Beta blocker treatment following acute myocardial infarction: an effective but underutilized intervention.

For the past six years, the Arkansas Foundation for Medical Care, Inc. (AFMC), Health Care Quality Improvement Program (HCQIP), has focused primarily on inpatient projects. In 1996, we began expanding project information to include outpatient issues. Earlier ambulatory topics included management of thyroid disease, diabetes and flu immunization. This AFMC project focuses on the prevalence of facility resources to manage hypertension and asthma as part of quality improvement efforts for Medicare and Medicaid patients in Arkansas. AFMC understands that outpatient facilities frequently lack an infrastructure to conduct outpatient chart audits in an efficient and effective fashion. This difficulty in data acquisition reflects a significant barrier. Nevertheless, certain processes and structural elements can be assessed to improve management of common outpatient conditions.

Antenatal corticosteroids for the prevention of neonatal respiratory distress in a predominantly rural state Medicaid population.

OBJECTIVE: To examine the use of prenatal intramuscular steroids in a community setting as outlined in National Institutes of Health (NIH) guidelines to reduce respiratory distress syndrome in premature infants. METHODS: We performed a complete chart review for 1 year of deliveries to Medicaid mothers at 25-34 weeks' gestation at all obstetric units in Arkansas, analyzing time of arrival to the hospital, time of delivery, and dosage, and route of steroid administration to compare processes between community and teaching center sites, and general performance with NIH guidelines. RESULTS: Of 191 deliveries at 25-34 weeks' gestation, 63.4% of mothers received at least one dose of corticosteroids before delivery. Only 124 (65%) of these mothers presented to the hospital more than 4 hours before delivery and 87% of these mothers received at least one dose of corticosteroids before delivery. Ninety percent of women who were transferred after presenting in labor and 94.9% of women who delivered at the tertiary care referral center received corticosteroids. There was no statistically significant difference in corticosteroid administration rates for women with or without preterm premature rupture of membranes. Many women received corticosteroids at dosages and intervals disparate with NIH guidelines. CONCLUSION: Obstetric providers in Arkansas administered antenatal steroids to Medicaid women in preterm labor at a rate higher than stated in previous literature. Delivery at a nonreferral center or within 4 hours of arrival to the hospital were associated with reduced antenatal corticosteroid administration. Improved performance efforts should target institutional usage and behavior of mothers at risk for premature delivery.

Laparoscopic cholecystectomy in the geriatric population.

OBJECTIVE: To assess effectiveness and conversion rates of inpatient laparoscopic cholecystectomy in older people living in the community. SETTING AND SUBJECTS: All acute care hospitals providing cholecystectomy in a single state. Medicare patients who underwent inpatient cholecystectomy in fiscal year 1994 in Arkansas. METHODS: A random sample comprising 449 of 2182 geriatric patients who underwent inpatient cholecystectomy in fiscal year 1994, stratified by hospital bed size, had charts reviewed for type of cholecystectomy performed, occurrence of conversion from a laparoscopic to an open cholecystectomy, surgical complications, and need for transfusion. RESULTS: Eighty-two percent of nonincidental cholecystectomies were initially laparoscopic. Total conversion rate for all inpatient laparoscopic cases was 20%. Forty-two percent of this group suffered acute cholecystitis with male patients exhibiting a higher rate of acute cholecystitis than female patients. Conversion rates for elective cholecystectomy for both sexes was between 13 and 14%. Conversion rate to an open procedures was 28% for patients with acute disease, with male patients again having a higher rate than female patients (40% vs 19%, P < .001). Surgical complications and intraoperative transfusions were rare. Conversion rates did not vary between large and small hospitals or among different age groups within the older population. CONCLUSIONS: Inpatient laparoscopic cholecystectomy is common in older people both for acute and chronic gallbladder conditions. Conversion rates ranged from 13% for elective cholecystectomy to 28% for acute disease. These rates are higher than published literature, which focuses on younger populations undergoing elective procedures. Audit committees need to be aware of this higher conversion rate in older people when assessing surgical proficiency.

