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Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.

https://arctichealth.org/en/permalink/ahliterature164254
Source
Ann Surg. 2007 Apr;245(4):526-32
Publication Type
Article
Date
Apr-2007
Author
Robert K Michaels
Martin A Makary
Yasser Dahab
Frank J Frassica
Eugenie Heitmiller
Lisa C Rowen
Richard Crotreau
Henry Brem
Peter J Pronovost
Author Affiliation
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
Source
Ann Surg. 2007 Apr;245(4):526-32
Date
Apr-2007
Language
English
Publication Type
Article
Keywords
Canada
Clinical Protocols
Humans
Joint Commission on Accreditation of Healthcare Organizations
Medical Errors - prevention & control
Medical Laboratory Science
Risk factors
Safety
Safety Management - methods
Societies, Medical
Surgery Department, Hospital - organization & administration - standards
Surgical Procedures, Operative - standards
United States
United States Department of Veterans Affairs
Abstract
Review the evidence regarding methods to prevent wrong site operations and present a framework that healthcare organizations can use to evaluate whether they have reduced the probability of wrong site, wrong procedure, and wrong patient operations.
Operations involving the wrong site, patient, and procedure continue despite national efforts by regulators and professional organizations. Little is known about effective policies to reduce these "never events," and healthcare professional's knowledge or appropriate use of these policies to mitigate events.
A literature review of the evidence was performed using PubMed and Google; key words used were wrong site surgery, wrong side surgery, wrong patient surgery, and wrong procedure surgery. The framework to evaluate safety includes assessing if a behaviorally specific policy or procedure exists, whether staff knows about the policy, and whether the policy is being used appropriately.
Higher-level policies or programs have been implemented by the American Academy of Orthopaedic Surgery, Joint Commission on Accreditation of Healthcare Organizations, Veteran's Health Administration, Canadian Orthopaedic, and the North American Spine Society Associations to reduce wrong site surgery. No scientific evidence is available to guide hospitals in evaluating whether they have an effective policy, and whether staff know of the policy and appropriately use the policy to prevent "never events."
There is limited evidence of behavioral interventions to reduce wrong site, patient, and surgical procedures. We have outlined a framework of measures that healthcare organizations can use to start evaluating whether they have reduced adverse events in operations.
Notes
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PubMed ID
17414599 View in PubMed
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Clinical practice guidelines: key resources to guide clinical decision making and enhance quality health care.

https://arctichealth.org/en/permalink/ahliterature148594
Source
J Emerg Nurs. 2009 Sep;35(5):460-1
Publication Type
Article
Date
Sep-2009
Author
Paula Cooper Clutter
Author Affiliation
Department of Acute Nursing Care, The University of Texas Health Science Center School of Nursing, San Antonio, 78229-3900, USA. clutter@uthscsa.edu
Source
J Emerg Nurs. 2009 Sep;35(5):460-1
Date
Sep-2009
Language
English
Publication Type
Article
Keywords
Centers for Disease Control and Prevention (U.S.)
Databases, Factual
Decision Making
Emergency Nursing
Evidence-Based Medicine
Humans
Ontario
Practice Guidelines as Topic
Quality of Health Care
Societies, Nursing
United States
United States Department of Veterans Affairs
United States Government Agencies
PubMed ID
19748032 View in PubMed
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Construction and characteristics of the RxRisk-V: a VA-adapted pharmacy-based case-mix instrument.

