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Emergency Medical Services Outcomes Project (EMSOP) II: Developing the foundation and conceptual models for out-of-hospital outcomes research

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ANNALS OF EMERGENCY MEDICINE 2001年第6期37卷 657-663页

作者： Spaite, DW Maio, R Garrison, HG Desmond, JS Gregor, MA Stiell, IG Cayten, CG Chew, JL MacKenzie, EJ Miller, DR O'Malley, PJ Univ Arizona Coll Med Div Emergency Med Arizona Emergency Med Res Ctr Tucson AZ USA Univ Michigan Med Ctr Dept Emergency Med Ann Arbor MI 48109 USA E Carolina Univ Brody Sch Med Dept Emergency Med Greenville NC 27834 USA Univ Ottawa Div Emergency Med Ottawa ON Canada Univ Ottawa Loeb Hlth Res Inst Ottawa ON Canada New York Med Coll Inst Trauma & Emergency Care Valhalla NY 10595 USA EMSSTAR Grp Annapolis MD USA Johns Hopkins Univ Sch Hyg & Publ Hlth Baltimore MD USA Hlth Span Transportat Serv St Paul MN USA Allina Hlth Syst St Paul MN USA Massachusetts Gen Hosp Pediat Emergency Serv Boston MA 02114 USA Massachusetts Dept Publ Hlth Emergency Med Serv Children Boston MA USA

Development of methodologically acceptable outcomes models for emergency medical services (EMS) is long overdue. In this article, the Emergency Medical Services Outcomes Project proposes a conceptual framework that will provide a foundation for future EMS outcomes research. The "Episode of Care Model" and the "Out-of-Hospital Unit of Service Model" are presented. The Episode of Care Model is useful in conditions in which interventions and outcomes, especially survival and major physiologic dysfunction, are linked in a time-dependent manner. Conditions such as severe trauma, anaphylaxis, airway obstruction, respiratory arrest, and nontraumatic cardiac arrest are amenable to this methodology. The Out-of-Hospital Unit of Service Model is essentially a subunit of the Episode of Care Model. it is valuable for evaluating conditions that have minimal-to-moderate therapeutic time dependency. This model should be used when studying outcomes limited to the out-of-hospital interval. An example of this is pain management for injuries sustained in motor vehicle crashes. These models can be applied to a wide spectrum of conditions and interventions. With the scrutiny of health care expenditures ever increasing, the identification of clinical interventions that objectively improve patient outcome takes on growing importance. Therefore, the development, dissemination, and use of meaningful methodologies for EMS outcomes research is key to the future of EMS system development and maintenance.

关键词：出院后医疗/组织和管理急救医疗服务/组织和管理治疗过程片断卫生工作重点卫生服务研究/组织和管理模型组织管理年患病率结果评价(卫生保健)/组织和管理规划制订/方法研究设计/标准风险调节/组织和管理存活率分析时间因素美国/流行病学人类

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Practical risk-adjusted quality control charts for infection control

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AMERICAN JOURNAL OF INFECTION CONTROL 2000年第6期28卷 406-414页

作者： Gustafson, TL Infect Control & Prevent Analysts Inc Austin TX 78735 USA

Background: Control chart methodology has been widely touted for monitoring and improving quality in the health care setting. P charts and U charts are frequently recommended for rate and ratio statistics, but their practical value in infection control may be limited because they (1) are not risk-adjusted, and (2) perform poorly with small denominators. The Standardized Infection Ratio is a statistic that overcomes both these obstacles. It is risk-adjusted, and it effectively increases denominators by combining data from multiple risk strata into a single value. Setting: The AICE National Database Initiative is a voluntary consortium of US hospitals ranging in size from 50 to 900 beds. The infection control professional submits monthly risk-stratified data for surgical site infections, ventilator-associated pneumonia, and central line-associated bacteremia. Methods: Run charts were constructed for 51 hospitals submitting data between 1996 and 1998. Traditional hypothesis tests (P values < .05) flagged 128 suspicious points, and participating infection control professionals investigated and categorized each flag as a "real problem" or "background variation." This gold standard was used to compare the performance of 5 unadjusted and 11 risk-adjusted control charts. Results: Unadjusted control charts (C, P, and U charts) performed poorly. Flags based on traditional 3-sigma limits suffered From sensitivity < 50%, whereas 2-sigma limits suffered from specificity < 50%. Risk-adjusted charts based on the Standardized Infection Ratio performed much better The most consistent and useful control chart was the mXmR chart. Under optimal conditions, this chart achieved a sensitivity and specificity > 80%, and a receiver operating characteristic area of 0.84 (P < .00001). Conclusions: These findings suggest a specific statistic (the Standardized Infection Ratio) and specific techniques that could make control charts valuable and practical tools for infection control.

关键词：菌血症/流行病学菌血症/病因学偏倚(流行病学) 交叉感染/流行病学交叉感染/病因学数据说明统计数据库事实型表格和记录管理/标准指导方针(主题) 医院病床数感染控制/组织和管理信息管理/标准病案/标准肺炎/流行病学肺炎/病因学质量控制问卷调查风险调节/组织和管理敏感性与特异性外科伤口感染/流行病学外科伤口感染/病因学美国/流行病学人类

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Risk adjusting capitation: Applications in employed and disabled populations

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Health Care Management Science 2000年第2期3.0卷 101-109页

作者： Madden, Carolyn W. Mackay, Bret P. Skillman, Susan M. Ciol, Marcia Diehr, Paula K. Department of Health Services University of Washington Seattle WA 98195 United States Department of Economics University of Washington Seattle WA 98195 United States Department of Biostatistics University of Washington Seattle WA 98195 United States

Risk adjustment may be a sensible strategy to reduce selection bias because it links managed care payment directly to the costs of providing services. In this paper we compare risk adjustment models in two populations (public employees and their dependents, and publicly-insured low income individuals with disabilities) in Washington State using two statistical approaches and three health status measures. We conclude that a two-part logistic/GLM statistical model performs better in populations with large numbers of individuals who do not use health services. This model was successfully implemented in the employed population, but the managed care program for the publicly insured population was terminated before risk adjustment could be applied. The choice of the most appropriate health status measure depends on purchasers' principles and desired outcomes. © Baltzer Science Publishers BV.