The cooperative cardiovascular project an AFMC special report.

Patients who suffer myocardial infarction can have improved outcomes if the following elements are part of their treatment plans: 1. Rapid diagnosis of the condition. 2. Use of thrombolytics or angioplasty early in the presentation, if appropriate. 3. Use of aspirin early in the course of care. 4. Discharge medications of aspirin and beta blockade, in appropriately selected patients. 5. Documentation of efforts to counsel the patient to quit smoking. The above material outlines the key indicators in the national project to improve care for heart attack victims. Hospitals should assess the diagnosis, immediate care, and long-term management of patients with this condition. Patients have a variety of comorbidities and do not always fit into a simplified therapeutic scheme. Nevertheless, the care of myocardial infarction victims in the pilot CCP states demonstrated that a sizable number of these patients could benefit from a more focused approach to the above therapeutic interventions.

Assessment of HCFA's 1992 Medicare hospital information report of mortality following admission for hip arthroplasty.

OBJECTIVE: The Health Care Financing Administration (HCFA) produced annually from 1987 through 1994 mortality data information as part of the Medicare Hospital Information Project (MHIP) report. We assessed the validity of these data for hip arthroplasty for one state Medicare population and we analyzed the accuracy of the predictions derived from the Bailey-Makeham mortality model for this procedure. DATA SOURCES AND STUDY SETTING: The study sample consisted of claims and model data from 1,421 Medicare patients who underwent hip arthroplasty at acute care Arkansas hospitals from October 1990 through September 1991. STUDY DESIGN: Patients were stratified into two groups based on reason for surgery (fracture status): reconstruction or fracture management. Patient survival experience was compared between the two groups. The effect of fracture status on the HCFA model's predictive ability was examined empirically and via a simulation study. RESULTS: Our results indicate that hip arthroplasty patients are not uniform with regard to outcome, depending on the reason for the surgery. Patients with fracture had a much higher 30-day mortality rate than those who underwent reconstruction (p < .001). The empirical data and the simulation study suggest that the Bailey-Makeham model underestimates mortality for reconstructive surgery in fracture patients, providing a false benchmark for those institutions that perform hip arthroplasty on predominantly one category of patients. CONCLUSION: Published HCFA data concerning mortality for hip arthroplasty combines two different patient populations into one statistic. Casual examination of these data could result in a false benchmark for analysis of institutional performance. An important implication from this study for policymakers who base decisions on "report cards" or performance measurement reports is that, although they are necessary,generic case-mix, comorbidity, and severity of illness adjustments may not be sufficient to achieve accurate representations of outcomes, and that more disease/procedure--specific adjustments may be needed to avoid inappropriate conclusions.

The relationship of episiotomy to third and fourth degree lacerations.

Third and fourth degree lacerations can produce significant long term morbidity to women undergoing childbirth. The incidence of third and fourth degree lacerations is variable depending on the institution and the obstetrical provider. While episiotomy remains a valuable intervention in selected cases, an improvement program directed at lowering the use of episiotomy can reduce the incidence of this clinical event. Hospitals and physicians with higher rates of third and fourth degree tears should examine the use of episiotomy, and midline episiotomy in particular, which is associated with an increased incidence of third and fourth degree tears.

Health care report cards. Validity of case definitions.

Administrative databases are increasingly being used to construct health care report cards. We analyzed information from one of the original report cards, the Medicare Hospital Information Project. Assessment of mortality statistics for three clinical entities--coronary artery bypass surgery, hip reconstruction, and treatment of sepsis--demonstrated widespread outcome variances that reflected imperfect definitions rather than performance issues in clinical care. The use of administrative data sets to design report cards requires clinical expertise to ensure validity of the data. Designers of report card measures should share preliminary data with providers to enable feedback in methods and uncover definitional and validity concerns before widespread dissemination.