The increase in angiotensin type-2 receptor mRNA level by glutamate stimulation in cultured rat cortical cells

Advanced practice nurses are challenged to assess comprehensively the value of their role and the impact of their practice. Value is defined as quality divided by cost. The correlations among the structure, strategies of care (process), and their objectives (outcome) are key to the assessment of the quality of care and the impact of the advanced practice nurse's role. Advanced practice nurses are challenged to provide high quality care for a competitive or decreased cost. For the profession of nursing, outcomes are the result of interventions based on the nurse's clinical judgment and theoretical, practical, or scientific knowledge. An evaluation model is presented that comprehensively measures the impact of advanced practice nurses on patients and families, and an example is presented. Using the model will give credibility and validity to the APNs' positive impact on the quality and financial outcomes of care for each patient and for entire patient populations.     

The primary care network--a new type of HMO for private practice physicians

A new type of health maintenance organization has been developed to encourage primary care physicians in private practice to become coordinators and financial managers for all medical care. Each patient chooses one internist, family or general physician, or pediatrician and must be referred by that physician for all hospital admissions and care by specialists. The primary care physician authorizes all payments from his own account for care provided to his patients. He shares any deficit or surplus remaining at the end of the year. Hospital admission rates and length of stay are lower than those of Blue Cross, with only one of three dollars paid to hospitals. The plan is providing care to 38,000 persons with 750 participating physicians in Northern California, Washington and Utah. This plan represents an attempt by physicians to control costs without government regulation.     

ClinCare: improving vascular outcomes through clinical care coordination

In the current health care environment, increasing emphasis is being placed on the quality and financial outcomes of care by both consumers and third party payors. The ClinCare (registered service mark of Jewish Hospital, Louisville, Ky) program uses an interdisciplinary approach and data-driven decision making to improve the clinical management of specific high-risk patient populations across the continuum of care. The experience of the Vascular and Thoracic Surgery Clinical Practice Team is discussed with emphasis on clinical and financial outcomes.     

Factors determining the quality of physician performance in patient care

The study determined the separate and joint effects of 1) physician specialty, 2) type of medical school attended, 3) time in practice, 4) type of ambulatory care setting, and 5) type of hospital on the quality of physician performance in patient care. The sample consisted of 454 physicians in 18 specialty categories. Multiple Classification Analysis was used to determine the effects of these predictors on the quality of physician performance. The study found that the organization of hospital care had a large independent effect, but that the other four predictors had relatively small effects on the quality of physician performance. The findings imply that the organization of the setting in which care is provided has more influence than the education and training that physicians had attained. All five predictors together explained 20 per cent of the variance. Methodological suggestions were made to improve the explanatory power of the variables, and various pragmatic for medical care administrators were presented.     

Making a transition from quality assurance to quality improvement

Health care leaders now recognize the importance of adding continuous quality improvement activities and the measurement of clinical outcomes to their longstanding quality programs. From other industry leaders, they have learned that there is great promise on quality/cost returns when quality programs focus on measuring performance outcomes rather than just using the longstanding process of measuring variation in staff and system capacity processes. The purpose of this article is to describe how one urban acute care hospital is taking steps to change its quality paradigm and therefore change its quality program, which until recently consisted largely of unrelated quality assurance activities and projects. The new system will be a truly coordinated hospital wide continuous quality improvement program that will align quality activities with the mission of the organization and focus on the measurement of outcomes.     

Assessing the quality of psychiatric hospital care: a German approach

OBJECTIVE: The German Ministry of Health commissioned a nonprofit organization to develop a tool for assessing the quality of psychiatric hospital care. METHODS: The authors were members of an expert group established to develop an assessment tool that could be used by professional caregivers, patients, patients' relatives, managers, purchasers, and mental health care planners. RESULTS: A three-dimensional model was developed in which 23 quality standards may be applied to 28 areas of practice. For each application, questions can be asked at four levels to stimulate ongoing quality management: the individual treatment process, the individual outcome, the treatment unit, and the hospital as a whole. The authors provide sample questions to illustrate the approach. CONCLUSIONS: The approach to quality assessment embodied in the model is comprehensive and addresses ethical issues, but it is also complicated and difficult to handle. Unlike models developed in the United States, it is not intended to be objective or standardized, and it does not yield a score. To some extent, the model's approach to assessment may reflect German cultural values and traditions.     

