decision to initiate spinal manipulation as appropriate, uncertain, or inappropriate.

RESULTS

Of the 1310 patients who sought chiropractic care for low back pain, 1088 (83%) had spinal manipulation. For 859 of these patients (79%), records contained data sufficient to determine whether care was congruent with appropriateness criteria. Care was classified as appropriate in 46% of cases, uncertain in 25% of cases, and inappropriate in 29% of cases. Patients who did not undergo spinal manipulation were less likely to have a presentation judged appropriate and were more likely to have a presentation judged inappropriate than were patients who did undergo spinal manipulation (P = 0.01).

CONCLUSIONS

The proportion of chiropractic spinal manipulation judged to be congruent with appropriateness criteria is similar to proportions previously described for medical procedures; thus, the findings provide some reassurance about the appropriate application of chiropractic care. However, more than one quarter of patients were treated for indications that were judged inappropriate. The number of inappropriate decisions to use chiropractic spinal manipulation should be decreased.

Member ratings of health care provided by 48 physician groups

BACKGROUND

Satisfaction with health plan performance has been assessed frequently, but assessment of physician group performance is rare.

OBJECTIVE

To present ratings of the care provided by physician groups to enrollees in a variety of capitated health maintenance organization plans.

METHODS

A random sample was drawn of adult enrollees receiving managed health care from 48 physician groups in a group practice association. Each individual in the sample was mailed a 12-page questionnaire and 7093 were returned (59% response rate). The mean age of those returning the questionnaire was 51 years; 65% were women.

RESULTS

Reliability estimates for 6 multi-item satisfaction scales were excellent, and noteworthy differences in ratings among groups were observed. In particular, ratings of overall quality ranged from a low of 28 to a high of 68 (mean, 50; SD, 10). Average scores for physician groups were strongly correlated across all scales, but no single group scored consistently highest or lowest on the different scales. Negative ratings of care were significantly related to the following: intention to switch to another physician group, difficulty in getting appointments, lengthy waiting periods in the reception area and examination room, the inability to get consistent care from one physician for routine visits, and not being informed by the office staff when there was a delay in seeing the primary care provider.

CONCLUSIONS

Monitoring of health care quality at the physician group level is possible, and could be used for benchmarking, internal quality improvement, and for providing information to the public about how these physician groups will meet its needs.

Toward assessing outcomes of emergency care

Establishing the efficacy of emergency care for patients--what should or should not be done in the emergency department--requires patients to come to an ED under close-to-ideal situations, and on leaving the ED to be treated under ideal circumstances. Randomized, controlled clinical trials are needed to answer the efficacy question.

Reliability of panel-based guidelines for colonoscopy: an international comparison

BACKGROUND

This study examined the reliability of explicit guidelines developed using the RAND-UCLA appropriateness method.

METHODS

The appropriateness of over 400 indications for colonoscopy was rated by two multispecialty expert panels (United States and Switzerland). A nine-point scale was used, which was consolidated into three categories of appropriateness: appropriate, uncertain, inappropriate. The distribution of appropriateness ratings between the two panels and the intrapanel and interpanel agreement for categories of appropriateness were calculated for all possible indications. Similar statistics were calculated for a series of 577 primary care patients referred for colonoscopy in Switzerland.

RESULTS

Over 80% of all indications (348) could be directly compared. The proportions of indications classified as appropriate, uncertain, or inappropriate were 28.4%, 24.7%, 46.6% and 33.0%, 23.0%, 44.0% for the U.S. and the Swiss panels, respectively. Interpanel agreement was excellent for all the possible indications (kappa value: 0.75) and lower for actual cases (kappa value: 0.51) because of lower agreement for the most frequently encountered indications.

CONCLUSIONS

Good agreement between the two sets of criteria was found, pointing to the reliability of the method. Partial disagreement occurred essentially for a few, albeit frequently encountered, indications for use of colonoscopy in cases of uncomplicated lower abdominal pain or constipation.

Changes in the healthcare system. Goals, forces, solutions

The goals of a health system should be to provide all necessary care to everybody, improve the mean level of quality of care, reduce variations in this care, and eliminate waste. In fact, the driving force currently promoting change in the health system is cost containment, and the greatest efforts being exerted in this regard are in those areas where the most money is being spent. Research suggests that increased health spending does not necessarily equate with improved healthcare. Furthermore, reducing expenditure does not ensure that only less than necessary procedures are eliminated. Thus, it is important to use a conceptual model that relates cost to quality of care when approaching the problem of reducing the costs of healthcare. It is also necessary to define quality of care and necessary care, so that the clinical process can be re-engineered to ensure that both quality and necessary care can be delivered. The financial incentives that support the implementation of this process can then be put in place. Quality of care at an acceptable cost can only be obtained if waste is identified and eliminated, resources are applied to necessary and appropriate care, variations in the quality of care are eliminated, and economic policies consistent with a country's culture and expectations of value for money are adopted. Accomplishing these objectives will be difficult and costly. However, the effort must be made, if for no other reason than that the existing system in the United States, whereby health insurance is not provided for everyone, is unacceptable.

