Developing criteria for ordering common ancillary services.

This article describes the process utilized to develop criteria for appropriately ordering five ancillary services frequently performed in hospitals: 1) arterial blood gases, 2) electrocardiograms (ECGs), 3) serum electrolytes, 4) chest x-rays, and 5) complete blood counts (CBCs). The development of each set of criteria involved an initial consultant, a panel of six additional regional expert consultants, and three national reviewers. Each criteria set was developed through a process involving seven steps: 1) an initial working draft, 2) revisions at an initial meeting of the regional experts, 3) revisions at a second meeting of the regional experts, 4) written comments from the regional experts, 5) written comments from national reviewers, 6) additional written comments from regional experts, and 7) application of the criteria to cases in a community hospital. The change in item content was measured between steps and agreement with individual items was measured at steps 2, 3, and 4. The results indicate that appreciable change in content occurred with each step except step 4. Agreement started fairly high and was over 90% by step 4. The discussion considers the utility of each developmental step, factors affecting the utility of the criteria, the extent to which the results can be generalized, and the need for more research to identify optimal processes for the development of criteria to evaluate quality of care.

Marketing Medicaid drugs: an analysis of cost factors.

The cost of drugs dispensed through the Medicaid program is the focus of this article. The research question addressed is, "What variables raise or lower the expense of marketing drugs to Medicaid recipients?" Medicaid drug programs are dichotomized into high- and low-cost groups and variables are identified that are linked with either the more or less expensive programs. Three groups should be interested in identifying factors that increase or decrease the cost of marketing drugs to Medicaid patients--pharmacy managers, Medicaid administrators at the state and federal levels, and public aid recipients.

USMGs versus FMGs. Are there performance differences in the ambulatory care setting?

Several earlier studies compared performance differences between USMGs and FMGs in inpatient care settings, mainly hospitals. This study compares performance differences between USMGs and FMGs in ambulatory care settings. The sample consisted of 14,203 patient episodes treated by 1,156 physicians (pediatricians, obstetricians/gynecologists, internists, and other specialty physicians). The study setting was a midwestern state. Little evidence was found to support the hypothesis that the medical school origin (U.S. and foreign) had influenced physicians' technical quality in practice. Mean differences between the USMGs and FMGs were either not significant or contrary to the general assumption. The FMGs provided equal care to the USMGs, and sometimes the FMGs provided even marginally better care than the USMGs.

Relationships of physician characteristics to performance quality and improvement.

The quality of ambulatory medical care provided by 1,135 physicians in five separate practice settings in the Midwest was measured using predetermined process criteria. Specialists performed better in their own areas of specialized training than did family/general practitioners or specialists performing outside their specialty areas. Physicians with fewer years of practice performed somewhat better than physicians with more years since medical school graduation. Board certification was not consistently related to performance. Performances of the physicians improved following quality assurance interventions in these sites. Differences in the rates of change in performance quality were not consistently related to any of the physician characteristics studied.

Method of evaluating and improving ambulatory medical care.

The usefulness of an action-research model is demonstrated in the evaluation and improvement of ambulatory medical care in a variety of settings: solo office practice, prepaid capitation multiple-specialty group practice, and medical school hospital-based outpatient clinic practice. Improvements in the process of medical care are found to relate directly to the intensity and duration of planned interventions by the study group and are demonstrated to follow organizational changes in the participating sites--primarily managerial and support services initiated by policy decisions in each study site. Improvement in performance approaching one standard deviation results from the most intense intervention, about one-half standard deviation at the next level of intervention, and virtually no change from a simple feedback of performance measures. On the basis of these findings and other operational and research efforts to improve physician performance, it is unlikely that simple feedback of performance measures will elicit a change in behavior. However, noncoercive methods involving health care providers in problem identification, problem solving, and solution implementation are demonstrated to be effective.

The effects of burn severity and institutional differences on the costs of care.

Burn care treatment is among the costliest yet least studied forms of care. This paper presents estimates of the magnitude and components of burn care costs. It analyzes the extent to which burn care cost is determined by severity of burns or by characteristics of the institution in which the patient is treated, based on patient-specific data from eight hospitals representing different levels of technical sophistication in the delivery of burn care. Costs of care are higher in specialized facilities. Many patients with small burns are treated in specialized facilities, at much higher costs than patients treated in general care facilities. Among specialized facilities, patient severity accounts for a portion of the variance in costs, but significant cost differences remain after adjusting for severity. These results suggest that cost-control efforts should concentrate on specifying criteria for admission to specialized burn facilities, regional coordination of facilities and institutions, and improved facilities design and management.

Ultrastructural identification of neoplastic histiocytes--monocytes: an application of a newly developed cytochemical technique.

We applied a newly developed ultrastructural cytochemical technique utilizing 2-naphthyl thiol acetate (NTA) as a substrate in 3 cases of true histiocytic-monocytic malignancy and 3 controls. The enzyme NTA esterase was identified in both neoplastic and benign histiocytes-monocytes in the form of electron-dense material within the cytoplasm. The NTA esterase varied in size and shape and showed no clear relationship with cytoplasmic organelles. The distribution and pattern of staining were very similar to those of the light-microscopically demonstrated alpha-naphthyl acetate esterase reaction. The main advantages of this method are: 1) histiocytes-monocytes can be identified in the absence of lysosomes or phagocytosis; 2) unequivocal, simultaneous documentation of both histiocytic esterase and subcellular structure is possible; and 3) both blood and solid tissue specimens can be utilized. Our findings demonstrate the usefulness and applicability of ultrastructurally demonstrated NTA esterase in the study of histiocytic-monocytic malignancies.

Domain of practice and the quality of physician performance.