Ambulatory visits to hospital emergency departments. Patterns and reasons for use. 24 Hours in the ED Study Group

OBJECTIVES: To characterize the reasons ambulatory patients use hospital emergency departments (EDs) for outpatient care and to determine the proportion of ED patients who initially are assessed as having nonurgent conditions, but subsequently are hospitalized. DESIGN: Cross-sectional survey during a single 24-hour period of time. SETTING: Fifty-six hospital EDs nationwide. PATIENTS OR OTHER PARTICIPANTS: Consecutive ambulatory patients presenting for care. Patents who arrived by ambulance were excluded. RESULTS: Of 6441 ambulatory patients (79 percent of all ED visits) who were eligible for study, interviews were obtained from 6187 (96 percent). A total of 5323 patients (86 percent) had clinical reasons or preferences for seeking care at an ED, including 2799 (45 percent) who thought they had an emergency or an urgent condition or were too sick to go elsewhere. Nineteen percent (n=1199) reported that they were sent to the ED by a health care professional. Patients with a regular clinician or with insurance cited similar reasons for seeking care at an ED. A total of 3062 patients (50 percent) cited 1 or more nonfinancial barriers to care as an important reason for coming to the ED, and 949 (15 percent) cited financial considerations. A total of 3045 patents (49 percent of ambulatory patients and 37 percent of total ED visits) were assessed at triage as having a nonurgent condition; 166 of them (5.5 percent; 95 percent confidence interval, 4.7 percent-6.3 percent) were admitted to the hospital. CONCLUSIONS: Most ambulatory patients seek care in an ED because of worrisome symptoms or nonfinancial barriers to care. Although many ambulatory patients appear to have nonurgent conditions based on triage classification, a small but disturbing percentage of nonurgent patients are hospitalized.     

Nonspecific resistance in patients with chronic gastritis undergoing treatment by drinking a calcium-sodium chloride low-mineralized mineral water

A Diabetes Care Management program was developed by PrimeCare, a network model HMO, to improve quality of life health outcomes and reduce the costs of medical care for its members with diabetes. The HMO used a systems-based approach to communicate information about appropriate self-management and standards of care to members and physicians. The focus of the program was to educate and encourage patients to self-manage their illness, and to partner with physicians, other health care providers and community organizations to achieve improved quality of life, clinical and financial results. Clinical process indicators were used to measure results of interventions. Significant increases in the percentage of participants receiving glycosylated hemoglobin (HbA1c) tests, retinal eye exams and lipid panel tests were achieved.     

Performance improvement integration: a whole systems approach

Performance improvement integration in health care organizations is a challenge for health care leaders. Required for accreditation by the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission), performance improvement (PI) can be designed as a sustainable model for performance to survive in a turbulent period. Central Baptist Hospital developed a model for PI that focused on strategy established by the leadership team, delineated responsibility through the organizational structure of shared governance, and accountability for outcomes evidenced through the organization's profitability. Such an approach integrated into the culture of the organization can produce positive financial margins, positive customer satisfaction, and commendations from the Joint Commission.     

Influence of patient age and co-morbidity on outcome of a collaborative care pathway after radical prostatectomy and cystoprostatectomy

PURPOSE: We determined whether standardized care patterns developed with a collaborative care methodology can be applied successfully across all patient groups with favorable effects on cost and quality. MATERIALS AND METHODS: We retrospectively analyzed financial and clinical outcomes in 109 radical retropubic prostatectomy and 47 radical cystectomy cases. Patients older than 70 years and/or with an American Society of Anethesiology status of 3 or greater were compared to younger, healthier patients undergoing these procedures. RESULTS: Standardized care patterns resulted in favorable financial and clinical outcomes in high and low risk patient groups. The only apparent difference was an increased need for rehospitalization after discharge for patients undergoing radical prostatectomy with a high American Society of Anesthesiology status. CONCLUSIONS: Standardized care patterns developed with a collaborative care methodology provide a high quality, cost-efficient approach to medical care. This methodology is applicable to all patient groups and is highly compatible with current medical practice.     