https://arctichealth.org/en/permalink/ahliterature6026
Source
Med Care. 2003 Jun;41(6):761-74
Publication Type
Article
Date
Jun-2003
Author
Kevin L Sloan
Anne E Sales
Chuan-Fen Liu
Paul Fishman
Paul Nichol
Norman T Suzuki
Nancy D Sharp
Author Affiliation
VA Puget Sound Health Care System, Seattle, Washington 98108, USA. Kevin.Sloan@med.va.gov
Source
Med Care. 2003 Jun;41(6):761-74
Date
Jun-2003
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Chronic Disease - classification - drug therapy - epidemiology
Clinical Pharmacy Information Systems
Comparative Study
Cost of Illness
Diagnosis-Related Groups - classification
Drug Utilization Review
Female
Humans
International Classification of Diseases
Male
Middle Aged
Models, Econometric
Multivariate Analysis
Northwestern United States - epidemiology
Pharmacies - statistics & numerical data
Prescriptions, Drug
Research Support, U.S. Gov't, Non-P.H.S.
Risk Adjustment - methods - standards
United States
United States Department of Veterans Affairs
Veterans - classification - statistics & numerical data
Abstract
BACKGROUND: Assessment of disease burden is the key to many aspects of health care management. Patient diagnoses are commonly used for case-mix assessment. However, issues pertaining to diagnostic data availability and reliability make pharmacy-based strategies attractive. Our goal was to provide a reliable and valid pharmacy-based case-mix classification system for chronic diseases found in the Veterans Health Administration (VHA) population. OBJECTIVE: To detail the development and category definitions of a VA-adapted version of the RxRisk (formerly the Chronic Disease Score); to describe category prevalence and reliability; to check category criterion validity against ICD-9 diagnoses; and to assess category-specific regression coefficients in concurrent and prospective cost models. RESEARCH DESIGN: Clinical and pharmacological review followed by cohort analysis of diagnostic, pharmacy, and utilization databases. SUBJECTS: 126,075 veteran users of VHA services in Washington, Oregon, Idaho, and Alaska. METHODS: We used Kappa statistics to evaluate RxRisk category reliability and criterion validity, and multivariate regression to estimate concurrent and prospective cost models. RESULTS: The RxRisk-V classified 70.5% of the VHA Northwest Network 1998 users into an average of 2.61 categories. Of the 45 classes, 33 classes had good-excellent 1-year reliability and 25 classes had good-excellent criterion validity against ICD-9 diagnoses. The RxRisk-V accounts for a distinct proportion of the variance in concurrent (R2 = 0.18) and prospective cost (R2 = 0.10) models. CONCLUSIONS: The RxRisk-V provides a reliable and valid method for administrators to describe and understand better chronic disease burden of their treated populations. Tailoring to the VHA permits assessment of disease burden specific to this population.
PubMed ID
12773842 View in PubMed
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Current issues in the management of hypertension.

https://arctichealth.org/en/permalink/ahliterature55766
Source
Clin Pharm. 1984 Jan-Feb;3(1):40-8
Publication Type
Article
Author
S L Sheaffer
D L Fye
Source
Clin Pharm. 1984 Jan-Feb;3(1):40-8
Language
English
Publication Type
Article
Keywords
Antihypertensive Agents - adverse effects
Australia
Diuretics - adverse effects
Female
Follow-Up Studies
Humans
Hypertension - complications - drug therapy - epidemiology
Hypokalemia - chemically induced
Lipids - blood
Male
Risk
Sweden
United States
United States Department of Veterans Affairs
Abstract
Major trials evaluating antihypertensive therapy are reviewed, and the current issues surrounding the choice of therapy in mild and isolated systolic hypertension are discussed. Several major trials have shown that patients with mild hypertension benefit from therapy. These results have prompted widespread use of antihypertensive agents; however, there are still no clear guidelines on when drug therapy should be initiated. Only the Hypertension Detection and Follow-up Program has shown significant decreases in coronary heart disease (CHD) related deaths. Thiazide diuretics are recommended as agents of first choice in the stepped-care approach to the management of uncomplicated mild to moderate hypertension. The Multiple Risk Factor Intervention Trial evaluated the effects of modifying several cardiovascular risk factors in more than 12,000 high-risk men. It failed to document significant differences in CHD-related mortality in patients who received special care as compared with those who received usual care. Concerns have been raised about the contribution of antihypertensive therapy, particularly diuretics, to the lack of differences in therapeutic outcomes. There is renewed interest in lipid alterations secondary to antihypertensive agents and the effect of diuretic-induced hypokalemia. Antihypertensive therapy should be instituted with an individualized assessment of the potential benefits of therapy relative to the short- and long-term risks of treatment.
PubMed ID
6365415 View in PubMed
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The development of a telemedical cancer center within the Veterans Affairs Health Care System: a report of preliminary clinical results.

