Implications For Quality Of Care Research Articles

The Health of Female Child Care Providers: Implications for Quality of Care

The purpose of this investigation was to determine the health behaviors and perceived health status of child care providers. Health behaviors and health status were also examined in relation to caring for children and the providers’ perceptions of quality child care. A researcher-developed questionnaire, adapted from Williams, Mason, and Wold (2001), was mailed to a random sample of 1,000 child care providers employed in 49 child care centers in Georgia. Results indicated that, overall, the sample was a healthy population with 86.8% rating their health as good to excellent. Seventy-three percent (73%) received a physical exam annually, and 70% reported having health insurance. Despite these ratings, participants reported that they were overweight, were emotionally strained, and did not engage in physical exercise at least 3 times per week. Although most performed breast self-exams, the majority did not fully understand breast health practices. Furthermore, the majority of the child care providers (78.7%) believed that their health does not impact the care that they provide to children. Last, their definitions of quality of care for children suggested a minimal standard of care or less. These findings provide information that can be useful in designing occupational health programs within community child care settings and in promoting healthy behaviors in women.

Availability of Integrated Care for Co-occurring Substance Abuse and Psychiatric Conditions

The co-occurrence of psychiatric conditions and substance abuse presents significant challenges for behavioral healthcare providers. The need for integrated care has received substantial recent attention from clinical, research, and funding entities. However, the availability of integrated care has been low, carrying potential adverse implications for quality of care and treatment outcomes. This article describes the prevalence and key correlates of the availability of integrated care for co-occurring conditions within public and private-sector addiction treatment programs. Several organizational attributes, caseload characteristics, and service provision patterns were associated with the availability of integrated care.

Relationship Between Performance Measurement and Accreditation: Implications for Quality of Care and Patient Safety

This study examined the association between the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation scores and the Agency for Healthcare Research and Quality's Inpatient Quality Indicators and Patient Safety Indicators (IQIs/PSIs). JCAHO accreditation data from 1997 to 1999 were matched with institutional IQI/PSI performance from 24 states in the Healthcare Cost and Utilization Project. Most institutions scored high on JCAHO measures despite IQI/PSI performance variation with no significant relationship between them. Principal component analysis found 1 factor each of the IQIs/PSIs that explained the majority of variance on the IQIs/PSIs. Worse performance on the PSI factor was associated with worse performance on JCAHO scores (P=.02). No significant relationships existed between JCAHO categorical accreditation decisions and IQI/PSI performance. Few relationships exist between JCAHO scores and IQI/PSI performance. There is a need to continuously reevaluate all measurement tools to ensure they are providing the public with reliable, consistent information about health care quality and safety.

Regulation, subsidy receipt and provider characteristics: What predicts quality in child care homes?

Far less is known about predictors of quality for family child care homes than for child care centers. The current study of 120 randomly-selected family child care providers in four Midwestern states examined distal, state policy-level variables (family child care regulations and the concentration of children cared for who received public child care subsidies, referred to as subsidy density), and proximal, provider-level variables (providers’ level of education and reported annual training hours) as influences on global quality and caregiver sensitivity. More regulation, lower subsidy density, higher levels of provider education and more training hours were associated with higher global quality in family child care homes. Lower subsidy density and higher provider education were associated with more sensitive caregiving, but no effects on sensitivity were observed for regulation and training hours. An interaction effect indicated that regulation moderated the relation between education and sensitivity; education was especially important for sensitive caregiving among providers low in regulation. In addition, after including all predictor variables in the model, significant mean differences between states were noted. Findings demonstrate that both policy-level variables and provider characteristics influence quality in family child care homes, and further, that they may interact to affect observed child care quality. Implications for state child care policies are discussed with emphasis on implications for quality of care for low-income children whose tuition is paid by public child care subsidies.

Geographic and Socioeconomic Variation in the Treatment of Prostate Cancer

Within a framework of quality assessment, primary treatment choice constitutes an indicator of quality of care. This study examines geographic and socioeconomic variation in the primary treatment of men with prostate cancer during the era of prostate-specific antigen testing. Using the National Cancer Institute's Surveillance, Epidemiology, and End Results public use data files, we identified men with localized/regional prostate cancer who underwent surgery, radiation therapy, or watchful waiting. We used the year 2000 US Census information to ascribe education and income levels to these men based on their county of residence and ethnicity. Among the 96,769 men with localized/regional prostate cancer (during 1995 to 1999) who had sufficient information for analysis, we observed significant geographic variation nationwide in surgical, radiation, and watchful waiting treatment rates (P <.0015). Patterns noted 10 years ago, such as higher surgical rates in western regions, persisted. Ethnicity, income, and grade were all independently associated with primary treatment, or lack thereof. Blacks and low-income patients had the lowest rates of surgery and radiation. Grade was the best predictor of aggressive treatment. Nonclinical factors, such as ethnicity and income, were associated with the use of watchful waiting rather than surgery or radiation in men with early-stage prostate cancer. These findings have implications for quality of care.

