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Abstracts
Abstracts
Detection of Alcoholism in Hospitalized Patients RD Moore, et al: Prevalence, detection, and treatment of alcoholism in hospitalized patients. Journal of the American Medical Association 261 (3): 403-407, January 20,1989. Alcoholism extracts a heavy price from health care systems; 10% to 50% of the inpatient population in community and teaching hospitals suffer from alcohol-related problems. Because of these high percentages, administrators of The Johns Hopkins Hospital (Baltimore) instituted the Johns Hopkins Alcohol Project in 1986 to determine the prevalence, detection, and treatment of alcoholism among their hospitalized patients. The project addressed four issues: the prevalence of hospitalized patients with alcoholism in the hospital 's clinical departments; characteristics of these patients; the rate of identification and treatment of these patients by physicians; and identifiable correlates of diagnosis and/or treatment of these patients. Trained interviewers used either the CAGE questionnaire (Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers) or the SMAST (Short Michigan Alcoholism Screening Test) to screen 2,002 patients for alcohol-related problems. Patients were identified within 48 hours of admission to the hospital. Patients admitted to the hospital's detoxification unit or to the short-stay unit were excluded from the study. Patients who screened positively for alcoholism on either the CAGE questionnaire or SMAST were then interviewed by the physician responsible for them. Physician interviews were conducted in the departments of medicine, surgery and the surgical subspecialties, neurology, psychiatry, and gynecology. Research130
ers sought to determine whether the physician had identified alcohol-related problems, how their diagnosis was determined, and what, if any, treatment was provided. Of the patients who screened positive for alcoholism through use of the CAGE questionnaire or the SMAST, house staff and faculty physicians detected less than 25% in surgery and gynecology, between 25% to 50% in neurology and medicine, and more than 50% in psychiatry. The method of identification used in all departments was primarily personal history-taking and/or medical record review. The CAGE questionnaire or SMAST was never used by house staff and family physiciafis. Psychiatry had the highest rate of instituting treatment, whereas surgery had the lowest.
Medication Usage and the Quality of Care in Rest Homes J Avorn, et al: Use of psychoactive medication and the quality of care in rest homes : Findings and policy implications of a statewide study. New England Journal of Medicine 320(4): 227-232, January 26, 1989. Rest homes are increasingly caring for deinstitutionalized psychiatric patients and frail elderly patients who require medication and some medical care. The Massachusetts Department of Public Health conducted a statewide survey and a follow-up survey to determine the patient population of rest homes, evaluate the adequacy of placement and patterns of medication use, inspect patients' medication profiles and clinical documentation, assess patients' functional statuses, and evaluate the ability of rest home staff members to recognize medication-related prob-
lems and to correctly administer psychoactive medications. They selected a stratified random sampling of 50 freestanding rest homes and five rest homes from multilevel facilities in Massachusetts. Data were collected on 1,201 residents in the statewide survey. Researchers found that 39% of these residents were taking antipsychotic medications and 55% were taking at least one psychoactive medication. The follow-up survey examined 837 residents in 44 rest homes with a high frequency of psychiatric illnesses and found that 82% of the residents were taking one or more antipsychotic drug. A clinical record review revealed that no notes were made by physicians on any mental health issue in 47.8% of resident records. Less than half of the staff respondents were able to place six commonly used psychoactive medications into one of four broad multiplechoice categories, indicating poor knowledge of the purpose and side effects of these drugs. The authors suggest that more regulatory monitoring may be necessary in rest homes with high frequencies of medication use and that more attention be paid to the medical supervision and education of rest home staff members.
Nursing Home Outcomes JA Nyman: Improving the quality of nursing home outcomes: Are adequacyor incentive-oriented policies more effective ? Medical Care 26(12):1158-1171, December 1988. Debates over the most effective policies for improving the quality of care in nursing homes usually pit "adequacy"-oriented policies against "incentive"-oriented policies. The author describes adequacy-oriented policies as those that try to assure QRB/April 1989
that nursing homes have adequate financial and physical resources to provide a certain minimal level of quality. Incentive-oriented policies identify incentives nursing homes can use to convert existing resources into quality outcomes. Health care policies such as retrospective reimbursement systems and higher reimbursement rates are adequacy-oriented. The author used data from the 1983 Iowa Outcome Oriented Survey, which evaluated the performance of Iowa's nursing homes based on nonhealth outcome-related criteria such as nursing home maintenance and residents' quality of life, to determine whether quality of care requires more resources. No significant relationship was found between the quality measures constructed from these data and higher costs. The author suggests that because previous studies have used quality measures that incorporated some form of inputs, they cannot be to used to evaluate whether nursing homes with better quality have higher costs. Incentives that may help improve the quality of care in nursing homes include more professional training, nonprofit status, and the attraction of private patients.
