Quality of Care for Two Common Illnesses in Teaching and Nonteaching Hospitals

Health Affairs

Volumn 17, Issue 6, 1998, Pages 194-205

  Ayanian, John Z ^a   Weissman, Joel S ^a   Chasan Taber, Scott ^a   Epstein, Arnold M ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

AGED; ARTICLE; CLASSIFICATION; CONGESTIVE HEART FAILURE; EPIDEMIOLOGY; FEMALE; HEALTH CARE QUALITY; HUMAN; MALE; MEDICARE; PNEUMONIA; STANDARD; STATISTICS; TEACHING HOSPITAL; UNITED STATES;

AGED; FEMALE; HEART FAILURE, CONGESTIVE; HOSPITALS, TEACHING; HUMANS; MALE; MEDICARE; PNEUMONIA; QUALITY OF HEALTH CARE; SAMPLING STUDIES; UNITED STATES;

EID: 0347506345     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.17.6.194     Document Type: Article

References (30)

1. L.I. Iezzoni et al., "Illness Severity and Costs of Admissions at Teaching and Nonteaching Hospitals," Journal of the American Medical Association 264, no. 11 (1990): 1426-1431; and J.E. Zimmerman et al., "Value and Cost of Teaching Hospitals: A Prospective, Multicenter, Inception Cohort Study," Critical Care Medicine 21, no. 10 (1993): 1432-1442.
2. L.I. Iezzoni et al., "Illness Severity and Costs of Admissions at Teaching and Nonteaching Hospitals," Journal of the American Medical Association 264, no. 11 (1990): 1426-1431; and J.E. Zimmerman et al., "Value and Cost of Teaching Hospitals: A Prospective, Multicenter, Inception Cohort Study," Critical Care Medicine 21, no. 10 (1993): 1432-1442.
3. D. Blumenthal, E.G. Campbell, and J.S. Weissman, "The Social Missions of Academic Health Centers," New England Journal of Medicine 337, no. 21 (1997): 1550-1553.
4. J.Z. Ayanian, "The Prospect of Sweeping Reform in Graduate Medical Education," Milbank Quarterly 72, no. 4 (1994): 705-712.
5. Health Care Financing Review Medicare and Medicaid Statistical Supplement, DHHS Pub. no. (PHS)96-03386 (Baltimore, Md.: HCFA Office of Research and Demonstrations, 1996).
6. K.L. Kahn et al., The Effects of the DRG-Based Prospective Payment System on Quality of Care for Hospitalized Medicare Patients: Final Report (Santa Monica, Calif.: RAND, 1992).
7. A.M. Epstein et al., Using Outcomes to Assess Quality: Do Readmissions Matter? Final Report to the Agency for Health Care Policy and Research (Boston, Mass.: Department of Health Care Policy, Harvard Medical School, 1996).
8. For congestive heart failure, confirmation required evidence of respiratory distress in a physician's note and a chest radiograph on the first or second hospital day showing congestive heart failure or pulmonary vascular congestion or evidence of bilateral lower extremity edema or anasarca in a physician's note. For pneumonia, confirmation required a chest radiograph within one week before or one day after admission showing an infiltrate and at least one of the following findings on the first or second hospital day: cough, sputum production, temperature greater than 37.8 degrees Celsius, white blood cell count greater than 15,000 cells per microliter, or a white blood cell differential with at least 90 percent neutrophils or 15 percent bands. To ensure relatively homogeneous samples, we also excluded patients who were transferred to or from another hospital (twelve patients), had an acute myocardial infarction on admission (seven patients), had a cardiac or respiratory arrest within twenty-four hours prior to admission (five patients), or had major surgery during the admission (six patients). Furthermore, for congestive heart failure, we excluded patients with hyperthyroidism; thiamine deficiency; Paget's disease of bone; end-stage renal disease; a prior kidney transplant; or cancer with active treatment, metastases, or poor prognosis (acute leukemia, sarcoma, and cancers of the brain, esophagus, stomach, liver, pancreas, and lung) (twenty-three patients). For pneumonia, we excluded patients with a history of lung cancer (forty-nine patients).
9. Prospective Payment Assessment Commission, Medicare and the American Health Care System: Report to the Congress (Washington: ProPAC, 1996).
