Articles: outcome-assessment-health-care.
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Critical care clinics · Jan 1994
Multicenter Study Comparative StudyThe case against using the APACHE system to predict intensive care unit outcome in trauma patients.
The use of outcome indices as a means of evaluating institutional performance for delivery of medical care is at the forefront of federal health policy reforms. Because an enormous number of clinical and financial data are generated by ICU patients, it is inevitable that integrated bedside computers will be necessary to supply the type of information that is being sought by governmental and private insurance agencies involved in assessment of hospital performance. The Health Care Financing Administration already has adopted the APACHE data collection protocols and predictive models for the severity of illness adjustments that were used in assessing the 1986 hospital-specific death rate for acute myocardial infarction, congestive heart failure, stroke, and pneumonia. ⋯ The inequities for certain subgroups of patients, including trauma patients, could create situations in which care is rationed rather than allocated according to a plan that distributes resources efficiently. The APACHE system has several shortcomings and adds little, if anything, to the potential solutions for trauma quality assurance and resource allocation. Nor has the APACHE system established procedures for documenting institutional review of unexpected trauma deaths that would be equivalent, for example, to the type of audit filters applied by the American College of Surgeons in conjunction with the TRISS methodology.(ABSTRACT TRUNCATED AT 400 WORDS)
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Multicenter Study Clinical Trial
The Canadian four-centre study of anaesthetic outcomes: I. Description of methods and populations.
The objectives of this study were first to develop and institute a methodology for the study of anaesthetic outcome for parallel use in four teaching hospitals in Canada and second, to compare rates of morbidity and mortality associated with anaesthesia between the four centres. The basic design of the study was occurrence screening with anaesthetists entering data on patient demographics, anaesthetic and surgical factors. Research nurses reviewed anaesthetic records and hospital charts and interviewed patients postoperatively. ⋯ There were major differences found across the hospitals, particularly with regard to volume, patient case-mix, anaesthetic drugs and monitoring used. The use of parallel training, repeated consultations and use of rounds and inservices contributed to the reliability and validity of the data collection. We conclude that outcome surveillance can be instituted in different hospital Departments of Anaesthesia with sufficient confidence to form the basis of comparison of anaesthetic outcome.
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Multicenter Study Clinical Trial
The Canadian four-centre study of anaesthetic outcomes: III. Are anaesthetic complications predictable in day surgical practice?
To understand better the factors important to the safety of anaesthesia provided for day surgical procedures, we analyzed the intraoperative and immediate postoperative course of patients at four Canadian teaching hospitals' day treatment centres. After excluding those who received only monitored anaesthesia care, there were 6,914 adult (non-obstetrical) patients seen over a twelve-month period in 1988-89. The rate of adverse outcome consequent to their care was identified by a comprehensive surveillance system which included review of anaesthetic records (four hospitals) and follow-up telephone calls (two hospitals). ⋯ Patients judged obese, or inadequately fasted, were found to experience a greater rate of recovery problems as well as discomfort. While the low response rate (36%) to the telephone interviews created a sampling bias, the high rate of patient dissatisfaction among those reached is disconcerting. We conclude that day surgical patients with preoperative medical conditions, even when optimally managed, are at higher risk for adverse events in the perioperative period.
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Multicenter Study Clinical Trial
The Canadian four-centre study of anaesthetic outcomes: II. Can outcomes be used to assess the quality of anaesthesia care?
Since anaesthesia, unlike medical or surgical specialties, does not constitute treatment, this study sought to determine if methods used to assess medical or surgical outcomes (that is the determination of adverse outcome) are applicable to anaesthesia. Anaesthetists collected information on patient, surgical and anaesthetic factors while data on recovery room and postoperative events were evaluated by research nurses. Data on 27,184 inpatients were collected and the analysis of outcomes determined for the intraoperative, post-anaesthetic care unit and postoperative time periods. ⋯ Possible reasons to account for these variations in outcome include compliance in recording events, inadequate case-mix adjustment, differences in interpretation of the variables (despite guidelines) and institutional differences in monitoring, charting and observation protocols. The authors conclude that measuring quality of care in anaesthesia by comparing major outcomes is unsatisfactory since the contribution of anaesthesia to perioperative outcomes is uncertain and that variations may be explained by institutional differences which are beyond the control of the anaesthetist. It is suggested that minor adverse events, particularly those of concern to the patient, should be the next focus for quality improvement in anaesthesia.