Fall risk assessment measures: an analytic review.

BACKGROUND: Clinicians are often unaware of the many existing scales for identifying fall risk and are uncertain about how to select an appropriate one. Our purpose was to summarize existing fall risk assessment scales to enable more informed choices regarding their use. METHODS: After a systematic literature search, 21 articles published from 1984 through 2000 describing 20 fall risk assessments were reviewed independently for content and validation by a panel of five reviewers using a standardized review form. Fourteen were institution-focused nursing assessment scales, and six were functional assessment scales. RESULTS: The majority of the scales were developed for elderly populations, mainly in hospital or nursing home settings. The patient characteristics assessed were quite similar across the nursing assessment forms. The time to complete the form varied from less than 1 minute to 80 minutes. For those scales with reported diagnostic accuracy, sensitivity varied from 43% to 100% (median = 80%), and specificity varied from 38% to 96% (median = 75%). Several scales with superior diagnostic characteristics were identified. CONCLUSIONS: A substantial number of fall risk assessment tools are readily available and assess similar patient characteristics. Although their diagnostic accuracy and overall usefulness showed wide variability, there are several scales that can be used with confidence as part of an effective falls prevention program. Consequently, there should be little need for facilities to develop their own scales. To continue to develop fall risk assessments unique to individual facilities may be counterproductive because scores will not be comparable across facilities.

Intraventricular B-cell lymphoma from the breast.

We report an unusual case of massive intraventricular spread of B-cell lymphoma of the breast, presenting with rapidly progressive ataxia and impaired cognition with need for ventriculostomy. Rapid resolution followed intravenous dexamethasone and radiation therapy.

Validity of utilization management criteria for psychiatry.

OBJECTIVE: This study examined the validity of four psychiatric utilization management criteria sets: the 1992 and 1993 InterQual Intensity, Severity, and Discharge (ISD) criteria, the Managed Care Appropriateness Protocol, and an instrument developed by the Department of Veterans Affairs (VA). METHOD: The appropriateness of acute care admission and continued stay for 70 randomly selected VA psychiatric inpatients was retrospectively assessed with each criteria set. The sensitivity and specificity of each instrument were evaluated by comparing its assessments to the consensus of judgments of a panel of expert psychiatrists who reviewed the same cases. Sensitivity was defined as the proportion of admissions or continued-stay days the panel found appropriate for acute care that the criteria judged to be appropriate for acute care; specificity was the proportion the panel found inappropriate for acute care that the criteria judged to be inappropriate for acute care. RESULTS: For admissions, there were only minor differences in the validity of the four criteria sets as assessed by agreement with the panel's judgments. For each of 4 continued-stay days studied, either the sensitivity or specificity of the 1993 InterQual ISD criteria was below 0.30. The specificity of the 1992 InterQual ISD criteria was below 0.60 for 2 days. In contrast, for the Managed Care Appropriateness Protocol, sensitivity was 0.73-0.93 and specificity was 0.78-0.88 over the 4 days. CONCLUSIONS: The findings raise major concerns about the validity of the widely used InterQual ISD psychiatry criteria, suggest that the Managed Care Appropriateness Protocol may be a useful tool for psychiatric utilization management, strongly underline the need to validate all criteria used to assess medical care, and support the appropriateness of the procedures used to perform these assessments.

Contribution of locally and externally designed quality management activities to hospitals' efforts to improve patient care.

We examined the effects of quality management activities on efforts by hospitals to improve patient care. Our primary objective was to assess the relative contribution to these efforts of quality management activities designed by facility staff and those designed by external organizations. We asked chiefs of medicine, surgery, psychiatry, and ambulatory care at 47 randomly selected Department of Veterans Affairs hospitals to identify the 3 actions taken by their departments during the previous year that most improved patient care. The sources of information contributing to each action were subsequently identified through 2 independent procedures: a review of hospital documents and attributions by the department chiefs. Quality management activities contributed to 31% of 493 actions to improve care in the analysis of the department chiefs' attributions and to 26% of 446 actions in the analysis of the sources found in hospital documents. Four locally designed quality management activities contributed to more than twice as many actions to improve patient care as did 12 externally designed ones, suggesting that locally designed quality management activities have a greater effect on efforts to improve patient care than do externally designed ones.