Effect of panel composition on physician ratings of appropriateness of abdominal aortic aneurysm surgery: elucidating differences between multispecialty panel results and specialty society recommendations

OBJECTIVE

To investigate how the composition of multispecialty physician panels is associated with both the summary ratings assigned by such panels and the agreement of such panels with the recommendations of specialty societies.

DATA SOURCES/STUDY SETTING

We examined the final ratings assigned by a nine-member multispecialty RAND Corporation physician panel regarding indications for abdominal aortic aneurysm surgery and the recommendations of a specialty society representing vascular surgeons who perform the same surgery.

STUDY DESIGN

The panel was retrospectively divided into two sub-panels, one composed of the three vascular surgeons on the panel and the other composed of the six remaining physicians. We analyzed the two sub-panels' rating patterns with respect to each other and with respect to concurrent guidelines generated by the Joint Council of the Society of Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery.

PRINCIPAL FINDINGS

Of the 782 indications considered by the panel for appropriateness, the vascular surgeons had an average of mean ratings for appropriateness of 5.1, significantly higher than the 4.5 average of the other physicians. Across the 221 indications considered by the panel for necessity, the vascular surgeons had an average of mean necessity ratings of 6.8, significantly higher than the 5.8 average of the other physicians. The vascular surgeons' rankings of agreement with the guidelines of the Joint Council were significantly higher than those of the physician panelists from other specialties.

CONCLUSIONS

statements of clinical appropriateness and necessity produced by summarizing ratings assigned to indications by expert panel members may disguise marked underlying disagreements among well-defined groups of practitioners within these panels. In the case of abdominal aortic aneurysm management, these disagreements within the RAND panel explain the marked discrepancy between the RAND multidisciplinary panel ratings and the recommendations issued by vascular surgeon professional societies.

Influence of projected complication rates on estimated appropriate use rates for carotid endarterectomy. Appropriateness Project Investigators. Academic Medical Center Consortium

OBJECTIVE

To examine specifically the influence of estimated perioperative mortality and stroke rate on the assessment of appropriateness of carotid endarterectomy.

DATA SOURCES/STUDY SETTING

An expert panel convened to rate the appropriateness of a variety of potential indications for carotid endarterectomy based on various rates of perioperative complications. We then applied these ratings to the charts of 1,160 randomly selected patients who had carotid endarterectomy in one of the 12 participating academic medical centers.

STUDY DESIGN

An expert panel evaluated indications for carotid endarterectomy using the modified Delphi approach. Charts of patients who received surgery were abstracted, and clinical indications for the procedure as well as perioperative complications were recorded. To examine the impact of surgical risk assessment on the rates of appropriateness, three different definitions of risk strata for combined perioperative death or stroke were used: Definition A, low risk < 3 percent; Definition B, low risk < 5 percent; and Definition C, low risk < 7 percent.

PRINCIPAL FINDINGS

Overall hospital-specific mortality ranged from 0 percent to 4.0 percent and major complications, defined as death, stroke, intracranial hemorrhage, or myocardial infarction, varied from 2.0 percent to 11.1 percent. Most patients (72 percent) had surgery for transient ischemic attack or stroke; 24 percent of patients were asymptomatic. Most patients (82 percent) had surgery on the side of a high-grade stenosis (70-99 percent). When the thresholds for operative risk were placed at the values defined by the expert panel (Definition A), only 33.5 percent of 1,160 procedures were classified as "appropriate." When the definition of low risk was shifted upward, the proportion of cases categorized as appropriate increased to 58 percent and 81.5 percent for Definitions B and C, respectively.

CONCLUSIONS

Despite the high proportion of procedures performed for symptomatic patients with a high degree of ipsilateral extracranial carotid artery stenosis and generally low rates of surgical complications at the participating institutions, the overall rate of "appropriateness" using a perioperative complication rate of < 3 percent was low. However, the rate of "appropriateness" was extremely sensitive to judgments about a single clinical feature, surgical risk. These data show that before applying such "appropriateness" ratings, it is crucial to perform sensitivity analyses in order to assess the stability of the results. Results that are robust to moderate in variation in surgical risk provide a much sounder basis for policy making than those that are not.

Primary care physicians' satisfaction with quality of care in California capitated medical groups

CONTEXT

Managed care and capitation have placed new responsibilities on primary care physicians, including formally acting as "gatekeepers" for specialty services and tests. Previous studies have not examined whether primary care physicians who provide services to patients under many coverage arrangements feel differently about caring for patients covered under capitation vs those covered through more traditional forms of insurance. An understanding of whether California primary care physicians feel that they deliver a different level of quality to capitated patients could help signal whether variations in care for patients with different coverage forms are evolving.

