Richard N. Winickoff

Quality Assurance through Automated Monitoring and Concurrent Feedback Using a Computer-Based Medical Information System

A computer-based medical information system (COSTAR) has been used to support a quality assurance program where the data collection is an integral part of the patient care recording activity and, therefore, does not require a separate abstracting or encoding process. This program utilizes concurrent audit to detect deficiencies in patient care, and automatic rapid feedback to the responsible provider in time to allow the provider to correct the deficiency. This system has been demonstrated to improve follow-up of throat cultures, positive for Group A Beta hemolytic streptococcus. It is well accepted by the medical staff whose practice is being audited. Because the data are collected as part of the routine operation of COSTAR, the computer monitoring and feedback have only a small incremental cost.

Improving Physician Performance Through Peer Comparison Feedback

A project to improve physician performance in colorectal cancer screening was evaluated as part of an ambulatory quality assurance program. A minimum standard was adopted requiring a digital examination and stool test for occult blood at annual check-ups of patients aged 40 years and older. During a 3½-year period, three different intervention strategies for improved compliance with the standard were sequentially implemented and assessed: educational meeting, retrospective feedback of group compliance rate, and retrospective feedback of individual compliance rate compared with that of peers. A pretest/posttest design was employed in evaluating the first two intervention strategies. Neither strategy resulted in significant improvement in compliance. Monthly feedback of individual performance ranked with that of peers was then implemented in a randomized clinical trial utilizing a crossover design. During the first 6-month period, the physicians receiving feedback (group 1) improved from 66.0% to 79.9% (P <0.001), while the control group (group 2) also improved, from 67.5% to 76.6% (P <0.001), suggesting a spillover effect. During the second 6-month period, group 2 received feedback and group 1 did not. Group 1 stabilized at approximately 80% while group 2 continued to improve from 76.6% to 84.0% (P <0.001). Behavior changes persisted at 6 and 12 months after intervention.

A Computer-Based Monitoring System for Follow-Up of Elevated Blood Pressure

An automated surveillance system utilizing a computer-based medical record system (COSTAR) was designed to improve the follow-up of patients with newly identified elevated diastolic blood pressure. A population of patients was selected where, in the 6-month period following the initial measurement of an elevated diastolic blood pressure, there were fewer than two visits during which blood pressure was recorded. In a randomized controlled clinical trial, this poor follow-up population was divided into two groups, with computer-generated reminders being automatically generated for only patients in the experimental group. Follow-up was significantly improved in the group receiving the reminders, both in terms of rate of follow-up attempted or achieved by the responsible physician and in the repeated recording of blood pressure. We conclude that a computer-based reminder system improves follow-up of newly discovered elevation in diastolic blood pressure.

The prediction of streptococcal pharyngitis in adults

The usefulness of clinical and laboratory findings for prediction of the presence of Group A streptococci on throat culture and of an increase in antistreptococcal antibodies was investigated in 693 adult patients. Several findings were shown to increase the likelihood of streptococcal isolation, alone and in combination: tonsillar exudate, tonsillar enlargement, tender anterior cervical adenopathy, myalgias, and a positive throat culture in the preceding year. Compared with a frequency of 9.7% in all patients, the probabilities of a positive culture were quite different (ranging from 2 to 53%) in subgroups of patients with different combinations of these clinical findings. The results of a leukocyte count and measurement of C-reactive protein added little additional predictive information. While clinical findings can never predict perfectly the results of a throat culture, they nevertheless can provide useful information — particularly in tending to “rule out” streptococcal infection — in adult patients with pharyngitis.

Familial calcification of the basal ganglions: a metabolic and genetic study.

Abstract A metabolic and genetic study of familial basal-ganglion calcification was undertaken after a kindred with five affected members was identified. Three of five patients were investigated wi...

A Comparison of the Quality of Maternity Care between a Health-Maintenance Organization and Fee-for-Service Practices

An intense controversy surrounds the promotion of the health-maintenance organization (HMO) as an alternative to the traditional fee-for-service (FFS) system of medical care. Advocates of HMOs beli...

Limitations of provider interventions in hypertension quality assurance.

