Margaret Flatley

Protocols for physician assistants. Management of diabetes and hypertension.

Abstract Physician assistants used problem-oriented protocols in management of patients with diabetes and hypertension. The protocols directed the physician assistant in determining what data to co...

Pitfalls in the serial assessment of cardiac functional status: How a reduction in “ordinary” activity may reduce the apparent degree of cardiac compromise and give a misleading impression of improvement

Because the New York Heart Association (NYHA) classification system categorizes patients based on subjective impression of the degree of functional compromise, a reduction in exercise might make a patient seem improved because the new lower level of ordinary activity produced fewer symptoms. To test this hypothesis, we studied three different sets of patients and compared their NYHA classes to their functional classes as determined by a new Specific Activity Scale (SAS) that is based on the metabolic equivalents of oxygen consumption required for activities the patient actually performs. Among ambulatory patients referred for exercise tests, the NYHA class was higher (i.e. indicated the patient was more limited) in 28% of patients and the SAS class was higher in 14% (p less than 0.001). Among patients interviewed at or near the time of catheterization for chest pain, the NYHA was higher in 20% and the SAS class was higher in 20% (p = NS). In both medically and surgically treated patients interviewed 1--3 yr after cardiac catheterization, the NYHA class was higher in only 4%, whereas the SAS class was higher in 28% (p less than 0.001). The SAS class was significantly more likely to be higher in patients who were not working full time and in patients who described their present activity level as sedentary or light. When the NYHA and SAS systems disagreed as to whether a patient was improved, SAS was significantly more likely to correlate with the patients self-assessment. These findings suggest that some patients restrict their activity as their cardiac disease progresses; the resultant change in the definition of ordinary activity may reduce the apparent degree of cardiac compromise and thus give a false impression of improvement by NYHA criteria.

Nurse practitioner management of common respiratory and genitourinary infections, using protocols.

Included in this Mudv were all patients with symptoms of respiratory tract infection and female patients with vimptoms of unmary tract and vaginal infections who sought care from a hospital-based outpatient department walk-in unit which was operated in two different modes: experimental the “nurse-protocol mode”) in which a nurse practitioner guided by a protocol initially evaluated all such patients and independently managed many patients and traditional in which only physicians managed patients. Safety, effectiveness, efficiency. and cost of care rendered for these tracer conditions in the two modes were compared. So serious illnesses were overlooked by practitioners in either mode. Eighty-six percent of patients in the nurse-protocol mode and -3 percent of patients in the traditional mode reported good symptom relief. Patients reported equivalent satisfaction with care. The time physicians spent managing patients with these complaints was reduced by of percent from 15.5 minutes to 1.4 minutes per patient. Personnel costs were equivalent in the two modes. Costs of laboratory tests and medications ordered were 2- percent less in the nurse-protocol mode. The study indicated that care in the nurse-protocol mode was of equivalent quality led to equivalent patient satisfaction. allowed a substantial reduction in physician time, and reduced overall costs of care.

Clinical utility and management impact of M-mode echocardiography☆

To determine the clinical utility and management impact of M-mode echocardiography, 182 echocardiograms were analyzed at a university teaching hospital. The physicians who ordered the echocardiograms said that 12 percent provided crucial information that was not available from other tests and that 26 percent resulted in a change in patient management. According to two independent board-certified cardiologist-reviewers, 86 percent of echocardiograms were appropriately ordered, but only 15 echocardiograms (8 percent) were actually needed for a change to a new and appropriate management. According to the reviewers, the 77 Group I M-mode echocardiograms (those ordered to evaluate left ventricular function, left atrial size, potential cardiac sources of emboli, or the possibility of bacterial endocarditis, or those ordered in patients who, according to the ordering physician, had undergone or would undergo catheterization regardless of the results of echocardiography) were less likely than the 105 Group II M-mode echocardiograms (those ordered to evaluate possible mitral valve prolapse, hypertrophic cardiomyopathy, valvular function, or the pericardium) to be ordered appropriately, to provide helpful information, or to provide crucial results. Group I echocardiograms had reviewer-assessed appropriate management impact in only one case (1 percent) compared with a 13 percent rate of management impact for Group II M-mode echocardiograms (p less than 0.01). Although echocardiography can be accurate and valuable with yields similar to those of other noninvasive procedures, 77 (42 percent) of 182 M-mode echocardiograms in this hospital could be predicted at the time of ordering to be in a low-yield group.

Quality, Efficiency, and Cost of a Physician-Assistant-Protocol System for Managment of Diabetes and Hypertension

Briefly trained physicians assistants using protocols (clinical algorithms) for diabetes, hypertension, and related chronic arteriosclerotic and hypertensive heart disease abstrated information from the medical record and obtained history and physical examination data on every patient-visit to a city hospital chronic disease clinic over a 18-month period. The care rendered by the protocol system was compared with care rendered by a “traditional” system in the same clinic in which physicians delegated few clinical tasks. Increased thoroughness in collecting clinical data in the protocol system led to an increase in the recognition of new pathology. Outcome criteria reflected equivalent quality of care in both groups. Efficiency time-motion studies demonstrated a 20 per cent saving in physician time with the protocol system. Coct estimates, based on the time spent with patients by various providers and on the laboratory-test-ordering patterns, demonstrated equivalent costs of the two systems, given optimal staffing patterns. Laboratory tests were a major element of the cost of patient care,and the clinical yield per unit cost of different tests varied widely.