https://arctichealth.org/en/permalink/ahliterature3935
Source
Telemed J E Health. 2002;8(1):123-30
Publication Type
Article
Date
2002
Author
Kevin G Billingsley
David L Schwartz
Susan Lentz
Eric Vallières
R Bruce Montgomery
William Schubach
David Penson
Bevan Yueh
Howard Chansky
Claudia Zink
Darla Parayno
Gordon Starkebaum
Author Affiliation
Department of Surgery, VA Puget Sound Health Care System and the University of Washington Seattle, Washington 98108, USA. kevinb@u.washington.edu
Source
Telemed J E Health. 2002;8(1):123-30
Date
2002
Language
English
Publication Type
Article
Keywords
Aged
Cancer Care Facilities - organization & administration - statistics & numerical data
Female
Humans
Male
Middle Aged
Organizational Innovation
Research Support, U.S. Gov't, Non-P.H.S.
Telemedicine - organization & administration - trends
United States
United States Department of Veterans Affairs - organization & administration - statistics & numerical data
Abstract
In order to optimize the delivery of multidisciplinary cancer care to veterans, our institution has developed a regional cancer center with a telemedical outreach program. The objectives of this report are to describe the organization and function of the telemedical cancer center and to report our early clinical results. The Veterans Affairs Health Care System is organized into a series of integrated service networks that serve veterans within different areas throughout the United States. Within Veterans Integrated Service Network 20 (Washington, Alaska, Idaho, Oregon) we have developed a regional cancer center with telemedicine links to four outlying facilities within the service area. The telemedical outreach effort functions through the use of a multidisciplinary telemedicine tumor board. The tumor board serves patients in outlying facilities by providing comprehensive, multidisciplinary consultation for the complete range of malignancies. For individuals who do require referral to the cancer center, the tumor board serves to coordinate the logistical and clinical details of the referral process. This program has been in existence for 1 year. During that time 85 patients have been evaluated in the telemedicine tumor board. Sixty-two percent of the patients were treated at their closest facility; 38% were referred to the cancer center for treatment and/or additional diagnostic studies. The patients' diagnoses included the entire clinical spectrum of malignant disease. Preliminary clinical results demonstrate the program is feasible and it improves access to multidisciplinary cancer care. Potential benefits include improved referral coordination and minimization of patient travel and treatment delays.
PubMed ID
12020412 View in PubMed
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Organized colorectal cancer screening in integrated health care systems.

https://arctichealth.org/en/permalink/ahliterature133398
Source
Epidemiol Rev. 2011 Jul;33(1):101-10
Publication Type
Article
Date
Jul-2011
Author
Theodore R Levin
Laura Jamieson
Daniel A Burley
Juan Reyes
Michael Oehrli
Cindy Caldwell
Author Affiliation
Theodore.Levin@kp.org
Source
Epidemiol Rev. 2011 Jul;33(1):101-10
Date
Jul-2011
Language
English
Publication Type
Article
Keywords
California - epidemiology
Colorectal Neoplasms - diagnosis - epidemiology - prevention & control
Delivery of Health Care, Integrated - organization & administration
Great Britain
Health Maintenance Organizations - organization & administration
Humans
Mass Screening - organization & administration
Occult Blood
Ontario
United States
United States Department of Veterans Affairs
Abstract
Colorectal cancer (CRC) is an ideal target for early detection and prevention through screening. Noninvasive screening options are the guaiac fecal occult blood test and the fecal immunochemical test. Organized screening offers the promise of uniformly delivering screening to all members of a population who are eligible and due. Organized screening is defined as an explicit policy with defined age categories, method, and interval for screening in a defined target population with a defined implementation and quality assurance structure, and tracking of cancer in the population. The UK National Health Service; the Ontario, Canada Ministry of Health and Long-Term Care; and the US Veteran's Health Administration have used varied organized approaches to deliver guaiac fecal occult blood test screening to their populations. Kaiser Permanente Northern California began CRC screening in the 1960s, initially using flexible sigmoidoscopy. Implementation of organized fecal immunochemical test outreach was associated with improved Healthcare Effectiveness Data and Information Set CRC screening rates between 2005 and 2010 from 37% to 69% and from 41% to 78% in the commercial and Medicare populations, respectively. Organized fecal immunochemical test screening has been associated with an increase in annually detected CRCs, almost entirely because of increased detection of localized-stage cancers.
PubMed ID
21709143 View in PubMed
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Predicting costs of care using a pharmacy-based measure risk adjustment in a veteran population.

