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1.  Developing quality indicators for older adults: transfer from the USA to the UK is feasible 
Quality & safety in health care  2004;13(4):260-264.
Background: Measurement of the quality of health care is essential for quality improvement, and patients are an underused source of data about quality of care. We describe the adaptation of a set of USA quality indicators for use in patient interview surveys in England, to measure the extent to which older patients receive a broad range of effective healthcare interventions in both primary and secondary care.
Method: One hundred and nineteen quality indicators covering 16 clinical areas, based on a set of indicators for the care of vulnerable elderly patients in the USA, were reviewed by a panel of 10 clinical experts in England. A modified version of the RAND/UCLA appropriateness method was used and panel members were supplied with literature reviews summarising the evidence base for each quality indicator. The indicators were sent for comment before the panel meeting to UK charitable organisations for older people.
Results: The panel rated 102 of the 119 indicators (86%) as valid for use in England; 17 (14%) were rejected as invalid. All 58 indicators about treatment or continuity and follow up were rated as valid compared with just over half (13 of 24) of the indicators about screening.
Conclusions: These 102 indicators are suitable for use in patient interview surveys, including the English Longitudinal Study of Ageing (ELSA). The systematic measurement of quality of care at the population level and identification of gaps in quality is essential for quality improvement. There is potential for transfer of quality indicators between countries, at least for the health care of older people.
doi:10.1136/qshc.2004.010280
PMCID: PMC1743867  PMID: 15289628
2.  Will changes in primary care improve health outcomes? Modelling the impact of financial incentives introduced to improve quality of care in the UK 
Quality & safety in health care  2004;13(3):191-197.
Objectives: To estimate the total health gain from improving the quality of care among patients with cardiovascular disease in line with the quality indicator targets in the new contract for general practitioners (GPs) in the UK.
Design: Statistical modelling, applying population impact measures to estimate cardiovascular health gains from achieving treatment targets in the GP contract, taking into account current levels of treatment and control.
Main outcome measures: Number of events prevented in the population over 5 years applied to a notional general practice population of 10 000.
Results: The greatest health gain in those aged 45–84 years would come from reaching cholesterol reduction targets. This could prevent 15 events in people with coronary heart disease, seven events in those with a history of stroke, and seven events in those with diabetes. Achieving blood pressure control targets in hypertensive patients without the above conditions could prevent 15 cardiovascular events, with further benefits from reducing blood pressure in patients with high blood pressure and coronary heart disease, stroke, or diabetes. Achieving other targets would have smaller impacts because high levels of care are already being achieved or because of the low prevalence of conditions or associated event risk.
Conclusion: It is possible to quantify the health gain to a practice population of achieving quality targets such as those set in the new GP contract. The amount of health gain is sensitive to current quality of care, prevalence of conditions, and risk factors, and to the size of change anticipated. Nevertheless, it appears that significant health gains could result from achieving the proposed quality targets.
doi:10.1136/qshc.2003.007401
PMCID: PMC1743844  PMID: 15175489
3.  Is the methodological quality of guidelines declining in the US? Comparison of the quality of US Agency for Health Care Policy and Research (AHCPR) guidelines with those published subsequently 
Quality & safety in health care  2003;12(6):428-434.
Objective: To determine whether North American guidelines published subsequent to and in the same topic areas as those developed by the US Agency for Health Care Policy and Research (AHCPR) meet the same methodological criteria.
Study design: A guideline appraisal instrument containing 30 criteria was used to evaluate the methodological quality of the AHCPR guidelines, "updates" of the AHCPR guidelines authored by others, and guidelines that referenced or were adapted from the AHCPR guidelines. The frequency with which the criteria appeared in each guideline was compared and an analysis was performed to determine guidelines with two key features of the ACHPR guidelines—multidisciplinary guideline development panels and systematic reviews of the literature. Data were extracted from the guidelines by one investigator and then checked for accuracy by the other.
Results: Fifty two guidelines identified by broad based searches were evaluated. 50% of the criteria were present in every AHCPR guideline. The AHCPR guidelines scored 80% or more on 24 of the 30 criteria compared with 14 for the "updates" and 11 for those that referenced/adapted the AHCPR guidelines. All of the 17 AHCPR guidelines had both multidisciplinary development panels and systematic reviews of the literature compared with five from the other two categories (p<0.05).