This study has attempted to determine the relationship between physician domain of practice and their quality of medical care. The study examined whether there was a quality difference in practice either 1) between general practitioners and specialists, or 2) between specialists practicing within and outside their specialty domains. The sample consisted of 454 physicians of Hawaii, involving 18 specialty categories: general practitioners (133) and specialists (321). The study finds that when the general practitioners in this study practices without limitation, their quality of care was not as good as that of the specialists. The study also found that when the specialists practiced outside their specialty areas, the relative quality of their performance declined. The latter finding was sustained even when other important practice and background variables were held constant. The study also discusses its generalizability and policy implications.

Problems of case finding and data collection in ambulatory care settings.

The experience gained in a four-year ambulatory care study suggests that major problems of patient care data collection include: 1) Difficulties in obtaining listings of patients by diagnosis/condition that accurately reflect the actual practice experience; 2) Inaccurate coding or identification of the reason for patient visits; and 3) Inability to find the medical record within the system. Data presented here suggest there are certain regularities in completion rates characteristic of research sites and of diagnostic categories.

A method for the ultrastructural demonstration of non-specific esterase in human blood and lymphoid tissue.

Using the substrate 2-naphthylthiol acetate (NTA), we developed a reproducible method of demonstrating a non-specific esterase while retaining nuclear and cytoplasmic details at the ultrastructural level. The NTA esterase had a distribution and pattern of staining similar to those of esterases demonstrable at the light microscopic level by the alpha-naphthyl acetate or naphthol AS-D acetate esterase reaction. The NTA esterase appeared as intensely electron-dense granules of varying size and shape in the cytoplasm. The granules were most abundant in the cells of the histiomonocytic series. The large number of diffusely scattered granules in the cytoplasm of the histiocytes and monocytes made it possible to separate these cells from other haematopoietic elements. There was usually no direct relationship between the NTA esterase positivity and the amount or the location of lysosomes or mitochondria, although in some histiocytes the granules appeared to be associated with lysosomes. The NTA esterase-positive granules were usually more numerous than lysosomes and were located outside the lysosomal granules. Some of the lymphocytes outside the germinal centres and most of the lymphocytes in the blood showed a punctate positivity in the form of 1--4 electron-dense dots. Plasma cells were usually negative but, in rare cases, contained an occasional single dot-like reaction product similar to that in some of the lymphocytes. Granulocytes were always negative. The method described in this paper can be used effectively for identification and study of human haematopoietic cells lines at the ultrastructural level.

The medical record as a basis for assessing physician competence.

The medical record can be used for evaluating physician performance. Within the limitations described, it is an essential source of information on the delivery of care as well as a measure of proficiency. The process of care should be particularly emphasized, without neglecting appropriate outcome measures. The confounding of outcome measures by compliance factors, natural history of the disease process, severity of illness, status of defense mechanisms, performance of ancillary services, and personnel does not make this an attractive single measure of physician performance. Knowledge assessment and performance assessment play a complementary role; both are necessary to identify competency. The potential for improving medical care and the recording of essential findings by such an emphasis on individual assessment based on medical records is enormous. Technologic progress in recording and retrieving medical information is facilitating use of the record to measure proficiency. A carefully structured blend of cognitive examination to establish a knowledge base and review of the medical record to measure performance will provide better measures of competency.

Patient race and physician performances: quality of medical care, hospital admissions and hospital stays.

The study has attempted to determine the extent of the relationship between patient race and physicians' performances in patient care. The sample of the study consisted of 3175 hospital episode of patients discharged from 22 short-term general hospitals in the state of Hawaii. The episodes were derived from 15 major diagnostic categories. Physicians performances were measured on the basis of the quality of medical care provided, the appropriateness of hospital admissions, and the appropriateness of hospital stays, including understays and overstays. The study has found: 1) that patient race had very limited influence on physicians' performances: the quality of medical care, the appropriateness of hospital admissions, and the appropriateness of hospital stays; 2) that Asian-Americans receive medical care equal to that of the white Americans (once they had access to the health care systems), at least in the state of Hawaii; 3) that among Asian-Americans, there was no distinct difference in medical care received by Japanese, Chinese, and Filipino; 4) that there was clear evidence of racial mutual selection between patients and physicians; and 5) that patients treated by the physicians with the same racial/ethnic backgrounds received care neither superior nor inferior to the care received by patients from the physicians with different backgrounds.

Interdiagnosis relationships of physician performance measures in hospitals.

Correlations among ten diagnostic categories of hospital care physican performance measures are reported. Using measures of conformance to predetermined criteria for optimal performance, mean scores of individual physican performances within diagnostic categories were calculated and correlated. Measurement reliability estimates were computed and it was suggested that a minimum of four cases in each diagnostic category be used for measurement of performance on the individual physician level of analysis. There appeared to be homogeneity of performance measures among some but not all diagnoses studied. This finding reinforces the need to examine interdiagnostic correlations before attempting to measure overall individual physican performance by combining measures from separate diagnostic categories.

Patient responses to request for written permission to review medical records.

2,163 patients of 55 physicians in one county, were sent letters asking for their written permission to have their medical records audited by the University of Michigan research team. The overall positive response rate was 64.1% for one county. Differences in response rates were statistically significant among specialties, among diagnoses, and among individual physicians.

The use of item importance weights in assessing physician performance with predetermined criteria indices.

Conditions for using single measures or combinations of measures of physician performance are discussed. Studies reporting combination indices of proficiency are reviewed for their use of equally or differentially weighted components and for the use of these with many or with single diagnoses, Comparisons of diagnostic-specific measures are made using differential and equal item weights. Under the general conditions of this research, few psychometric differences existed. The use and acceptability of differential item weights in this research are also discussed.