1.
Pressure Ulcer
Prevention and Treatment in Hospitals. A PBE study conducted at a hospital in the
Rocky Mountain West to determine if development of pressure ulcers (PrUs) is
related to the severity of illness of the patient, and if implementation of a
protocol to stabilize the process of care for prevention of PrUs reduces the
incidence of PrUs.
Population: 2,500 at-risk patients/2,500
admissions from 1992 to 1993 in a tertiary-care hospital in the Rocky Mountain
West.
Example
of Findings: Patients who
developed PrUs were sicker on average on admission than patients at risk who
did not develop PrUs. Following
implementation of the PrU prevention protocol, PrUs decreased 300 per year,
saving on average $1.268 million per year.
2. Managed Care Outcomes Project. A PBE study was conducted at six HMOs
throughout the US to determine the effect of HMO organizational strategies on
outpatient visits, hospital admissions, and prescriptions for patients with at
least one of five diseases (arthritis, asthma, epigastric pain/ulcer,
hypertension, and otitis media).
Population: 13,158
patients/90,158 office visits/1,871 hospital admissions from 1992 to 1993 (patients followed
for one year) in six HMOs throughout the US.
Example
of Findings: For the five study
diseases, physician continuity was associated with reduced healthcare
utilization. The findings lend credence
to the hypothesis that physician continuity, combined with chart and site continuity,
is associated with reduced health care costs.
3. Formulary Limitations and the
Elderly: Results from the Managed Care Outcomes Project. A PBE study was
conducted at six HMOs throughout the US to determine whether restrictive
formulary limitations on drugs are associated with differences in health care
resource utilization, including office visits, prescriptions, and
hospitalizations, and whether this association varies by age.
Population: 13,000 patients from
six HMOs throughout the US were assessed for severity of illness at every
encounter for one year, totaling more than 99,000 outpatient visits, 480
emergency department visits, 1,000 hospitalizations, and 240,000 prescriptions.
Example
of Findings: Greater limitations in drug classes
were significantly associated with greater health care resource utilization;
these associations were sometimes significantly greater for elderly patients
after controlling for severity of illness and other variables.
4. Intended and Unintended
Consequences of HMO Cost Containment Strategies: Results from the Managed Care
Outcomes Project. A
PBE study was conducted at six HMOs throughout the US to determine the effect
of HMO cost-containment strategies on outpatient visits, hospital admissions,
and prescriptions on patients with at least one of five diseases (arthritis,
asthma, epigastric pain/ulcer, hypertension, and otitis media).
Population: 13,000 patients from
six HMOs throughout the US were assessed for severity of illness at every
encounter for one year, totaling more than 99,000 outpatient visits, 480
emergency department visits, 1,000 hospitalizations, and 240,000 prescriptions.
Example
of Findings: For four study diseases (but not for
otitis media), greater levels of formulary limitations on drugs to treat these
diseases were associated significantly with higher rates of emergency
department visits and hospitalizations and positively (but not always
significantly) with drug cost, drug count, and office visits.
5. Abdominal Surgery. A PBE study was conducted at eight hospitals
to determine areas of significant improvement in the management of abdominal
surgery patients.
Population: 1,007
patients/1,007 admissions from 1994 to 1997 in eight hospitals in the Pacific
West.
Examples
of Findings:
After controlling for disease severity,
patients with parenteral or enteral feeding that occurred within 48 hours of
surgery and met at least 60% of the patient's protein and calorie goals had
lower lengths of stay and hospital costs. The study also found the use of PCA
pump to be significantly associated with a higher rate of post-operative
surgical wound infection, 10.7% for PCA users vs. 4.0% for non PCA users.
6. Pediatric Asthma and
Bronchiolitis. A PBE study
to improve treatment of asthma and bronchiolitis and to measure pediatric
severity of illness generally.
Population: Severity
of illness data for 13,884 patients/16,557 admissions from 1995 to 1996 in 10
pediatric hospitals throughout the US. PBE
data for 762 asthma patients and 782 bronchiolitis patients.