OBJECTIVE

To evaluate whether primary care physicians in California capitated groups report different satisfaction levels with quality of care for patients in their overall practice than for patients covered by capitated contracts and to examine whether physicians' satisfaction with capitated care quality is influenced by the characteristics of the practice setting.

DESIGN

Cross-sectional questionnaire.

SETTING

A total of 89 California physician groups with capitated contracts.

PARTICIPANTS

A total of 910 primary care physicians (80% response rate).

MAIN OUTCOME MEASURE

Satisfaction with 4 aspects of quality of care provided to patients covered by capitated contracts vs patients overall.

RESULTS

Physicians reported lower satisfaction with all 4 aspects of care for patients covered by capitated contracts than for patients in their overall practice: 71% were very or somewhat satisfied with relationships with capitated patients (compared with 88% for overall practice), 64% were very or somewhat satisfied with the quality of care they provided to capitated patients (compared with 88% for overall practice), 51% were very or somewhat satisfied with their ability to treat capitated patients according to their own best judgment (compared with 79% for overall practice), and 50% were very or somewhat satisfied with their ability to obtain specialty referrals (compared with 59% for overall practice) (P< or =.001 for all comparisons). Being in a medical group practice (vs an independent practice association) and having a larger percentage of capitated patients were independently associated by multivariate analysis with higher levels of satisfaction with capitated quality of care (P< or =.005).

CONCLUSION

These California primary care physicians were less satisfied with the quality of care they deliver to patients covered by capitated contracts than with the quality of care they deliver to patients covered by other payment sources. However, those in medical group practices and with a higher percentage of capitated patients were more satisfied with capitated care. National expansion of capitation should be accompanied by efforts to ensure that the satisfaction of practicing physicians with the care they deliver does not decline.

Variations in cataract extraction rates in Medicare prepaid and fee-for-service settings

OBJECTIVE

To compare rates of cataract extraction in 2 prepaid health settings and in traditional fee-for-service (FFS) settings.

DESIGN

A cross-sectional analysis using 1993 health maintenance organization (HMO) Medicare claims and encounter files, the Health Care Financing Administration (HCFA) 5% Medicare Part B provider/supplier file, and the HCFA October 1992 100% Medicare population file.

SETTING

Southern California Medicare FFS settings and the staff-model and independent practice association (IPA) plans of a large California HMO.

PATIENTS

1993 Medicare beneficiaries aged 65 years and older. The study included 43387 staff-model HMO enrollees, 19050 IPA enrollees, and 47 150 FFS beneficiaries (a 5% sample of all Southern California FFS beneficiaries).

MAIN OUTCOME MEASURE

Age and risk-factor adjusted rates of cataract extraction per 1000 beneficiary-years.

RESULTS

After controlling for age, sex, and diabetes mellitus status, FFS beneficiaries were twice as likely to undergo cataract extraction as were prepaid beneficiaries (P<.01). Female FFS beneficiaries were nearly twice as likely to undergo the procedure as were male FFS beneficiaries (P<.001); there were no extraction rate differences by sex in the prepaid settings.

CONCLUSION

Because of the potential implications for vision care in the elderly, the significantly different rates of cataract extraction in FFS and prepaid settings warrant further clinical investigation to determine whether there is overuse in FFS vs underuse in prepaid settings. Such investigations must assess the appropriateness of cataract surgery by evaluating its use relative to clinical need.

Underuse of coronary revascularization procedures: application of a clinical method

OBJECTIVES

Our main objective was to apply a new method to determine whether coronary revascularization procedures are underused, especially among African-Americans and uninsured patients.

BACKGROUND

Although overuse of revascularization procedures has been studied, underuse as defined clinically has not been examined before.

METHODS

The study was conducted at four public and two academically affiliated private hospitals in Los Angeles; 671 patients who underwent coronary angiography between June 1, 1990 and September 30, 1991 and met explicit clinical criteria for coronary revascularization were included. The main outcome measure was the proportion of patients undergoing an indicated procedure within 12 months (ascertained by medical record review and confirmed with a telephone survey). Adjusted relative odds of undergoing an indicated procedure for African-Americans and patients in public hospitals compared with whites and patients in private hospitals were calculated.

RESULTS

Overall, 75% of patients underwent a revascularization procedure. Of 424 patients requiring bypass surgery, 107 angioplasty and 140 either bypass surgery or angioplasty, 59%, 66% and 75% underwent the procedure, respectively. African-Americans were less likely than whites to undergo operation (adjusted odds ratio [OR] 0.49, p < 0.05) and angioplasty (adjusted OR 0.20, p < 0.05). Patients in public hospitals were less likely than those in private hospitals to undergo angioplasty (adjusted OR 0.10, p < 0.005).