https://arctichealth.org/en/permalink/ahliterature5542
Source
Med Care. 2003 Jun;41(6):753-60
Publication Type
Article
Date
Jun-2003
Author
Anne E Sales
Chuan-Fen Liu
Kevin L Sloan
Jesse Malkin
Paul A Fishman
Amy K Rosen
Susan Loveland
W. Paul Nichol
Norman T Suzuki
Edward Perrin
Nancy D Sharp
Jeffrey Todd-Stenberg
Author Affiliation
VA Puget Sound Health Care System, Seattle, Washington 98108, USA. Ann.Sales@med.va.gov
Source
Med Care. 2003 Jun;41(6):753-60
Date
Jun-2003
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Age Distribution
Aged
Clinical Pharmacy Information Systems
Comparative Study
Diagnosis-Related Groups - economics
Drug Utilization Review
Female
Forecasting - methods
Health Care Costs - trends
Humans
Male
Middle Aged
Models, Econometric
Northwestern United States
Pharmacies - statistics & numerical data
Prescriptions, Drug - statistics & numerical data
Research Support, U.S. Gov't, Non-P.H.S.
Risk Adjustment - methods
United States
United States Department of Veterans Affairs
Veterans - statistics & numerical data
Abstract
BACKGROUND: Although most widely used risk adjustment systems use diagnosis data to classify patients, there is growing interest in risk adjustment based on computerized pharmacy data. The Veterans Health Administration (VHA) is an ideal environment in which to test the efficacy of a pharmacy-based approach. OBJECTIVE: To examine the ability of RxRisk-V to predict concurrent and prospective costs of care in VHA and compare the performance of RxRisk-V to a simple age/gender model, the original RxRisk, and two leading diagnosis-based risk adjustment approaches: Adjusted Clinical Groups and Diagnostic Cost Groups/Hierarchical Condition Categories. METHODS: The study population consisted of 161,202 users of VHA services in Washington, Oregon, Idaho, and Alaska during fiscal years (FY) 1996 to 1998. We examined both concurrent and predictive model fit for two sequential 12-month periods (FY 98 and FY 99) with the patient-year as the unit of analysis, using split-half validation. RESULTS: Our results show that the Diagnostic Cost Group /Hierarchical Condition Categories model performs best (R2 = 0.45) among concurrent cost models, followed by ADG (0.31), RxRisk-V (0.20), and age/sex model (0.01). However, prospective cost models other than age/sex showed comparable R2: Diagnostic Cost Group /Hierarchical Condition Categories R2 = 0.15, followed by ADG (0.12), RxRisk-V (0.12), and age/sex (0.01). CONCLUSIONS: RxRisk-V is a clinically relevant, open source risk adjustment system that is easily tailored to fit specific questions, populations, or needs. Although it does not perform better than diagnosis-based measures available on the market, it may provide a reasonable alternative to proprietary systems where accurate computerized pharmacy data are available.
PubMed ID
12773841 View in PubMed
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Providing culturally competent services for American Indian and Alaska Native veterans to reduce health care disparities.