Improving peer review: alternatives to unstructured judgments by a single reviewer.

BACKGROUND: Peer review, usually involving unstructured judgments by a single peer reviewing medical records, was the backbone of quality management in health care organizations until recent years. Although other approaches to quality management, such as continuous quality improvement, are now being widely adopted, peer review can still play a role in identifying dysfunctional organizational processes and individuals delivering poor care. Given the questionable reliability and validity of peer review as usually practiced, however, a more rigorous and thoughtful approach is needed-with consideration of issues such as the number of peers involved, the nature of their interaction while forming judgments, and the type of assessment instruments they use. MULTIPLE-REVIEWER PROCEDURES: Such procedures include the use of two or more reviewers making their assessments independently, discussion to consensus among reviewers, and committee review. STRUCTURED ASSESSMENT INSTRUMENTS: A number of studies suggest that instruments that carefully guide the reviewer have higher interrater reliability than less structured instruments. IDENTIFICATION OF SYSTEM ISSUES: The focus of peer review can be expanded beyond individual practitioner performance to include assessment of the operational environment in which the clinician functions. For example, one might ask whether any changes in hospital policies or procedures or in administrative or computerized support for clinicians might have improved the care received by a patient. CONCLUSION: The available data and the known limitations of unstructured judgments by a single reviewer justify serious consideration of multiple reviewer procedures and structured assessment instruments, particularly for reviews that have major consequences for patients and practitioners.

Overutilization of acute-care beds in Veterans Affairs hospitals.

The authors tested the hypothesis that the Department of Veterans Affairs (VA) hospitals would have substantial overutilization of acute care beds and services because of policies that emphasize inpatient care over ambulatory care. Reviewers from 24 randomly selected VA hospitals applied the InterQual ISD* (Intensity, Severity, Discharge) criteria for appropriateness concurrently to a random sample of 2,432 admissions to acute medical, surgical, and psychiatry services. Reliability of hospital reviewers in applying the ISD* criteria was tested by comparing their reviews with those of a small group of expert reviewers. Validity of the ISD* criteria was tested by comparing the assessments of master reviewers with the implicit judgments of panels of nine physicians. The physician panels validated the ISD* admission criteria for medicine and surgery (74% agreement with master reviewers, kappa > 0.4), whereas the psychiatry criteria were not validated (66% agreement, kappa 0.29). Hospital reviewers reliably used all three criteria sets (> 83% agreement with master reviewers, kappa > 0.6). Rates of nonacute admissions to acute medical and surgical services were > 38% as determined by the hospital and master reviewers and by the physician panels. Nonacute rates of continued stay were > 32% for both medicine and surgery services. Similar rates of nonacute admissions and continued stay were found for all 24 hospitals. Reasons for nonacute admissions and continued stay included lack of an ambulatory care alternative, conservative physician practices, delays in discharge planning, and social factors such as homelessness and long travel distances to the hospital. Using criteria that the authors showed to be reliable and valid, substantial overutilization of acute medicine and surgical beds was found in a representative sample of VA hospitals. Correcting this situation will require changes in physician practice patterns, development of ambulatory care alternatives to inpatient care, and modification of current VA policies determining eligibility for care.

Developing private health care in Macedonia.

The Republic of Macedonia is the sole former Yugoslavian republic that has had a peaceful transition to independence. The current socialist health care system is bankrupt with an over-emphasis on specialty care and too many doctors. While clinical standards equal those in Western Europe, customer service is at a low level. Private initiatives are being encouraged by most members of the health care community. However, the current state system should be retained with a sound financial base. Private initiatives have a high potential for success.

Magnetic resonance angiography in the diagnosis of deep cerebral venous thrombosis.