Health Plan Disenrollment in a Choice-Based Medicaid Managed Care Program

Consumer decisions to switch health plans have implications for quality of care and risk selection. We examine factors related to time to disenrollment in a Medicaid managed care program where beneficiaries face a menu of plans and can change plans every month. Several findings have direct policy relevance. Families and individuals who make active choices upon entering the program are at substantially lower risk of disenrollment than those who are auto-assigned. Interactions between enrollee ethnicity and provider language proficiency suggest that enrollee satisfaction depends on the cultural competence of providers. Differential disenrollment by risk status results in adverse retention for certain types of plans.

VHA enrollees' health care coverage and use of care.

The authors examined health care coverage for Veterans' Health Administration (VHA) enrollees and how their reliance on VHA care varies by coverage, using the largest and most detailed survey of veterans using VHA services ever conducted. The results showed that a majority of veterans who use VHA services have alternative health care coverage and that most of them use both VHA and non-VHA health care. The findings have important implications for quality of care and coordination of care.

An analysis of the completion of physiotherapy clinical records in Gauteng Province.

The purpose of this study was to rate the completion of physiotherapy assessment, treatment and progress records in the Gauteng province of South Africa. There is a dearth of literature on physiotherapy patient records, yet it has been demonstrated that clinical records have significant implications for quality of care, resource allocation, research and for professional litigation.A combined retrospective and prospective research design, using a quality assurance instrument was used to rate the completeness of physiotherapy records obtained from multiple study sites. Breakdown in clinical recording in the following areas is described:areas of care (private and public sectors),patient conditions (e.g. orthopaedic and surgical)patient categories (in and out patients),section of the record (e.g. demographics, physical examination), andproviders of care (physiotherapists, physiotherapy assistants and physiotherapy students).The 644 records analyzed scored a mean overall completion rate of 64%. There was a significant difference observed in overall record completion (p = 0.0004) between private and public sector providers. Significant differences were also observed for each section of the record. Factors most associated with a high degree of completion of physiotherapy patient records included; private sector physiotherapy services, use of pre-formatted assessment charts and clinicians’ participation in relevant continuing education.Physiotherapy patient records in Gauteng were found to be incomplete. The implications of this finding in an increasingly competitive global, national, corporate and domestic healthcare arena include; physiotherapy service quality, professional litigation, resource allocation and policy development, as well as professional growth, development and satisfaction with ones’ career. Recommendations on how the physiotherapy profession can improve clinical recording from an educational, clinical and managerial perspective are suggested.

Specialist–Primary Care Provider–Patient Communication in Telemedical Consultations

The use of videoconferencing enables a primary care provider and patient at one location to confer with a specialist at a distant site. Although this encounter may benefit all parties, this arrangement may also pose potential communication problems. This investigation analyzed the verbal content in typical telemedical consultations in an effort to identify patterns of talk that could affect quality of care, the specialist-primary care provider relationship, and future utilization. From the video archives of the Texas Tech Telemedicine program, 26 consultations were selected for analysis. These cases met inclusion criteria (e.g., English was spoken, the consultation was at least 10 minutes long, etc.). Four types of verbal responses were studied - information-giving, questions, controlling utterances (e.g., directives, recommendations, disagreements), and partner-centered talk (e.g., showing support, asking for another's opinion). The specialist was the most dominant communicator in terms of asking questions, displaying controlling behavior, and generally talking more than the other participants. Patients were the least active participants, and they also received the least amount of information. Group discussion was limited. Each interactant tended to talk to one participant at a time with most of the conversation occurring between the specialist and primary care provider. Differences in the way these specialists, primary care providers, and patients communicated with one another may have important implications for quality of care and future utilization of telemedicine. Future research should examine the relationship between these patterns of interaction and outcomes of care.

