This study compared psychiatric and substance abuse acute care programs, within both inpatient and residential modalities of care, on organization and staffing, clinical management practices and policies, and services and activities. A total of 412 (95% of those eligible) Department of Veterans Affairs' programs were surveyed nationwide. Some 40% to 50% of patients in psychiatric and substance abuse programs, in both inpatient and residential venues of care, had dual diagnoses. Even though psychiatric programs had a sicker patient population, they provided fewer services, including basic components of integrated programs, than substance abuse programs did. Findings also showed that there is a strong emphasis on the use of clinical practice guidelines, performance monitoring, and obtaining client satisfaction and outcome data in mental health programs. The author's suggest how psychiatric programs might better meet the needs of acutely ill and dually diagnosed patients (e.g., by incorporating former patients as role models and mutual help groups, as substance abuse programs do; and by having policies that balance patient choice with program demand).
Objective: To understand fundamental attitudes towards patient safety culture and ways in which attitudes vary by hospital, job class, and clinical status.
Design: Using a closed ended survey, respondents were questioned on 16 topics important to a culture of safety in health care or other industries plus demographic information. The survey was conducted by US mail (with an option to respond by Internet) over a 6 month period from April 2001 in three mailings.
Setting: 15 hospitals participating in the California Patient Safety Consortium.
Subjects: A sample of 6312 employees generally comprising all the hospitals attending physicians, all the senior executives (defined as department head or above), and a 10% random sample of all other hospital personnel. The response rate was 47.4% overall, 62% excluding physicians. Where appropriate, responses were weighted to allow an accurate comparison between participating hospitals and job types and to correct for non-response.
Main outcome measures: Frequency of responses suggesting an absence of safety culture ("problematic responses" to survey questions) and the frequency of "neutral" responses which might also imply a lack of safety culture. Responses to each question overall were recorded according to hospital, job class, and clinician status.
Results: The mean overall problematic response was 18% and a further 18% of respondents gave neutral responses. Problematic responses varied widely between participating institutions. Clinicians, especially nurses, gave more problematic responses than non-clinicians, and front line workers gave more than senior managers.
Conclusion: Safety culture may not be as strong as is desirable of a high reliability organization. The culture differed significantly, not only between hospitals, but also by clinical status and job class within individual institutions. The results provide the most complete available information on the attitudes and experiences of workers about safety culture in hospitals and ways in which perceptions of safety culture differ among hospitals and between types of personnel. Further research is needed to confirm these results and to determine how senior managers can successfully transmit their commitment to safety to the clinical workplace.
This abstract was presented at the Academy Health 20th Annual Research Meeting on June 28, 2003, in Nashville, Tennessee.
Measures based on routinely collected data would be useful to examine the epidemiology of patient safety. Extending previous work, we established the face and consensual validity of twenty Patient Safety Indicators (PSIs). We generated a national profile of patient safety by applying these PSIs to the HCUP Nationwide Inpatient Sample. The incidence of most nonobstetric PSIs increased with age and was higher among African Americans than among whites. The adjusted incidence of most PSIs was highest at urban teaching hospitals. The PSIs may be used in AHRQ's National Quality Report, while providers may use them to screen for preventable complications, target opportunities for improvement, and benchmark performance.
The second half of the 20th century witnessed spectacular advances in health care. Innovations such as magnetic resonance imaging, genetically engineered growth factors, and highly effective drugs for the treatment of depression, gastroesophageal reflux, high blood cholesterol, and HIV disease greatly improved the detection and treatment of both rare and common diseases. The advances greatly improved the outcomes of complex procedures such as organ transplantation, coronary artery bypass surgery, and high-dose chemotherapy (bone marrow transplantation) for acute myeloid leukemia and multiple myeloma. As the 21st century opens, technological progress in medicine is continuing and may be accelerating. It is a source of hope for the prevention, effective treatment, and cure of disease.
Technological innovation is also the major source of increases in real per capita medical spending in the United States. If medical advances continue to be adopted as rapidly as they have been, they will pose knotty economic, political, and ethical challenges for health care policy at a time when spending on health care in the United States has once again begun to surge after a mid-1990s pause and the number of Americans without health insurance has once again begun growing.
Background: Patient-controlled analgesia (PCA) pumps are widely used after surgery, but their association with various outcomes is not completely understood. Is PCA pump use related to the incidence of postoperative surgical site infections among patients undergoing open intestinal surgery?
Materials and Methods: We undertook a comprehensive retrospective chart review of 515 randomly selected patients over age 18 who had major rectal or intestinal surgery (Diagnosis Related Groups [DRGs] 146-149) between January 1994 and March 1997 from eight community or teaching hospitals along the U.S. west coast. Of these patients, 214 used PCA pumps. Outcome measures were in-hospital postoperative surgical site infections, respiratory complications, ileus/abdominal distention, urinary tract infection/urinary retention, and length of stay.
