Finding order in heterogeneity: types of quality-improvement intervention publications.

BACKGROUND: Stakeholders in quality improvement agree on the need for augmenting and synthesising the scientific literature supporting it. The diversity of perspectives, approaches, and contexts critical to advancing quality improvement science, however, creates challenges. The paper explores the heterogeneity in clinical quality improvement intervention (QII) publications. METHODS: A preliminary classification framework was developed for QII articles, aiming for categories homogeneous enough to support coherent scientific discussion on QII reporting standards and facilitate systematic review. QII experts were asked to identify articles important to QII science. The framework was tested and revised by applying it to the article set. The final framework screened articles into (1) empirical literature on development and testing of QIIs; (2) QII stories, theories, and frameworks; (3) QII literature syntheses and meta-analyses; or (4) development and testing of QII-related tools. To achieve homogeneity, category (1) required division into (1a) development of QIIs; 1(b) history, documentation, or description of QIIs; or (1c) success, effectiveness or impact of QIIs. RESULTS: By discussing unique issues and established standards relevant to each category, QII stakeholders can advance QII practice and science, including the scope and conduct of systematic literature reviews.

From understanding health care provider behavior to improving health care: the QUERI framework for quality improvement. Quality Enhancement Research Initiative.

Basic science and health care research provide the evidence base for the scientific practice of medicine. Over the past 2 decades, as increasingly refined tools for improving health and health care have been developed, the health care community has attempted to bridge the gap between available tools and actual health care practices. This gap can be bridged only by influencing health care provider behavior. The VA Quality Enhancement Research Initiative (QUERI) is a program designed to systematically translate research findings into better health care practices, and thus better health outcomes for enrolled veterans. Integrating provider behavior research considerations and findings into each step of the QUERI process will enhance the effectiveness of the initiative. This article presents a provider behavior research framework for planning, implementing, and evaluating quality improvement interventions within QUERI.

Health habit counseling amidst competing demands: effects of patient health habits and visit characteristics.

OBJECTIVE: This study assesses the effects of competing demands, such as poor health habits or new medical problems, on health-habit counseling during a primary care visit. METHODS: We surveyed a consecutive sample of 1,259 patients visiting primary care clinicians at an academic VA medical center. Before the visit, patients reported their health status, health habits, and sociodemographics; immediately after the visit, patients reported reasons for the visit and whether they had been counseled about specific health habits. We scored visit acuity ranging from visits for unscheduled walk-in care or new medical problems to scheduled visits for check-ups or old problems. We defined counseling "triggers" as clinical indications for counseling about particular health habits (e.g., smoking). We developed a logistic model predicting primary care provider counseling during a visit. RESULTS: Over two-thirds of patients (68.9%) received some health habit counseling. Controlling for other independent variables, patients with more triggers were more likely to report being counseled. Counseling rates went up as visit acuity went down; patients with the lowest visit acuity having 67% greater odds of being counseled than patients with the highest visit acuity. CONCLUSIONS: Physicians set priorities for health-habit counseling during a visit based on patients' health habit problems or triggers; whether the visit is scheduled or walk-in; and whether the patient has new or acute problems. Future research about primary care performance of health habit counseling should account for these patient and visit characteristics, and prevention-oriented health care organizations should ensure access to scheduled "check-up" visits.

Evaluation of the VA's Pilot Program in Institutional Reorganization toward Primary and Ambulatory Care: Part I, Changes in process and outcomes of care.

PURPOSE: To evaluate the impact of the reorganization of an academic Veterans Affairs medical center toward primary and ambulatory care--including the implementation of a medical-center-wide interdisciplinary firm system and ambulatory care training program--on the quality of primary ambulatory care. METHOD: Randomly selected male veterans visiting the Veterans Affairs Medical Center in Sepulveda, California, were surveyed in 1992, early in the implementation of the program, and in 1993, after the program had been fully implemented. Two surveys were used: one before the veterans saw their primary care providers (practice-based survey) and the other immediately after patient visits (visit-based survey). Survey-participant data were then linked to computerized utilization and mortality data. Survey topics were mapped to the medical center's strategic plan and goals for ambulatory care, and focused on patients' reports about the care they had received in terms of continuity, access, preventive care, and other aspects of the biopsychosocial model of care. Administrative computer data were then used to evaluate effects on medical center workload. Statistical analyses included analysis of variance, analysis of covariance, chi-square, and logistic regression. RESULTS: For practice-based comparisons, complete data were available for 1,262 veterans in 1992 and 1,373 in 1993. For visit-based comparisons, complete data were available for 1,407 veterans in 1992 and 643 in 1993. Results included statistically significant improvements in continuity of care and detection of depression as well as increased rates of preventive care counseling (smoking and exercise). The proportion of veterans reporting being seen by physicians increased, as did the proportion of patients seen for check-ups rather than for acute problems. Fewer patients were seen in subspecialty clinics than in general medicine clinics. Patient satisfaction increased, hospitalizations decreased, and death rates decreased. Alcohol counseling and access to care for acute symptoms declined. Workload shifted from subspecialists to generalists and from inpatient care to outpatient care. CONCLUSION: The institutional reorganization toward primary and ambulatory care succeeded in substantially improving the quality of ambulatory care, reflecting improvements in the system of care and of health care provider training in ambulatory care.