Conclusions: North American guidelines developed subsequent to and in the same topic areas as the AHCPR guidelines are of substantially worse methodological quality and ignore key features important to guideline development. This finding contrasts with previously published conclusions that guideline methodological quality is improving over time.
doi:10.1136/qhc.12.6.428
PMCID: PMC1758044  PMID: 14645758
4.  Can health care quality indicators be transferred between countries? 
Objective: To evaluate the transferability of primary care quality indicators by comparing indicators for common clinical problems developed using the same method in the UK and the USA.
Method: Quality indicators developed in the USA for a range of common conditions using the RAND-UCLA appropriateness method were applied to 19 common primary care conditions in the UK. The US indicators for the selected conditions were used as a starting point, but the literature reviews were updated and panels of UK primary care practitioners were convened to develop quality indicators applicable to British general practice.
Results: Of 174 indicators covering 18 conditions in the US set for which a direct comparison could be made, 98 (56.3%) had indicators in the UK set which were exactly or nearly equivalent. Some of the differences may have related to differences in the process of developing the indicators, but many appeared to relate to differences in clinical practice or norms of professional behaviour in the two countries. There was a small but non-significant relationship between the strength of evidence for an indicator and the probability of it appearing in both sets of indicators.
Conclusion: There are considerable benefits in using work from other settings in developing measures of quality of care. However, indicators cannot simply be transferred directly between countries without an intermediate process to allow for variation in professional culture or clinical practice.
doi:10.1136/qhc.12.1.8
PMCID: PMC1743668  PMID: 12571338
6.  Socioeconomic inequalities in indicator scores for diabetes: poor quality or poor measures? 
BMJ : British Medical Journal  2004;329(7477):1269-1270.
doi:10.1136/bmj.38285.603692.7C
PMCID: PMC534443  PMID: 15548560
8.  Development of review criteria for assessing the quality of management of stable angina, adult asthma, and non-insulin dependent diabetes mellitus in general practice 
OBJECTIVE: To develop review criteria to assess the quality of care for three major chronic diseases: adult asthma, stable angina, and non- insulin dependent diabetes mellitus. SUBJECTS AND METHODS: Modified panel process based upon the RAND/UCLA (University College of Los Angeles) appropriateness method. Three multiprofessional panels made up of general practitioners, hospital specialists, and practice nurses. RESULTS: The RAND/UCLA appropriateness method of augmenting evidence with expert opinion was used to develop criteria for the care of the three conditions. Of those aspects of care which were rated as necessary by the panels, only 26% (16% asthma, 10% non-insulin dependent diabetes, 40% angina) were subsequently rated by the panels as being based on strong scientific evidence. CONCLUSION: The results show the importance of a systematic approach to combining evidence with expert opinion to develop review criteria for assessing the quality of three chronic diseases in general practice. The evidence base for the criteria was often incomplete, and explicit methods need to be used to combine evidence with expert opinion where evidence is not available.
PMCID: PMC2483627  PMID: 10557672
9.  Are nonspecific practice guidelines potentially harmful? A randomized comparison of the effect of nonspecific versus specific guidelines on physician decision making. 
Health Services Research  2000;34(7):1429-1448.
OBJECTIVE: To test the ability of two different clinical practice guideline formats to influence physician ordering of electrodiagnostic tests in low back pain. DATA SOURCES/STUDY DESIGN: Randomized controlled trial of the effect of practice guidelines on self-reported physician test ordering behavior in response to a series of 12 clinical vignettes. Data came from a national random sample of 900 U.S. neurologists, physical medicine physicians, and general internists. INTERVENTION: Two different versions of a practice guideline for the use of electrodiagnostic tests (EDT) were developed by the U.S. Agency for Health Care Policy and Research Low Back Problems Panel. The two guidelines were similar in content but varied in the specificity of their recommendations. DATA COLLECTION: The proportion of clinical vignettes for which EDTs were ordered for appropriate and inappropriate clinical indications in each of three physician groups were randomly assigned to receive vignettes alone, vignettes plus the nonspecific version of the guideline, or vignettes plus the specific version of the guideline. PRINCIPAL FINDINGS: The response rate to the survey was 71 percent. The proportion of appropriate vignettes for which EDTs were ordered averaged 77 percent for the no guideline group, 71 percent for the nonspecific guideline group, and 79 percent for the specific guideline group (p = .002). The corresponding values for the number of EDTs ordered for inappropriate vignettes were 32 percent, 32 percent, and 26 percent, respectively (p = .08). Pairwise comparisons showed that physicians receiving the nonspecific guidelines ordered fewer EDTs for appropriate clinical vignettes than did physicians receiving no guidelines (p = .02). Furthermore, compared to physicians receiving nonspecific guidelines, physicians receiving specific guidelines ordered significantly more EDTs for appropriate vignettes (p = .0007) and significantly fewer EDTs for inappropriate vignettes (p = .04). CONCLUSIONS: The clarity and clinical applicability of a guideline may be important attributes that contribute to the effects of practice guidelines.
