1995 Fast Track: cost reduction and improvement.

To respond to a cost reduction crisis, Strong Memorial Hospital implemented an aggressively managed program of accelerated improvement teams. "Fast-track" teams combined the application of many management tools (total quality management, breakthrough thinking, reengineering, etc.) into one problem-solving process. Teams and managers were charged to work on specific cost reduction strategies. Teams were given additional instruction on interpersonal skills such as communication, teamwork, and leadership. Paradoxically, quality improvement in our hospital was advanced more through this effort at cost reduction than had previously been done in the name of quality itself.

The appropriateness of coronary artery bypass graft surgery in academic medical centers. Working Group of the Appropriateness Project of the Academic Medical Center Consortium.

OBJECTIVE: To compare the appropriateness of use of coronary artery bypass graft (CABG) surgery in Academic Medical Center Consortium hospitals as judged 1) according to criteria developed by an expert panel, 2) according to revisions of those criteria made by cardiac surgeons from the Academic Medical Center Consortium, and 3) by review of cases by the surgeons responsible for those cases. DESIGN: Retrospective, randomized medical record review. SETTING: 12 Academic Medical Center Consortium hospitals. PATIENTS: Random sample of 1156 patients who had had isolated CABG surgery in 1990. MAIN OUTCOME MEASURES: 1) Percentage of patients with indications for which CABG surgery was classified as appropriate, Inappropriate, or of uncertain appropriateness and 2) percentage of cases in which CABG surgery was judged inappropriate or uncertain for which ratings changed after local case review. RESULTS: Data were retrieved from medical records by trained abstractors using an explicit data collection instrument. Cases in which CABG surgery was judged to be inappropriate or uncertain were individually reviewed by the responsible surgeons. According to the expert panel ratings, 83% of the CABG operations (95% CI, 81% to 85%) were necessary, 9% (CI, 8% to 10%) were appropriate, 7% (CI, 5% to 8%) were uncertain, and 1.6% (CI, 0.6% to 2.5%) were inappropriate. These rates are almost identical to those found in a previous study that was done in New York State and that used the same criteria (in that study, 91% of operations were classified as necessary or appropriate, 7% were classified as uncertain, and 2.4% were classified as inappropriate). Rates of inappropriate procedures varied from 0% to 5% among the 12 member hospitals (P = 0.02). The Academic Medical Center Consortium cardiac surgeons revised 568 (24%) of the indications used by the expert panel. However, because those revisions altered the appropriateness ratings in both directions and affected only 50 cases (4%), the net effect of the revisions was slight: The rate of inappropriate CABG surgery increased from 1.6% to 1.9%. Local review found that data collection errors had caused erroneous ratings in 12.5% of 64 cases in which surgery had been classified as inappropriate or uncertain. CONCLUSIONS: The Academic Medical Center Consortium hospitals had low rates of inappropriate and uncertain use of CABG surgery, regardless of the criteria used for assessment. Even though surgeons from the Consortium revised the appropriateness ratings extensively, their revisions had a negligible effect on the overall assessment of appropriateness. However, because of potential data collection errors, appropriateness criteria should be used for individual case audits only if supplemented by subsequent physician review.

Are hospital quality improvement and public accountability compatible?

BACKGROUND: The goals of public accountability and quality improvement are compatible in theory but not necessarily in practice. Both concepts emphasize the customer. However, those working toward these two goals design systems with quite different roles and relationships between the providers and consumers of health care. Superficial interactions obstruct meaningful dialogue about how to build a better system meeting both sets of goals. ISSUES: Current practices of public accountability and quality improvement have fundamentally different paradigms concerning the roles and responsibilities of those who provide and those who consume health care. CONCLUSIONS: There are at least three ways to improve the current relationship between public accountability and quality improvement. First, optimizing the design and performance of each effort would be an improvement since the goals are highly compatible. Neither ideal currently meets its own expectations, creating distrust among the proponents of each when reality falls short. Second, the two efforts could be coordinated through joint community-level planning and sharing. Finally and optimally, the two concepts could be made part of the same community-level cooperative system, an approach that offers the greatest opportunity for achieving shared goals.

Reporting tools for clinical quality improvement.

