[Clinical pathways: effective and efficient inpatient treatment]

The new hospital funding system based on a diagnosis-related group (DRG) system and the economic competition involved require large-scale changes in hospital structures and processes. Clinical pathways are multidisciplinary plans of best clinical practice for specified groups of patients with a particular diagnosis that aid the coordination and delivery of high quality care. The clinical pathway originally used in the USA and Australia was aimed at shortening the hospital stay and reducing healthcare costs, which has become an increasingly important issue in medicine. Furthermore, it is an appropriate tool to standardize medical care and increase patient satisfaction. Clinical pathways are able to standardize care for patients with a similar diagnosis, procedure, or symptom. There are four essential components of a clinical pathway: a timeline, the categories of care or activities and their interventions, intermediate- and long-term outcome criteria, and the variance record. In contrast to practice guidelines, protocols, and algorithms, clinical pathways are utilized by a multidisciplinary team and focus on quality and coordination of care.

Treatment and blood pressure control in isolated systolic hypertension vs diastolic hypertension in primary care

Cross-sectional surveys on prevalence, treatment and control of hypertension could not satisfactorily distinguish between diastolic hypertension and isolated systolic hypertension because the definition of hypertension included patients under pharmacological treatment. We assessed the situation in the two types of hypertension in general practice in Belgium, based on current blood pressure (BP) measurements and on BP prior to the initiation of drug therapy. Participating physicians enrolled the first 15 at least 55-year-old men visiting the surgery, measured their BP and recorded data on medical history including pretreatment BP, drug utilization, cardiovascular risk factors and target organ damage. Diastolic hypertension was defined as diastolic BP> or =90 mmHg, irrespective of systolic BP, and isolated systolic hypertension as systolic BP > or =140 mmHg and diastolic BP < 90 mmHg. Among 3761 evaluable patients, 74% were hypertensive. Among the 1533 hypertensive patients in whom blood pressure was known prior to treatment (n=965) or who were untreated at the study visit (n=568), 1164 had diastolic hypertension and 369 isolated systolic hypertension. The prevalence of antihypertensive treatment was, respectively, 75 and 25% (P<0.001) in these two types of hypertension. The odds of being treated were independently determined by type of hypertension, severity of hypertension and level of risk (P<0.001). BP was controlled in 25% of all patients with diastolic hypertension and in 13% of all patients with isolated systolic hypertension (P<0.001). About half of the treated patients with systolic hypertension were on a diuretic and/or a calcium-channel blocker. In conclusion, isolated systolic hypertension is less frequently treated than diastolic hypertension, overall BP control is poor and actual drug therapy diverges from recommendations based on placebo-controlled intervention trials.

Factors influencing referral of cardiac patients for cardiac rehabilitation

This study asked the question: Are there differences in the characteristics and referral rates of men and women who are referred for cardiac rehabilitation? The sample consisted of 203 men (n = 148) and women (n = 55) who were hospitalized with at least one cardiac diagnosis and were eligible for Phase II cardiac rehabilitation. Hospital records were reviewed to obtain information on gender, age, ethnicity, insurance coverage, marital status, employment status, proximity to rehabilitation services, transportation availability, concurrent disease processes, domestic responsibilities, documentation of referral for cardiac rehabilitation, and the attending physician. A survey sent to the patients approximately 3 weeks after their discharge from the hospital also addressed these variables. Logistic regression analysis indicated only one predictor of referral: the gender of the physician. Male physicians were more likely to refer patients for cardiac rehabilitation. This finding must be viewed with caution because of the small number of female patients and female physicians included in the study. The current literature reflects conflicting findings about the proposed relationships; therefore, they merit further investigation.

Cross-sectional versus longitudinal performance assessments in the management of diabetes

BACKGROUND

Performance assessments help to quantify the level of adherence with practice standards and are often used to measure and compare the quality of care. However, most performance assessments are based on a cross-sectional analysis of patient information, whereas patient care is inherently longitudinal. This discordance could confound the relationship between the performance measure and the true quality of care.

