Ann Barry Flood

Does Practice Make Perfect?: Part I: The Relation Between Hospital Volume and Outcomes for Selected Diagnostic Categories

The effect of a greater volume of patients with similar conditions being treated at a hospital on the outcomes achieved is studied using a variety of categories of patients, 15 surgical and 2 medical, and involving 550,000 patients treated in over 1,200 nonfederal United States acute care hospitals. After demonstrating that there are significant differences in the outcomes of patients, taking into account patient health status, the authors examine the impact of being treated in a hospital with a high or low volume of similar patients. Strong and consistent evidence is found that high volume is associated with better outcomes for surgical patients, which supports regionalizing patient care by procedure. Two additional variables, relative difficulty of the procedure and risk level of the patients, are analyzed to determine whether they change the relationship between volume and outcome. Some evidence is found that low-volume hospitals are associated with the poorest outcome for low-risk surgical patients. The evidence for medical patients is weak and mixed. Possible alternative explanations for the observed findings for surgical and medical patients are discussed.

Does practice make perfect? Part II: The relation between volume and outcomes and other hospital characteristics.

The effect of a greater volume of patients with similar conditions being treated at a hospital on the outcomes achieved is investigated for almost 500,000 selected surgical and medical patients treated in over 1,200 nonfederal United States hospitals. In Part I the authors found strong and consistent evidence for surgical patients that high volume is associated with better outcome; evidence for medical patients was mixed. In this paper the authors include other hospital variables related both to volume and outcome—hospital size, teaching status, and expenditures—to determine whether they mask the true relationship; still, strong and consistent evidence that greater volume produces better outcome was found for both surgical and medical patients. This relation was significant for low-, medium-, and high-risk patients. Among the hospital variations added, only size was consistently and strongly related to outcome; greater size was associated with poorer outcome after accounting for volume. The potential importance of the findings for reducing deaths and days in hospital on a national level is discussed. The evidence is strongly supportive of the need for policies that would promote greater regionalization of a given service, and not greater size, to obtain better quality outcome for patients treated.

Reliability of questionnaire responses as compared with interview in the elderly: Views of the outcome of transurethral resection of the prostate

Three hundred and eighty-eight men undergoing transurethral resection of the prostate for benign prostatic hypertrophy completed a presurgical questionnaire and three follow-up questionnaires 3, 6 and 12 months after surgery. The questionnaires covered details of prostatic symptoms, general health, and expectations and results of surgery. At each follow-up point 40 randomly selected patients were interviewed by two female research assistants. The response rate to the questionnaires was over 90% at each follow-up point while that for the interviews was lower at around 80%. We examine the reliability of the postal questionnaires in assessing health status by comparing questionnaire and interview responses, with a view to the wider employment of such a method in the follow-up of surgical patients. In general, and as reported elsewhere, responses to questions on easily defined topics are highly comparable between questionnaire and interview. Responses to more subjective questions are moderately reliable, but with a tendency for postal questionnaires to underestimate a patients health problems. It is difficult to assess the reliability of the questionnaires with regard to questions of an intimate nature since such questions caused embarrassment during interview with consequent incomplete responses.

Criterion validation of the Nottingham health profile: Patient views of surgery for benign prostatic hypertrophy

As part of a prospective cohort study of 388 men undergoing TURP for benign prostatic hypertrophy, the Nottingham Health Profile (NHP) was self-administered before and at 3, 6 and 12 months after surgery. By comparison of pre- and post-operative NHP scores with other patient-reported health measures the criterion validity of the Profile was examined. Before surgery, statistically significant linear trends were observed for increasing NHP score (i.e. having more health problems) with both worsening self-rated general health and increasing severity of prostatic symptoms. One year after surgery, the extent of reduction in NHP score was significantly linearly associated with a perceived favourable outcome of surgery and to a lesser extent with a reduction in prostatic symptoms. In addition, changes in NHP scores during follow-up were associated with perceived changes in operative outcome during the same period, patients with the greatest reduction in NHP score tending to report more successful surgery at 12 months than at the 3 month assessment.

