Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991.

Background: As part of an interdisciplinary study of medical injury and malpractice litigation, we estimated the incidence of adverse events, defined as injuries caused by medical management, and of the subgroup of such injuries that resulted from negligent or substandard care.

Methods: We reviewed 30121 randomly selected records from 51 randomly selected acute care, non-psychiatric hospitals in New York State in 1984. We then developed population estimates of injuries and computed rates according to the age and sex of the patients as well as the specialties of the physicians.

Rethinking quality in the context of persons with disability.

Objective: To review the current health services literature related to quality of care for persons with disabilities and to highlight the need for a unique framework for conceptualizing quality and patient safety issues for this population.

Design: Drawing on quality measurement theory, we formulate a multi-dimensional model of quality of care for persons with disability. This model is then used to identify and summarize findings from existing health services research that relate to the quality, of care for persons with disability.

Identification of in-hospital complications from claims data. Is it valid?

Objectives: This study examined the validity of the Complications Screening Program (CSP) by testing whether (1) ICD-9-CM codes used to identify a complication are coded completely and accurately and (2) the CSP algorithm successfully separates conditions present on admission from those occurring in the hospital.

Methods: We compared diagnosis and procedure codes contained in the Medicare claim with codes abstracted from an independent re-review of more than 1,200 medical records from Connecticut and California.

Results: Eighty-nine percent of the surgical cases and 84% of the medical cases had their CSP trigger codes corroborated by re-review of the medical record.

Using patient surveys to measure the quality of outpatient care in Kraków, Poland.

Objective: To test the feasibility of using patient reported information to create indicators of quality (access, patient experience--including satisfaction, and clinical quality) with the goal of providing Kraków city clinic managers (and potentially other audiences) with information about the quality of outpatient care in selected clinics. Setting and methods. Almost 2,000 patients from 19 outpatient clinics in Kraków, Poland were surveyed in November and December 1997 and January 1998.

Profiling resource use by primary-care practices: managed Medicare implications.

Variations in elderly Medicare beneficiaries' health service use are examined using a 100-percent sample of fee-for-service (FFS) claims data from Alabama, Iowa, and Maryland. Provider specialty, group practice type, practice size, and location are found to be significant factors affecting hospital and ambulatory care utilization and cost, after controlling for patient and regional characteristics. These results provide insights into utilization and cost expectations from different types of primary-care gatekeepers as the Medicare managed care market develops.

Identifying adverse events caused by medical care: degree of physician agreement in a retrospective chart review.

Objective: To 1) assess the degree of agreement among physicians on the cause of previously flagged adverse outcomes and 2) relate the findings to systems of quality assurance and performance assessment and proposals for no-fault compensation for medical injuries.

Design: Observational study of 7533 pairs of "structured implicit" reviews (subjective opinions based on guidelines) of medical records done by 127 physicians working independently.

Setting: Random sample of 51 inpatient facilities in New York State.

Education to improve the quality of clinical care in group practices.

Intervening to improve the quality of medical care is an essential component of an effective quality improvement program. Although interventions may take many forms, most have some educational component. This article discusses different types of educational strategies that may be used in group practices and describes our experience with a continuing medical education (CME) program based on the results of clinical performance measurement.

Processing the tort deterrent signal: a qualitative study.

Medical mistakes often are responsible for patient injury and suffering, but not all such mistakes are negligent. In the United States, injured patients have recourse to legal action under the common law. The medical malpractice tort trial system is intended to provide compensation for patients who have been negligently injured and to deter future negligent acts by physicians.

Validity review of performance measures.

A structured process for evaluating the validity of performance measures is essential if the rates generated by these measures are to be relied upon for large-scale programmes to improve clinical care. In this evaluation process a panel of objective clinicians who were not involved in developing the performance measures examines the criteria, coding instructions, and coding form. The panel's job is to determine the degree to which a sample of patient records containing treatment elements that have been flagged for nonconformance to certain criteria are truly nonconformant.

Physicians' discourses on malpractice and the meaning of medical malpractice.

Recent analyses of the professions have considered the question of the changing nature of professional power. This study is an interpretive analysis of the meaning of physicians' discourse in the face of a perceived challenge to the traditional boundaries of clinical practice from malpractice suits. The data for this analysis were drawn from interviews with physicians from three specialties and from documents produced by the AMA/Specialty Society.

Agreement between physicians' office records and Medicare Part B claims data.

This article tests agreement between demographic, diagnostic, and procedural information from primary-care physicians' office records and Medicare Part B claims for Maryland Medicare beneficiaries. The extent of agreement depended on the category of information being compared. Demographics matched poorly, probably due to incomplete record samples.

Variation in office-based quality. A claims-based profile of care provided to Medicare patients with diabetes.