CONCLUSIONS

Underuse of coronary revascularization procedures is measurable and occurs to a significant degree even among insured patients attending private hospitals. Underuse is especially pronounced among African-Americans and patients attending public hospitals. Future cost-containment efforts must incorporate safeguards against underuse of necessary care.

Appropriateness of upper gastrointestinal endoscopy: comparison of American and Swiss criteria

OBJECTIVE

Examine the reproducibility of the RAND method for developing criteria for the appropriateness of medical procedures.

DESIGN

Comparison of two sets of explicit criteria for appropriateness of upper gastrointestinal (UGI) endoscopy, developed by separate expert panels from two countries.

SETTING

United States, Switzerland.

STUDY PARTICIPANTS

National experts from different medical specialties involved in the referral or application of UGI endoscopy.

INTERVENTIONS

Each panel was presented with about 500 clinical scenarios (indications) that were rated on a nine-point scale as to the appropriateness of performing UGI endoscopy for a patient with that clinical presentation.

MAIN OUTCOME MEASURES

(1) distribution of appropriateness ratings and intrapanel agreement categories between the two panels, (2) between-panel agreement of assigning appropriateness for comparable indications and, (3) percentage of indications with major between-panel differences.

RESULTS

Ratings for 2/3 of indications could be compared. The Swiss panel showed higher intrapanel agreement (54.6% versus 46.2%, P = 0.002). Seventy-eight per cent of comparable indications were assigned to identical categories of appropriateness by both panels (kappa = 0.76, P < 0.001). For 93% of the 376 comparable indications, there were no major interpanel differences.

CONCLUSION

Separate expert panels in different countries, using a standardized methodology, produce criteria for appropriateness of medical procedures that are similar. Given the resources being invested throughout the world in developing criteria and guidelines, international collaboration in seeking optimal use of limited health care resources should be intensified.

Underutilization of upper gastrointestinal endoscopy

BACKGROUND & AIMS

Efforts to reduce costs in health care may raise concerns about underuse of medical procedures. This study prospectively assessed underuse of upper gastrointestinal endoscopy in a cohort of patients in whom we have recently published data on overuse of endoscopy.

METHODS

Underuse was identified by formal necessity criteria for endoscopy, obtained by an explicit panel process. Outpatients were consecutively included in two clinical settings. Setting A consisted of 20 primary care physicians and 7215 patient visits that occurred within 1 month. Setting B consisted of 920 visits that occurred during 3 weeks at an outpatient clinic.

RESULTS

During these 8135 visits, 611 patients complained of upper digestive symptoms; 63 of them underwent endoscopy. Underuse was identified in 72 patients (11.8%). The two clinical situations mainly responsible for underuse of endoscopy were uninvestigated peptic symptoms resistant to treatment and dysphagia. At first follow-up, 29 of the patients with initial underuse still fulfilled criteria of necessity (underuse rate, 4.7%). One-year follow-up showed underuse of endoscopy in 5 patients.

CONCLUSIONS

This prospective evidence shows that underuse of a medical procedure exists. The estimated overuse and underuse of endoscopy in this cohort were approximately equal (5%). Improving quality of care will require reductions of both overuse and underuse of medical procedures.

The appropriateness of intention to treat decisions for invasive therapy in coronary artery disease in The Netherlands

OBJECTIVE

To determine the appropriateness of intention to treat decisions concerning coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for patients with coronary artery disease in The Netherlands.

DESIGN

Prospective study of intention to treat decisions using a computerised expert system.

SETTING

"Presentation" sessions in 10 tertiary referral heart centres in 1992.

PATIENTS

3207 consecutive patients: 1618 CABG and 1589 PTCA candidates.

MAIN OUTCOME MEASURE

Percentage of invasive treatment decisions rated appropriate, uncertain, or inappropriate by the expert system.

RESULTS

PTCA decisions were common for patients with one-vessel disease and CABG decisions for patients with three-vessel and left main disease. PTCA decisions outnumbered CABG decisions in acute myocardial infarction. Of CABG decisions, 84% were rated appropriate, 12% uncertain, and 4% inappropriate. The proportions for PTCA decisions were 39% appropriate, 31% uncertain, and 29% inappropriate. Type C lesion was the main determinant of inappropriateness of PTCA decisions. If type C lesions were downgraded to type A/B lesions the rate of inappropriate PTCA decisions dropped to 6%.

CONCLUSIONS

Clinicians in tertiary referral centres in The Netherlands favoured CABG if vessel disease was extensive or involved the left main artery, and PTCA for patients with less extensive disease and with acute myocardial infarction. Few CABG decisions were inappropriate. The main determinant of inappropriateness of PTCA decisions was its intended use in patients with type C lesions.

Under use of coronary angiography: application of a clinical method

OBJECTIVE

To estimate the extent of under use of coronary angiography and to determine whether women, ethnic minorities and poor and uninsured patients are less likely than their counterparts to receive necessary coronary angiography.

DESIGN

Retrospective cohort study employing chart review and patient interviews.

