Iatrogenic illness on a general medical service at a university hospital. 1981.

We found that 36% of 815 consecutive patients on a general medical service of a university hospital had an iatrogenic illness. In 9% of all persons admitted, the incident was considered major in that it threatened life or produced considerable disability. In 2% of the 815 patients, the iatrogenic illness was believed to contribute to the death of the patient. Exposure to drugs was a particularly important factor in determining which patients had complications. Given the increasing number and complexity of diagnostic procedures and therapeutic agents, monitoring of untoward events is essential, and attention should be paid to educational efforts to reduce the risks of iatrogenic illness.

Telematics in the neonatal ICU and beyond: improving care for high-risk newborns and their families.

The Beth Israel-Deaconess has recently been awarded one of 19 contracts from the National Library of Medicine (NLM) to develop, implement and test a telemedicine application to support the care of Very Low Birth Weight Infants. This project is the only one to focus on the care of newborns. We believe that this project will provide a new national approach to managing the care of high-risk newborns by leveraging evolving communication technology.

Can payment incentives improve quality and efficiency of care?

Faced with increasing health care costs, America's major corporations are beginning to explore a variety of mechanisms to assure that health care providers are delivering high quality care. The General Motors Corporation (GM), with approximately two million employees, retirees and family members, and annual health care expenditures of approximately $3 billion, has developed a quality review system and a hospital payment mechanism that includes incentives to enhance the quality of care provided to GM beneficiaries. The following article describes this project.

Factors affecting appropriateness of hospital use in Massachusetts.

To determine the extent of inappropriate hospital use, and to investigate factors related to variations in appropriateness, 8,031 hospital records of patients discharged from 41 hospitals in 3 Massachusetts professional standards review organization (PSRO) areas were reviewed in 1973 and 1978. The Appropriateness Evaluation Protocol (AEP) was used for the reviews and logistic regression analysis was used to analyze factors associated with inappropriate use. Based on the results, the authors conclude that utilization review should focus on: longer stays among surgical patients and shorter stays among medical patients; (projected) last third of the stay; and on diagnoses or diagnosis-related groups in which there is less clinical consensus on treatment method. For maximum effectiveness, utilization review must include incentives beyond simple monitoring (e.g., financial incentives).

Referral of musculoskeletal disease patients by family and general practitioners.

We surveyed general and family practitioners to evaluate their patterns of referring musculoskeletal disease patients to rheumatologists and orthopedists. Patients who had rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis were most often referred to rheumatologists, whereas patients with osteoarthritis, persistent low back pain, and post-traumatic knee pain were most often referred to orthopedists. As conditions worsened in severity, referrals were more frequent. Patients with conditions that were difficult to diagnose, such as possible shoulder tendinitis that was unresponsive to initial nonsteroidal therapy, undiagnosed polyarthritis, and intermittent knee swelling with pain, were most often treated without referral and, when referred, were most often sent to orthopedists. Belief in the effectiveness of rheumatologists or orthopedists correlated strongly with reported referral behavior, yet most respondents considered themselves capable of managing the majority of patients with musculoskeletal diseases. Neither practice arrangement, board certification, nor educational background affected referral behavior. However, younger physicians were more likely (P = 0.002) to refer patients to rheumatologists. Multivariate analysis showed that the significant predictors of global referral behavior were belief in the effectiveness of subspecialists and a small number of musculoskeletal problems seen by the generalist. The predictors of referral to rheumatologists were belief in rheumatologist efficacy and young physician age.

Three-dimensional vector graphics: a method for displaying results in a drug trial.

Three-dimensional computer graphics are used to depict multidimensional outcome measures in a clinical drug trial. This graphics approach was used in a study of 116 patients with active rheumatoid arthritis, in a randomized, double-blind 21-week comparison of placebo, oral gold, and injectable gold. Three health status components, physical disability, psychological status, and pain, were generated using the Arthritis Impact Measurement Scales (AIMS). Results were presented in a three-axis perspective, one axis for each component, plotting individual patient vectors for magnitude and direction on a 10 X 10 X 10 coordinate matrix. Vectors for each patient are plotted from time 1 (start) to time 2 (finish) over the 21-week trial period. Vector symbols were added for clarity and subgroup delineation. Vector displays show trends in treatment response that clarify and strongly reinforce the statistical results. It is concluded that three-dimensional vector graphics are a useful adjunct to the statistical analysis of clinical trial results. The graphics facilitate the visual interpretation of a complex data set, and clarify the analysis of the results for both the clinician and researcher.

Computers in rheumatology practice: implications for clinical research.

We conducted a survey to determine the current and potential uses of computerized information systems in clinical rheumatology. One in 3 rheumatologists currently uses an office based computer, primarily for administrative functions, and at least one in 5 is likely to acquire a computer in the near future. Survey responses indicate that the increased use of office based computers will increase the willingness of community practitioners to participate in clinical research. This development will provide an opportunity to broaden the scope of clinical research participation and to increase the pool of patients available for cooperative clinical trials in rheumatology.