Example of Findings: Extensive
variation in practice was found across all 10 pediatric hospitals regardless of
severity of illness. If the best
practices were used in all the study institutions we would expect on average a
0.5 day decrease in length of stay and a $1,679 decrease in cost per case for
pediatric asthma. For pediatric bronchiolitis,
we would expect on average a 2.0 day decrease in length of stay and a
$4,982 decrease in cost per case.
7. Coronary Artery Bypass Graft
Surgery. A PBE study to improve surgical processes and CABG
outcomes.
Population: 2,241
patients/2,243 admissions from 1994 to 1996 in 15 hospitals throughout the US.
Example
of Findings: After controlling for severity of
illness, several treatments were associated with longer length of stay, higher
cost, larger increase of severity of illness from admission (first 24 hours) to
maximum during the hospital stay, and more post-operative infections.
8. Bone Marrow Transplant and
Colorectal Cancer. A PBE study
to improve nutritional support during chemotherapy and radiotherapy for bone
marrow transplant or colorectal cancer patients.
Population: 352
bone marrow transplant patients/443 admissions from 1995 to 1997 in four tertiary-care hospitals in the Northeast and Southwest and 217
colorectal cancer patients/137 admissions/791 visits from 1992 to 1996 in four
hospitals in the Northeast, Midwest, and Pacific Southwest.
Example
of Findings:
Special nutritional supplements were associated with fewer complications and better
survival.
9. Congestive Heart Failure. A PBE study was
conducted to determine areas of significant improvement in the management of
congestive heart failure (CHF) patients.
Populations: 215
patients/338 admissions/791 visits from 1995 to 1996 in a hospital in the
Pacific Northwest and 116 patients/384 admissions/316 visits from 1994 to 1996
in a hospital in the mid-Atlantic region.
Examples of Findings: Longer
length of stay was associated with drug underdosing. A greater number of
admissions was associated with not giving education, as well as with noncompliance
with diet by patients.
10. National Pressure Ulcer Long-Term
Care Study. A PBE study
to improve prevention and treatment of pressure ulcers in nursing homes. Further analyses include best care for
nutrition deficiencies, incontinence, dementia, and nurse staffing.
Population: 2,486
residents/6,833 severity assessments from 1996 to 1997 in 109 facilities
belonging to six long-term-care provider systems throughout the US.
Examples
of Findings:
Disposable
briefs, supplement use, and combination medications are significantly
associated with development of fewer pressure ulcers, which results in less
resident suffering and decreases costs in nursing homes. Registered nurse direct care time >0.5
hours/resident/day was associated with fewer PrUs, urinary tract infections,
and hospitalizations with a cost savings to society of $3,191 per resident per
year.
11. Falls in Hospitals. A PBE
study to improve prevention of falls in
hospitals.
Population: 280
patients/285 admissions from 1995 to 1996 in a hospital in the Pacific
Northwest.
Examples of Findings: Fall patients stayed an average of 2.8 days longer
than non-fall patients. Older patients,
those with restraints, those using nicotine substitute, and those with medical
equipment were less likely to fall.
Patients who were sicker, used glasses or contacts, used non-narcotic
analgesics, had a secondary psychiatric diagnosis, climbed out of bed, or used
a walker or wheel chair during hospitalization were more likely to fall.
12. Abdominal Surgery Complications. A PBE study was conducted to determine areas of
significant improvement in the management of abdominal surgery patients
Population: 977 patients/977 admissions from
1997 to 1998 in three hospitals in the Rocky Mountain West.
Examples
of Findings:
After
controlling for disease severity, several treatment variables under provider
control including timing and amount of nutritional support, use of PCA pump to
control pain, and use of drains were associated with greater increase in
severity from admission (first 24 hours) to maximum during the hospital stay,
longer length of stay, higher cost, and higher infection rates.
13.
Optimal Ambulatory
Type 2 Diabetes Care. The purpose of this PBE
study was to determine interventions associated with significant improvement in
the management of adult type 2 diabetes.
The study was conducted at four West Coast ambulatory clinics between
March 1999 and December 2002.
Population: Detailed patient,
treatment, and outcome data were collected on 228 adult type 2 diabetes
patients 35-65 years old. The patients
had 3,069 diabetes care visits to 65 physicians. Patients were followed for 3
years.