To support clinical quality improvement (QI), effective quality analysis tools are essential. New strategies that we have incorporated into our routine assessment activities include comparative screening, clinical process benchmarking tables, and run charts for key quality indicators. To target areas for improvement, we use comparative screening. We have access to clinical data for 11 comparable medical centers. Currently, these data are used to identify our ranking relative to the others for mortality, readmission, and length of stay. Diagnosis-related groups and ICD-9-CM clusters serve as clinical groupings with defined minimal case volume requirements to ensure meaningful comparisons. These comparative reports permit our clinical leaders and hospital administrators to focus QI activities. Clinical process benchmarking involves peer-to-peer interfacility communication to identify those factors that create outstanding clinical performance. We successfully have used this tool to support process improvement in cardiac-surgery, administration of patient controlled analgesia, and respiratory therapy. Interdisciplinary QI teams identify the key investigative questions. Team members then contact their counterparts at similar facilities, which differ from our hospital in quality, based on empirical evidence or through comparative screening. The information that is obtained is collated in a tabular format, along with our own information, to permit easy identification of key clinical processes associated with better outcomes. Key quality and utilization goals at our hospital include reducing unplanned readmissions by 10%, achieving a 5% lower average length of stay, and not exceeding Health Care Financing Administration expected mortality rates in any clinical area.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical evaluation of stenosis of the carotid bifurcation with magnetic resonance angiographic techniques.

We evaluated the images of 60 carotid artery bifurcations in 31 patients suspected to have carotid artery disease who underwent invasive carotid angiography and combined two-dimensional, phase-sensitive and a gradient-echo magnetic resonance angiography. The phase scans consisted of seven serial projections that were obtained at 20 degrees intervals (11.0 minutes) around the carotid bifurcation; the gradient-echo (GRASS) scans were composed of 11 axial images (2.4 minutes) acquired through the bifurcation. The two magnetic resonance angiographic techniques yielded complementary pieces of information and were used together to compare magnetic resonance angiography with invasive angiography. Comparison of magnetic resonance and invasive angiograms of the 60 carotid arteries shows that the sensitivity (86%) and specificity (92%) of the magnetic resonance angiographic techniques we used to diagnose clinically significant carotid stenosis approach but do not reach those of invasive angiography.

Evaluation of the carotid artery bifurcation: comparison of magnetic resonance angiography and digital subtraction arch aortography.

Thirty-four carotid artery bifurcations were examined using both magnetic resonance angiography (MRA) and digital subtraction arch aortography to determine their accuracy when compared to selective carotid angiography. The sensitivity of MRA was 73% and its specificity was 91% when compared with selective carotid angiography. The sensitivity of arch aortography was 27% and its specificity was 100%.

A hospital payment system with incentives for improvement in quality of care: first lessons.

A demonstration program of five member hospitals of the Rochester Area Hospitals Corporation in Rochester, New York, is introducing two major changes into traditional quality assurance programs in hospitals: (1) a shift of focus from structure and process to outcomes and (2) replacement of punitive approaches with a positive, reward-oriented approach. Relying on the MedisGroups information system to measure outcomes and on statistical techniques to identify variations in hospitals' performance, the demonstration offers financial awards in the form of a payment adjustment incorporated into the hospital reimbursement system, based on each hospital's outcomes compared to both an external and a local standard. The authors report the first experiences with the demonstration and the prospects for continuous improvement of quality of care.

Innovations in clinical practice through hospital-funded grants.

Improving patient outcomes while controlling the costs of care requires a partnership between clinical researchers and hospital management. To this end, Strong Memorial Hospital in Rochester, New York, dedicated hospital operating funds to a program of small grants designed to align the patient care and academic interests of clinicians with the goals of efficient hospital management. The grants gave clinicians an opportunity to test the efficacy of specific patient care maneuvers. These studies resulted in improved guidelines for the use of diagnostic and therapeutic modalities, new technology, and length of hospitalization. Annual marginal cost savings from implementing the first-year study results are projected to be $587,255, an 8 to 1 return on the first year's expenses. The authors conclude that a hospital-funded applied research program encourages those delivering patient care to identify inefficiencies and introduce change while ensuring quality patient care. This joint faculty-management effort can augment the hospital's quality-assurance, utilization management, and technology assessment programs while advancing the scholarship of faculty members.

Improving the utilization of screening mammography in primary care practices.