https://arctichealth.org/en/permalink/ahliterature257090
Source
Am J Public Health. 2014 Sep;104 Suppl 4:S548-54
Publication Type
Article
Date
Sep-2014
Author
Timothy D Noe
Carol E Kaufman
L Jeanne Kaufmann
Elizabeth Brooks
Jay H Shore
Author Affiliation
The authors are with the Department of Veterans Affairs Office of Rural Health, Veterans Rural Health Resource Center-Western Region, Native Domain, and the Centers for American Indian and Alaska Native Health, School of Public Health, University of Colorado, Denver.
Source
Am J Public Health. 2014 Sep;104 Suppl 4:S548-54
Date
Sep-2014
Language
English
Publication Type
Article
Keywords
Communication
Cultural Competency
Health Services Accessibility - organization & administration
Health services needs and demand
Humans
Indians, North American
Inuits
Leadership
Organizational Innovation
Program Evaluation
United States
United States Department of Veterans Affairs - organization & administration
Veterans
Veterans Health
Abstract
We conducted an exploratory study to determine what organizational characteristics predict the provision of culturally competent services for American Indian and Alaska Native (AI/AN) veterans in Department of Veterans Affairs (VA) health facilities.
In 2011 to 2012, we adapted the Organizational Readiness to Change Assessment (ORCA) for a survey of 27 VA facilities in the Western Region to assess organizational readiness and capacity to adopt and implement native-specific services and to profile the availability of AI/AN veteran programs and interest in and resources for such programs.
Several ORCA subscales (Program Needs, Leader's Practices, and Communication) statistically significantly predicted whether VA staff perceived that their facilities were meeting the needs of AI/AN veterans. However, none predicted greater implementation of native-specific services.
Our findings may aid in developing strategies for adopting and implementing promising native-specific programs and services for AI/AN veterans, and may be generalizable for other veteran groups.
Notes
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PubMed ID
25100420 View in PubMed
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Racial/ethnic differences in influenza vaccination in the Veterans Affairs Healthcare System.

https://arctichealth.org/en/permalink/ahliterature80193
Source
Am J Prev Med. 2006 Nov;31(5):375-82
Publication Type
Article
Date
Nov-2006
Author
Straits-Tröster Kristy A
Kahwati Leila C
Kinsinger Linda S
Orelien Jean
Burdick Mary B
Yevich Steven J
Author Affiliation
Veterans Affairs National Center for Health Promotion and Disease Prevention-NCP, Durham, North Carolina 27705, USA. straits-troster@biac.duke.edu
Source
Am J Prev Med. 2006 Nov;31(5):375-82
Date
Nov-2006
Language
English
Publication Type
Article
Keywords
African Americans - statistics & numerical data
Aged
Female
Health Care Surveys
Health Services Accessibility
Hispanic Americans - statistics & numerical data
Humans
Immunization Programs - utilization
Indians, North American - statistics & numerical data
Influenza A virus - immunology
Influenza Vaccines - administration & dosage
Influenza, Human - ethnology - prevention & control
Logistic Models
Male
Middle Aged
Patient Acceptance of Health Care - ethnology
United States
United States Department of Veterans Affairs
Veterans - statistics & numerical data
Abstract
BACKGROUND: Racial/ethnic differences in influenza vaccination exist among elderly adults despite nearly universal Medicare health insurance coverage. Overall influenza vaccination prevalence in the Veterans Affairs (VA) Healthcare System is higher than in the general population; however, it is not known whether racial/ethnic differences exist among older adults receiving VA healthcare. Racial/ethnic differences in influenza vaccination in VA were assessed, and barriers to and facilitators of influenza vaccination were examined among veteran outpatients aged 50 years and older. METHODS: A random sample of 121,738 veterans receiving care at VA outpatient clinics during the 2003-2004 influenza season completed the mailed Survey of Health Experiences of Patients (77% response rate). Multivariate logistic regression was used to examine associations among race/ethnicity and influenza vaccination prevalence, barriers, and facilitators. Analyses were conducted during 2005 and 2006. RESULTS: Based on unadjusted prevalences, non-Hispanic blacks, Hispanics, and American Indian/Alaskan Natives were significantly less likely to be vaccinated for influenza compared to non-Hispanic whites (71%, 79%, and 74%, respectively, vs 82%). After adjustment for age, gender, marital status, education level, employment, having a primary care provider, confidence and/trust in provider, and health status, only non-Hispanic blacks remained significantly less likely to be vaccinated compared to non-Hispanic whites (75% vs 81%). Influenza vaccination barriers and facilitators varied by race/ethnic group. CONCLUSIONS: Compared to non-Hispanic whites, non-Hispanic blacks were less likely to receive influenza vaccination in the VA healthcare system during the 2003-2004 influenza season. Although these differences were small, results suggest the need for further study and culturally informed interventions.
PubMed ID
17046408 View in PubMed
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19 records – page 1 of 2.