Technology and Quality Assessment
A Donabedian: The assessment of technology and quality: A comparative study of certainties and ambiguities. International Journal of Technology Assessment in Health Care 4(4):487296,1988. Technology assessment and quality assessment are two frequently confused terms. Simply, technology assessment is concerned primarily with modalities of care, whereas quality assessment is concerned with how
QRB/April1989
well these modalities of care, or technologies, are used in various settings. The author delineates the subtle differences between these two types of assessments in several areas, including the phenomena subject to assessment, level and scope of concern, outcomes, and cost and efficiency. One of technology assessment's main tasks is to generate criteria and standards of care. This is accomplished through three different methods : mathematical modeling, systematic observations of events in the existing world, and experimental trial. However, it is the role of quality assessment to evaluate the extent to which these criteria and standards have been observed. This difference points to a fundamental distinction between outlooks: technologyassessment focuses on societal factors whereas quality assessment focuses on the individual patient. The author suggests that this distinction has been arbitrarily assigned; it is possible that technology assessment, as it identifies groups of growing internal homogeneity, will come closer to a more individualized outlook. Both assessments work to arrive at an optimal balance between costs and benefits. However, society itself will have to address the growing disparity between social and individualized definitions of quality.
Initiatives To Improve Health Care
WL Roper, et al: Effectiveness in health care: An initiative to evaluate and improve medical practice. New England Journal of Medicine 319(18):1197-1202, November 3, 1988. Exchanging information on new research findings , medical techniques, and practice patterns is vital to the overall improvement of health care. The Health Care Financ-
ing Administration (HCFA) and the Public Health Service are working to produce better information for the improvement of patient outcomes and quality of care. HCFA is planning four different projects: (1) Monitoring trends and assessing the effectiveness of specific interventions by using data from the Medicare system of claims processing, (2) Developing a data resource center and making files of Medicare data available for appropriate research by private individuals and organizations, (3) Funding clinical research that examines the appropriateness and effectiveness of various procedures and interventions, and (4) Expanding data bases and improving research methods on medical effectiveness. HCFA's assessment of medical effectiveness and improvement of clinical practice involves four steps: monitoring, analysis of variations, assessment of interventions, and feedback and education. The Public Health Service is also looking at studies that will develop and disseminate information on practices that enhance patient outcomes. Both of these agencies are looking to the private sector to obtain help in research activities, organizing studies, and reviewing results. HCFA envisions sharing data qases between public and private health care payers, better training and education in the evaluation sciences, and the refinement of medical practice guidelines and standards by professional societies. The agencies also hope to improve guidelines for medical practice and provide better legal protection for physicians who follow these new guidelines. "Abstracts" was prepared by Nancy Koch, Senior Editor.
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Detection of Alcoholism in Hospitalized Patients RD Moore, et al: Prevalence, detection, and treatment of alcoholism in hospitalized patients. Journal of the American Medical Association 261 (3): 403-407, January 20,1989. Alcoholism extracts a heavy price from health care systems; 10% to 50% of the inpatient population in community and teaching hospitals suffer from alcohol-related problems. Because of these high percentages, administrators of The Johns Hopkins Hospital (Baltimore) instituted the Johns Hopkins Alcohol Project in 1986 to determine the prevalence, detection, and treatment of alcoholism among their hospitalized patients. The project addressed four issues: the prevalence of hospitalized patients with alcoholism in the hospital 's clinical departments; characteristics of these patients; the rate of identification and treatment of these patients by physicians; and identifiable correlates of diagnosis and/or treatment of these patients. Trained interviewers used either the CAGE questionnaire (Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers) or the SMAST (Short Michigan Alcoholism Screening Test) to screen 2,002 patients for alcohol-related problems. Patients were identified within 48 hours of admission to the hospital. Patients admitted to the hospital's detoxification unit or to the short-stay unit were excluded from the study. Patients who screened positively for alcoholism on either the CAGE questionnaire or SMAST were then interviewed by the physician responsible for them. Physician interviews were conducted in the departments of medicine, surgery and the surgical subspecialties, neurology, psychiatry, and gynecology. Research130
ers sought to determine whether the physician had identified alcohol-related problems, how their diagnosis was determined, and what, if any, treatment was provided. Of the patients who screened positive for alcoholism through use of the CAGE questionnaire or the SMAST, house staff and faculty physicians detected less than 25% in surgery and gynecology, between 25% to 50% in neurology and medicine, and more than 50% in psychiatry. The method of identification used in all departments was primarily personal history-taking and/or medical record review. The CAGE questionnaire or SMAST was never used by house staff and family physiciafis. Psychiatry had the highest rate of instituting treatment, whereas surgery had the lowest.
