Measuring the quality of clinical performance with hernia and myocardial infarction patients, controlling for patient risks.

This article describes a method for measuring the performance of clinicians treating patients with unilateral inguinal hernia or myocardial infarction. The scoring was based upon the percentage of occasions when appropriate education was given and acute conditions resolved in accordance with clinical expectations. The method was applied to patients of general surgical and general medical firms at two London teaching hospitals in 1972 and 1975. Scores for samples of each diagnosis correlated significantly with subjective evaluations of care by clinicians. Multiple regression was used to identify and weight the patient risk factors (physiological and demographic) significantly associated with lower scores in each disease. Score of patients with these risks were adjusted upward to compensate for the difficulty of achieving good clinical results when these risks were present. Comparison of firms was based upon adjusted scores. Being older and being single, widowed or divorced were significant in both diseases. High blood pressure and anemia were also significantly associated with lower scores for hernia patients, as were the number of cigarettes smoked for infarction patients. The range of scores was wide in surgical firms in both years. While relatively narrow in the medical firms, scores suggest that there is still scope for improvement in some firms. The authors discuss a plan for using these data to arrive at score standards for each disease which could be used to screen clinical care routinely.

The effect of problem-oriented medical records on clinical management controlled for patient risks.

This study examines the change in clinical management by 28 medical and surgical firms in three London teaching hospitals following the introduction of Problem-Oriented Medical Records (POMR) in one of the hospitals. Comparison is made between firms using and not using POMR. The data are analyzed using a regression model. Analysis is based on the coefficient of change in each firm between the two study years when modified by the physiological and demographic patient variables significantly associated with the management of each disease. Although not conclusive, the results in four of the seven diseases studied encourage the speculation that POMR may have improved the thoroughness of patient management. The significant patient variables in each diagnosis suggest that patient risk on admission can affect management scores. Were this to be found elsewhere, the influences of patient mix might be considered in using explicit criteria to make comparisons between hospitals that serve different kinds of populations.

Firm, patient, and process variables associated with length of stay in four diseases.

Factors associated with length of stay in three London teaching hospitals during 1972 and 1975 were examined in patients treated for myocardial infarction, cerebrovascular disease, inguinal hernia without obstruction, and gall stones. Statistical analyses were carried out with multiple regressions on log lengths of stay.Increased length of stay was associated with infection in all four groups and with the seriousness of operative procedures in all but patients with cerebrovascular disease. Although age was a significant variable in patients with hernias and gall stones, it had relatively little practical effect on length of stay. Other significant variables in at least one disease were obesity, number of abnormalities in blood chemistry, administration of parenteral fluids or oxygen, or use of monitoring devices, and whether chest radiography was carried out, blood electrolytes and urea were measured, or anticoagulants were used. Patients with cerebrovascular disease who were not discharged to their own homes stayed on average more than two and a half times longer than other patients.Between a third and a half of the variance was explained by these variables and the variation among firms. The method described is reproducible in other hospital settings, and the study shows that much new information could be available routinely without mounting expensive field trials.

Communication as a method of medical audit.

Advances in the practice of medicine over the past forty years have rendered informal communication ineffective in setting and maintaining standards of clinical care. In the past five years, four methods in communication have been introduced in the department of surgery at Guy's Hospital: problem-oriented medical records, death-and-complications meetings, unit review meetings, and a clinical information service. It is suggested that these can achieve quality control.