OBJECTIVE

The objective of this study was to illustrate differences in performance assessment as measured by a traditional cross-sectional analysis compared with a longitudinal analysis.

METHODS

We conducted a cross-sectional and longitudinal analysis of a cohort of diabetic patients in an integrated delivery system having primary care visits and hemoglobin A1c (HBA1c) testing in both 1999 and 2000.

RESULTS

In the cross-sectional analysis of 4661 patients, we found a modestly increasing proportion achieved an HBA1c level of <8.0%: 73.1% in 1999 and 75.6% in 2000. Longitudinal analysis, however, suggested that certain subsets of patients were more likely to switch from good to poor control or retain their level of poor control over the 2 years studied. In particular, compared with whites, blacks were 1.76 (95% confidence interval [CI], 1.31-2.37) times as likely to switch from good to poor control and only 0.56 (95% CI, 0.41-0.76) times as likely to switch from poor to good control. Patients aged 35 to 49 were 2.54 (95% CI, 1.79-3.45) times as likely to switch from good to poor and only 0.66 (95% CI, 0.47-0.94) times as likely to switch from poor to good control than patients over age 64 years.

CONCLUSIONS

Cross-sectional performance assessments could mask changes in diabetes control among individuals belonging to a cohort and, conceptually, are poorer indicators of care process than longitudinal measures. In addition, longitudinal analyses suggest the influence of patient sociodemographic factors on the performance assessment that should be accounted for when comparing quality of care for diabetes.

Gender disparities in tuberculosis: report from a rural DOTS programme in south India

SETTING

Tiruvallur District, south India.

OBJECTIVES

To examine gender differences in tuberculosis among adults aged >14 years with respect to infection and disease prevalence, health care service access, care seeking behaviour, diagnostic delay, convenience of directly observed treatment (DOT), stigma and treatment adherence.

METHODS

Data were collected from 1) community survey, 2) self-referred out-patients seeking care at governmental primary health institutions (PHIs), 3) tuberculosis suspects referred for sputum microscopy at PHIs, and 4) tuberculosis patients notified under DOTS. Community survey results were compared with those for patients notified at PHIs.

RESULTS

In the community, 66% of males and 57% of females had tuberculosis infection. The prevalence of smear-positive tuberculosis was 568 and 87/100,000, respectively, among males and females. Fewer males than females attended PHIs (68 men for every 100 women). Females constituted 13% of all smear-positive patients detected in the community survey, and 20% of those detected at PHIs (P < 0.05). The probability of notification decreased significantly with age among both males and females. Significantly more females than males felt inhibited discussing their illness with family (21% vs. 14%) and needed to be accompanied for DOT (11% vs. 6%). Males had twice the risk of treatment default than females (19% vs. 8%; P < 0.01).

CONCLUSIONS

Despite facing greater stigma and inconvenience, women were more likely than men to access health services, be notified under DOTS and adhere to treatment. Men and elderly patients need additional support to access diagnostic and DOT services.

Computer simulation assesses PI design prior to implementation

Hospital seeks sense of assurance that process will work. Consultants apply process capability tools from industry. Nurses' time estimates are compared to historical data.

The validity of emergency department triage blood pressure measurements

OBJECTIVE

Automated blood pressure (ABP) devices are ubiquitous at emergency department (ED) triage. Previous studies failed to evaluate ABP devices against accepted reference standards or demonstrate triage readings as accurate reflections of blood pressure (BP). This study evaluated ED triage measurements made using an ABP device and assessed agreement between triage BP and BP taken under recommended conditions.

METHODS

A prospective study was conducted at an urban teaching hospital. Patients were enrolled by convenience sampling. Simultaneous automated and manual triage BPs were obtained using one BP cuff with a Y-tube connector. Research assistants were certified in obtaining manual BP as described by the British Hypertension Society (BHS). Patients were placed in a quiet setting, and manual BP was repeated by American Heart Association (AHA) standards. Data analysis was performed using methods described by Bland and Altman. The ABP device was assessed using Association for the Advancement of Medical Instrumentation (AAMI) and BHS criteria.