Example
of Findings:
After controlling for severity of illness, self-monitoring of blood glucose
along with consistent provider discussion was strongly associated with better serum
glucose control and with fewer hospitalizations. The findings from this study
of adult outpatients with type 2 diabetes in actual practice of care confirm
findings from randomized trials of similar patients. These indicate that intensive therapy is an
effective way to reach the major goals of diabetes treatment: lowering blood glucose to appropriate levels
and avoiding and postponing the onset of serious complications.
14.
Telemedicine
Depression Study. Study
to discover impact of telemedicine to treat depression in patients in rural
areas.
Population: 998 patients/4,273 clinic
visits from 1999 to 2000 in rural settings in the Midwest.
15.
Telemedicine
Dermatology Study. Study
to discover impact of telemedicine to treat dermatology patients in rural
areas.
Population:
343 patients/779
visits from 1999 to 2000 in rural settings in the Midwest
16.
IV
Heparin Study. The
purpose of this study was to determine patient, environment, and treatment
factors that are associated with significantly lower rates of intravenous (IV)
heparin medication errors, and to discover optimal ways to prevent IV Heparin
medication errors.
Population: 426 patients from 2001 to 2003 in six
hospitals in the Pacific West.
Examples
of Findings: 63.9% of heparin orders were
written in Physician Orders, 13.2% were in facility protocols, 13.1% were in
specialized disease protocols such as for Acute MI, and the remaining 9.8% were
written in ER orders. Only 82.1% of
patients are weighed on the first day of hospital admission. Clinicians have
not agreed on a standard method to determine a heparin bolus dose or infusion
rate across facilities. Patients with
reported medication errors and/or abnormal PTT values had longer lengths of
stay by approximately two days although there was not a significant difference
in severity of illness. Patients who are
under anticoagulated (PTT<50) had longer lengths of stay than
patients who were over anticoagulated (PTT>120). Heparin protocols are not
used frequently in practice although they have been shown to improve
anticoagulation. The resistance by
physicians to use protocols perpetuates an environment that allows medication
errors to be prevalent in acute care settings.
The development of efficient and effective heparin protocols and
adherence by clinical staff has the potential to improve patient
care and safety and greatly reduce care costs by decreasing length of stay.
17.
National
Hospice Outcomes Project. A PBE
study to discover optimal pain control, dyspnea control, and self-determined
life closure methods for hospice patients.
Population: 1,306 patients from
2001 to 2003 in 13 hospices throughout the US.
Example
of Findings: The NHOP analyses demonstrate that final opioid dose, but
not percent change in dose, was one of several factors associated with
survival, but the association was weak; in multivariate analyses, this and
other relevant factors explain only a very small percentage of variation in
survival. The implication that opioid dose poses an extremely small risk of
hastened death in this population was supported further by the relatively long
intervals between final dose change and death, and the lack of higher opioid risk
in subsamples receiving high doses. This analysis suggests that the timing of
death in populations with far advanced illness involves a complex interplay of
variables, including important factors that were not assessed in this study,
and that opioid therapy should not be the focus of future research of this
type.
18.
C-Section Study. A PBE study to discover optimal labor and
delivery methods to reduce C-section rates and prevent labor and delivery
complications.
Population: 1,343 labor and delivery patients from
December 2001 and January 2002 in 8 southwest Texas hospitals.
Examples
of Findings: In comparing rates
of postpartum complications with vaginal vs. C-section deliveries, there was a
trend of fewer complications when the C-section was scheduled. When looking at gender of delivering
physician, the proportion all C-section
vs. vaginal deliveries was significantly higher for female delivery physicians
compared to males. The proportion of unscheduled C-sections was significantly
higher for female delivering physicians.
There was no significant difference in female delivering physicians for scheduled C-sections.
Female delivering
physicians had significantly fewer years of experience on average (8.1 years
vs. 21.9 years, p<0.0001) and significantly fewer law suits on average (1.0
vs. 3.4, p<0.0001). To control for
years of experience, we did a sub-analysis of physicians with <15 years
experience. We found the unscheduled C-section rate for female delivering
physicians was 42% compared to 13% (p=0.0009) for male delivering physicians.
