American Journal of Medical Quality

Our objective was to explore reasons why vaccines are not provided to adult patients receiving primary health care. The study setting was a primary health care clinic in a urban hospital staffed primarily by residents and teaching faculty. The patients were identified as all continuity care patients with a scheduled visit to the clinic during the 4-week study period in April 1995. The providers were all primary care providers for the patients during the study period. The providers were given two surveys before the study: one to assess their knowledge of published preventive health care guidelines and one to assess their perspective of the guidelines. During the study period, the charts of the patients were reviewed for the services they had received. An assessment was placed in each patient's chart for the provider's completion during the visit. The assessment enabled the provider to explain why services had not been provided. The results showed that influenza, pneumococcal, and diphtheria-tetanus vaccines were provided at varying rates. Each vaccine had a different profile as to noncompliance with guidelines. Lack of provider knowledge of the guideline was most apparent with pneumococcal vaccine. Providers' ambivalence regarding the scientific basis and/or clinical importance was most apparent with influenza vaccine. Patient refusal was a prominent cause with influenza vaccine in the elderly. Patient appointment behavior (opportunity for care and compliance) also seemed to play an important role. We conclude that explanations for nondelivery of vaccines to adults seem to be multiple. Lack of physician knowledge and physician perception of the guidelines provide some explanations. Patient-related factors including refusal, decreased opportunity for care, and noncompliance also play important roles in why vaccinations are not provided. Improvement in the rates at which immunizations to adults are provided will require interventions in multiple areas.

Although approximately one of five people in the United States die in nursing homes (NHs), little has been written about their quality of dying, including the quality of terminal medical care. The purpose of this study is to review actual medical practices in NHs to suggest factors important for delivering good quality terminal care. Four NHs were surveyed for management of residents who died in 1992. A convenience sample of charts of newly admitted and longer term residents were abstracted for demographic variables, death, diagnostic categories, and various laboratory and other parameters. Charts of those residents who died were further reviewed using indicators of quality medical care, such as presence of advance directives, control of pain, and control of dyspnea, based upon recent published clinical practice guidelines for terminal care in NHs. Three hundred and seventy-one charts were abstracted. Forty-one charts documented the resident's death. We found that NHs without regulatory difficulties usually had expected deaths that were managed appropriately as measured by terminal medical care quality indicators. NHs with a history of regulatory difficulties had a higher prevalence of residents who died suddenly and unexpectedly, often with problems in the quality of care as measured by the same indicators. There was a correspondence between physician certification, antemortem diagnosis of terminal illness, and appropriate terminal care. We conclude that physicians are able to recognize impending death and redirect the medical care of dying NH residents toward goals of terminal care management. This is more likely to occur in a NH environment that places greater emphasis upon total quality management. We suggest that another indicator in providing good NH terminal care is the physician's performance in predicting a short life expectancy.

CARE PATHS are a managed care tool used in many of today's acute care hospitals. Developed by a hospital's health care team, their strength lies in a clear statement of expectations and accountability, and in their use as a communication tool among those involved in the care of a specific patient. Because individual patients are unique and may require detours from a CARE PATH, these tools are most successful if used as guide lines rather than strict protocols.

However, managed care has forced us to expand our definition of health and health care, and the goal of efficiently managing a population or panel of patients has become the focus of a successful health care organization. This includes an increased emphasis on preventive care or wellness programs as well as the use of new, innovative approaches to providing traditionally inpatient services. With this shift, CARE PATHS have had to evolve as well. The following describes the current approach being used in our delivery system, the EXTENDED CARE PATH (ECP).

This research was designed to validate data collected through a survey—an inexpensive way to provide information for quality measurement. The survey was sent to health maintenance organization (HMO) enrollees who had given birth(s) between October 1, 1994, and May 31, 1995. The responses were compared with the medical records. A sample of 407 women was randomly selected from the completed surveys. Medical records were reviewed for 89.9% (362/407) of the sample based on medical record availability. Over 98% of responses agreed with the medical record information regarding whether there were cesarean sections for previous deliveries (K = 1.0), cesarean section for recent delivery (κ = 0.95), and vaginal birth after cesarean section (κ = 0.96). Over 99% of the mothers agreed with the information regarding whether the newborn birth weight was under 2500 g (κ = 0.91). The findings strongly support the validation of this instrument. Using this validated instrument enables health plans to cost-effectively obtain crucial information.

An important question for facilities monitoring acute care bed admissions with proprietary criteria is whether these methodologies remain valid after substantial changes to the criteria sets. This is especially true for publicly funded hospitals whose medical and social mission is often broader than that of private sector facilities for which insurance-based claim review is most relevant. To further address this issue, we used sequential sets (1994 and 1995) of InterQual Intensity, Severity, and Discharge criteria to assess a cohort of patients referred to our Veterans Affairs facility as acute care admissions between December 1, 1994, and February 28, 1995. We found that the appropriateness rate for the subset of medical admissions dropped from 88% when using the 1994 criteria set to 49% when using the more stringent 1995 criteria set (P < 0.001). We conclude that substantive changes to previously validated criteria sets require revalidation. Furthermore, consideration should be given to the role that insurance-based utilization review should play in publicly funded hospital systems.

We report on the introduction of a new technology and a new method for the management of chronic coronary artery disease into a managed care environment. The introduction incurred substantial resistance from subspecialty consultants, primary care physicians, and top management. Strategies were developed to overcome these resistances. Modification of the program as well as the development of incentives occurred. These measures continue to evolve. The program, to date, has achieved approximately 50% penetration. The demonstration of better health outcomes and financial savings will almost certainly temper the resistance encountered from all three groups identified.