Necesidad de variaciones en las estructuras hospitalarias de los servicios de geriatría / Need for variations in the hospital structures of the geriatrics services

El envejecimiento conlleva a variaciones en las estructuras hospitalarias. La experiencia del autor durante más de 20 años en la atención hospitalaria a adultos mayores reservistas y veteranos de la defensa, permite afirmar que debemos continuar trabajando por mejorar las capacidades estructurales y la asistencia geriátrica. Una investigación realizada en adultos mayores veteranos de la defensa mostró la existencia de elevada prevalencia de diversas deficiencias y enfermedades crónicas que afectan la salud. Los Hospitales Militares Centrales y de Ejércitos deben de disponer de un Servicio de Geriatría donde los adultos mayores serán evaluados integralmente. Preparar las instituciones de salud para enfrentar el reto que impone el envejecimiento poblacional constituye una proyección estratégica de trabajo concebida en los Lineamientos del Partido(AU)

Aging leads to variations in hospital structures. The author's experience for more than 20 years in hospital care for elderly reservists and veterans allows us to affirm that we must continue working to improve structural capacities and geriatric care. An investigation in elderly veterans of the defense showed the existence of high prevalence of diverse deficiencies and chronic diseases that affect health. Central Military Hospitals and Army Hospitals must have a Geriatrics Service where the elderly will be fully evaluated. Preparing health institutions to meet the challenge of aging population is a strategic projection of work conceived in the Cuban Communist Party Guidelines(AU)

Differential adoption of pharmacotherapy recommendations for type 2 diabetes by generalists and specialists.

Newer, multimedication (novel) regimens provide better glycemic control for many type 2 diabetics when sulfonylurea monotherapy (traditional) becomes ineffective. Because better glycemic control is associated with decreased likelihood of complications and lower utilization and cost of care, the authors examined change in prescribing patterns for veterans with type 2 diabetes between FY 97 and 99. They classified medication regimens as traditional and novel based on the combination of diabetes medications patients received at the end of each year. Multivariate logistic regression analyses controlling for disease severity indicated that patients were more likely to receive novel regimens over time, but those seen only in primary care were less likely to receive novel regimens than those previously seen by a specialist. Geographic differences and differences in how recommendations were implemented by generalists and specialists suggest that diffusion of innovations theory may help explain variations in practice and guide interventions designed to translate research into practice.

Time series monitors of outcomes. A new dimension for measuring quality of care.

OBJECTIVES: Despite the popularity of risk-adjusted outcomes as quality of health care indicators, their instability with time and their inability to provide reliable comparisons of small volume providers have raised questions about the feasibility and credibility of using these measures. In this article the authors describe a new analytic strategy to address these problems by examining risk-adjusted mortality with time, "Time Series Monitors of Outcome" (TSMO), and its application to cardiac surgery performed throughout the Department of Veterans Affairs between April 1987 and September 1992. METHODS: Expected operative mortality for 24,029 patients undergoing coronary artery bypass surgery at all 43 centers performing this procedure was estimated using a logistic regression model to adjust for patient-specific risk factors. The ratio of observed-to-expected operative mortality was calculated for each hospital for each of the 11 6-month periods. Poisson regression models were used to identify high and low outlier hospitals based on significant deviation from the 5.5 year overall mean and/or the individual hospital's trend of observed-to-expected ratios with time. RESULTS: This method identified four high and one low outlier hospitals based on significant deviations from the overall mean and three upward and seven downward trending outlier hospitals based on significant deviations in trend with time. A significant downward trend in observed-to-expected ratios of 4% per year also was observed for all coronary artery bypass graft procedures performed throughout the Department of Veterans Affairs during the last 5.5 year period. CONCLUSIONS: Time Series Monitors of Outcome should help reduce misclassification of outliers due to random variation in outcomes as well as provide more reliable comparative information from which to evaluate provider performance.

Achieving hospital operating objectives in the light of patient preferences.