Quality assurance from the viewpoint of medical management by health insurance

Legal requirements of SGB V make provisions for quality assurance (QA) activities in relation to inpatient and outpatient care. Available contracts between health providers and institutions covering costs presently regulate QA in three distinct areas in surgery: inpatient and outpatient care, Fallpauschale (fee for case) and Sonderentgelte (fee for service), and out-patient surgical treatment. MDK as a medical counselling and review agency working on behalf of health insurance companies has a more or less well defined role in the organization (board membership) and actual work (evaluation and probing) of external QA. Its participation and competence derive from legal authorization (SGB V) and hence from its given assignments: review of indication, economical aspects and quality of services provided--each on a single case basis and on a more general basis, nursing care, hospital budgets and finally planning capacity for hospital care.     

Evaluation of the hospital management of insulin-dependent diabetics

OBJECTIVE: There is a known relationship between blood glucose control and development or progression of complications in diabetes mellitus. The aim of our study was to assess the quality of hospital care in patients with insulin-dependent diabetes. PATIENTS AND METHODS: A prospective study was conducted over a 6-month period (April 95-September 95) to perform a clinical audit comparing results obtained with care standards. The study group included 257 consecutive patients (age range 15-39 years) who consulted the hospital outpatient clinic of were hospitalized for insulin-dependent diabetes mellitus RESULTS: Results differed depending on the care standards used for comparison. There were 45 patients (17%) who consulted 4 times or more; 43% of the patients were not hospitalized and 32% did not had a fundus examination during the preceding year. There was a 51% deviation from the standard number of capillary blood glucose measurements and 72% of the patients stated they adapted their insulin dose. Mean glycosylated hemoglobin level (HPLC method) was 9.78 +/- 2.37% (standard = 7%). CONCLUSION: This assessment of hospital care demonstrated a deviation of medical surveillance from standard care. More frequent consultations would help improve patient information. It is important to recall that an annual hospitalization and rigorous application of clinical surveillance with annual fundus examination are essential. Information provided by physicians, nurses and dietitians should be an integral part of hospital care. Likewise, it is undoubtedly useful to provide psychological counselling for diabetic patients. A reassessment should evaluate the impact of such recommendations in order to determine the impact, in terms of reduced mortality, of improved hospital care.     

Improving functional outcomes in older patients: lessons from an acute care for elders unit

BACKGROUND: Hospitalization often marks the beginning, and may be partially responsible for, a downward trajectory characterized by declining function, worsening quality of life, placement in a long term care facility, and death. At the University Hospitals of Cleveland, an Acute Care for Elders (ACE) unit that reengineered the process of caring for older patients (> or = 70 years of age) to improve functional outcomes was established in September 1990. DESCRIPTION OF INTERVENTION: The general principles of ACE included an approach to care guided by the biopsychosocial model and recognition of the importance of fitting the hospital environment to the patient's needs. The design of the intervention was consistent with principles of comprehensive geriatric assessment and continuous quality improvement. Care, which focused on maintaining function, was directed by an interdisciplinary team that considered the patient's needs both at home and in the hospital. The major components of the ACE Unit intervention included patient-centered nursing care (daily assessment of functional needs by nursing, nursing-based protocols to improve outcomes, daily rounds by a multidisciplinary team), a prepared environment, planning for discharge, and medical care review. RESULTS: In a randomized trial comparing ACE with usual care, patients receiving ACE had improved functional outcomes at discharge. The costs to the hospital for ACE unit care were less than for usual care. The functional status of ACE and usual care patients was similar 90 days after discharge. FUTURE DIRECTIONS: The ACE unit intervention is being expanded to preserve the improvements observed during the hospitalization in the outpatient setting. In addition, needs other than function which are critical to patients' long-term quality of life are being considered.     