The scheduled C-section rate for
female delivering physicians was 24% compared to 18% (p=0.62) for male
delivering physicians. The average number of law suits for female delivering
physicians was 1.0 compared to 2.0 (p<0.0001) for male delivering
physicians.
In determining if there
was an association with the time of starting prenatal care and C-Section
deliveries, the study found that, for scheduled and unscheduled C-sections
combined, patients delivering by C-section had borderline significantly younger
average gestational age at start of prenatal care than those who delivered
vaginally (12.6 weeks vs. 14.6 weeks, respectively, p=0.06). Patients delivering by C-section were also
significantly older at delivery than those who delivered vaginally (30 years
vs. 26.7 years, p=<.0001).
19.
Post-Stroke
Rehabilitation Outcomes Project. A PBE study to
discover optimal interventions in post-stroke rehabilitation.
Population: 1,291 post-stroke
rehabilitation patients from 2001 to 2003 in 7 inpatient rehabilitation
facilities (6 across the US and 1 in New Zealand).
Examples
of Findings: Fewer
days from stroke symptom onset to rehabilitation admission (earlier
rehabilitation admission) is significantly associated with higher total, motor,
mobility, and ADL discharge FIM
scores, controlling for severity of illness and initial functioning. Tube feeding severe stroke patient
more than 25% of their stay is significantly associated with higher total,
motor, and cognitive FIM, and greater improvement of severity of illness by discharge, even though tube fed patients
had a higher pneumonia development rate, which is a known complication of tube
feeding. More time spent in high-level
rehabilitation activities, such as gait, upper extremity control, and problem
solving in the first three hours of therapy for low-level stroke rehabilitation
patients is significantly associated
with higher total, motor, and cognitive FIM at discharge.
20.
Joint Replacement
Outcomes in IRFs and Nursing Treatment Sites.
A
PBE study to discover optimal interventions in hip and knee joint replacement
rehabilitation.
Population: 2,158 hip and knee replacement rehabilitation
patients from February 2006 through February 2007 in 8 freestanding skilled
nursing facilities, 1 hospital-based SNF, and 11 inpatient rehabilitation
facilities.
Examples
of Findings: Hip and knee replacement patients in hospital-based
rehabilitation centers, commonly known as inpatient rehabilitation facilities
(IRFs), recover faster and have marginally better functional outcomes compared
to patients who receive their rehabilitation in skilled nursing facilities
(SNFs) where patients typically stay longer but receive less intense services.
Apart from setting, the study found three things that are associated with
better outcomes:
·
Starting
rehabilitation earlier rather than later after surgery,
·
Obtaining
more intense therapy, namely more physical and occupational therapy per day
akin to what is found in IRFs,
·
Going
to a facility that serves a ‘medium volume’ of joint replacement patients. The
study’s medium-volume facilities, both SNFs and IRFs that treated between 100
and 183 joint replacement rehabilitation patients yearly, had the best
results. Low-volume facilities did much
less well.
21.
Analysis of Staff
Workflow and Associated Costs Among Green House and Traditional Nursing Home
Sites. Study
to analyze front-line caregiver daily workflow in
skilled nursing settings, including Green House (GH) homes, and assess if Green
House staffing was more expensive than traditional nursing home staffing.
Population:
Hundreds
of residents and staff in 27 sites: 13
nursing units in Traditional skilled nursing facilities and 14 Green House
homes across the US.
Examples
of Findings: Staffing from nursing and non-nursing departments
combined, excluding administrative staff, was 0.3 hours per resident per day
(18 minutes) less in GH homes compared to Traditional SNFs. CNAs in GH homes,
while responsible for more non-nursing activities like laundry and
housekeeping, spent 0.4 more hours per resident per day (24 minutes) in direct
care activities compared to CNAs in Traditional SNFs. The results challenge the
assumption that staffing efficiencies cannot be achieved in small environments
like a GH home. While GH model has higher ratio of CNA staff to residents
compared to Traditional SNF units, overall staff time (combined total of
nursing and non-nursing HPRD) is slightly less in GH homes. Compared to
Traditional SNFs, the GH model allows for expanded responsibilities of CNAs in
indirect care activities and more time in direct care activities and engaging
directly with resident.