SETTING

Four teaching hospitals: three government owned (public) and one private university medical center in Los Angeles, California.

PATIENTS

Three hundred and fifty two patients who had a positive exercise stress test between 1 January 1990 and 30 June 1991 and met explicitly defined criteria for the necessity of coronary angiography established by a multidisciplinary expert panel.

MAIN OUTCOME MEASURES

Percentage of patients who received necessary coronary angiography within 3 and 12 months following exercise stress testing, adjusted for demographic and clinical characteristics using logistic regression.

RESULTS

Overall 43% received necessary coronary angiography within 3 months and 56% within 12 months of the stress test. Women were less likely than men to receive necessary coronary angiography. Adjusted odds ratio (AOR) 0.54, 95% confidence interval (CI) 0.34-0.90 for angiography within 3 months of the stress test; AOR 0.47, 95% CI 0.29-0.77 for angiography within 12 months of the stress test. Public hospital patients underwent necessary coronary angiography less often than private hospital patients. AOR 0.40, 95% CI 0.23-0.79 for within 3 months; AOR 0.52, 95% CI 0.30-0.91 for within 12 months.

CONCLUSIONS

Under use of coronary angiography can be measured and occurs to a significant degree. It is important to develop standards of quality to address and safeguard against under use of necessary medical care.

Appropriateness of indications for surgery of lumbar disc hernia and spinal stenosis

STUDY DESIGN

This prospective study examines the appropriateness of indications for surgery of herniated intervertebral disc and spinal stenosis in patients undergoing surgery in a university hospital setting.

OBJECTIVE

To evaluate the appropriateness of surgery using explicit criteria developed by an expert panel in the United States.

SUMMARY OF BACKGROUND DATA

The use of surgery for herniated intervertebral disc and spinal stenosis varies widely within and among countries. It has been postulated that the main reason for treatment failure is poor selection of candidates for the procedure.

METHODS

The authors prospectively evaluated appropriateness of surgical indications for herniated lumbar intervertebral disc or spinal stenosis in 328 consecutive patients undergoing the operation in two university neurosurgery departments. Outcome was measured 1 year after surgery by a standardized interview.

RESULTS

Indications for surgery were considered to be appropriate or equivocal in 202 (62%) patients and inappropriate in 126 (38%). Among the 126 inappropriate procedures, 66 were so rated because of insufficient activity restriction before the procedure. One year after surgery, 74% of the patients perceived the results of the operation as good or very good.

CONCLUSIONS

Appropriateness as measured by the criteria established by the American panel identified a large percentage of day-to-day practice in the two surgical units as inappropriate. However, use of criteria that include new findings about lack of efficacy of bed rest probably would lower this percentage. Criteria of appropriateness of medical and surgical procedures, developed through the panel process, need to be updated regularly.

Understanding changes in health status. Is the floor phenomenon merely the last step of the staircase?

OBJECTIVES

Previous studies have found that health-status measures may be unable to detect clinically important changes for patients whose baseline health is poor (the "floor phenomenon"). It is not known whether this inability to detect change is confined to patients in very poor baseline health or whether the sensitivity of health-status instruments varies across the entire range of health states. The goals of this study were to see how changes in physical health, mental health, and overall health (1) depend on baseline (usual) health and (2) compare with patients' global assessment of changes in their health.

METHODS

Stable, ambulatory patients presenting to the emergency department of a public hospital retrospectively rated their usual physical health (eight items), mental health (three items), and overall health (one item); their health on the day of study entry using these same items; and their global assessment of the change in their health compared with baseline. Complete information on these items was available for 1,005 patients. Baseline scores on the physical and mental health subscales and the overall health item were divided into five categories: 81 to 100 (best), 61 to 80, 41 to 60, 21 to 40, and 0 to 20 (worst).

RESULTS

The mean difference in health from baseline to emergency department presentation decreased as the baseline health category worsened, as follows: physical health, -26.0, -35.9, -15.1, -9.5, +1.0; mental health, -23.0, -16.1, -9.6, 0.0, 6.6; overall health -64.0, -45.3, -28.4, -8.4, 10.4, respectively. However, patients' global assessment of health change showed the opposite trend; the proportion of patients rating their health as "much worse" than baseline increased as baseline health worsened. When only patients whose physical health score declined less than 10 points were analyzed, 14% of those in the best baseline health said their health was "much worse," whereas 74% of those with the worst baseline physical health said their health was "much worse" than baseline.

CONCLUSIONS

These findings suggest that the sensitivity of health-status measures to change and the meaning of an incremental change in physical health or mental health vary depending on baseline health. This may result from noninterval properties of response options or from patients being at the lowest health state (the "floor") of individual questions. If health-status measures similar to this are to be used to compare the outcomes of treatment across diseases and for patients in a wide variety of baseline health states, weighting schemes may be needed to account for these effects.