Reactive oxygen species in human semen: investigations and measurements

OBJECTIVES: The introduction of the Medicare Prospective Payment System and the more recent rise of managed care plans have greatly increased the importance of effective hospital financial management. Because physicians play a central role in directing hospital resource use, policies to influence physician behavior and to align physician and hospital interests more effectively are being advocated increasingly. This article evaluates the effect of nine strategies to facilitate physician involvement and integration into the hospital on hospital financial performance. METHODS: Data came primarily from the Prospective Payment Assessment Commission's hospital-physician relations survey of 1,485 hospitals and the Medicare Cost Reports. Both ordinary least squares and first differencing models were used to evaluate the effect of physician integration on hospital financial performance. RESULTS: Hospitals with lower margins and higher costs were more likely to have implemented strategies to integrate physicians and to modify physician behavior than their counterparts. Analysis using first differencing models indicated that making department heads responsible for the profits and losses had a significant positive effect on margins, whereas including medical staff on the hospital's board and offering physicians management services had a significant negative impact on average Medicare costs. In addition the number of strategies implemented was associated positively with financial performance. The paper also emphasizes the importance of model specification in evaluations of hospital-physician arrangements. CONCLUSIONS: Changes in hospital-physician relations may have been one reason why hospitals have been relatively successful at containing costs and retaining profitability in recent years. More research needs to be done on which specific arrangements affect hospital financial performance, as well as their effect on the quality of patient care.     

Measuring and evaluating hospital restructuring efforts. Eighteen-month follow-up and extension to critical care, Part 1

Increasingly, hospital restructuring is viewed with skepticism because of a lack of systematic and rigorous evaluation of its impact on quality of care. This first article in a two-part series describes comprehensive evaluation of the effects of hospital restructuring on patient satisfaction, nurse satisfaction, costs of care, and clinical quality on four medical-surgical units at a large tertiary hospital. In addition, early application of the model to critical care is described. A quasiexperimental pre- and post-design combined with concurrent control units for selected measures was the overall strategy. The authors conclude that comprehensive restructuring of hospital-based care can take place in a manner that preserves multiple dimensions of quality while decreasing costs. This only can be ascertained, however, through rigorous and systematic measurement and evaluation. Part 2 will detail application and evaluation of the restructuring model in the critical care environment.     

Safety of dipyridamole testing in 73,806 patients: the Multicenter Dipyridamole Safety Study

Use of the acute hospital has markedly decreased over the past four decades for various reasons: the decentralization of diagnostic treatment technologies to out-of-hospital sites; the clinical substitutions of quick diagnostic testing of the ambulatory patient for the longer diagnostic testing of the hospitalized patient; the diminished use of hospital bed rest and the expanded use of exercise for treatment; the corporate organization of hospital work that emphasizes efficiency; and the group practice organization of generalists and specialists that avoids hospital use for the diagnosis of complex disorders in ambulatory patients. A smaller domain for hospital bed care and renewed attention to chronic disease and prevention in the community diminish the hold of the acute hospital on care. The evolution of more collaborative, decentralized arrangements promises to be a positive development for community care.     

Is gatekeeping better than traditional care? A survey of physicians' attitudes

CONTEXT: Nearly all managed care plans rely on a physician "gatekeeper" to control use of specialty, hospital, and other expensive services. Gatekeeping is intended to reduce costs while maintaining or improving quality of care by increasing coordination and prevention and reducing duplicative or inappropriate care. Whether gatekeeping achieves these goals remains largely unproven. OBJECTIVE: To assess physicians' attitudes about the effects of gatekeeping compared with traditional care on administrative work, quality of patient care, appropriateness of resource use, and cost. DESIGN: Cross-sectional survey of primary care physicians SETTING: Outpatient facilities in metropolitan Boston, Mass. PARTICIPANTS: All physicians who served as both primary care gatekeepers and traditional Blue Cross/Blue Shield providers for the employees of Massachusetts General Hospital, Boston. Of the 330 physicians surveyed, 202 (61%) responded. OUTCOMES MEASURES: Physician ratings of the effects of gatekeeping on 21 aspects of care, including administrative work, physician-patient interactions, decision making, appropriateness of resource use, cost, and quality of care. RESULTS: Physicians reported that gatekeeping (compared with traditional care) had a positive effect on control of costs, frequency, and appropriateness of preventive services and knowledge of a patient's overall care (P<.001). They also felt that gatekeeping increased paperwork and telephone calls and negatively affected the overall quality of care, access to specialists, ability to order expensive tests and procedures, freedom in clinical decisions, time spent with patients, physician-patient relationships, and appropriate use of hospitalizations and laboratory tests (P<.001). Overall, 32% of physicians rated gatekeeping as better than traditional care, 40% the same, 21% gatekeeping as worse, and 7% were of mixed opinion. Positive ratings of gatekeeping were associated with fewer years in clinical practice, generalist training, and experience with gatekeeping and health maintenance organization plans. CONCLUSIONS: Physicians identified both positive and negative effects of gate-keeping. Overall, 72% of physicians thought gatekeeping was better than or comparable to traditional care arrangements.     