RESULTS

One hundred seventy-one patients were enrolled. Systolic BP (sBP) range was 81 to 218 mm Hg; diastolic BP (dBP) range was 43 to 130 mm Hg. Automated vs. manual sBP difference was 3.8 +/- 11.2 mm Hg (95% confidence interval [CI] = 2.1 to 5.4); dBP difference was 6.6 +/- 9.0 mm Hg (95% CI = -7.9 to -5.2). Manual triage BP vs. AHA standard SBP difference was 11.6 +/- 12.8 mm Hg (95% CI = 9.1 to 14.1); dBP difference was 9.9 +/- 10.4 mm Hg (95% CI = 7.9 to 12.0). The ABP device failed to meet AAMI criteria and received a BHS rating of "D." Poor operator technique and extraneous patient and operator movement appeared to hamper accuracy.

CONCLUSIONS

ABP triage measurements show significant discrepancies from a reference standard. Repeat measurements following AHA standards demonstrate significant decreases in the measured blood pressures.

Leading by Example

A multisectoral model promoting sociocultural environmental change to increase physical activity levels among African Americans in Los Angeles County, California, was developed and implemented. This model represents a true collaboration between a local health department and a community lead agency. Community organizations serving targeted areas of the county participated in one or more interventions incorporating physical activity into routine organizational practice, which centered around modeling the behaviors promoted ("walking the talk"). In the current study, level of organizational support for physical activity integration was assessed, as reflected in the extent of organizational commitment associated with each intervention. Individual-level data, characterizing the sociodemography, health status, and health behaviors of organization staff, members, and clients, are presented to document the average risk burden in the targeted population. Nearly half of the more than 200 participating organizations actively embraced incorporating physical activity into their regular work routines, with more than 25 percent committed at the highest level of involvement. Broad capacity and support for organizational integration of physical activity was demonstrated, with the observed level of commitment varying by organization type. Similar to the successful evolution of tobacco control, some of the responsibility ("cost") for physical activity adoption and maintenance can and should be shifted from the individual to organizational entities, such as workplaces.

Defaulting from anti-tuberculosis treatment in a teaching hospital in Rio de Janeiro, Brazil

SETTING

Few studies have investigated factors associated with defaulting from anti-tuberculosis (TB) therapy in hospital settings.

OBJECTIVE

To identify the factors associated with defaulting from treatment among TB in-patients in Rio de Janeiro city, Brazil.

DESIGN

Case-control study.

METHODS

All study participants initiated anti-tuberculosis treatment in a teaching hospital. A defaulting case was defined as a person who did not return for anti-tuberculosis medications after 60 days. Cases and controls were interviewed by a trained health care worker using a standardized form.

RESULTS

From 1 January to 31 December 1997, 228 TB cases were registered. After a review of the medical records, 39 were excluded. Household visits were performed in 189 patients; 46 subjects were identified as cases and 117 as controls. Defaulting from anti-tuberculosis treatment was observed in 66 cases (28.9%) before and in 46 (20.2%) after a home visit. After multivariate analysis, the strongest predictors of defaulting from treatment were: 1) returning card not provided (OR 0.099; 95%CI 0.008-1.2; P = 0.07), 2) not feeling comfortable with a doctor (OR 0.16; 95%CI 0.33-0.015; P = 0.001), and 3) blood pressure not measured (OR 0.072; 95%CI 0.036-0.79; P = 0.024).

CONCLUSIONS

In this hospital, the factors associated with defaulting from anti-tuberculosis treatment highlight the necessity for a structured TB Control Program. It is expected that the implementation of such a program, pursuing specific approaches, should enhance completion of anti-tuberculosis treatment and cure.