Medication Usage and the Quality of Care in Rest Homes J Avorn, et al: Use of psychoactive medication and the quality of care in rest homes : Findings and policy implications of a statewide study. New England Journal of Medicine 320(4): 227-232, January 26, 1989. Rest homes are increasingly caring for deinstitutionalized psychiatric patients and frail elderly patients who require medication and some medical care. The Massachusetts Department of Public Health conducted a statewide survey and a follow-up survey to determine the patient population of rest homes, evaluate the adequacy of placement and patterns of medication use, inspect patients' medication profiles and clinical documentation, assess patients' functional statuses, and evaluate the ability of rest home staff members to recognize medication-related prob-
lems and to correctly administer psychoactive medications. They selected a stratified random sampling of 50 freestanding rest homes and five rest homes from multilevel facilities in Massachusetts. Data were collected on 1,201 residents in the statewide survey. Researchers found that 39% of these residents were taking antipsychotic medications and 55% were taking at least one psychoactive medication. The follow-up survey examined 837 residents in 44 rest homes with a high frequency of psychiatric illnesses and found that 82% of the residents were taking one or more antipsychotic drug. A clinical record review revealed that no notes were made by physicians on any mental health issue in 47.8% of resident records. Less than half of the staff respondents were able to place six commonly used psychoactive medications into one of four broad multiplechoice categories, indicating poor knowledge of the purpose and side effects of these drugs. The authors suggest that more regulatory monitoring may be necessary in rest homes with high frequencies of medication use and that more attention be paid to the medical supervision and education of rest home staff members.
Nursing Home Outcomes JA Nyman: Improving the quality of nursing home outcomes: Are adequacyor incentive-oriented policies more effective ? Medical Care 26(12):1158-1171, December 1988. Debates over the most effective policies for improving the quality of care in nursing homes usually pit "adequacy"-oriented policies against "incentive"-oriented policies. The author describes adequacy-oriented policies as those that try to assure QRB/April 1989
that nursing homes have adequate financial and physical resources to provide a certain minimal level of quality. Incentive-oriented policies identify incentives nursing homes can use to convert existing resources into quality outcomes. Health care policies such as retrospective reimbursement systems and higher reimbursement rates are adequacy-oriented. The author used data from the 1983 Iowa Outcome Oriented Survey, which evaluated the performance of Iowa's nursing homes based on nonhealth outcome-related criteria such as nursing home maintenance and residents' quality of life, to determine whether quality of care requires more resources. No significant relationship was found between the quality measures constructed from these data and higher costs. The author suggests that because previous studies have used quality measures that incorporated some form of inputs, they cannot be to used to evaluate whether nursing homes with better quality have higher costs. Incentives that may help improve the quality of care in nursing homes include more professional training, nonprofit status, and the attraction of private patients.
Technology and Quality Assessment
A Donabedian: The assessment of technology and quality: A comparative study of certainties and ambiguities. International Journal of Technology Assessment in Health Care 4(4):487296,1988. Technology assessment and quality assessment are two frequently confused terms. Simply, technology assessment is concerned primarily with modalities of care, whereas quality assessment is concerned with how
QRB/April1989
well these modalities of care, or technologies, are used in various settings. The author delineates the subtle differences between these two types of assessments in several areas, including the phenomena subject to assessment, level and scope of concern, outcomes, and cost and efficiency. One of technology assessment's main tasks is to generate criteria and standards of care. This is accomplished through three different methods : mathematical modeling, systematic observations of events in the existing world, and experimental trial. However, it is the role of quality assessment to evaluate the extent to which these criteria and standards have been observed. This difference points to a fundamental distinction between outlooks: technologyassessment focuses on societal factors whereas quality assessment focuses on the individual patient. The author suggests that this distinction has been arbitrarily assigned; it is possible that technology assessment, as it identifies groups of growing internal homogeneity, will come closer to a more individualized outlook. Both assessments work to arrive at an optimal balance between costs and benefits. However, society itself will have to address the growing disparity between social and individualized definitions of quality.
Initiatives To Improve Health Care
WL Roper, et al: Effectiveness in health care: An initiative to evaluate and improve medical practice. New England Journal of Medicine 319(18):1197-1202, November 3, 1988. Exchanging information on new research findings , medical techniques, and practice patterns is vital to the overall improvement of health care. The Health Care Financ-
ing Administration (HCFA) and the Public Health Service are working to produce better information for the improvement of patient outcomes and quality of care. HCFA is planning four different projects: (1) Monitoring trends and assessing the effectiveness of specific interventions by using data from the Medicare system of claims processing, (2) Developing a data resource center and making files of Medicare data available for appropriate research by private individuals and organizations, (3) Funding clinical research that examines the appropriateness and effectiveness of various procedures and interventions, and (4) Expanding data bases and improving research methods on medical effectiveness. HCFA's assessment of medical effectiveness and improvement of clinical practice involves four steps: monitoring, analysis of variations, assessment of interventions, and feedback and education. The Public Health Service is also looking at studies that will develop and disseminate information on practices that enhance patient outcomes. Both of these agencies are looking to the private sector to obtain help in research activities, organizing studies, and reviewing results. HCFA envisions sharing data qases between public and private health care payers, better training and education in the evaluation sciences, and the refinement of medical practice guidelines and standards by professional societies. The agencies also hope to improve guidelines for medical practice and provide better legal protection for physicians who follow these new guidelines. "Abstracts" was prepared by Nancy Koch, Senior Editor.
131