Medical care
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This study uses the Herfindahl index to investigate the specialization patterns of physicians. "Specialization" is defined as the degree to which an individual doctor concentrates his practice into a narrow range of disease categories. This application is the specialization pattern of office-based obstetrician/gynecologists in the United States. Physician's age and solo practice both exhibit a systematic negative effect on specialization. ⋯ The nonsolo practitioner effect suggests the efficiency of multiple doctor practices for allocating physicians' time in activities with high hourly variability in demand. The method used to measure specialization can be extended to investigate other specialty categories and important issues regarding the future supply of physicians' services. These include the effects of an aging physician population and proposed changes in physician reimbursement.
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A recursive estimation model is used to investigate the roles of cardiopulmonary resuscitation (CPR) and advanced life support in improving survival from out-of-hospital cardiac arrest. The importance of life support measures is clearly evidenced in the analysis: Fewer elapsed minutes between the cardiac arrest and the start of CPR increase the probabilities of both a favorable cardiac rhythm and defibrillation and the probability of survival. ⋯ Personal characteristics also contribute to survival, but primarily via their association with a favorable initial postarrest cardiac rhythm and the probability of defibrillation. The initial postarrest cardiac rhythm is shown to be an indicator of the heart's condition, but when other factors associated with survival are included in the analysis, it does not independently influence an individual's probability of survival.
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Comparative Study
Predicting in-hospital survival of myocardial infarction. A comparative study of various severity measures.
This study reports on the ability of several indices to predict in-hospital survival from acute myocardial infarction. The following indices were included: Acute Physiological and Chronic Health Evaluation (APACHE II), Medisgroups (MDGRP), Computerized Severity Index (CSI), Patient Management Categories (PMC), Coded Disease Staging (CDS), Ischemic Heart Disease Index (IHDI), and Predictive Index for Myocardial Infarction (PIMI). An arbitrary strategy of predicting that all patients will live was also applied and correctly classified 78% of the cases. ⋯ Indices based on discharge abstracts were as accurate as some of the indices based on physiologic variables, in particular PMC was as accurate as CSI, MDGRP, APACHE, and IHDI, and CDS was as accurate as MDGRP, APACHE, and IHDI. This study was limited in scope and application and should not be generalized to other settings until additional data confirm the findings. We discuss the implications of these findings for measuring quality of care and suggest improvements for design of future severity indices.
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Randomized Controlled Trial Clinical Trial
Ethical issues in administrative continuous improvement. Applying the concept of prior notification to the conduct of firm trials.
Consensus exists concerning the distinctions to be drawn between clinical practice and research. When the latter is undertaken, established regulations require that protocols including plans for obtaining subjects' informed consent be submitted to Institutional Review Boards for approval. Less consensus or codification exists concerning evaluations conducted by managers in health care settings. ⋯ Accordingly, the history of firm trials from an ethical perspective is reviewed. At the University of Washington, participants of such studies are informed through the process of prior notification, an adaptation of procedures employed widely to inform patients that records or specimens may be used in epidemiologic or biomedical research. Prior notification appears to be a useful refinement of the firm system methodology, one that may have application to managerial manipulations in other arenas.
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Factors related to hospital resource use by intensive care unit (ICU) patients, including severity of illness at admission and intensity of therapy during the first 24 ICU hours were explored in this study. Analysis was based on 2,749 patients admitted to the general medical-surgical ICU at Baystate Medical Center, Springfield, Massachusetts, between February 1, 1983 and January 10, 1985. Resource use was indexed by hospital length of stay (LOS) adjusted for differences between ICU and other hospital days. ⋯ Variability in resource use was analyzed using four diagnosis-related groups (DRGs) accounting for large numbers of ICU patients. The relationship between severity of illness and resource was nonlinear: as severity increased from low levels, resource use increased at a decreasing rate, reached a plateau, and eventually declined. Within each DRG, MPM0 explained a statistically significant percentage of the variability in resource use.