Overuse of upper gastrointestinal endoscopy in a country with open-access endoscopy: a prospective study in primary care

BACKGROUND

This prospective observational study was aimed at evaluating the appropriateness of use of upper gastrointestinal endoscopy (UGE) in primary care in a country with open access to and high availability of the procedure.

METHODS

Outpatients were consecutively included in two clinical settings: Setting A (20 primary care physicians during 4 weeks) and B (university-based outpatient clinic during 3 weeks). In patients undergoing UGE, appropriateness of referral was judged by explicit Swiss criteria developed by the RAND/UCLA panel method.

RESULTS

Patient visits (8135) were assessed. Six hundred eleven patients complained of upper gastrointestinal symptoms. Physicians decided to perform UGE in 63 of these patients. Twenty-five (40%) of the endoscopies were rated appropriate, 7 (11%) equivocal, and 31 (49%) inappropriate. Overuse of UGE occurred in 5.1% (setting A: 4.7%; setting B:6.5%; p = 0.39) of the patients who presented with upper gastrointestinal symptoms. The decision to perform UGE in previously untreated dyspeptic patients was the most common clinical situation resulting in overuse.

CONCLUSIONS

Inappropriate use of UGE is high in Switzerland. However, to better reflect primary care decision making, overuse should be related not only to patients referred for a medical test, but also to the number of patients who complain of the symptoms that would be investigated by the procedure.

Determinants of emergency department use: are race and ethnicity important?

STUDY OBJECTIVE

To determine whether race/ethnicity is an important determinant of emergency department use.

METHODS

We conducted a cross-sectional survey in a public ED to determine self-reported ED visits over the preceding 3 months. The study group comprised consecutive ambulatory patients (N = 1,049) with nonemergency medical problems.

RESULTS

Blacks, whites, and Hispanics were equally likely to report one or more visits to an ED in the 3 months before study enrollment. Blacks were the most likely to report two or more ED visits in the preceding 3 months (19.0%), followed by whites (13.5%) and Hispanics (11.4%) (P = .01; unadjusted odds ratio, 1.82 for blacks versus Hispanics). In multivariate analysis, older age (P < .001), health insurance coverage (P < .001), regular source of care (P < .001), and difficulty obtaining transportation to a physician's office (P = .011) were positively associated with two or more previous ED visits. After adjustment for these variables, race/ethnicity was not significantly associated with ED use (P = .23; adjusted odds ratio for blacks versus Hispanics, 1.48 [95% confidence interval, .95 to 2.30]).

CONCLUSION

Race/ethnicity was not an important determinant of ED use after adjustment for age, health insurance coverage, regular source of care, and barriers to health care. Population-based studies of ED use should be conducted to further evaluate whether racial/ethnic differences in ED use exist that are not explained by differences in demographics, health, socioeconomic status, access to care, or other determinants of ED use.

The effect of race and ethnicity on the use of selected health care procedures: a comparison of south central Los Angeles and the remainder of Los Angeles county

The purpose of this study was to compare the use of eight hospital-based procedures (appendectomy, cesarean section, coronary artery angioplasty (PTCA), coronary artery bypass grafting (CABG), carotid endarterectomy, hysterectomy, mastectomy, and transurethral prostate resection) in South Central Los Angeles (SCLA) to the remainder of Los Angeles County. The authors used age- and gender-adjusted procedure rates and population-weighted multivariate regression techniques, adjusting for illness proxies, physician distribution, hospital distance, income, and ethnicity variation to quantitate the effect of SCLA residence. Four procedures were performed at significantly lower rates among residents of SCLA: PTCA, CABG, carotid endarterectomy, and cesarean section. In multivariate regression models, SCLA was also a significant predictor for appendectomy, mastectomy, and transurethral prostatectomy (TURP). The SCLA effect was diminished but not eliminated when ethnicity variables were incorporated into regression models. The use of selected procedures by residents of SCLA frequently differs from that of residents of the remainder of Los Angeles Country. Some differences are not attributable to level of health, income, ethnicity, or the availability of medical resources.

Quality assurance in capitated physician groups. Where is the emphasis?

OBJECTIVE

To describe quality assurance (QA) programs implemented by capitated physician groups; to measure their relative emphasis on monitoring of overuse compared with underuse and monitoring and improving preventive services compared with chronic disease care; and to examine how group characteristics influence QA activity.

DESIGN

Cross-sectional questionnaire.

SETTING

A large network-model health maintenance organization in California (133 contracting physician groups).

PARTICIPANTS

Ninety-four physician groups (71%) caring for 2.9 million capitated patients.

MAIN OUTCOME MEASURES

Self-reported use of quality monitoring and improvement methods.