Do Doctors and Patients Agree?: Views of the Outcome of Transurethral Resection of the Prostate

In an attempt to establish the extent to which patients and doctors agree on the outcome of health care, the pre- and postoperative states of health of 388 men undergoing transurethral resection of the prostate for benign disease were studied. Generally, high levels of concordance (greater than 70%) were obtained. The strongest agreement was for clearly defined events, such as episodes of acute retention (95%); the weakest agreement occurred over the most subjective symptoms, prognostic expectations, and ambiguous terms (around 60%). The level of agreement was not associated with any characteristics of the patient, surgeon, or treatment.

Organizational Determinants of Services, Quality and Cost of Care in Hospitals

Characteristics of hospitals may be useful predictors of the economy, efficiency, and effectiveness of services delivered. But it is difficult to explain the variables of cost and quality among hospitals until differences among patients and outcomes are accounted for. A promising new research approach is explored as a source of information on that most elusive of all measures in service organizations--the outcome experienced by clients.

The relationship between intensity and duration of medical services and outcomes for hospitalized patients.

Much recent research on the delivery of care in health care systems has concentrated on the issues of cost containment and assurance of quality care. The research reported here is part of a larger study examining the organizational and contextual determinants of service intensity and duration, costs, and quality of outcomes for hospitalized patients in a stratified random sample of short-term hospitals in the United States. The focus of this paper is on the relationship between the services received by patients in a hospital and their resultant outcomes, i.e., do hospitals which provide more services to their patients achieve better outcomes? The adequacy of previous research bearing on this relationship is briefly reviewed and the problems for defining these measures and for making comparisons among hospitals with differing case mixes of patients are described. Data for assessing the amount and mix of services and the outcomes of patients were obtained from an abstract of each patients medical record for over 600,000 patients treated in 17 hospitals. Both for the intensity and duration of services and for outcome, an empirical standardization procedure is used to predict the level of services and outcome required by a patient, given his type of disease and physical status as indicated by various demographic and medical history attributes recorded on the abstract. This procedure allows comparisons of levels of services and outcomes for patients which take into account differences in patient populations. Thus the question being asked finally is whether services in excess of those typically provided to this type of patient produce outcomes better than expected. Using a composite measure of the intensity of specific medical services reflecting the mix, amount, and relative costliness of the services provided, out data clearly supported the expectation that hospitals providing higher than expected levels of specific services to their patients also had better outcomes than expected. When a measure of duration of services—the number of days stay—was used, hospitals which kept their patients longer than expected had worse outcomes than expected for their patients. However, when these results were examined for regional effects, strong evidence for regional variations in medical practice was found, especially for duration of services. Further, when the relationship between services and outcomes was examined for hospitals within regions, there was no longer any relationship between duration of services and outcomes. In contrast, even within regions, hospitals providing more specific services to patients also had better outcomes.

Review Article : Costs and Quality of Hospital Care: a Review of the Literature:

*Based on material presented in Flood, A. B. and Scott, W. R. Hospital Structure and Performance. Baltimore: Johns Hopkins University Press, forthcoming. †Professor, Department of Sociology, Stanford University, Stanford, Calif. ‡Assistant Professor, Department of Sociology and College of Medicine, University of Illinois, Urbana, III. Over the past three decades, the cost of care in hospitals has continued to rise, regularly outstripping the general cost-of-living indices. But during this period, factors contributing to the increase have changed: factors prominent in the 1960s are less significant in the 1980s, and new factors have been introduced. Moreover, because of the increased salience of the topic, many more studies of hospital costs have been conducted recently than earlier in the period under review, and the later studies have employed larger samples and more sophisticated methods although they have not always produced better data. Most observers would agree that the quality of hospital care has also increased over the same three decades, but by no means at a rate commensurate with increases in costs. While quality itself may not have improved dramatically, there has been considerable progress in its conceptualization and measurement. A number of studies assessing hospital factors related to quality of care have been carried out, but much more research attention has been devoted to

Measuring the Complexity and Uncertainty of Surgery and Postsurgical Care

This article reports the results of a survey of a nationwide sample of more than 900 surgeons and post-surgical nurses, who were asked to rate the relative complexity and uncertainty of 71 surgical procedures frequently performed in hospitals. Average scores assigned to each surgical procedure by both types of raters are reported and the extent of agreement is assessed across indicator questions and types of raters. A surprisingly high level of agreement was observed. Explanations for the extent of agreement are discussed and uses for these scores are described