PMCID: PMC1975662  PMID: 10737446
10.  Evaluating the use of the appropriateness method in the Agency for Health Care Policy and Research Clinical Practice Guideline Development process. 
Health Services Research  1996;31(4):453-468.
OBJECTIVE: To assess the feasibility of the appropriateness method in the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline Development process, and to compare the results of the appropriateness method with those obtained using evidence tables and an informal consensus method. SETTING: AHCPR Low Back Problems Clinical Practice Guideline. DESIGN: Two different group process methods with the same panel of experts were used in observational comparison of results of and satisfaction with guideline development. DATA COLLECTION: Practice guideline statements were created for topics using the conventional AHCPR method; then six months later new guideline statements for four topics were created using the appropriateness method. Panelist satisfaction with each process and resulting set of guideline statements was assessed. PRINCIPAL FINDINGS: Results of the appropriateness method for TENS, discography, and traction showed no disagreement among panel members and no appropriate indications for their use in the patient scenarios considered. These results are qualitatively similar to the guideline statements produced using evidence tables and informal consensus. Clinical practice guideline statements about electro-diagnostics created from appropriateness ratings were much more clinically specific than those created using evidence tables and informal consensus. Neither informal consensus building nor the appropriateness method was clearly preferred by a majority of panelists. CONCLUSIONS: It is feasible to use the appropriateness method in the AHCPR Clinical Practice Guideline Development process, and in some instances it produces more clinically specific guideline statements than does informal consensus.
PMCID: PMC1070131  PMID: 8885858
11.  Impact of varying panel membership on ratings of appropriateness in consensus panels: a comparison of a multi- and single disciplinary panel. 
Health Services Research  1995;30(4):577-591.
OBJECTIVE. The objective of the study was to examine the appropriateness ratings for the use of spinal manipulation for low back pain of a multidisciplinary panel of medical and chiropractic physicians, and those of a panel composed only of chiropractic physicians. DATA SOURCES. The study analyzed data from two consensus panels conducted at RAND in 1990 and 1991. STUDY DESIGN. The study design followed that of the traditional RAND consensus panels. Nine individuals comprised each panel, and each panelist was asked to rate, on a nine-point scale, the indications for spinal manipulation twice, the first time alone and the second time jointly with the panel. DATA COLLECTION. The ratings of the panelists from both groups, for both round one and round two, were collated and compared. PRINCIPAL FINDINGS. While both panels were more likely to rate the indications as inappropriate than appropriate, the single disciplinary panel was more likely to rate an indication as appropriate than the multidisciplinary panel. CONCLUSION. The composition of a panel clearly influences the ratings and those who use a given procedure in practice, in this case manipulation, are more likely to rate it as appropriate than those who do not use the procedure.
PMCID: PMC1070076  PMID: 7591782
12.  Coordinate synthesis of the enzymes of pyrimidine biosynthesis in Bacillus subtilis. 
Journal of Bacteriology  1982;149(2):775-778.
Strains of Bacillus subtilis that were resistant to repression of pyrimidine nucleotide biosynthetic enzymes were selected by isolating spontaneous uracil-tolerant derivatives of a uracil-sensitive strain, which lacks arginine-repressible carbamyl phosphate synthetase. The relative content of all six enzymes of uridylic acid biosynthesis de novo in these strains was in a constant ratio over a 10-fold range of derepression, which indicates that synthesis of these enzymes is coordinately regulated.
PMCID: PMC216572  PMID: 6120161

Results 1-12 (12)