RESULTS

All capitated physician groups conducted some QA. Groups' QA programs monitored areas subject to overuse, such as cesarean delivery and angioplasty rates, more than areas subject to underuse, such as childhood immunization rates and performance of retinal examinations for diabetic patients (64% vs 43%, P<.001). They monitored underuse of preventive services more than follow-up services for chronic diseases (54% vs 31%, P<.001). Groups also used reminders for preventive services more than they monitored follow-up services for chronic diseases (26% vs 15%, P<.01). Physician group characteristics independently associated with higher overall QA activity were greater number of years in existence, higher profitability, and capitated care penetration.

CONCLUSION

Capitation places a large share of responsibility for QA in the hands of physician groups, but not all aspects of QA are being equally addressed. The emphasis on overuse may result from financial incentives inherent in capitation, while the focus on preventive services may stem from lack of adequate quality measurement tools for monitoring chronic disease care. Further research efforts should address how capitated physician groups might expand their QA programs to include monitoring of underuse, especially for patients with chronic disease.

Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy unit

BACKGROUND AND STUDY AIMS

This prospective study tested the appropriateness of referrals for upper gastrointestinal endoscopy in an open-access endoscopy unit, using the criteria of the American Society for Gastrointestinal Endoscopy. It also examined whether there was any relationship between appropriateness of use and the presence of significant lesions detected by endoscopy.

METHODS

Four hundred fifty consecutive upper gastrointestinal endoscopies were studied prospectively. The referral indication was recorded by the endoscopist before the procedure was performed, and was compared with the current criteria of the American Society for Gastrointestinal Endoscopy and with endoscopic findings.

RESULTS

The appropriateness of referral was assessed in 442 consecutive endoscopies. Of these, 252 (57%) were judged to be appropriate. In 168 (88%) of the 190 endoscopies rated as inappropriate, the reason was that the patient had not undergone empirical anti-ulcer therapy before endoscopy. The probability of finding a significant lesion did not differ between the endoscopies judged to be appropriate (50%) and those judged to be inappropriate (46%)

CONCLUSIONS

Upper gastrointestinal endoscopy was frequently used for inappropriate indications. The main reason for inappropriate use was insufficient treatment, or no treatment, of dyspeptic symptoms prior to endoscopy. In this study, the criteria for appropriateness did not predict the probability of finding a significant endoscopic lesion.

Documentation patterns before cataract surgery at ten academic centers

PURPOSE

To determine the adequacy of documenting the preoperative evaluation for cataract surgery using criteria derived from published practice guidelines.

METHODS

In 1990, 1139 surgeries that were performed on 1139 patients at ten institutions of the Academic Medical Center Consortium were reviewed for completeness of documentation of the preoperative evaluation. Criteria for completeness were derived from the American Academy of Ophthalmology Preferred Practice Pattern on cataract evaluation and the Agency for Health Care Policy and Research-sponsored guidelines.

RESULTS

Twenty-six percent of charts lacked documentation of at least one of four basic elements of the preoperative evaluation. These four elements are (1) vision in the surgical eye; (2) vision in the fellow eye; (3) evaluation of the fundus, macula, or visual potential in the surgical eye: and (4) presence of some form (general or specific) of functional visual impairment. If, as stated in the guideline, a specific deficit in visual functioning should be identified, then 40% of charts fail to meet criteria.

CONCLUSION

Documentation of the ocular preoperative assessment for cataract surgery is inadequate in more than one quarter of cases. The relation between lack of documentation and incompleteness of the examination is unknown. Improved documentation is needed to better measure and enhance the quality of care.

The appropriateness of coronary artery bypass graft surgery in academic medical centers. Working Group of the Appropriateness Project of the Academic Medical Center Consortium

OBJECTIVE

To compare the appropriateness of use of coronary artery bypass graft (CABG) surgery in Academic Medical Center Consortium hospitals as judged 1) according to criteria developed by an expert panel, 2) according to revisions of those criteria made by cardiac surgeons from the Academic Medical Center Consortium, and 3) by review of cases by the surgeons responsible for those cases.

DESIGN

Retrospective, randomized medical record review.

SETTING

12 Academic Medical Center Consortium hospitals.

PATIENTS

Random sample of 1156 patients who had had isolated CABG surgery in 1990.

MAIN OUTCOME MEASURES

1) Percentage of patients with indications for which CABG surgery was classified as appropriate, Inappropriate, or of uncertain appropriateness and 2) percentage of cases in which CABG surgery was judged inappropriate or uncertain for which ratings changed after local case review.