10. For implicit criteria, see K.L. Kahn et al., Structured Implicit Review for Physician Implicit Measurement of Quality of Care: Development of the Form and Guidelines for Its Use (Santa Monica, Calif.: RAND, 1989); H.R. Rubin et al., Guidelines for Structured Implicit Review of the Quality of Hospital Care for Diverse Medical and Surgical Conditions (Santa Monica, Calif.: RAND, 1990); and L.V. Rubenstein et al., "Changes in Quality of Care for Five Diseases Measured by Implicit Review, 1981-1986," Journal of the American Medical Association 264, no. 15 (1990): 1974-1979. For explicit criteria, see Kahn et al., The Effects of the DRG-Based Prospective Payment System on Quality of Care; and K.L. Kahn et al., "Measuring Quality of Care with Explicit Process Criteria before and after Implementation of the DRG-Based Prospective Payment System," Journal of the American Medical Association 264, no. 15 (1990): 1969-1973. Space limitations preclude a complete description of our methodology. Interested readers may contact John Z. Ayanian, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, Massachusetts 02115.
11. For implicit criteria, see K.L. Kahn et al., Structured Implicit Review for Physician Implicit Measurement of Quality of Care: Development of the Form and Guidelines for Its Use (Santa Monica, Calif.: RAND, 1989); H.R. Rubin et al., Guidelines for Structured Implicit Review of the Quality of Hospital Care for Diverse Medical and Surgical Conditions (Santa Monica, Calif.: RAND, 1990); and L.V. Rubenstein et al., "Changes in Quality of Care for Five Diseases Measured by Implicit Review, 1981-1986," Journal of the American Medical Association 264, no. 15 (1990): 1974-1979. For explicit criteria, see Kahn et al., The Effects of the DRG-Based Prospective Payment System on Quality of Care; and K.L. Kahn et al., "Measuring Quality of Care with Explicit Process Criteria before and after Implementation of the DRG-Based Prospective Payment System," Journal of the American Medical Association 264, no. 15 (1990): 1969-1973. Space limitations preclude a complete description of our methodology. Interested readers may contact John Z. Ayanian, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, Massachusetts 02115.
12. For implicit criteria, see K.L. Kahn et al., Structured Implicit Review for Physician Implicit Measurement of Quality of Care: Development of the Form and Guidelines for Its Use (Santa Monica, Calif.: RAND, 1989); H.R. Rubin et al., Guidelines for Structured Implicit Review of the Quality of Hospital Care for Diverse Medical and Surgical Conditions (Santa Monica, Calif.: RAND, 1990); and L.V. Rubenstein et al., "Changes in Quality of Care for Five Diseases Measured by Implicit Review, 1981-1986," Journal of the American Medical Association 264, no. 15 (1990): 1974-1979. For explicit criteria, see Kahn et al., The Effects of the DRG-Based Prospective Payment System on Quality of Care; and K.L. Kahn et al., "Measuring Quality of Care with Explicit Process Criteria before and after Implementation of the DRG-Based Prospective Payment System," Journal of the American Medical Association 264, no. 15 (1990): 1969-1973. Space limitations preclude a complete description of our methodology. Interested readers may contact John Z. Ayanian, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, Massachusetts 02115.
13. For implicit criteria, see K.L. Kahn et al., Structured Implicit Review for Physician Implicit Measurement of Quality of Care: Development of the Form and Guidelines for Its Use (Santa Monica, Calif.: RAND, 1989); H.R. Rubin et al., Guidelines for Structured Implicit Review of the Quality of Hospital Care for Diverse Medical and Surgical Conditions (Santa Monica, Calif.: RAND, 1990); and L.V. Rubenstein et al., "Changes in Quality of Care for Five Diseases Measured by Implicit Review, 1981-1986," Journal of the American Medical Association 264, no. 15 (1990): 1974-1979. For explicit criteria, see Kahn et al., The Effects of the DRG-Based Prospective Payment System on Quality of Care; and K.L. Kahn et al., "Measuring Quality of Care with Explicit Process Criteria before and after Implementation of the DRG-Based Prospective Payment System," Journal of the American Medical Association 264, no. 15 (1990): 1969-1973. Space limitations preclude a complete description of our methodology. Interested readers may contact John Z. Ayanian, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, Massachusetts 02115.
