Measuring and improving quality using information systems.

Information systems (IS) are increasingly important for measuring and improving quality. In this paper, we describe our integrated delivery system's plan for and experiences with measuring and improving quality using IS. Our approach is that for quality measurement to be practical, it must be integrated with the routine provision of care, and whenever possible should be done using IS. Thus, at one hospital, we now perform almost all quality measurement using IS. However, IS are not only useful for measuring care, but represent powerful tools for improving care using decision support. Specific areas in which IS has already been particularly effective include reducing the unnecessary use of laboratory testing, reporting important abnormalities to key providers rapidly, adverse drug event detection and prevention, initiatives to reduce the costs of drugs, and making critical pathways available to providers. The next wave of effort will be to promote widespread use of computerized guidelines, which is likely to prove more challenging. However, the advent of managed care in the U.S. has produced strong incentives to provide high quality care at low cost, and our perspective is that only with better IS than exist today will this be possible on a widespread basis. Such systems make feasible implementation of care improvement and cost reduction initiatives on a scale which could not previously be considered.

Gonorrhea case-finding among asymptomatic men seeking ambulatory care: a cost effectiveness analysis.

Case-finding for gonorrhea in asymptomatic men is generally not performed in primary care settings and often not performed when men are seen for other reasons in clinics for sexually transmitted diseases. We performed a cost-effectiveness analysis of case-finding among asymptomatic men seeking ambulatory care, using culture of the first-voided urine and treatment of culture-positive patients with tetracycline. The analysis demonstrated that care-finding is increasingly cost-effective as the probability of asymptomatic gonorrhea becomes greater. Over a reasonable expected range of the probability of asymptomatic gonorrhea (0.1-15%) in such settings, the additional cost to avert one additional day of morbidity ranged from $47,000 to $260; the additional cost to avert one additional case of residual asymptomatic infection ranged from $26,000 to $140; and the additional cost to avert one additional case of pelvic inflammatory disease in a contact ranged from $250,000 to $1,400. We conclude that the cost-effectiveness of case-finding for gonorrhea among asymptomatic men compares favorably with that of other medical interventions when the probability of infection is relatively high (perhaps greater than or equal to 5%). In order to make use of such information, physicians in ambulatory care settings require better information about the probability of gonorrhea in asymptomatic men who differ in their medical histories and socioeconomic and ethnic backgrounds.

Benefits, risks, and costs of alternative approaches to the evaluation and treatment of severe ankle sprain.

A cost-effectiveness analysis was used to compare five methods of management of severe ankle sprain: (1) wrapping the ankle immediately (i.e., without obtaining further roentgenograms); (2) casting the ankle immediately; (3) obtaining stress films and providing treatment accordingly by wrapping, casting, or surgery; (4) obtaining arthrograms and performing appropriate treatment; and (5) obtaining stress films, followed by arthrograms, in patients with positive stress films and administering appropriate treatment. The probability of ankle stability was high for all five strategies (greater than 97%). However, the expected days of morbidity from different strategies ranged from 36.2 to 73.4 per patient, the probability of premature death ranged from 1.5 to 17.7 per 100,000 patients, and the dollar costs ranged from $318 to $941 per patient. Cost-effectiveness and risk/benefit ratios indicated that the "wrap strategy" and the "stress film strategy" were clearly more cost-effective than the other three strategies.

Appointment reminders to reduce no-show rates. A stratified analysis of their cost-effectiveness.

To determine whether reminders are cost-effective for an adult primary care internal medicine center, we randomized 590 scheduled, follow-up appointments to no reminder, computer-generated letter reminders, and telephoned reminders. The no-show rate was reduced from 24% in the control group to 14% in the reminder groups, and letter and telephoned reminders were equally effective. An economic analysis showed that about two thirds of the savings realized from reminders was generated in 23% of the patients whose prior predicted probability of a no-show appointment was above 20%. However, in our primary care center, computer-generated letter reminders were estimated to be cost-effective whenever the probability of a no-show was above 5%, and telephoned or manual letter reminders were estimated to be cost-effective whenever the probability of a no-show was above about 11%. Based on our sensitivity analysis, telephoned or manual letter reminders should be cost-effective in many other ambulatory settings as well, although in some settings, reminders may be restricted to patients at high risk for no-show behavior.

Impact of inter-physician communication on the effectiveness of medical consultations.

To evaluate the impact of the inter-physician communication on the effectiveness of consultations, consultations performed by general and subspecialty medical consultation services for one week both early and late in the academic year were prospectively evaluated. Physicians commonly requested consultations to get advice on diagnosis (56 percent), advice on management (37 percent), or assistance in arranging or performing a procedure or test (20 percent). Despite our very liberal definitions, the requesting physician and the consultant completely disagreed on both the reason for the consultation and the principal clinical issue in 22 (14 percent) of 156 consultations. Consultants were twice as likely as the requesting physicians to rate consultations as crucial for management (35 percent versus 18 percent, p = 0.001) because they gave significantly higher ratings when they and the requesting physicians did not agree on the reasons for consultation. Consultations ordered for very specific purposes, such as assistance in arranging or performing a test, were rated significantly higher by the requesting physicians. It was found that breakdowns in communication are not uncommon in the consultation process and may adversely affect patient care, cost effectiveness, and education.

Measurement of medication compliance in a clinical setting. Comparison of three methods in patients prescribed digoxin.

Medication compliance is an important medical process, and useful methods are needed to measure compliance in clinical practice. Interview, pill count, and serum digoxin concentration (SDC) were compared in 173 patients prescribed digoxin to determine (1) feasibility, ease, timeliness; (2) reasons for noncompliance; and (3) validity of interview and pill count compared with SDC. All patients were interviewed; among 33 (19%) not taking their medication correctly, nine (5%) did not know how. Pill counts were possible for 68 patients (39%). One patient had a correct pill count. Steady-state SDCs were obtained for 143 patients (83%), but were not available during patients' visits. The SDCs for 25 patients were less than 0.50 ng/mL. Interviews correlated with SDCs, pill counts did not. Pill counts and SDCs required telephoning patients before appointments. In clinical practice, interview may be the most useful methof of measuring medication compliance.

A teaching hospital medical clinic: secondary rather than primary care.

Although medical clinics in teaching hospitals are said to dispense primary care, the assertion has not been established by formal descriptions of care in such clinics. In this paper the authors describe 287 patient visits to a medical polyclinic (where generalists and subspecialists of internal medicine practice together) over a one-year period. The prevalence of disease was much higher than in existing descriptions of office-based primary care. The majority of visits to subspecialists involved medical problems relevant to the subspecialty, but both subspecialists and generalists dealt with medical problems across subspecialty lines because most patients had multiple problems. Although the data indicate these patients' need for accessibility, comprehensiveness, coordination, and continuity is at least as great as that of patients receiving primary care, this clinic is most appropriately described as a secondary-care facility.

Comparison of epicardial and endocardial pacemaker insertion.

The authors compared the results of 100 pacemaker insertion procedures: 50 endocardial and 50 epicardial. The late pacing threshold and the postoperative pain and pulmonary complications were higher in the epicardial group. Although dislodgement occurred in 28% of cases of insertion through the endocardial route, the authors concluded that this route was preferable.