Clinical response to coronary artery reoperations

Repeat coronary artery bypass operations were performed on 112 patients at a university hospital between 1971 and 1981. When compared with patients who did poorly after a first operation but did not have repeat surgery, patients undergoing repeat surgery tended to be younger, to have a higher smoking rate and to have fewer prior myocardial infarctions, fewer diseased vessels and fewer lesions in distal vessels. At least 1 graft was occluded in 83% of patients undergoing reoperation, and a mean of 1.7 grafts were placed at reoperation. The operative mortality rate was 4%, with a follow-up mortality rate of 6% at a mean of 3.8 years. After reoperation, patients initially showed improvement to a mean specific activity scale class of 1.6, compared with 2.4 before the first operation and 2.7 before the second operation. The principal correlate of a better long-term symptomatic response compared with that in the period before the first operation was a lower serum cholesterol level, whereas the principal correlate of a better symptomatic response compared with that in the period just before the reoperation was the left ventricular ejection fraction. As recurrent symptoms after a first coronary artery operation become more prevalent, consideration of the selection factors and prognostic correlates of reoperation will become increasingly important.

Data Assessing the Usefulness of screening Obstetrical Ultrasonography for Detecting Fetal and Placental Abnormalities in Uncomplicated Pregnancy Effects of Screening a Low-risk Population

To investigate the usefulness of screening in low-risk populations, the authors evaluated the yield of ultrasonography for detecting abnormalities in 678 clinically uncomplicated preg nancies. The yield of ultrasonography in high-risk women who were referred for amniocen tesis was remarkably similar to the yield in other women. All four diagnoses of twins were correct, but overall only six of 12 initial ultrasound diagnoses of fetal demise or fetal anomalies were confirmed at delivery. Of the eight major fetal anomalies present at delivery, including two cases of Downs syndrome, three had been detected by ultrasonography; none of the nine minor anomalies had been detected, usually because they were too small or might be detectable only at a later gestational age. Although ultrasonography may have a nearly perfect predictive value for certain anomalies, on average, in this study, positive ultrason ography increased the probability of an adverse outcome of pregnancy from 5.3% to 36%, while a normal ultrasound examination decreased the probability to 4.4%. These data, which emphasize the implications of screening a low-risk population, suggest that recommendations regarding routine screening obstetrical ultrasonography should await sufficiently large con trolled trials demonstrating consistent clinical benefit, in terms of reassurance or of providing a baseline for future comparison or in terms of improved outcome at a reasonable cost. Key words: ultrasonography; fetal anomaly; screening. (Med Decis Making 8:48-54, 1988)

The Selective Impact of a Cardiology Data Bank on Physicians' Therapeutic Recommendations

We asked the physicians and medical students caring for 60 patients with symptomatic coronary artery disease, immediately after reviewing cardiac catheterization data, to choose medical or surgical therapy and to estimate prognosis one and three years after either therapy. The next day, each participant was given prognostic estimates generated from a large coronary artery disease data bank and again asked to estimate prognosis and choose therapy. Participants unanimously chose medicine for 20 patients (Group I) and surgery for 21 patients (Group III). For 19 patients (Group II), participants were divided on their choice of therapy. After seeing data bank estimates, participants rarely changed recommendations for Group I or Group III, but changed ten percent (9/90, p less than 0.01) of their Group II recommendations. Changes of recommendations by far (9/12, p = 0.02) favored medicine, causing the majority recommendation to change to medicine for two Group II patients. Therapeutic recommendations were guided mostly by pathoanatomy and the chance of improving medical regimens. Computer-generated prognostic data selectively influenced choices among the Group II cases where recommendations had been divided, resulting in changes toward less costly therapy.

Dissecting the hospital stay: a method for studying patient staging in hospitals.

A methodology is proposed and tested for the staging of patients thorugh a hospital stay. Measurements in a university-affiliated hospital and a community hospital in the Boston area showed similar staging patterns with about half of the sample having abnormal signs and symptoms while under treatment. The second-largest sample group in both hospitals, consisting of 11% of the sample, occupied beds although ready for discharge. The methodology indicated those patient-time units in the hospital which might be amenable to further reduction and gave upper bounds on that compression. Contrary to prior expectations, 90% of the patients sampled followed a well-defined sequence from admission to discharge with only 10% having complications of the admitting diagnosis, new diagnosis or iatrogenic illness.

Benefits of Experience: Treating Coronary Artery Disease

The authors examined the issue of learning by doing in terms of both the cost and outcome of treating coronary artery disease at one hospital between 1977 and 1981. Over time, the quality of outcome improved for both medical and surgical patients. During this time of cost-plus reimbursement, there was less conclusive evidence of concurrent technical efficiency gains. These findings are consistent with the hypothesis that the benefits of experience can be substantial but they do not just happen: they require proper provider motivation.