Given the nonspecific and conflicting "indirect" signs and rare occurrence of the true "direct" signs on computed tomography (CT) and magnetic resonance imaging (MRI), conventional angiography has been the "gold standard" in the diagnosis of cerebral venous thrombosis. Visualization of the deep venous system by magnetic resonance angiography (MRA) suggests this modality may accurately demonstrate thrombosis at this level. We present a 34-year-old Down syndrome patient with deep cerebral venous thrombosis demonstrated by MRA who was initially misdiagnosed as a bithalamic glioma due to the similarity in the imaging characteristics of the two conditions. No direct evidence of venous thrombosis was present on CT or MRI. MRA was the sole noninvasive imaging modality to "directly" demonstrate venous thrombosis and is suggested in the evaluation of unexplained or atypical cerebral events that may represent deep cerebral venous thrombosis.

Symptomatic leiomyoma of the adrenal.

Although small leiomyomas of the adrenal are a common incidental finding at autopsy, larger examples are extremely rare and have been asymptomatic, discovered as an incidental finding during computed abdominal scanning. We report the first, to our knowledge, instance of a large, symptomatic adrenal leiomyoma, and discuss the pathological and radiological features of the lesion.

Using mortality rates as a screening tool: the experience of the Department of Veterans Affairs.

BACKGROUND: Despite widespread agreement that outcome analyses should be followed by in-depth review of the care provided by outlier providers, there are few, if any, reports in the literature describing the effectiveness of this approach to quality improvement. In 1991, the Department of Veterans Affairs (VA) completed a study to measure hospital-specific mortality rates for VA facilities and to use these rates as a screening tool for focused medical record reviews. METHODS: The first phase of the project consisted of a comparison of fiscal year 1986 mortality rates for each VA medical center with aggregated VA data, using logistic regression analysis to adjust for patient characteristics related to mortality. In the second phase, medical record reviews of cases from hospitals with elevated levels of mortality were conducted. RESULTS: The mortality rate analysis identified 44 facilities with rates that were significantly elevated overall or within specific patient categories. Both the mortality rate analysis and the medical record review suggested that quality concerns were more common in predominantly psychiatric medical centers than in other facilities. CONCLUSION: The study uncovered important opportunities for improvement, particularly regarding the quality of medical care provided in VA psychiatric hospitals, suggesting there is value in performing intensive review of outlier providers in outcome analyses. However, serious questions remain concerning the validity of the use of administrative data-bases to assess hospitalwide mortality.

Managed care in Eastern Europe: an opportunity for U.S. firms.

Health care in Eastern Europe is in transition; the former state-run health systems are in shambles. This article describes elements of these systems, discusses transition problems, such as corruption, and suggests areas in which American firms can prosper. Problems with capital development and red tape will need to be overcome. However, the quality of physician training is high, and many doctors are eager to work with American institutions to emulate their standards of care. Their need for training in Western management techniques is quite apparent. The author suggests that managed care organizations can be established rapidly if local partners are included in their development.

The reliability of peer assessments. A meta-analysis.

A meta-analysis of studies examining the interrater reliability of the standard practice of peer assessments of quality of care was conducted. Using the Medline, Health Planning and Administration, and SCISEARCH databases, the English-language literature from 1966 through 1991 was searched for studies of chance corrected agreement among peer reviewers. The weighted mean kappa of 21 independent findings from 13 studies was .31. Comparison of this result with widely used standards suggests that the interrater reliability of peer assessment is quite limited and needs improvement. Research needs to be directed at modifying the peer review process to improve its reliability or at identifying indexes of quality with sufficient validity and reliability that they can be employed without subsequent peer review.

Pure squamous cell carcinoma of the larynx with cervical nodal metastasis showing rhabdomyosarcomatous differentiation. Clinical, pathologic, and immunohistochemical study of a unique example of divergent differentiation.

We describe a unique case of pure squamous carcinoma of the larynx that developed a cervical lymph node metastasis showing rhabdomyosarcoma admixed with squamous carcinoma (that is, carcinosarcoma). The rhabdomyosarcoma showed foci immunoreactive to multiple cytokeratin monoclonal antibodies, as well as to markers for striated muscle, thus indicating true divergent epithelial and rhabdomyosarcomatous differentiation. Although the morphogenesis of carcinosarcomas remains controversial, the sequence of events for the current case favors sarcomatous transformation of the original carcinoma (that is, sarcomatous neometaplasia of the primary carcinoma clone). The possible contributory role of radiation therapy in this case in inducing such a change is noted.