Patient satisfaction is becoming increasingly important for the successful operation of private and public hospitals. The quality of the service provided can be improved if internal and external customers' opinions are taken into account during the definition of hospital operating objectives. This research presents a new methodology, called the simulation service quality system (SSQS), developed to improve operating performance measures in the light of customer preferences. The motivation for the development of the SSQS methodology arose from the need to achieve timeliness standards at United States Veterans' Hospitals. The Harry S. Truman Memorial Veterans' Hospital in Columbia Missouri served as the validation and initial application site for the SSQS methodology. Details one such project: the objective of reducing customer waiting times to 30 minutes or less at an outpatient treatment clinic. Through the identification of relationships and interactions, discrete-event simulation techniques are applied to model and experiment with the system to ultimately arrive at recommended changes in hospital operating policies which achieve the objective.

Adverse drug reactions: the San Juan Department of Veterans Affairs Medical Center experience.

The San Juan Department of Veterans Affairs Medical Center's adverse drug reactions (ADRs) reporting and monitoring program is described. ADRs for the first 2 years of the program are discussed. These were mainly hypersensitivity (29.3%), drug intoxications (19.9%), cardiovascular (15.9%), hematologic (7.6%), neurologic (4.9%), and gastrointestinal (4.7%) ADRs. Drugs most frequently involved were antibiotics (28.7%), cardiovascular agents (21.2%), anticonvulsants (10.2%), psychotropics (9.4%), and theophylline (5.1%). Preventive interventions include the development of a clinical pharmacist-run anticoagulation clinic, a drug utilization evaluation of phenytoin, development of a dosing algorithm for theophylline, and the possible future initiation of a pharmacokinetic consult service. The success of the ADR program is evidenced by a 750% increase in ADR reports over the 2-year period. This was possible by the establishment of a clear definition of an ADR, the creation of a simple reporting method, and an ongoing educational campaign.

Continuous assessment and improvement in quality of care. A model from the Department of Veterans Affairs Cardiac Surgery.

OBJECTIVE: The authors organized the Department of Veterans Affairs (VA) Continuous Improvement in Cardiac Surgery Study (CICSS) to provide risk-adjusted outcome data for the continuous assessment and improvement of quality of care for all patients undergoing cardiac surgery in the VA. BACKGROUND: The use of risk-adjusted outcomes to monitor quality of health care has the potential advantage over consensus-derived standards of being free of preconceived biases about how health care should be provided. Monitoring outcomes of all health care episodes, as opposed to review of selected cases (e.g., adverse outcomes), has the advantages of greater statistical power, the opportunity to compare processes of care between good and bad outcomes, and the positive psychology of treating all providers equally. These two concepts, together with a pre-existing peer committee (the VA Cardiac Surgery Consultants Committee) to review, interpret, and act on the risk-adjusted outcome data, form the primary design considerations for CICSS. METHODS: Patient-level risk and outcome (operative mortality and morbidity) data are collected prospectively on each of the approximately 7000 patients undergoing cardiac surgery in the VA each year. These outcomes, adjusted for patient risk using logistic regression, are provided every 6 months to each cardiac surgery program and to a national peer review committee for internal and external quality assessment and improvement. RESULTS: For the most recent 12-month period with complete data collection, observed-to-expected (O/E) ratios ranged from 0.2 to 2.2, with eight centers falling outside of the 90% confidence limits for an O/E ratio equaling 1.0. The O/E ratio for all centers has fallen by 14% over the 4.5-year period of this program (p = 0.06). CONCLUSIONS: A large-scale, low-cost program of continuous quality improvement using risk-adjusted outcome is feasible. This program has been associated with a decrease in risk-adjusted operative mortality.

You can be prepared when JCAHO visits.

Preparations for Joint Commission on Accreditation of Healthcare Organizations (JCAHO) surveys are rarely described in the literature. This article is intended to provide much-needed information on survey preparation processes, not only to Department of Veterans Affairs medical centers, but also to all hospitals undergoing surveys of biopsychosocial delivery of care. Beginning in 1995, JCAHO will apply biopsychosocial reviews to all assessments of patients. Facilities whose preparations include those detailed in this article will be better prepared for such reviews.

Computerizing drug usage evaluation.

Drug usage evaluation (DUE) has been computerized at the Department of Veterans Affairs Medical Center in Coatesville, PA. This article describes the implementation of a simple, cost-effective process and provides examples of facility-wide and provider-specific reports that can be used at the time of reappointment for privileges. As a result of computerization and the involvement of all pharmacists, the number of drug reviews have increased dramatically, and there is more consistency in the reviews.