RESULTS

Data were retrieved from medical records by trained abstractors using an explicit data collection instrument. Cases in which CABG surgery was judged to be inappropriate or uncertain were individually reviewed by the responsible surgeons. According to the expert panel ratings, 83% of the CABG operations (95% CI, 81% to 85%) were necessary, 9% (CI, 8% to 10%) were appropriate, 7% (CI, 5% to 8%) were uncertain, and 1.6% (CI, 0.6% to 2.5%) were inappropriate. These rates are almost identical to those found in a previous study that was done in New York State and that used the same criteria (in that study, 91% of operations were classified as necessary or appropriate, 7% were classified as uncertain, and 2.4% were classified as inappropriate). Rates of inappropriate procedures varied from 0% to 5% among the 12 member hospitals (P = 0.02). The Academic Medical Center Consortium cardiac surgeons revised 568 (24%) of the indications used by the expert panel. However, because those revisions altered the appropriateness ratings in both directions and affected only 50 cases (4%), the net effect of the revisions was slight: The rate of inappropriate CABG surgery increased from 1.6% to 1.9%. Local review found that data collection errors had caused erroneous ratings in 12.5% of 64 cases in which surgery had been classified as inappropriate or uncertain.

CONCLUSIONS

The Academic Medical Center Consortium hospitals had low rates of inappropriate and uncertain use of CABG surgery, regardless of the criteria used for assessment. Even though surgeons from the Consortium revised the appropriateness ratings extensively, their revisions had a negligible effect on the overall assessment of appropriateness. However, because of potential data collection errors, appropriateness criteria should be used for individual case audits only if supplemented by subsequent physician review.

Variations by specialty in physician ratings of the appropriateness and necessity of indications for procedures

The authors compare the appropriateness ratings and mutual influence of panelists from different specialties rating a comprehensive set of indications for six surgical procedures. Nine-member panels rated each procedure: abdominal aortic aneurysm surgery, carotid endarterectomy, cataract surgery, coronary angiography, and coronary artery bypass graft surgery/percutaneous transluminal coronary angioplasty (common panel). Panelists individually rated the appropriateness of indications at home and then discussed and re-rated the indications during a 2-day meeting. Subsequently, they rated the necessity of those indications scored by the group as appropriate. There were 45 panelists, including specialists (either performers of the procedure or members of a related specialty) and primary care providers, all drawn from nominations by their respective specialty societies. Main outcome measures included: individual panelists' mean ratings over all indications, mean change and conformity scores between rounds of ratings, and the percentage of audited actual procedures rated appropriate or necessary. Performers had the highest mean ratings, followed by physicians in related specialties, trailed by primary care providers. One fifth of all actual procedures were for indications rated appropriate by performers and less than appropriate by primary care providers. At the panel meetings, primary care providers and related specialists showed no greater tendency to be influenced by other panelists than did performers. Multispecialty panels provide more divergent viewpoints than panels composed entirely of performers. This divergence means that fewer actual procedures are deemed performed for appropriate or necessary indications.

Adapting practice patterns to a managed care environment: carotid endarterectomy--a case example

The way American medicine is practiced is changing rapidly. By the beginning of the next century, most Americans may be enrolled in for-profit managed care plans in which physicians are responsible for both a budget and a population of patients. As health care is revolutionized, the overriding issue is whether the mission of health care organizations will be simply to contain costs, or whether it will be to increase the value (i.e., the quality) that we get for the money we are willing to spend on health care. The purpose of this article is to illustrate for carotid endarterectomy how quality can remain on the health care reform agenda. Vascular surgeons must assume a leadership role, and they must be willing to alter their practice patterns. More specifically, they should: (1) support and facilitate the development of clinically-detailed multispecialty criteria that describe under what circumstances carotid endarterectomy is both appropriate and necessary; (2) support the development of a system for publicly reporting outcome data by physician and hospital; (3) support regionalization of carotid endarterectomy; (4) conduct a prospective assessment of appropriateness before the procedure is performed; (5) consider changing the system by which carotid angiographies are read to increase their reliability; and (6) help develop a system to ensure that people who need carotid endarterectomy are offered the procedure.

Outcomes in 248 patients who had diagnostic evaluations for epilepsy surgery

Surgery for intractable epilepsy is a widely used treatment that is not readily assessed by randomised trials. We evaluated the impact of epilepsy surgery on seizures, medication use, employment, and the quality of life in 248 adults and adolescents consecutively referred to one medical centre between 1974 and 1990. Outcomes were determined through self-administered questionnaire and medical record review for 202 surgery and 46 non-surgery patients whose treatment was usually determined by the presence or absence of an epileptogenic focus. Surgery and non-surgery patients differed at baseline only in median monthly seizure frequency (surgery lower than non-surgery). After adjustment for baseline covariates, surgery patients at follow-up had greater decline in average monthly seizure frequency (-11.9 vs - 1.5; difference -10.4, 95% CI -20.5, -0.3) and took fewer antiepileptic medications (average number 1.4 vs 2.0; difference -0.67, 95% CI -0.94, -0.40). Although quality-of-life scores were higher (p < 0.05) with surgery on 5 of 11 scales that were administered only at follow-up, there were no significant differences in employment status or prospectively assessed quality of life. Relative to a non-surgery group, patients treated surgically had better seizure control with less antiepileptic medication. The impact of epilepsy surgery on quality of life and employment needs to be assessed in larger prospective studies.