Use and interpretation of HbA1c testing in general practice. Implications for quality of care

We evaluate the interpretation and use of HbA1c results in general practice in relation to diabetes follow-up and case-finding. As part of an external quality assurance scheme for laboratory analyses, two case histories were mailed to all Norwegian GPs with equipment for HbA1c analysis in their office laboratory (n=566) and to a random sample of GPs without such instruments (n=419). Patient A represented a monitoring situation and the GPs were asked to state changes in HbA1c signifying any improvement or deterioration of metabolic control. The initial HbA1c value stemmed from analysis of quality control material in the instrument group and was a preset value for the other group. In patient B, we focused on the use of HbA1c and other laboratory tests in diabetes case-finding. In the monitoring situation, 22% of GPs in the instrument group misclassified changes in HbA1c values, since these were less than the analytical uncertainty. Further, when interpreting HbA1c results, 64-93% of GPs (i) assumed that analytical quality was better than it really was, (ii) did not appreciate biological variation of HbA1c, or (iii) acted on small differences to be on the safe side. In case-finding, HbA1c was deemed important by 29% of GPs; doctors choosing not to perform a glucose tolerance test relied more on HbA1c. GPs have to be aware of analytical quality and biological variation when interpreting HbA1c results. The present limitations of HbA1c in the diagnosis of diabetes are not properly understood.

Hospital restructuring initiatives in Canada.

Recent changes in the organization, staffing, and utilization of acute hospitals in Canada are reviewed with regard to the potential implications for quality of care, national nurse workforce requirements, and research. Available national and selected provincial data and trends in hospital utilization, capacity, and staffing are synthesized. Health system reform in Canada has resulted in lower utilization of acute inpatient resources, excess hospital capacity, and increased budgetary constraints in the hospital sector. In response, there is widespread hospital restructuring, which includes modifications in nurse staffing ratios and skill mix. Little is known about the potential impact of these changes on patient outcomes. From a workforce perspective, changes in the hospital sector have reduced demand for registered nurses but nursing schools have not modified enrollments. As a result, new graduates are experiencing difficulty obtaining registered nurse positions. Research should be undertaken to evaluate the impact of changes in the organization and staffing of hospitals on patient outcomes, and on the future requirements for nurses.

Collaboration Between a Referring Hospital and a Tertiary Care Center in Improving the Transfer Process for Cardiac Patients

Transfer of cardiac patients between hospitals is a complex process with many implications for quality of care. In the case of heart disease, specialized procedures such as coronary angioplasty, coronary bypass surgery, and valve replacement or repair require the performance of cardiac catheterization and coronary arteriography in a catheterization laboratory, as well as the availability of cardiac surgical services. The Department of Veterans Affairs Medical Center (DVAMC) at Muskogee, Oklahoma, transfers most cardiac patients requiring specialized diagnostic procedures and advanced cardiac care to DVAMC at Oklahoma City, Oklahoma. Concerns about the inefficiency of the transfer process led to the launch of a quality improvement project in late 1992. CHANGES IN THE TRANSFER PROCESS: Greater emphasis was placed on medical aspects compared to administrative aspects of transfer, and ready access to the physicians at DVAMC at Oklahoma City was provided. The time from request for transfer to the actual transfer decreased. Before the quality improvement project, only 33% of transfers of cardiac patients were completed within 24 hours-versus 78% in 1993 and 1994, 89% in 1995, and 84% in the first half of 1996. In addition, DVAMC-Muskogee physician satisfaction regarding services at DVAMC-Oklahoma City improved. Ongoing discussion between the cardiology team at the accepting hospital and physicians at the referring hospital expanded the continuum of care to both hospitals. Priority of transfers could be upgraded at any time without unduly jeopardizing patient safety or increasing resource utilization at the receiving center.

Constant Observation in a Medical-Surgical Setting: The Role of Consultation-Liaison Psychiatry

Constant observation (CO) is commonly used in general hospital settings to protect patients who are at risk for harming themselves or others. The role of consultation-liaison psychiatry in the implementation of this procedure is often assumed, but has not been well studied. The authors report the findings of a 6-month study of the use of CO in a general hospital and discuss its implications for quality of care and, possibly, cost-effectiveness.

Health Care Reform and Its Implications for Quality of Care

Health care reform packages are being designed primarily to address two important problems with the current U.S. health care system: access and cost. One component of the access problem is that 15% of the U.S. population is uninsured, and the other is that a substantial percentage of the insured U.S. population is concerned about the portability of its insurance coverage. One component of the cost problem is that many are concerned about the current total cost of health care in the United States or the cur-

Doctor-shopping in Hong Kong: implications for quality of care.

Doctor-shopping is defined as the changing of doctors without professional referral in the same illness episode. Two surveys on samples of patients attending Government Out-Patient Departments (GOPDs) in Hong Kong in 1989 (n = 869) and 1990 (n = 901) estimated the prevalence of shopping at nearly 40%, the main reason being a persistence of symptoms. Doctor-shoppers were likely to be younger with higher expectations of health care and who expressed dissatisfaction about aspects of the present service. In Hong Kong, patients perceive western medicine to be more effective and have high expectations of the effects of western drugs, in particular, in their administration by injection. Patients should be warned about iatrogenic health risks incurred from doctor-shopping; health education programmes are needed to modify unrealistic views about quality care. Health care providers in a mixed care system should promote greater continuity of care between doctors and both the public and private sectors, and identify and resolve problems which may be responsible for discontinuity of care.