14. For implicit criteria, see K.L. Kahn et al., Structured Implicit Review for Physician Implicit Measurement of Quality of Care: Development of the Form and Guidelines for Its Use (Santa Monica, Calif.: RAND, 1989); H.R. Rubin et al., Guidelines for Structured Implicit Review of the Quality of Hospital Care for Diverse Medical and Surgical Conditions (Santa Monica, Calif.: RAND, 1990); and L.V. Rubenstein et al., "Changes in Quality of Care for Five Diseases Measured by Implicit Review, 1981-1986," Journal of the American Medical Association 264, no. 15 (1990): 1974-1979. For explicit criteria, see Kahn et al., The Effects of the DRG-Based Prospective Payment System on Quality of Care; and K.L. Kahn et al., "Measuring Quality of Care with Explicit Process Criteria before and after Implementation of the DRG-Based Prospective Payment System," Journal of the American Medical Association 264, no. 15 (1990): 1969-1973. Space limitations preclude a complete description of our methodology. Interested readers may contact John Z. Ayanian, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, Massachusetts 02115.
15. Kahn et al., The Effects of the DRG-Based Prospective Payment System on Quality of Care.
16. For both conditions, variables included the Acute Physiology Score (see: W.A. Knaus et al., "APACHE II: A Severity of Disease Classification System," Critical Care Medicine 13, no. 10 [1985]: 818-829), age, blood pressure, congestive heart failure by chest radiograph, blood urea nitrogen, and coma or confusion. Additional variables included digitalis toxicity, hematocrit, serum sodium, and serum aspartate aminotransferase for congestive heart failure; and respiratory distress, temperature, ambulatory status, recent hospitalization, prior respiratory failure, thoracic disease, and septic complications on admission for pneumonia.
17. P.S. Levy and S. Lemeshow, Sampling of Populations: Methods and Applications (New York: John Wiley and Sons, 1991). Additional details about our use of sampling weights are available upon request.
18. Intraclass correlation coefficients of physicians' implicit ratings were somewhat lower for each condition (r = 0.30) in the full study. The overall explicit and implicit ratings were significantly correlated (p < 0.001) for both congestive heart failure (r = 0.33) and pneumonia (r = 0.19).
19. Two-tailed P values are reported for all statistical tests.
20. J. Mant and N. Hicks, "Detecting Differences in Quality of Care: The Sensitivity of Measures of Process and Outcome in Treating Acute Myocardial Infarction," British Medical Journal 311, no. 7008 (1995): 793-796.
21. The SOLVD Investigators, "Effect of Enalapril on Survival in Patients with Reduced Left Ventricular Ejection Fractions and Congestive Heart Failure," New England Journal of Medicine 325, no. 5 (1991): 293-302; J.N. Cohn et al., "A Comparison of Enalapril with Hydralazine-Isosorbide Dinitrate in the Treatment of Chronic Congestive Heart Failure," New Eng and Journal of Medicine 325, no 5 (1991): 303-310; and T.P. Meehan et al., "Quality of Care and Process-Outcome Relationships in Elderly Pneumonia Patients," Journal of the American Medical Association 278, no. 23 (1997): 2080-2084.
