Lee H. Hilborne

MEASURING THE NECESSITY OF MEDICAL PROCEDURES

This is a report on the extension of the concept of the appropriateness of a procedure to the necessity, or crucial importance, of that procedure. To state that a procedure is crucial means that withholding the procedure would be deleterious to the patients health. Appropriateness and necessity ratings for six procedures were obtained using a modified Delphi panel process developed in earlier work. Panels were composed of practicing clinicians who were recognized leaders in their fields. The panels included both performers and nonperformers of the procedure under discussion. For most procedures and panelists, necessity was related to appropriateness, but was distinct from it. The proportion of indications for which the procedure was crucial varied in clinically consistent ways both among and within procedures. However, panelists did not achieve a consensus on necessity. Further research is suggested to refine the method to promote consensus and to validate further the ratings of necessity. In conclusion, necessity ratings can be used together with appropriateness ratings to address not only the overuse of procedures, but also to indicate limited access to care through underuse of procedures.

Developing and Interpreting Models to Improve Diagnostics in Developing Countries

Developing a strategy for investment in diagnostic technologies requires an understanding of the need for, and the health impact of, potential new tools, as well as the necessary performance characteristics and user requirements. In this paper, we outline an approach for modelling the health benefits of new diagnostic tools.

Rates and types of events reported to established incident reporting systems in two US hospitals

Background: US hospitals have had voluntary incident reporting systems for many years, but the effectiveness of these systems is unknown. To facilitate substantial improvements in patient safety, the systems should capture incidents reflecting the spectrum of adverse events that are known to occur in hospitals. Objective: To characterise the incidents from established voluntary hospital reporting systems. Design: Observational study examining about 1000 reports of hospitalised patients at each of two hospitals. Patients and setting: 16 575 randomly selected patients from an academic and a community hospital in the US in 2001. Main outcome measures: Rates of incidents reported per hospitalised patient and characteristics of reported incidents. Results: 9% of patients had at least one reported incident; 17 incidents were reported per 1000 patient-days in hospital. Nurses filed 89% of reports, physicians 1.9% and other providers 8.9%. The most common types were medication incidents (29%), falls (14%), operative incidents (15%) and miscellaneous incidents (16%); 59% seemed preventable and preventability was not clear for 32%. Among the potentially preventable incidents, 43% involved nurses, 16% physicians and 19% other types of providers. Qualitative examination of reports indicated that very few involved prescribing errors or high-risk procedures. Conclusions: Hospital reporting systems receive many reports, but capture a spectrum of incidents that differs from the adverse events known to occur in hospitals, thereby substantially underdetecting physician incidents, particularly those involving operations, high-risk procedures and prescribing errors. Increasing the reporting of physician incidents will be essential to enhance the effectiveness of hospital reporting systems; therefore, barriers to reporting such incidents must be minimised.

Patient Safety in the Clinical Laboratory: A Longitudinal Analysis of Specimen Identification Errors

CONTEXT Patient safety is an increasingly visible and important mission for clinical laboratories. Attention to improving processes related to patient identification and specimen labeling is being paid by accreditation and regulatory organizations because errors in these areas that jeopardize patient safety are common and avoidable through improvement in the total testing process. OBJECTIVE To assess patient identification and specimen labeling improvement after multiple implementation projects using longitudinal statistical tools. DESIGN Specimen errors were categorized by a multidisciplinary health care team. Patient identification errors were grouped into 3 categories: (1) specimen/requisition mismatch, (2) unlabeled specimens, and (3) mislabeled specimens. Specimens with these types of identification errors were compared preimplementation and postimplementation for 3 patient safety projects: (1) reorganization of phlebotomy (4 months); (2) introduction of an electronic event reporting system (10 months); and (3) activation of an automated processing system (14 months) for a 24-month period, using trend analysis and Student t test statistics. RESULTS Of 16,632 total specimen errors, mislabeled specimens, requisition mismatches, and unlabeled specimens represented 1.0%, 6.3%, and 4.6% of errors, respectively. Student t test showed a significant decrease in the most serious error, mislabeled specimens (P < .001) when compared to before implementation of the 3 patient safety projects. Trend analysis demonstrated decreases in all 3 error types for 26 months. CONCLUSIONS Applying performance-improvement strategies that focus longitudinally on specimen labeling errors can significantly reduce errors, therefore improving patient safety. This is an important area in which laboratory professionals, working in interdisciplinary teams, can improve safety and outcomes of care.

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.

Programmable Infusion Pumps in ICUs: An Analysis of Corresponding Adverse Drug Events

BackgroundPatients in intensive care units (ICUs) frequently experience adverse drug events involving intravenous medications (IV-ADEs), which are often preventable.ObjectivesTo determine how frequently preventable IV-ADEs in ICUs match the safety features of a programmable infusion pump with safety software (“smart pump”) and to suggest potential improvements in smart-pump design.DesignUsing retrospective medical-record review, we examined preventable IV-ADEs in ICUs before and after 2 hospitals replaced conventional pumps with smart pumps. The smart pumps alerted users when programmed to deliver duplicate infusions or continuous-infusion doses outside hospital-defined ranges.Participants4,604 critically ill adults at 1 academic and 1 nonacademic hospital.MeasurementsPreventable IV-ADEs matching smart-pump features and errors involved in preventable IV-ADEs.ResultsOf 100 preventable IV-ADEs identified, 4 involved errors matching smart-pump features. Two occurred before and 2 after smart-pump implementation. Overall, 29% of preventable IV-ADEs involved overdoses; 37%, failures to monitor for potential problems; and 45%, failures to intervene when problems appeared. Error descriptions suggested that expanding smart pumps’ capabilities might enable them to prevent more IV-ADEs.ConclusionThe smart pumps we evaluated are unlikely to reduce preventable IV-ADEs in ICUs because they address only 4% of them. Expanding smart-pump capabilities might prevent more IV-ADEs.