Screening mammography is underutilized in many primary care practices. We designed a prospective, controlled trial to evaluate two strategies for improving the utilization of mammography in an academic general medicine clinic. We assigned teams of house officers to (1) physician audit with periodic feedback, (2) a visit-based strategy directed at both patient and physician, or (3) a no intervention concurrent control arm. After 6 months, the percentage of 50- to 74-year-old women meeting the standard of an annual mammogram was 36% for patients in the control arm, 62% for patients of feedback residents, and 54% for patients of the arm receiving the visit-based strategy. Patients of female providers were slightly more likely to meet the standard, but no effects were detected for patient race, new as opposed to follow-up patient, or higher frequency of clinic visits. We conclude that audit with feedback and a new visit-based strategy of a patient cue associated with a simplification of the ordering process each greatly improved the rate of utilization of screening mammography. Practitioners could reasonably choose the strategy most suited to their own situation.

Quality of care during a community-wide experiment in prospective payment to hospitals.

To determine whether a community-wide experiment in hospital prospective payment adversely affected quality of care, availability and outcomes of care were studied in Rochester, NY from 1980 to 1984. During this 5-year period, prospective payment contained hospital expenditures in a community that was already below the national average in health-care costs. Access to necessary care was maintained, and there were increased admissions for management of maternal illness and acute myocardial infarction. Rates of inpatient elective surgery declined. Outcomes of care remained stable, including neonatal deaths, ischemic heart disease deaths, deaths from five selected surgical conditions, and rates of adverse outcomes from sentinel medical and surgical conditions. These results indicated that prospective payment programs in which incentives to decrease marginal or unneeded care are linked with a community-wide effort to plan for the delivery of services can be financially and clinically successful.

Workup bias in prediction research.

Studies often suggest that accepted clinical predictors actually have little predictive strength. One explanation for some such results is the presence of workup bias. To explore the effects of workup bias in prediction research, the authors modeled the effects of workup bias on the ability of early clinical findings to predict intracerebral hemorrhage in patients with stroke. In a simulated biased sample, workup bias resulted in distorted operating characteristics for those clinical findings influencing application of the "gold standard" and for other related findings. Sensitivity was increased, but both specificity and likelihood ratios were decreased in the biased sample. Workup bias can spuriously decrease predictive abilities for accepted clinical findings when such findings guide application of the "gold standard." Investigators should be aware of the potential effects of workup bias, search for clues to its occurrence, and interpret study results carefully when it is present.

Echocardiography, endocarditis, and clinical information bias.

Although clinical information provided to the interpreter of imaging tests may improve disease detection, it may also bias the interpreter towards certain diagnoses, increasing the chance of false positives. To determine the possibility of this bias, the authors studied patients who were referred for echocardiography with a clinical suspicion of endocarditis. Hospital charts from a two-year period were reviewed to determine clinical data available to the echocardiographer, echocardiogram results, and the final diagnosis. Four clinical features, when present at the time of echocardiography, were associated with increased numbers of false-positive results. Test specificity was 97% (34/35) for patients without any of these features, but dropped to 80% (16/20) when two or more features were present. The authors conclude that clinical information may bias echocardiogram interpretations such that both test specificity and the posttest probability of disease may be overestimated when tests are used in clinical practice.

A methodologic assessment of studies comparing magnetic resonance imaging and computed tomography of the brain.

To evaluate the methods used in studies comparing magnetic resonance imaging (MRI) and computed tomography (CT) of the brain, we reviewed English language articles published between 1981 and early 1986. Of 83 studies comparing the accuracy of MRI and CT in 10 or more patients, few met methodologic standards for evaluations of the efficacy of new diagnostic tests. Limitations were found in how study populations were assembled, in test performance and interpretation, and in analysis of study findings. Greater attention to design and execution of comparison studies could overcome these limitations and help demonstrate MRI's true diagnostic value.

Predicting the likelihood of hemorrhage in patients with stroke.

To identify those clinical findings that independently help differentiate intracranial hemorrhage from cerebral infarction, we studied patients who were admitted to a hospital with acute focal neurologic deficits after strokes during a 17-month period. The predictive strength of a decision-making aid incorporating these findings was then assessed by studying patients who were admitted to a different hospital after experiencing strokes. The decision-making aid stratified the patients into groups having probabilities of intracranial hemorrhage ranging from 5% to 67%. The results of this study may facilitate more discriminating test selection during the early evaluation of patients who have had strokes.