22. The SOLVD Investigators, "Effect of Enalapril on Survival in Patients with Reduced Left Ventricular Ejection Fractions and Congestive Heart Failure," New England Journal of Medicine 325, no. 5 (1991): 293-302; J.N. Cohn et al., "A Comparison of Enalapril with Hydralazine-Isosorbide Dinitrate in the Treatment of Chronic Congestive Heart Failure," New Eng and Journal of Medicine 325, no 5 (1991): 303-310; and T.P. Meehan et al., "Quality of Care and Process-Outcome Relationships in Elderly Pneumonia Patients," Journal of the American Medical Association 278, no. 23 (1997): 2080-2084.
23. The SOLVD Investigators, "Effect of Enalapril on Survival in Patients with Reduced Left Ventricular Ejection Fractions and Congestive Heart Failure," New England Journal of Medicine 325, no. 5 (1991): 293-302; J.N. Cohn et al., "A Comparison of Enalapril with Hydralazine-Isosorbide Dinitrate in the Treatment of Chronic Congestive Heart Failure," New Eng and Journal of Medicine 325, no 5 (1991): 303-310; and T.P. Meehan et al., "Quality of Care and Process-Outcome Relationships in Elderly Pneumonia Patients," Journal of the American Medical Association 278, no. 23 (1997): 2080-2084.
24. L.H. Aiken, H.L. Smith, and E.T. Lake, "Lower Medicare Mortality among a Set of Hospitals Known for Good Nursing Care," Medical Care 32, no. 8 (1994): 771-787.
25. G.E. Rosenthal et al., "Severity-Adjusted Mortality and Length of Stay in Teaching and Non-Teaching Hospitals: Results of a Regional Study," Journal of the American Medical Association 278, no. 6 (1997): 485-490.
26. A.J. Hartz et al., "Hospital Characteristics and Mortality Rates," New England Journal of Medidne 321, no. 25 (1989): 1720-1725; T.A. Brennan et al., "Hospital Characteristics Associated with Adverse Events and Substandard Care," Journal of the American Medical Association 265, no. 24 (1991): 3265-3269; E.M. Kuhn et al., "The Relationship of Hospital Characteristics and the Results of Peer Review in Six Large States," Medical Care 29, no. 10 (1991): 1028-1038; and E.B. Keeler et al., "Hospital Characteristics and Quality of Care," Journal of the American Medical Association 268, no. 13 (1992): 1709-1714.
27. A.J. Hartz et al., "Hospital Characteristics and Mortality Rates," New England Journal of Medidne 321, no. 25 (1989): 1720-1725; T.A. Brennan et al., "Hospital Characteristics Associated with Adverse Events and Substandard Care," Journal of the American Medical Association 265, no. 24 (1991): 3265-3269; E.M. Kuhn et al., "The Relationship of Hospital Characteristics and the Results of Peer Review in Six Large States," Medical Care 29, no. 10 (1991): 1028-1038; and E.B. Keeler et al., "Hospital Characteristics and Quality of Care," Journal of the American Medical Association 268, no. 13 (1992): 1709-1714.
28. A.J. Hartz et al., "Hospital Characteristics and Mortality Rates," New England Journal of Medidne 321, no. 25 (1989): 1720-1725; T.A. Brennan et al., "Hospital Characteristics Associated with Adverse Events and Substandard Care," Journal of the American Medical Association 265, no. 24 (1991): 3265-3269; E.M. Kuhn et al., "The Relationship of Hospital Characteristics and the Results of Peer Review in Six Large States," Medical Care 29, no. 10 (1991): 1028-1038; and E.B. Keeler et al., "Hospital Characteristics and Quality of Care," Journal of the American Medical Association 268, no. 13 (1992): 1709-1714.
29. A.J. Hartz et al., "Hospital Characteristics and Mortality Rates," New England Journal of Medidne 321, no. 25 (1989): 1720-1725; T.A. Brennan et al., "Hospital Characteristics Associated with Adverse Events and Substandard Care," Journal of the American Medical Association 265, no. 24 (1991): 3265-3269; E.M. Kuhn et al., "The Relationship of Hospital Characteristics and the Results of Peer Review in Six Large States," Medical Care 29, no. 10 (1991): 1028-1038; and E.B. Keeler et al., "Hospital Characteristics and Quality of Care," Journal of the American Medical Association 268, no. 13 (1992): 1709-1714.
30. K.L. Kahn et al., "Health Care for Black and Poor Hospitalized Medicare Patients," Journal of the American Medical Association 271, no. 15 (1994): 1169-1174.