Physician buy-in helps PI team reduce LOS

Benchmarking database helps win oversceptical physicians. The Initiative is positioned as an education collaborative. An opportunity assessment is conducted to identify clinical area to target.

Measuring Quality of Life in Routine Oncology Practice Improves Communication and Patient Well-Being: A Randomized Controlled Trial

Purpose

To examine the effects on process of care and patient well-being, of the regular collection and use of health-related quality-of-life (HRQL) data in oncology practice.

Patients and Methods

In a prospective study with repeated measures involving 28 oncologists, 286 cancer patients were randomly assigned to either the intervention group (regular completion of European Organization for Research and Treatment of Cancer-Core Quality of Life Questionnaire version 3.0, and Hospital Anxiety and Depression Scale on touch-screen computers in clinic and feedback of results to physicians); attention-control group (completion of questionnaires, but no feedback); or control group (no HRQL measurement in clinic before encounters). Primary outcomes were patient HRQL over time, measured by the Functional Assessment of Cancer Therapy-General questionnaire, physician-patient communication, and clinical management, measured by content analysis of tape-recorded encounters. Analysis employed mixed-effects modeling and multiple regression.

Results

Patients in the intervention and attention-control groups had better HRQL than the control group (P = .006 and P = .01, respectively), but the intervention and attention-control groups were not significantly different (P = .80). A positive effect on emotional well-being was associated with feedback of data (P = .008), but not with instrument completion (P = .12). A larger proportion of intervention patients showed clinically meaningful improvement in HRQL. More frequent discussion of chronic nonspecific symptoms (P = .03) was found in the intervention group, without prolonging encounters. There was no detectable effect on patient management (P = .60). In the intervention patients, HRQL improvement was associated with explicit use of HRQL data (P = .016), discussion of pain, and role function (P = .046).

Conclusion

Routine assessment of cancer patients' HRQL had an impact on physician-patient communication and resulted in benefits for some patients, who had better HRQL and emotional functioning.

Improving care for patients dying in the intensive care unit

It is impossible for ICU clinicians to avoid caring for dying patients and their families. For many, this is an extremely rewarding aspect of their clinical practice. There is ample evidence that there is room to improve the care of patients who are near death in the ICU. Despite the considerable holes in our knowledge about optimal care of dying critically ill patients, there is considerable agreement on the general principles of caring for these patients and about how to measure the outcomes of palliative care in the ICU. Practical approaches to improving the quality of end-of-life care exist and should be implemented.

Variability in asthma care and services for low-income populations among practice sites in managed Medicaid systems

OBJECTIVE

To characterize and describe variability in processes of asthma care and services tailored for low-income populations in practice sites participating in Medicaid managed care (MMC).

STUDY SETTING

Eighty-five practice sites affiliated with five not-for-profit organizations participating in managed Medicaid (three group-model health maintenance organizations [HMOs] and two Medicaid managed care organizations [MCOs]).

STUDY DESIGN/DATA COLLECTION

We conducted a mail survey of managed care practice site informants using a conceptual model that included chronic illness care and services targeting low-income populations. The survey asked how frequently a number of processes related to asthma care occurred at the practice sites (on a scale from "never" to "always"). We report mean and standard deviations of item scores and rankings relative to other items. We used within-MCO intraclass correlations to assess how consistent responses were among practice sites in the same MCO.

PRINCIPAL FINDINGS

Processes of care related to asthma varied gready in how often practice sites reported doing them, with information systems and self-management support services ranking lowest. There was also significant variation in the availability of services targeting low-income populations, specifically relating to cultural diversity, communication, and enrollee empowerment. Very little of the site-to-site variation was attributable to the MCO.

CONCLUSIONS

Our conceptual framework provides a means of assessing the provision of chronic illness care for vulnerable populations. There is room for improvement in provision of chronic asthma care for children in managed Medicaid, particularly in the areas of self-management support and information systems. The lack of consistency within MCOs on many processes of care suggests that care may be driven more at the practice site level than the MCO level, which has implications for quality improvement efforts.