The Self-Administered Comorbidity Questionnaire: a new method to assess comorbidity for clinical and health services research.

OBJECTIVE: To develop the Self-Administered Comorbidity Questionnaire (SCQ) and assess its psychometric properties, including the predictive validity of the instrument, as reflected by its association with health status and health care utilization after 1 year. METHODS: A cross-sectional comparison of the SCQ with a standard, chart abstraction-based measure (Charlson Index) was conducted on 170 inpatients from medical and surgical care units. The association of the SCQ with the chart-based comorbidity instrument and health status (short form 36) was evaluated cross sectionally. The association between these measures and health status and resource utilization was assessed after 1 year. RESULTS: The Spearman correlation coefficient for the association between the SCQ and the Charlson Index was 0.32. After restricting each measure to include only comparable items, the correlation between measures was stronger (Spearman r = 0.55). The SCQ had modest associations with measures of resource utilization during the index admission, and with health status and resource utilization after 1 year. CONCLUSION: The SCQ has modest correlations with a widely used medical record-based comorbidity instrument, and with subsequent health status and utilization. This new measure represents an efficient method to assess comorbid conditions in clinical and health services research. It will be particularly useful in settings where medical records are unavailable.

Costs of measuring outcomes of acute hospital care in a longitudinal outcomes measurement system.

It is widely acknowledged that the measurement of outcomes of care and the comparison of outcomes over time within health care providers and risk-adjusted comparisons among providers are important parts of improving quality and cost-effectiveness of care. However, few studies have assessed the costs of measuring outcomes of care. We sought to evaluate the personnel and financial resources spent for a prospective assessment of outcomes of acute hospital care by health professionals in internal medicine. The study included 15 primary care hospitals participating in a longitudinal outcomes measurement program and 2005 patients over an assessment period with an average duration of 6 months. Each hospital project manager participated in a previously-tested structured 30-minute telephone interview. Outcome measures include time spent by the individual job titles in implementing and running the outcomes measurement program. Job-title-specific times were used to calculate costs from the hospitals' perspective. One-time costs (2132 +/- 1352 Euros) and administrative costs (95 +/- 97 Euros per week) varied substantially. Costs per patient were fairly stable at around 20 Euros. We estimated that the total cost for each hospital to assess outcomes of care for accreditation (10 tracer diagnoses over 6 months) would be 9700 Euros and that continuous monitoring of outcomes (5 tracer diagnoses) would cost 12,400 Euros per year. This study suggests that outcomes of acute hospital care can be assessed with limited resources and that standardized training programs would reduce variability in overall costs. This study should help hospital decision makers to estimate the necessary funding for outcomes measurement initiatives.

Total hip replacement due to osteoarthritis: the importance of age, obesity, and other modifiable risk factors.

We studied whether several modifiable factors were associated with the risk of total hip replacement due to hip osteoarthritis among women.We identified 568 women from the Nurses' Health Study who reported total hip replacement due to primary hip osteoarthritis on questionnaires from 1990 to 1996, using a validated algorithm. The relation of potential risk factors, such as age, body mass index, physical activity, smoking, alcohol intake, and hormone use, to hip replacement was assessed using pooled logistic regression models. Higher body mass index was associated with an increased risk of hip replacement due to osteoarthritis (P for trend = 0.0001). Compared with women in the lowest category of body mass index (<22 kg/m(2)), those in the highest category of body mass index (> or =35 kg/m(2)) had a twofold increased risk (95% confidence interval [CI]: 1.4 to 2.8), whereas those in the highest category of body mass index at age 18 years had more than a fivefold increased risk (95% CI: 2.5 to 10.7). Age also had a positive association; women aged > or =70 years were nine times more likely to have hip replacement than those aged <55 years (95% CI: 5.4 to 13.9). Recreational physical activity, smoking, alcohol use, and postmenopausal hormone use were not associated with an increased risk of hip replacement. In the Nurses' Health Study, higher body mass index and older age significantly increased the risk of total hip replacement due to osteoarthritis. Part of this risk appeared to be established early in life.

[Outcomes count: the importance of measuring the outcomes of hospital care]. / Ergebnisse zählen: Bedeutung der Erfassung von Ergebnisqualität im Krankenhaus.

A century ago the Boston surgeon Earnest A. Codman described in detail the requirements for monitoring quality of care and emphasized the importance of outcomes in evaluating care. At the time the medical societies were disconcerted by his ideas, which were perceived as revolutionary. After several decade of focusing on the structures and processes of care we are now witnessing a renaissance of measuring outcomes. This paper emphasizes the need for outcomes measurement monitor quality of care. The introduction of diagnosis-related groups in Germany is the most recent development that underlines the importance of outcomes measurement and benchmarking.

Metric properties of the appropriateness evaluation protocol and predictors of inappropriate hospital use in Germany: an approach using longitudinal patient data.

BACKGROUND: The German health care system, renowned for its unrestricted access, high quality care, and comprehensive coverage, is challenged by increasing health care costs. This has been attributed partly to inefficiencies in the in-patient sector, but has been studied little. Attempts at quality improvement need to relate costs to outcomes. Until now, there has been no standardized methodology to evaluate the appropriateness of hospital care. OBJECTIVE: To develop and evaluate the metric properties of a method to assess inappropriate hospital care in Germany based on a widely used measure, the Appropriateness Evaluation Protocol (AEP). METHODS: The original AEP was translated and adapted to reflect differences in the provision of health care in Germany. Psychometric testing was performed in a stratified sample of all patients admitted to the Departments of Medicine and Surgery of a 400-bed teaching hospital during 1 year. Three board-certified physicians participated in each department to evaluate intra-rater reliability, while two additional independent physicians judged inter-rater reliability. RESULTS: Inter-rater agreement for the evaluation of hospital days among surgical patients was 84% (80-87%), with an average kappa value of 0.58 (0.48-0.68). Corresponding figures for patients in medicine were 76% (73-80%) with a K value of 0.42 (0.34-0.42). Inter-rater agreement for hospital admissions and K was 74% (62-86%) and 0.44 (0.21-0.67) in surgery, and 92% (85-100%) and 0.31 (0-0.80) in medicine, respectively. Thirty-three per cent of all admissions and 28% of consecutive hospital days were judged inappropriate in surgery; among medicine patients, reviewers found 6% of admissions and 33% of hospital days inappropriate. Time since admission was the strongest predictor of inappropriate hospital use adjusted for length of stay, comorbidity, age, and gender.