Martin A. Strosberg

Quality Improvement in Health Care: Is the Patient Still Left Out?

Quality improvement methodologies as applied to health care reflect a traditional practitioner-centered approach to defining and improving quality of services. However, health care must reconcile the values, needs, and preferences of providers with those of consumers if effective quality improvement programs are to be developed.

The Impact of Legislation Requiring DNR Orders: New York State Compared with Neighboring States

Decisions to place limitations on the care of patients are complex, and they often involve physicians, other medical professionals, patients, or a surrogate decision-maker, family members, and others. In 1988, the Joint Commission on Accreditation of Health Care Organizations (JCAHO) and the New York State government adopted two different approaches to this complex issue of do-not-resuscitate (DNR) orders: one involved professional self-regulation, whereas the other mandated a standardized procedure requiring completion of legal documents. This study examines the impact of these two different approaches to writing of DNR orders for adult intensive care unit (ICU) patients on utilization and resulting length of stay. The study used three data bases. One is from a larger study designed to update the Mortality Probability Model (MPM), a measure of severity of illness for ICU patients. This data base includes consecutive admissions to the adult ICUs of four hospitals in the northeastern United States. The second is a similar data base from the European-North American Study of Severity Systems (ENAS), and it includes 20 hospitals. The third data base, a 1991 national survey of ICUs by the Society of Critical Care Medicine (SCCM), lists characteristics of patients in ICUs in the United States on a specific day. Logistic regression was used to analyze the first two data bases; the percentage of patients in New York with DNR orders was calculated for each of the three data bases and compared with patients in neighboring states. Length of ICU and hospital stay was measured in the first two data sets. In the MPM data, 14.4% of medical patients in New York had a DNR order written at the time of ICU discharge, compared with 198% of medical patients in Massachusetts; and 4.3% of New York surgical patients had a DNR order written at the time of ICU discharge, compared with 8.3% of surgical patients in Massachusetts. In the ENAS data, 7.4% of New York nonoperative patients has a DNR order in place within 24 hours, compared with 8.4% of such patients in the other states; and 1.0% of New York operative patients had DNR orders, compared with 3–5% of operative patients from other states. Logistic regression revealed that a New York patient was less likely to have a DNR order written than a patient located in one of the other states studied. Data from the SCCM survey demonstrated that the New York percentage of patients with “no CPR” orders was 5.50%, compared with a percentage of 6.87% in other states. With few exceptions, these differences between New York and surrounding states did not have an impact on hospital length of stay. During the period studied following implementation of New Yorks DNR Law, utilization of DNR orders in New York State was significantly lower than neighboring states. This decreased utilization, however, did not effect hospital utilization as measured through length of stay and ICU admissions.

Introduction to Ethics and Epidemics

This volume of essays is based upon the proceedings of a conference on “Ethics and Epidemics” hosted in March 2004 by Albany Medical College and the Graduate College of Union University in the wake of the SARS epidemic. The SARS epidemic was a stark reminder of how quickly infectious disease can spread in our era of fast and frequent worldwide travel. Furthermore, it reawakened interest in and debate about major ethical, policy, political and social issues that arise as societies respond to such acute threats to health, life and liberty. Current concerns about the threat of avian influenza, due to the H5N1 virus, and its potential to evolve into a worldwide pandemic highlight the urgent need to address these issues.

Public policy making in organ transplantation

Rationing is a controversial and confusing concept. Nevertheless, for almost 15 years, the federal government has successfully, and up until recently with relatively little public controversy, rationed organs for transplant. The National Organ Transplant Act of 1984 and subsequent acts and regulations established a centrally guided, explicit rationing policy for organ transplants. As one of the few examples of explicit government rationing of life-saving health services, it is worthy of study in its own right. Some have suggested that our national organ transplant policy serves as a model for national health care reform (Benjamin et al., 1994). Rettig (1989), who has chronicled the evolution of the federal end-stage renal disease (ESRD) program, divides transplantation policy into three different areas: