Although we've never met, Dr Norbert Goldfield and I go way back. Studying Dr Goldfield's pioneering work in developing the application of diagnosis-related groups (DRGs) in evaluating the relationships among length of stay, medical interventions, patient outcomes, and the cost of health care inspired me to explore the idea of combining the then-stylish "indicator theory" with DRGs. Here, Kelly, Goldfield, and Patel present and analyze the 5 potentially preventable events (PPEs) that reflect unnecessary, inappropriate, or even harmful services that increase the cost of care without bringing benefit to the patient. The authors explain new risk adjustment strategies for dealing with potentially preventable readmissions, using a construct called a CRG (clinical risk group).
Do the clinical consequences of having to change the patient's diagnosis and treatment during his or her hospital stay inevitably result in an increase in the cost of care? To answer this question, Johnson, McNutt, Kane, Ackerman, Odwazny, and Bardhan employed a construct called diagnosis discrepancy in analyzing the quantifiable results of such discrepancies.
Rohrer, Sheeler, Furst, and Bartel report on a study in a large group practice of "avoidable" after hours phone calls to physicians. They provide a tentative definition of "avoidable" that some might consider a bit slippery. It really depends on which side of the picture you're on-are you the apprehensive patient or the busy physician looking forward to a relaxing evening at home? Interestingly, the authors found that variation in the incidence of avoidable calls was associated with the physician on call, rather than with the patient's age, time of day, or day of the week. This finding suggests the possibility that personal definition of "avoidable" carries significant weight. Admittedly, developing the group's plan for improving its handling of after-hour patient contacts is a work in progress. As the authors report, the evidence so far indicates a lack of consensus among the physicians on call in evaluating a patient's actual need for physician-level consultation in this after-hour context.
As Rossi, Devlin, Wellins, and Savic point out, even a universally recommended therapy can occasionally be associated with adverse effects in the presence of known contraindications. Using retrospective chart review, they explored histories of hospitalized patients with type 2 diabetes and certain additional diagnoses or characteristics that would contraindicate the administration of metformin or who were in critical care or postoperative care units. The objective was to determine the relative efficacy of a "soft" computer alert, basically a warning, in the presence of a metformin order, versus a "hard stop" electronic alert that cannot be overridden, effectively preventing metformin administration. The researchers found that the soft stop alert alone was not fully effective in preventing the inappropriate administration of metformin. They recommend a combination of soft stop and hard stop computer alerts as more effective in preventing inappropriate medication administration.
The long-range success of workplace innovation depends on whether or not it can be sustained. This in turn depends in large part on the attitudes and flexibility of the workforce. Ford, Krahn, Oliver, and Kirchner explore this dynamic in a real life setting and report their findings.
Medical authorities and the media diligently remind the public that in the presence of certain symptoms or suspicious findings, colonoscopy should be performed without undue delay. However, the occurrence of significant time gaps between referral and the procedure have been documented. For their investigation of the causes and effects of postreferral delay in performing indicated colonoscopies, Singh, Khan, Giardina, Paul, Daci, Gould, and El-Serag conducted a mixed method analysis of postreferral colonoscopy delays in patients diagnosed with colorectal cancer. They explored referring physicians' perceptions of the processes surrounding the observed delays.
Lean Six Sigma is always an inviting topic for a discussion and a report describing its pros and cons during the course of a hospital's experience with it. Here, Niemeijer, Trip, de Jong, Wendt, and Does review the course of the program in the traumatology services of Netherlands' second largest hospital. They emphasize the importance of support by the organization's leaders in ensuring the success of the program.
Digital video recording of conditions and behaviors within the patient's hospital room was employed in conjunction with implementation of a program viewing care through the eyes of patients and their families. In the setting of the Patient- and Family-Centered Care Methodology and Practice developed at the University of Pittsburgh. Anthony M. DiGioia, Pamela K. Greenhouse, and Christopher S. DiGioia report on a project combining these 2 approaches at a university hospital. They conclude that digital video recording can be useful in fostering patient safety, efficiency, and quality.
Discrepancies in data compilation and reporting among different databases used in assessing the quality of health care are explored by Martensson, Fredericksen, Brown, Dalton, and Osler. They point to the vital importance of completeness and validity of data used in performance comparisons across organizational units and illustrate their argument with comparisons of data from the Danish National Patient Registry and the Danish National Lymphoma Database.