Results: Use of a PCA pump was significantly associated with increased in-hospital postoperative surgical site infections (10.7% for PCA, 4.0% for no PCA). The odds ratio for PCA use was about 4.0 after controlling for many variables, including severity of illness at admission, body mass index, preadmission use of corticosteroids, perforated viscus, number of previous abdominal operations, wound classification category, hypothermia, malnutrition on admission, preoperative antibiotic use within 2 h before incision, time from hospital admission to surgery, skin prep to incision time, anesthesia start to incision time, surgical skin to skin time, wound closure type, time from incision closure to the start of PCA, use of drains, blood product use, central line use, line infection, mobility assistance required, hospital, DRG, and surgeon.
Conclusion: No confounding variables explained the significant association between PCA pump use and in-hospital surgical site infection. These results stand firmly on data that merit additional study to further elucidate possible immunologic effects of PCA pumps.
Background: Because no validated "gold standard" for measuring asthma outcomes exists, asthma interventions are often evaluated using a large number of disease status measures. Some of these measures may be redundant, whereas others may be complementary. Use of multiple outcomes may lead to ambiguous results, increased type I error rates, and be an inefficient use of resources including caregiver and patient/participant time and effort. Understanding the relationship between these measures may facilitate more parsimonious and valid evaluation strategies without loss of information.
Objective: To assess the relationships between multiple measures of asthma disease status over time.
Design/Methods: We used data from a randomized, controlled trial of a comprehensive disease management program involving 119 disadvantaged inner-city children aged 5 to 12 years with moderate to severe asthma. Spearman correlations were calculated between the following asthma disease status measures: parent-reported disease symptoms, parent-reported health care utilization, functional health status using the American Academy of Pediatrics' validated Child Health Survey for Asthma (CHSA), diary data (symptom scores, night wakings, and bronchodilator use), and pulmonary function tests at baseline, 32 weeks, 52 weeks, and changes from baseline to 52 weeks.
Results: Ninety-four (79%) of randomized patients participated at baseline and 52 weeks. Completion rates for outcome measures ranged from 79% (CHSA, spirometry data) to 64% (diary data). At baseline, asthma symptoms, health care utilization, and individual domains from the CHSA were significantly correlated (r = 0.21-0.53). These correlations were stable over the 52-week follow-up. Forced expiratory volume in 1 second and diary data did not correlate to any other measures at baseline, and these measures correlated only inconsistently with other measures at 32 weeks and 52 weeks. Baseline to 52-week changes in asthma symptoms, utilization, and the CHSA domains were significantly correlated (0.22-0.56), as were baseline to 52-week changes in symptom days, night wakings, and the CHSA domains (r = 0.24-0.64). Baseline to 52-week changes in forced expiratory volume in 1 second and diary data did not correlate with other measures.
Conclusions: These results suggest that asthma status and change in asthma status over time after introduction of a disease management intervention are best characterized by parent-reported symptoms, parent-reported utilization, and functional health status measures. Asthma diaries and pulmonary function tests did not seem to provide additional benefit, although they may play an important role in individual patient management. Our findings suggest a parsimonious evaluation strategy would include collection of key data elements regarding symptoms, utilization, and functional health status only, without loss of vital response information.
OBJECTIVES: The authors examined whether continuing outpatient mental health care, the orientation of the treatment program (12-step, cognitive-behavioral, or eclectic), and involvement in self-help groups were linked to substance abuse patients' remission status two years after discharge.
METHODS: The data were from a cohort of 2,805 male patients who were treated through one of 15 Department of Veterans Affairs substance abuse programs. Remission was defined as abstinence from illicit drug use and abstinence from or nonproblem use of alcohol during the previous three months. The relationships of the three variables to remission were tested with regression models that controlled for baseline characteristics.
RESULTS: About a quarter of the study participants (28 percent) were in remission two years after discharge. Intake characteristics that predicted remission at two years included less severe substance use and psychiatric problems, lower expected disadvantages and costs of discontinuing substance use, and having abstinence as a treatment goal. No significant relationship emerged between treatment orientation and remission status two years later. Involvement in outpatient mental health care during the first follow-up year and participation in self-help groups during the last three months of that year were associated with a greater likelihood of remission at the two-year follow-up.
CONCLUSIONS: The results extend previously published one-year outcome findings showing that cognitive-behavioral and 12-step treatment programs result in similar remission rates. Patients who enter intensive substance abuse treatment with polysubstance use, psychiatric symptoms, or significant emotional distress have more difficulty achieving remission. Routinely engaging patients in continuing outpatient care is likely to yield better outcomes. The duration of such care is probably more important than the number of sessions.