Evaluation of the VA's Pilot Program in Institutional Reorganization Toward Primary and Ambulatory Care: Part II, A study of organizational stresses and dynamics.

BACKGROUND: Many academically affiliated hospitals are moving from an inpatient, subspecialty orientation in their patient care and educational programs toward a greater emphasis on ambulatory and primary care. Few studies have focused on the organizational, staffing, and management issues involved in implementing these changes. METHOD: The authors carried out a qualitative evaluation of the process of change in an academic Department of Veterans Affairs hospital during implementation of a major ambulatory primary care program. They interviewed four top managers individually and 59 top and middle managers, house officers, and patients in focus groups in the spring of 1992, nine months after implementation of the key components of the program. Four raters independently evaluated written transcripts of focus-group sessions and identified themes. RESULTS: The main problems identified were difficulty with administrative integration between inpatient and outpatient services; need for training, retraining, and orientation; tensions due to changes in roles and organizational culture; and inefficiency due to the need for frequent negotiations in daily work life. These four problems reflected tensions associated with new demands imposed by matrix management, changing job descriptions, policies and procedures, and changing patterns of communication and record keeping. CONCLUSION: During the process of implementation of a primary care focus throughout a medical center, extra demands upon staff are inevitable and should be anticipated and planned for. Twelve key factors for successful organizational change are discussed.

Anatomy of an outpatient visit. An evaluation of clinic efficiency in general and subspecialty clinics.

The time spent in outpatient visits to a Veteran's Administration medical center was measured to determine clinic efficiency. Patient flow through the outpatient department of the medical center was studied to: 1) evaluate how time is spent in VA outpatient settings as compared to non-VA outpatient settings, including waiting time, checking of vital signs, seeing the doctor, etc., 2) develop a baseline to gauge the comparison of the effects of management changes; and 3) develop a mechanism for collecting clinic activity efficiency.

Increasing the impact of quality improvement on health: an expert panel method for setting institutional priorities.

BACKGROUND: Successful implementation of modern ongoing quality improvement (QI) methods requires investment of institutional resources, but can produce significant improvements in medical care. A health care organization's goals and objectives for improving care are expressed in strategic plan documents, which could provide a framework for planning quality improvement initiatives. However, institutional strategic planning processes are often not well linked to QI staff and resources. We developed the Quality Action Program (QAP) to connect QI to strategic planning. HISTORY: In 1991, Sepulveda VHAMC implemented a major primary care initiative, documented in a comprehensive strategic plan. The QAP was developed to enable the initiative to be evaluated within a QI context. THREE-ROUND EXPERT PANEL PROCESS: To carry out the QAP, members of an institution's quality council engage in a structured consensus process. The first round involves reading educational materials and filling out a quality action survey the second round includes participation in an expert panel meeting, and the third round involves making final priority rankings. EIGHT-STEP QAP IMPLEMENTATION PLAN: QI staff carry out activities to prepare for and carry out the three-round expert panel process. RESULTS: QAP induced significant institutional QI activity directed toward achieving the top-ranked QI criterion--ensuring continuity of care. Continuity of care improved significantly over time between the pre- and post-QAP periods. CONCLUSIONS: Expert panel methods can be used to link strategic plan goals and objectives to QI efforts.

Helping practices reach primary care goals. Lessons from the literature.

We reviewed rigorous evaluations of programs to enhance the quality and economy of primary care. We identified 36 evaluations published from 1980 through 1992. We abstracted data on objectives, setting(s), patients and processes, outcomes, and costs of care. We identified successful programs, as well as significant gaps in our knowledge of how to improve aspects of care. In specific, computer reminders and social influence-based methods fostered preventive and economic care. Nurse implementation of prevention protocols increased their performance. Multidisciplinary teams improved access and economy. Regional organization of practices or telephone management improved access; regionalization also reduced emergency care. Improvements were not found in continuity, comprehensiveness, humanistic process, physical environment, or health outcomes. Primary care practices can implement several programs to continuously improve prevention and access, and to reduce costs and use of unnecessary services. Research documenting how to accomplish other major goals, including health outcome changes, in different practice types is needed.

Uniform prehospital data elements and definitions: a report from the uniform prehospital emergency medical services data conference.