Objectives: To demonstrate that claims data "profiling" can be used as an ongoing method to support ambulatory care quality improvement; to measure the quality of office-based care provided to elderly patients with diabetes in three states; and to identify factors associated with better attainment of quality standards.

Study Design: A cross-sectional study based on a 100% sample of the Medicare claims (Part B and Part A) submitted between July 1, 1990, and June 30, 1991.

Setting: All primary care practices (both solo and group) actively seeing Medicare patients with diabetes in Alabama, Iowa, and Maryland (n = 2980).

Developing a quality improvement database using health insurance data: a guided tour with application to Medicare's National Claims History file.

Health policy researchers are increasingly turning to insurance claims to provide timely information on cost, utilization, and quality trends in health care markets. This research offers an in-depth description of how to systematically transform raw inpatient and ambulatory claims data into useful information for health care management and research using the Health Care Financing Administration's National Claims History file as an example. The topics covered include: (a) understanding the contents and architecture of claims data, (b) creating analytic files from raw claims, (c) technical innovations for health policy studies, (d) assessing data accuracy, (d) the costs of using claims data, and (e) ensuring confidentiality.

Designing and using measures of quality based on physician office records.

This article presents our principles for developing performance measures to assess the quality of ambulatory care. The measures were developed as part of a project for developing and evaluating methods to promote ambulatory care quality (DEMPAQ). We describe our design for the performance measures, present examples of the DEMPAQ review criteria, and show the formats we used to feed back information to physicians.

A computerized system for reviewing medical records from physicians' offices.

Background: Review of clinical performance in office-based care is increasing in importance as more medical care shifts to outpatient settings. Decisions made in primary care settings can save lives and limit disability through prevention and early intervention in disease. Information is needed to assess quality of care by answering such questions as whether drugs are prescribed and monitored appropriately, follow-up on serious health threats is carried out promptly, or procedures are performed for appropriate indications.

Focus on quality: profiling physicians' practice patterns.

This article presents a physician practice profiling system developed using Medicare data to evaluate the quality of care provided by primary care physicians. We discuss four attributes to physicians' practice profiles that make them useful for quality improvement: flexibility, user involvement in developing profiles, explicit plans for evaluation, and fairness to groups of providers. This system serves as a model for physician profiling with a focus on quality of care measurement.

Developing and evaluating performance measures for ambulatory care quality: a preliminary report of the DEMPAQ project.

Because of the focus on technical quality, the content of the DEMPAQ performance measures is clinically detailed and oriented toward processes of care relevant to the everyday practice of medicine in the ambulatory setting. This emphasis is crucial if the performance measures are to be useful to practicing physicians.

Preventing medical injury.

Although adverse events (AEs) are not uncommon in hospitalized patients, they are by no means inevitable. A review of records from a population-based study in New York revealed that nearly 4% of hospitalized patients suffered AEs. Two-thirds of those events were considered to be caused by errors in management, most of which were not because of negligence.

Relationship between malpractice claims and cesarean delivery.

Objective: To investigate whether an association exists between the probability of a cesarean delivery and the level of malpractice claims risk faced by hospitals and physicians.

Design: Survey of computerized discharge data linked with physician and hospital malpractice claims records based on stratified, random sample of hospitals.

Setting: Acute care hospitals in New York State in 1984.

The economic consequences of medical injuries. Implications for a no-fault insurance plan.

Background: There has been little research into the actual economic consequences of medical injuries. This inhibits informed discussion of alternatives to malpractice litigation. For example, the cost of no-fault medical accident insurance has been thought to be prohibitive.

Physicians' perceptions of the risk of being sued.

We explore the deterrent effect of the tort system by assessing physician perceptions of the risk of being sued and the impact of those perceptions on their own practice. The data are from a mailed survey conducted in 1989 of a random sample of physicians who were practicing in New York State in 1984. The survey results were compared to the actual risk of suit using the between-group (Wald) test and logistic regression methods.

Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III.

Background And Methods: By matching the medical records of a random sample of 31,429 patients hospitalized in New York State in 1984 with statewide data on medical-malpractice claims, we identified patients who had filed claims against physicians and hospitals. These results were then compared with our findings, based on a review of the same medical records, regarding the incidence of injuries to patients caused by medical management (adverse events).

Results: We identified 47 malpractice claims among 30,195 patients' records located on our initial visits to the hospitals, and 4 claims among 580 additional records located during follow-up visits.

Hospital characteristics associated with adverse events and substandard care.

To explore the epidemiology of adverse events (AEs), which were defined as injuries due to medical treatment, and that subset of AEs caused by negligence, we studied interhospital variation in these outcomes in a sample of 31,000 medical records drawn from a random selection of 51 hospitals in New York in 1984. We found a substantial variation in both AE rates (0.2% to 7.