Effect of HIV Antibody Testing and AIDS Education on Communication about HIV Risk and Sexual Behavior: A Randomized, Controlled Trial in College Students

OBJECTIVE To evaluate the effects of human immunodeficiency virus (HIV) antibody testing and education about HIV infection on communication about sexual risk behaviors for HIV transmission. DESIGN Randomized, controlled trial with three arms. SETTING University student health center. PATIENTS Of 2196 heterosexual university students attending the student health clinic for medical care, 435 were interested in education about HIV and HIV testing and were randomly assigned to three groups. Follow-up at 6 months was done in 370 subjects (85%): 90 control subjects, 144 subjects who received education alone, and 136 subjects who received education plus HIV testing. MEASUREMENTS AND RESULTS Subjects who received HIV testing plus education questioned sexual partners about their HIV status more than subjects receiving education alone or those in the control group (56%, 42%, and 41% of subjects, respectively; P = 0.01). No consistent differences among groups in the number of sexual partners or in the use of condoms were found at follow-up. CONCLUSIONS Heterosexual university students who received education about HIV infection plus HIV testing had increased communication with sexual partners about the risk for HIV infection after 6 months. Further reduction in risk behaviors for HIV transmission may require additional interventions in this population.

Strengthening laboratory systems in resource-limited settings.

Considerable resources have been invested in recent years to improve laboratory systems in resource-limited settings. We reviewed published reports, interviewed major donor organizations, and conducted case studies of laboratory systems in 3 countries to assess how countries and donors have worked together to improve laboratory services. While infrastructure and the provision of services have seen improvement, important opportunities remain for further advancement. Implementation of national laboratory plans is inconsistent, human resources are limited, and quality laboratory services rarely extend to lower tier laboratories (eg, health clinics, district hospitals). Coordination within, between, and among governments and donor organizations is also frequently problematic. Laboratory standardization and quality control are improving but remain challenging, making accreditation a difficult goal. Host country governments and their external funding partners should coordinate their efforts effectively around a host countrys own national laboratory plan to advance sustainable capacity development throughout a countrys laboratory system.

Adherence to Quality Indicators and Survival in Patients With Breast Cancer

Background:International initiatives increasingly advocate physician adherence to clinical protocols that have been shown to improve outcomes, yet the process-outcome relationship for adhering to breast cancer care protocol is unknown. Objective:This study explores whether 100% adherence to a set of quality indicators applied to individuals with breast cancer is associated with better survival. Research Design and Subjects:Ten quality indicators (4 diagnosis-related and 6 treatment-related indicators) were used to measure the quality of care in 1378 breast cancer patients treated from 1995 to 2001. Adherence to each indicator was based on the number of procedures performed divided by the number of patients eligible for that procedure. The main analysis of adherence was dichotomous (ie, 100% adherence vs. <100% adherence). Measures:The outcome measures studied were 5-year overall survival and progression-free survival, calculated using the Kaplan-Meier method. The Coxs proportional hazard regression model was used for univariate and multivariate analyses. Results:Most patients received care that demonstrated good adherence to the quality indicators. Multivariate analysis revealed that 100% adherence to entire set of quality indicators was significantly associated with better overall survival [hazard ratio (HR): 0.46; 95% confidence interval (CI): 0.33–0.63] and progression-free survival (HR 0.51; 95% CI, 0.39–0.67). One hundred percent adherence to treatment indicators alone was also associated with statistically significant improvements in overall and progression-free survivals. Conclusions:Our study strongly supports that 100% adherence to evidence supported quality-of-care indicators is associated with better survival rates for breast cancer patients and should be a priority for practitioners.

Components of Care Vary in Importance for Overall Patient-Reported Experience By Type of Hospitalization

Background:Patients are hospitalized for disparate conditions and procedures. Patient experiences with care may depend on hospitalization type (HT). Objectives:Determine whether the contributions of patient experience composite measures to overall hospital ratings on the Hospital Consumer Assessment of Healthcare Providers and Systems Survey vary by HT. Research Design:In cross-sectional observational data, we defined 24 HTs using major diagnostic category and service line (medical, surgical, or obstetrical). To assess the importance of each composite for each HT, we calculated the simultaneous partial correlations of 7 composite scores with an overall hospital rating, controlling for patient demographics. Subjects:Nineteen thousand seven hundred twenty English- or Spanish-speaking adults with nonpsychiatric primary diagnoses discharged home 12/02-1/03 after an overnight inpatient stay in any of 132 general acute care hospitals in 3 states. Measures:Patient-reported doctor communication, nurse communication, staff responsiveness, physical environment, new medicines explained, pain control, and postdischarge information; overall 0 to 10 rating of care. Results:Nurse communication was most important overall, with a 0.34 average partial correlation (range: 0.17-0.49; P < 0.05 and among the 3 most important composites for all HTs). Discharge information was least important (0.05 average partial correlation; P < 0.05 for 10 of 24 HTs). Interactions demonstrated significant (P < 0.05) variation in partial correlations by HT for 5 of 7 composites (all but responsiveness and environment), with nurse communication, doctor communication, and pain control showing the most variation (F > 2, P < 0.05). Conclusions:The importance of patient experience dimensions differs substantially and varies by HT. Quality improvement efforts should target those aspects of patient experience that matter most for each HT.