General practitioners' awareness of different techniques of cataract surgery: implications for quality of care

With the introduction of fundholding, general practitioners can now purchase treatment from theprovider of their choice. To obtain the best treatment for their patients they need to keep abreast of new developments in a large range of specialties. The past decade has seen profound changes in ophthalmology, particularly in cataract surgery. Extracapsular cataract extraction and phacoemulsification have largely superseded intracapsular cataract extraction, mainly because of the higher risk of sight threatening complications with intracapsular extraction.1,2 Although extracapsular surgery is now the most commonly used method in the United Kingdom, 2%-4% of ophthalmologists routinely perform intracapsular surgery3,4 and 1% do not routinely use intraocular …

Relationships Between Home Care Clients and Their Workers: Implications for Quality of Care

In-depth interviews were conducted with 54 home care clients and their home health aides and personal care attendants. The interview data reveal that home care relationships tend to be both formal and informal, in that job responsibilities tend to be diffusely defined and home care workers often become involved in the "backstage" world of their clients. The study also suggests, however, that personal bonds may be problematic for both workers and clients. For workers there is the risk of exploitation; for clients, there is the potential for loss of control over their own care. The quality of relationships also affects quality of care.

The quality of medical evidence: implications for quality of care.

Prologue: Most of the proposals advanced in the 1980s for rationalizing the use of medical care derived chiefly from an economic model —more consumer cost sharing, the development of alternative health delivery systems, and new financial incentives. One of the working assumptions of the analysts and policymakers who designed these proposals was that the scientific basis of medicine was solid. If purchasers of care could only determine how to make providers more efficient, they reasoned, the growth of medical costs could be moderated. In this paper, David Eddy and John Billings call into question that assumption. They make a case for why it is imperative that the medical profession get on with the job of examining more closely the scientific basis of medical practice. Eddy holds a medical degree from the University of Virginia and a doctor of philosophy degree in applied mathematics from Stanford University. Eddy, who currently directs the Center for Health Policy at Duke University, is the J. Alexander McMahon professor of Health Policy Research and Management. Eddy operates at the intersection of math and medicine, applying probability theory to the uncertainty of approaches to care. Billings holds a law degree from the University of California, Berkeley, and has been actively involved in a variety of health care activities for a decade. Billings, who is currently an independent consultant, wrote this article with Eddy while serving as a visiting professor at Duke. He served as one of the first staff directors of a community-based (Salt Lake City) health care coalition (1979–1980) and was executive director of The John A. Hartford Foundation for four years (1981–1985).

A physician role typology: Colleague and client dependence in an HMO

This paper reports on physicians' role definitions in one prepaid group practice, a health maintenance organization (HMO). Colleague and client dependence are reviewed and analyzed as separable dimensions of physician role definitions. Data are derived from documents, interviews, and staff questionnaires collected in 1979–1980. The evidence reported suggests widespread colleague dependence in the HMO. Physicians consulted with one another about patient care and engaged in informal referral and review, developing practice standards; and some of these physicians relied on colleagues for handling their patient visits when needed. In relation to their patients, some physicians viewed themselves as bureaucratic officials relatively dependent on client approval in carrying out their health care activities, while others saw themselves as trusted medical experts in a setting free of nonmedical constraints in patient care. The relationship of organizational structure to these different role definitions is discussed. Classifying these HMO physicians according to a fourfold typology of professional dependence shows that most are Organizational Physicians (Type I), who are both colleague and client dependent. Collegial Physicians (Type II) are colleague dependent and, at the same time, do not perceive clients as demanding. Implications for quality of care and physician satisfaction and turnover are considered.

Psychiatric records: variations based on discipline and patient characteristics, with implications for quality of care

In this study of the delivery of outpatient psychiatric care to Medicaid patients at all 29 free-standing psychiatric clinics and at six hospital clinics in New York City, the authors found that nonphysician mental health workers provided much direct patient care: diagnosis and identifying data, necessary for reimbursement, were always included in records whereas mental status and medical history were poorly documented; and nonphysicians in hospitals generally surpassed physicians in the latter two areas. An additional observation was that attitudes of mental health workers toward certain diagnostic and ethnic groups may be inferred from the selective completeness of their psychiatric record keeping.