Annette M. Bernard

AN EVALUATION OF GENERIC SCREENS FOR POOR QUALITY OF HOSPITAL CARE ON A GENERAL MEDICINE SERVICE

In this study, 675 general medicine admissions at a university teaching hospital were reviewed to evaluate six potential generic quality screens: 1) in-hospital death; 2) 28-day early readmission; 3) low patient satisfaction; 4) worsening severity of illness (as determined by an increase in Laboratory Acute Physiology and Chronic Health Evaluation APACHE-L); and 5) deviations from expected hospital length of stay; and 6) expected ancillary resource use. The quality of care for a stratified random sample of admissions were evaluated using structured implicit review (inter-rater reliability, Kappa=0.5). Patients who died in-hospital were substantially more likely than those who were discharged alive to be rated as having had substandard care (30% vs. 10%; P<0.001). In contrast, cases who had subsequent early readmissions did not have poorer quality ratings. Similarly, lower patient satisfaction was not associated with poorer ratings of technical process of care. Cases with lower-than-expected ancillary resource use (case-mix adjusted for diagnosis-related group) were more likely to be rated as having received substandard care than those with higher-than-expected resource use (16% vs. 6%; P<0.05), and there was a similar trend for cases with shorter than expected length of stays. Associations between worsening severity of illness, as determined by APACHE-L scores, and quality were confounded because such patients were more likely to have died in-hospital. When deaths were excluded from the analysis, we found no association between increases in APACHE-L scores during the hospital course and quality of care. It was found that in-hospital death and lower-than-expected ancillary resource use were associated with poorer implicit quality ratings, but that early readmission, lower patient satisfaction, and increases in APACHE-L scores were not. Quality screens, such as early readmissions, should be critically evaluated before being used administratively.

The effects of a low-cost intervention program on hospital costs

Objective:To assess the impact of a low-cost education and feedback intervention designed to change physicians’ utilization behavior on general medicine services.Design:Prospective, nonequivalent control group study of 1,432 admissions on four general medicine services over 12 months. Two services were randomly selected to receive the intervention. The other two served as controls. Admissions alternated between control and intervention services each day. Results were casemix-adjusted using diagnosis-related groups (DRGs). Three internists blinded to patient study group assignment assessed quality of care using a structured implicit instrument.Setting:Four general medicine services at a university hospital.Interventions:A brief orientation, a pamphlet of cost strategies and common charges, detailed interim bills, and information about projected length of stay and usual hospital reimbursement for each patient.Patients/participants:Each service was staffed by a full-time internal medicine faculty member, one third-year and two first-year internal medicine houseofficers, three medical students, and a clinical pharmacist. Physicians were assigned to services for one-month periods by a physician unaware of the study design. To prevent crossover, houseofficers assigned to a service returned to the same service for all subsequent general medical inpatient assignments.Measurements and main results:Geometric mean length of stay was 0.44 days (7.8%) shorter for the intervention services than for the control services (p<0.01), and geometric mean charges were

The integrated inpatient management model. A new approach to clinical practice.

341 (7.1%) less (p<0.01). Effects persisted despite using a more precise cost estimate or casemix adjustment. Intervention houseofficers demonstrated superior cost-related attitudes but no difference in knowledge of charges. Audits of quality of care detected no significant difference between groups.Conclusion:This low-intensity intervention reduced length of stay and charges, even under the cost-constrained context of the prospective payment system.

An integrated inpatient management model.

The delivery and financing of health care have undergone a metamorphosis over the past 10 years. These changes have been particularly dramatic for hospital care. The new health care environment, with more prospective-payment and managed-care systems and less fee-for-service payment for both physicians and hospitals, has made physicians and hospitals mutually dependent. A hospitals long-term financial viability is now dependent largely on the practice style of its physicians. The Department of Internal Medicine at The University of Michigan has developed a new clinical management system called the Integrated Inpatient Management Model (IIMM). This new system includes a major revision of the hospital organization structure, new administrative information systems, and new clinical information systems. Physicians in the Department of Internal Medicine have assumed for the first time formal organizational responsibility for many aspects of the operations of the inpatient medical service. The IIMM represents a prototype of a system that we believe offers considerable promise for involving physicians to a much greater extent in the management of the nations hospitals. We hope that describing the system in detail will facilitate the development of other systems for the management of the inpatient practice of internal medicine.

A Mathematical Representation of the Expert Panel's Guidelines for Nigh Blood Cholesterol Case-finding and Treatment

The academic health center has emerged as the cornerstone of the American health care system. To assess the uvlnerability of the academic medical center to the new competitive forces that exist today, a prototype project has been developed that attempts to address the issue of competition in clinical activity, while at the same time enhancing the academic health centers education and research roles.

The integrated inpatient management model lessons for managed care

The National Cholesterol Education Program (NCEP) for high blood cholesterol case-finding and treatment recommended discrete treatments according to the results of sequential mea surements of continuous variables (total and low-density lipoprotein cholesterol [LDL-C]). These measurements are subject to intra- and interindividual variability. The authors describe a computer simulation of the NCEP that acknowledges these complexities. The simulation reduces the NCEP into steps, which are represented in a decision tree. The calculation of probabilities at chance nodes takes into account the conditional nature of sequential mea surements of blood cholesterol. The simulation tracks medical resource use and estimates LDL-C reductions within 20 strata, each defining 5% of population distribution for LDL-C. This approach enables a detailed representation of the case-finding process—the sequence of blood cholesterol tests and associated cut-off values that identify individuals needing more intensive evaluation and treatment. Key words: mathematical modeling; screening programs; hypercholesterolemia. (Med Decis Making 1990;10:135-146)

The influence of attending physician subspecialization on hospital length of stay.

The Integrated Inpatient Management Model was a 2.5-year controlled prospective trial of using a clinical information system to direct and monitor physician and hospital practice on general medicine services of an 880-bed university hospital. For the over 2,000 admissions on both a control service and the intervention service, the mean length of stay (LOS) decreased when compared with historic norms (0.68 and 0.95 days respectively; P < 0.01 for both). This difference in mean LOS represents a savings of 580 hospital days for the intervention over the control service; (95% confidence interval, 300 to 1420 days). There also was a trend for the intervention service to have fewer LOS outliers than expected (P = 0.14). Ancillary service use decreased by 17% on both control and intervention services (a trend that disappeared after the study was terminated), while other internal medicine services experienced a 29% increase in this measure of resource use. The intervention service experienced fewer preventable deaths (P = 0.04), but there were no differences in global quality of care measures, readmission and mortality rates, and patient satisfaction. This use of a clinical information system is a prototype for the systems that will be needed for all forms of managed care.

Evaluating the Care of General Medicine Inpatients: How Good Is Implicit Review?

During the past decade, hospitals, the federal government, and other payers have become increasingly concerned about the rising costs of health care. In instituting the diagnosis-related-group based Prospective Payment System (PPS) for Medicare inpatients, the federal government no longer assured hospitals of reimbursement for every resource utilized. Rather, the Medicare program now pays hospitals based upon the types of patients they treat. To remain solvent in this new environment, hospital administrators and physicians must rigorously address variation in resource use that is not