The Ancillary Services Review Program in Massachusetts. Experience of the 1982 pilot project.

In 1982, a pilot program to review the use of ancillary services in 25 hospitals was implemented in Massachusetts. The program analyzed hospital claims data to generate statistical models of ancillary use. Hospitals where the model demonstrated substantially higher use were subjected to clinical review. For laboratory services, three of the four hospitals reviewed were found to have more than 30% inappropriate use of selected tests, compared with approximately 20% in other hospitals. For cardiac services, three hospitals were each found to have more than 30% inappropriate use of selected tests, compared with 16% in other hospitals. When informed of these results, five of the six hospitals used them to develop plans of corrective action. Based on the pilot program, a review of ancillary services began in all Massachusetts hospitals in 1983.

Cardiac nuclear imaging. Adoption of an evolving technology.

A national survey was conducted to examine the extent of adoption and use of nuclear imaging procedures in cardiology in hospitals by 1979 and to develop estimates for 1983. The data are based on the responses of 171 hospitals from a representative 200-hospital sample stratified for region, bed-size, and teaching status. Extrapolating the data, it is estimated that 2,106 hospitals nationally use cardiac nuclear imaging. In 1979, hospitals with at least 200 beds performed an estimated 396,000 cardiac nuclear imaging studies at a cost of $93 million. By 1983, it is estimated that 4,061 hospitals had the capability to perform cardiac nuclear imaging and that national expenditures would exceed $200 million ( noninflated dollars). Although cardiac nuclear imaging procedures have been demonstrated to be valuable in detecting coronary artery disease or measuring ventricular function, these procedures were rapidly being adopted by the medical community at a time when only limited information about their effectiveness and efficiency are available.

The dimensions of health outcomes: a cross-validated examination of health status measurement.

Two independently developed patient outcome measurement instruments were administered to forty-eight subjects with rheumatoid arthritis using a random cross-over design. The independent estimates of physical disability and pain are highly correlated. Each instrument displayed highly significant relationships with global health, providing evidence for convergent validity. The results demonstrate that health status is composed of at least three major dimensions: physical disability, psychological disability, and pain.

A research paradigm for severity for illness: issues for the diagnosis-related group system.

The new Medicare Prospective Payment System has been challenged with regard to its fairness in reimbursing hospitals adequately, given the true resource needs in caring for patients. Most of these criticisms are now labelled as issues about adjustments for severity of illness. Critics point to the large amount of unexplained variation in charges and length of stay within the existing DRG's as indirect support for their contentions about inadequate adjustments. A paradigm is presented which argues that the key questions on the types of severity of illness measures to be utilized in future refinements of DRG's revolve around the extent and type of data which can feasibly be included in any workable reimbursement approach. A paradigm is presented on how these questions about information define a series of research options in the severity of illness arena.

Health status in chronic disease: a comparative study of rheumatoid arthritis.

A self-administered questionnaire has been used to measure and compare health status in rheumatoid arthritis (RA) and 5 other chronic diseases. Subjects with RA, hypertension, cancer, diabetes, cardiac disease, or pulmonary disease were assessed along 11 aspects of health status. Results showed significant differences in health status across the 6 diseases, particularly for physical function and pain. The psychological status measures were similar. A summary estimate indicated that RA and pulmonary diseases produced poorer health status than the others. This study confirms the severe negative health status associated with chronic RA.

The arthritis impact measurement scales. Further investigations of a health status measure.

The Arthritis Impact Measurement Scales (AIMS) have been developed to assess the health status of arthritis patients. In this study, the self-administered AIMS questionnaire, which includes scales designed to measure the physical, psychologic, and social aspects of health status, was completed by 625 patients with various forms of arthritis. A comprehensive battery of analytic techniques was used to investigate the performance of these scales in this large sample. The results confirmed the reliability and validity of the AIMS instrument. They also showed that AIMS performs well in at least 4 major types of arthritis, in a range of sociodemographic groups, and across time. These findings emphasize the strengths of the AIMS approach and suggest that the instrument will prove useful as a tool to assess arthritis outcome in a wide variety of clinical settings.

Surgery in an era of constrained resources.

The key studies of surgical policy that will effect the coming debates over the allocation of federal money and funds from private industry are reviewed. The author suggests that the surgical community should more critically conduct its own review efforts and follow up with corrective actions. Not to do so may jeopardize the stature, autonomy, and economic well-being of the profession.

General internal medicine units in academic medical centers: their emergence and functions.

By 1979, 77% of medical school primary teaching hospitals had functioning general internal medicine units; less than 5% had existed before 1970. These units were established to meet institutional needs for primary care internal medicine teachers and clinicians. By the end of the decade they had achieved major administrative and staffing responsibility for a wide variety of general education and service activities. The scope of general internal medicine units goes beyond the narrow definition of primary care internal medicine, to include activities traditionally considered those of the entire department of medicine.