In an institutional quality assurance program in hypertension, performance of tests, control of blood pressure, and follow-up were monitored through a computer program that was developed to audit records in an automated record system. Two types of feedback previously shown to be effective were provided quarterly for a period of one year to experimental providers. For all hypertensives considered together, there were no differences between scores of Experimental and Control providers based on percentage of patients meeting pre-set criteria in testing--87% vs 87%--, blood pressure control--58% vs 59%--, or follow-up--79% vs 77%. Only small but significant differences occurred in the subgroup of moderate to severe hypertensives. There appear to be limitations to what can be accomplished through hypertension quality assurance interventions directed at providers of care in this institutional setting. Interventions designed to deal directly with patients whose blood pressures are uncontrolled may be more effective.

Urinary excretion of 3',5'-AMP in syndromes considered refractory to parathyroid hormone.

Abstract Earlier studies showed that parathyroid hormone increases the urinary excretion of cyclic 3′,5′-AMP in normal subjects; patients with pseudohypoparathyroidism showed little or no response. In the current investigation this response to parathyroid hormone was examined in several apparently unrelated syndromes previously characterized as resistant to the hormone in tests for phosphaturia. The disorders studied included the basal cell nevus syndrome (BCN), Gardners syndrome (GS), vitamin D-resistant osteomalacia (DRO), and the syndrome of basal ganglia calcification (BGC). Urine was collected on two successive mornings and 180 USP units of purified bovine parathyroid hormone were infused between 9 and 9:15 a.m. on day 2. During the control day (Day 1) normal volunteers showed average excretion of 3′,5′-AMP of 3.90 nmoles/mg. creatinine (range 2.4–5.4). Baseline excretion for patients averaged 2.90 (BCN), 5.19 (GS), 5.30 (DRO), and 5.27 (BGC) nmoles of 3′,5′-AMP/mg. creatinine. Base-line excretion rates for patients with GS, DRO, and BGC were significantly greater than normal. This finding possibly reflects secondary hyperparathyroidism in DRO but remains unexplained in GS and BGC. Infusion of hormone into normal subjects caused an increase to 23.7 nmoles of 3′,5′-AMP/mg. creatinine (range 13–42). The responses to the hormone for the patient groups were 32 (BCN), 48 (GS), 56.1 (DRO), and 47.4 (BGC) nmoles of 3′,5′-AMP/mg. creatinine. These results were within the limits of normal. There were wide fluctuations in phosphate excretion from day-to-day as well as hour-to-hour in all groups. These variations obscured the phosphaturic response in the normal subjects and in patients with Gardners syndrome, vitamin D-resistant osteomalacia and the family with calcification of the basal ganglia. The basal cell nevus syndrome showed a significant phosphaturic response to the hormone. These results confirm previous conclusions that the phosphaturic response is not sufficiently reliable to categorize a syndrome as refractory to PTH. On the other hand, the rate of excretion of 3′,5′-AMP shows less variation and the response provides more valid discrimination between normal subjects and those refractory to the hormone. Thus, the current studies show that several syndromes previously described as resistant to parathyroid hormone indeed respond normally.

Appropriateness of Short-Stay Admissions for Procedures In Six Veterans Affairs Hospitals

Admissions records were reviewed for six acute care Veterans Affairs Medical Centers (VAMCs) in New England to determine appropriateness of short-stay admissions (two days or less) in fiscal years 1986 and 1987 for certain medical and surgical procedures. Results indicated that such admissions accounted for 18,588 (22%) of a total of 84,266 admissions for the six hospitals; of these admissions, 4,362 were for procedures commonly performed on an outpatient basis. Criteria developed by a peer review board of physicians was applied to a sample of 728 (16.7%) of the 4,362 short-stay admissions for these procedures; 190 (26.1%) admissions from this sample were found to be inappropriate. Inappropriateness rates (9.1% to 46.1%), as well as the number and type of procedures, varied among the six VAMCs. Some VAMCs may be able to improve efficiency by performing more procedures on an outpatient basis.

Semiautomated reminder system for improving syphilis management

This project utilized an automated record system, COSTAR, to assess and improve the quality of care in managing syphilis in a health maintenance organization. A scoring tool was developed to assess care. There were four experimental periods, each lasting one year. The periods were Baseline (no intervention), Education (publication of guidelines and an educational session), Reminder (deficiencies in care brought to the attention of providers in time to permit correction), and Post-reminder (no intervention). Scores for overall management of syphilis rose from 70.4 to 90.5% during the Reminder period and did not deteriorate significantly in the Post-reminder period. Scores in the Education period were not significantly higher than baseline. The cost of the system was