One of the district and universal aspects of emergency medical service (EMS) is the belief that before its implementation many people were dying or being killed by ill-equipped, poorly trained "hearse drivers" and that this tragic state of affairs has been rectified by the advances in the prehospital phase of care. Except for cases of nontraumatic, out-of-hospital cardiac arrest there is almost no convincing scientific evidence to prove that prehospital care has had an impact on morbidity or mortality. At the very foundation of this problem is the lack of a set of broad-based, well-conceived, accurate, reliable, uniform EMS data. Many attempts have been made to develop a uniform EMS data set, but without a national consensus these have not achieved wide distribution. In 1992, with the assistance of the National Highway Traffic Safety Administration, the national consensus process began with a series of meetings involving many EMS agencies and organizations. This culminated in August 1994 with the development of an 81-item uniform EMS data set. We detail the prior attempts at data set development and outline the process leading to the this uniform, national EMS data set.

Prenatal programs: what the literature reveals.

OBJECTIVES: To review evaluations of prenatal health care programs, examine their methodologic features, and synthesize the findings of high-quality studies. DATA SOURCES: We combined a computerized search of the literature and recommendations of experts to select evaluations published between 1981-1991. METHODS OF STUDY SELECTION: After reviewing the quality of each evaluation in relation to methods and clinical applicability, we selected the highest-quality evaluations and summarized their methods and findings. DATA EXTRACTION AND SYNTHESIS: Trained researchers used a standardized abstraction form for information on main objectives and activities, setting, study design and sample, data collection methods, results, and conclusions. Seven of 22 evaluations met the review criteria. Maternal care coordination and visits by nurses, and specially targeted smoking and nutrition programs, were associated with optimized pregnancy outcomes for certain women, including the poor and very young. Longer participation in prenatal care was an important factor in achieving positive outcomes. Women receiving care from nurse-midwives did not differ in their pregnancy outcomes from women cared for by physicians. CONCLUSIONS: No evaluation met all the review criteria. Selection biases are likely, and thus positive findings may have reflected the types of women who were likely to comply with care rather than the effects of program participation. Many topics were not systematically evaluated. Carefully controlled evaluations of the content, number, and timing of prenatal care visits for women with differing medical and social risks are essential in identifying effective ways to achieve the nation's public health objectives regarding maternal and infant mortality.

Ambulatory testing for capitation and fee-for-service patients in the same practice setting: relationship to outcomes.

Previous studies of the impact of varying reimbursement incentives on physician behavior have not explored the simultaneous implications for patients' health outcomes. Using a single group of physicians who provided care for hypertensive patients with either capitation (N = 99) or fee-for-service (N = 66) health insurance plans, physicians' test-ordering behavior and patients' subsequent health outcomes were examined. After controlling for patients' age, severity of hypertension, and level of comorbidity, it was found that patients with capitation health insurance had fewer laboratory tests and lower overall charges than the fee-for-service patients, with no clinical or statistically significant differences in 1-year health outcomes, specifically blood pressure control. The study concludes that capitation can result in reduction in charges associated with management of hypertension, without apparent compromise in proximate health outcomes.

The condition of the literature on differences in hospital mortality.

The quiescent interest in understanding the variations in the quality of hospital care has been revitalized recently with the government's release of hospital-specific mortality data. The authors reviewed all published studies that either named hospitals and gave their death rates or explored which of their characteristics explained the differences in their rates. The literature is only in fair condition. It is sparse and flawed, and, before the government's release, did not identify an individual hospital's mortality experience by name. Twenty-two studies were analyzed; only five (23%) met criteria for validity. Seventeen (77%) focused on in-hospital mortality. Data were collected for a short time, were not gathered uniformly, and came from a sample of local hospitals. Researchers identified and explained limitations in their studies and were particularly concerned with their inability to measure differences in patients that might affect death rates. Several characteristics of hospital care were found to be associated with lower inpatient mortality: communication among and commitment of staff, clinical experience and performing operations frequently, board certification, size, and teaching status. The authors urge caution in applying the literature's findings to evaluations of hospital quality and offer suggestions for researchers. Improved research is critically important in facilitating current policy discussions regarding the use of mortality as a measure of hospital quality.

Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes.

To maximize disease control, patients must participate effectively in their medical care. The authors developed an intervention designed to increase the involvement of patients in medical decision making. In a 20-minute session just before the regular visit to a physician, a clinic assistant reviewed the medical record of each experimental patient with him/her, guided by a diabetes algorithm. Using systematic prompts, the assistant encouraged patients to use the information gained to negotiate medical decisions with the doctor. A randomized trial was conducted in two university hospital clinics to compare this intervention with standard educational materials in sessions of equal length. The mean pre-intervention glycosylated hemoglobin (HbA1) values were 10.6 +/- 2.1% for 33 experimental patients and 10.3 +/- 2.0% for 26 controls. After the intervention the mean levels were 9.1 +/- 1.9% in the experimental group (p less than 0.01) and 10.6 +/- 2.22% for controls. Analysis of audiotapes of the visits to the physician showed the experimental patients were twice as effective as controls in eliciting information from the physician. Experimental patients reported significantly fewer function limitations. The authors conclude that the intervention is feasible and that it changes patient behavior, improves blood sugar control, and decreases functional limitations.