22.
Analysis of Changes
in ADL Assistance Levels in Traditional Nursing Homes and THE GREEN HOUSE®
Project Sites. The principal objectives of this study were to conduct an
analysis of ADL change among
Green House elders compared to residents in the traditional nursing home, and
gain an understanding of Green House model ADL outcomes compared to those in
traditional nursing homes.
Population:
A total of 4 Green House organizations participated in the
study. From these organizations, 13
sites (GH homes and Traditional SNF units) were included in analyses. The total sample size was 255 residents: 97
GH residents and 158 Traditional SNF residents.
Example
of Findings: After controlling for resident characteristics known to
be associated with ADL decline, there was significantly less decline in ADL
assistance levels at 9- and 15-month follow-up time periods for GH residents
compared to residents in Traditional SNFs.
23.
Traumatic Brain
Injury Outcomes Project. A PBE study to
discover optimal interventions in post-traumatic brain injury rehabilitation. Study in progress.
Population: 2,315 traumatic brain injury rehabilitation
patients from October 2008 through August 2011 in 10 inpatient rehabilitation
facilities (9 across the US and 1 in Canada).
24.
Spinal Cord Injury Outcomes
Project. A PBE study to
discover optimal interventions in spinal cord injury rehabilitation. Study in progress.
Population: 1,500 spinal cord
injury rehabilitation patients from September 2007 through December 2009 in 6
inpatient rehabilitation facilities across the US.
25.
Pressure Ulcer
Prevention in Spinal Cord Injury. A PBE study to
discover optimal interventions to prevent pressure ulcers in spinal cord injury
patients in hospitals and rehabilitation.
Study in progress.
Population: 900 spinal cord injury patients from
September 2007 through March 2010 in 1 hospital and 1 inpatient rehabilitation
facility in the eastern US.
26.
Turning Frequency in
Nursing Home Residents. A PBE study to
determine the impact of turning at 2, 3, or 4 hour intervals for frail elderly
nursing home residents. Study in progress.
Population: 900 frail nursing home residents from March
2008 through December 2010 in nursing homes across the US and Canada.
27.
Pressure Ulcer
Healing Outcomes Project. A PBE study to
determine optimal treatments for pressure ulcers at various stages. One of the
outputs of this project in an On-Time
quality improvement manual that describes how to prevent pressure ulcers. Study in progress.
Population: Approximately 2,600 frail nursing home
residents with approximately 5,000 pressure ulcers from December 2007 through September
2010 in nursing homes across the US.
28.
Preventing Injurious Falls
in Nursing Homes. Study to implement fall prevention strategies
in nursing homes. Study in progress.
29.
Genetic Risk Factors
for Severe Influenza in Children. Study to determine
genetic factors that are associated with severe influenza in children. Study in progress.
30.
Comparative
Effectiveness of Interventions for Chronic Pain Management. Study to determine the combinations of
medications, surgery types, and ancillary interventions that are associated
with best pain management for patients with chronic cancer or non-cancer pain. Study in progress.
Population:
Several
thousand patients with chronic cancer or non-cancer pain seen in four pain
clinics located at Cornell Weill Medical Center, Memorial Sloan Kettering
Cancer Center, and Hospital for Special Surgery in New York City.
31.
Severity of Illness
Measurement Using the Comprehensive Severity Index.
Population: 14,324
patients/15,853 admissions from 1991 to 1992 in 13 ICUs in the Rocky Mountain
West.
Population: 10,856
patients/13,962 admissions from 1993 to 1996 in a tertiary-care hospital in the
Pacific West.
Population: 8,014
patients/9,554 admissions/51 visits from 1991 to 1995 in a tertiary-care
hospital in the Rocky Mountain West.
Population: 3,490 patients/3,487
admissions/492 visits from 1993 to 1997 in a hospital system in the Midwest.
Population:
480 patients/480 admissions from 1993 to 1995 in a psychiatric hospital
in Eastern Canada.