The media vs managed health care: are we seeing a full court press?

BACKGROUND: Despite the fact that medical coverage for many Americans is shifting rapidly from traditional insurance to managed care, studies suggest that most citizens have limited knowledge or understanding of the implication of this change. OBJECTIVE: To evaluate the predominant message being portrayed by the lay press on managed care. METHODS: We conducted a review of newspaper articles dealing with managed care from several leading national newspapers. Surveys, editorials, letters to the editor, or nonclinical articles were excluded. The articles were examined to evaluate their likely effect on the reader's willingness to join a managed care organization, and were scored using a standardized survey instrument. The final analysis included data from 85 articles from an original pool of 277. RESULTS: In only 8% of cases, the articles were considered likely to have had a positive influence on the reader and, thus, encourage them to join or remain with a managed care organization. More important, in fully two thirds of cases, we believed the articles portrayed so unfavorable a message that the reader was less likely to join, or might even decide to leave, a managed care organization. The articles dealt most frequently (67%) with patient concerns with managed care, focused mainly on cost and quality issues, and managed care representatives were the people whose opinions were most commonly (53%) solicited. CONCLUSIONS: It seems highly likely that public perception of managed health care will be influenced by the strongly negative representation being portrayed by the newspapers. While debate over the good vs bad features of managed care continues, available evidence suggests this form of health care coverage continues to grow. The press is likely to remain an important source by which information about managed care is transmitted to the public and will certainly influence public decision making on the issue. If the current negative representation continues, we may soon begin to see a widespread backlash of public opinion opposing this form of health care.     

Fibromatosis of the mandible: case report and review of previous publications

OBJECTIVE: This study investigated the clinical and financial impact of self-reported maternal drug history and documented intrauterine substance exposure on maternal-neonatal morbidity and hospital costs. STUDY DESIGN: This two-part, case-controlled, retrospective study used matching control groups. RESULTS: Among women reporting a history of substance abuse during or prior to the index pregnancy, (a) maternal hospital costs were significantly higher and more variable; (b) birth weight, length, and gestational age were lower; (c) no significant differences were noted in the number of maternal risk factors or neonatal complications and hospital costs. In comparison of neonates with positive toxicology screens and a matched control group, there were no differences in neonatal outcomes or costs, but the number of complicating maternal risk factors and maternal hospital costs were significantly different. CONCLUSION: Knowledge of maternal substance abuse history may be useful in planning for maternal-neonatal care needs and reimbursement for hospital care for this at-risk patient population.     

Management service organizations: effective strategy to assume and manage full risk agreements?

A management services organization (MSO) has emerged as one structure to manage professional and hospital risk agreements. Health plans and direct payers are transferring traditional functions to medical groups and health systems under these agreements. How does a hospital and affiliated medical group develop a strategy to assume, manage, and mutually benefit from these agreements? When do market forces dictate whether an MSO is the most appropriate organizational model to utilize? The development of an MSO can offer an effective organizational strategy to capture capitated contracts and assume responsibility for population-based medical services. This article explores the features of such an organization, areas for potential collaboration between the medical group and hospital, as well as the impact on patient care.