关键词：按人收费/组织和管理残疾人筹资政府保健福利计划雇员/组织和管理健康状况保险选择偏倚 Logistic模型管理医疗规划/组织和管理 Medicaid/组织和管理贫困风险调节/组织和管理州卫生计划/组织和管理美国华盛顿青少年成年人老年人女(雌)性人类男(雄)性中年人

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Risk adjustment and the fear of markets: The case of Belgium

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Health Care Management Science 2000年第2期3卷 121-130页

作者： Schokkaert, Erik Van De Voorde, Carine Center for Economic Studies KU Leuven Leuven Belgium

In Belgium the management and administration of the compulsory and universal health insurance is left to a limited number of non-governmental non-profit sickness funds. Since 1995 these sickness funds are partially financed in a prospective way. The risk adjustment scheme is based on a regression model to explain medical expenditures for different social groups. Medical supply is taken out of the formula to construct risk-adjusted capitation payments. The risk-adjustment formula still leaves scope for risk selection. At the same time, the sickness funds were not given the instruments to exert a real influence on expenditures and the health insurance market has not been opened for new entrants. As a consequence, Belgium runs the danger of ending up in a situation with little incentives for efficiency and considerable profits from cream skimming. © Baltzer Science Publishers BV.

关键词：比利时按人收费/组织和管理效率组织筹资政府/组织和管理预测卫生经费支出/统计学和数值数据保险选择偏倚管理医疗规划/组织和管理卫生服务使用研究/组织和管理国家卫生规划/组织和管理回归分析风险调节/组织和管理成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Risk-adjusted in-hospital death rates for peer hospitals in rural and urban regions

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JOURNAL OF RURAL HEALTH 1999年第1期15卷 94-107页

作者： Glenn, LL Jijon, CR E Tennessee State Univ Off Rural & Community Hlth Johnson City TN 37614 USA

The purpose of this research project Ic,as to compare impatient mortality rates for rural hospitals with mortality rates of urban hospitals of given sizes and ranges of service. Statistical adjustments for risk were made in the probability of death during hospitalization for 43,000 patients across 166 hospitals by age, gender, principal diagnosis, principal surgical procedure, characteristics of the secondary diagnoses, and whether or not cancer was a secondary diagnosis. Eighty-three small hospitals that had a relatively unspecialized range of services constituted the stimy group. Patients characteristics of this study group were moderately representative, of the national population. A standardized score was calculated for each hospital using a formula based oil the actual hospital death rate and the death rate expected for a given hospital with patients of the same demographic and medicinal characteristics. Patients admitted to hospitals ill nonmetropolitan areas had a mortality rate of 0.41 percent compared with a mortality rate of 0.66 percent in peer hospitals in metropolitan areas. After mortality rates were risk-adjusted and converted to z scores, nonmetropolitan areas had an nz,average z of +0.16, and metropolitan areas had an average z of -0.25, where positive z scores reflect a lower-than-average adjusted mortality rate. The metropolitan-nonmetropolitan (urban-rural) difference ic,ns not statistically significant, but if is meaningful in that rural hospitals tended to have a lower adjusted mortality rate than urban hospitals of the same size and type, indicating that rural hospitals had the same or lower adjusted mortality rates. The possibility of urban hospitals having riskier patients was minimized but could not be definitely ruled out. Taken together with other studies, the data are consistent ,with the view ro that small rural hospitals generally make appropriate transfer decisions for severely ill patients and quality cars for retained patients.

关键词：年龄分布诊断相关患者组卫生服务研究医院病床数医院死亡率医院乡村/标准医院乡村/统计学和数值数据医院市区/标准医院市区/统计学和数值数据前瞻性研究卫生保健质量可重复性结果风险调节/组织和管理性别分布田纳西青少年成年人老年人老年人 80以上儿童儿童学龄前女(雌)性人类婴儿婴儿新生男(雄)性中年人

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Risk adjustment of capitation payments to behavioral health care carve-outs: How well do existing methodologies account for psychiatric disability?

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Health Care Management Science 2000年第2期3卷 159-169页

作者： Ettner, Susan L. Frank, Richard G. Mark, Tami Smith, Mark W. Division of General Internal Medicine and Health Services Research UCLA Department of Medicine Los Angeles CA 90095 United States Department of Health Care Policy Harvard Medical School Boston MA United States MEDSTAT Group Inc. Washington DC United States

This study used 1994-1995 administrative data from a large public employer to examine the viability of commercial risk adjustment systems for setting capitation payments to competing behavioral health care "carve-outs". The ability of Hierarchical Condition Categories and Adjusted Diagnostic Groups to predict psychiatric expenditures was improved by controlling separately for psychiatric disability. However, even the best models underpredicted expenditures of patients with psychiatric disability by 15%. Relative to full capitation, "mixed" payment systems and soft capitation reduce the ability of carve-outs to earn disproportionate profits by enrolling healthy patients and avoiding sick ones, yet also diminish incentives for cost containment. © Baltzer Science Publishers BV.

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