Annotated Bibliography

Articles listed here present information related to process and/or outcomes of individual hospital clinical peer review programs.

Butler JJ, Quinlan JW. Internal audit in the department of medicine of a community hospital: Two years’ experience. JAMA. 1958;167(5):567-572.
An excellent article describing a quality improvement initiative that anticipates many of the features of the QI Model. By contrast, it reveals that the QA Model was an anomalous deviation from historical practice.
Deuschele JM, Alvarez B, Logsdon DN, Stahl WM, Smith H. Physician performance in a prepaid health plan: results of the peer review program of the health insurance plan of greater New York. Med Care 1982;20(2):127-142.
Abstract
A peer review program to evaluate the quality of medical care was established by the Health Insurance Plan of Greater New York in 1973. Physician performance is assessed through application of explicit process criteria to medical care as recorded in the patient record. A total of 6,788 records were reviewed in terms of the clinical management of acute otitis media, hypertension and breast lesions. Follow-up procedures to bring about positive changes in delivery of health care were integrated into the program at the time of the initial audit. Re-audit of 715 records was used to measure change in physician compliance with medical care standards. Results of this audit/re-audit process demonstrated statistically significant improvement in quality of clinical practice as measured by the assessment parameters.
Weinberg NS. Creating a culture of quality practice among physicians. QRB Qual Rev Bull. 1987;13(12):405-410.
Describes the process the author established for the department of medicine in a 200+ bed community hospital focused on physicians and DRGs with above average lengths of stay. Looked at both process and outcomes. During chart review, used a form to rate multiple indicators such as admission and management appropriateness on a 3 point scale with comments. Provided feedback to individual physicians based on aggregate data from 15-20 charts using copies of the review forms. The process was not particularly efficient (3 paid committee members independently reviewed each chart), but did anticipate a number of features of the QI Model. The report provides no quantitative measures of effectiveness.
Zaloznik AJ, Montgomery RM. Effective peer review at Brooke Army Medical Center. Perspect Healthcare Risk Manage. 12(1):6-8, 1992.
This article offers a description of a QA-oriented program and does not really provide any evidence of effectiveness.
Olt F, Wilson D, Ron A, Soffel D. Quality improvement through review of inpatient deaths. J Healthcare Qual. 19(1):12-18, 1997.
Describes a QI-oriented process of case review and presents evidence of effectiveness.
Abstract
Emphasis on hospital mortality as a monitoring tool has raised concerns about the validity of mortality rates as a measure of quality of care. An indepth review of all mortalities at Beth Israel Medical Center was conducted from 1988 through 1993. Clinical issues identified from chart review were referred for departmental physician peer review, and quarterly reports of trends and issues were disseminated to all levels of the institution. Mortality rates declined 21% over the 6 years, from 3.3% to 2.6% of all discharges. Clinical quality issues were identified in less than 3% of all mortalities. The majority of problems were related to delays and appropriateness of treatment (57% of quality issues). The review program identified specific hospital processes for improvement, and, more importantly, created a "watchful concern" about quality-of-care issues throughout the hospital.
Weinberg NS, Stason WB. Managing quality in hospital practice. Int J Qual Health Care. 1998;10(4):295-302.
http://intqhc.oxfordjournals.org/content/intqhc/10/4/295.full.pdf
Describes an effort to improve hospital quality among participating primary care physicians through a peer review process that attended to the root causes of problems. Found quality improvement opportunities among 6% of the group’s admissions. The authors’ efforts to improve the effectiveness of screens for quality problems were marginally successful (5 charts reviewed to identify 1 quality improvement opportunity). Provides data on the classification of identified problems and their root causes (including prior outpatient care among 17%). Inadequate evaluation of objective program impact on quality.
Abstract
BACKGROUND: While routine clinical decision-making has a substantial effect on quality, most practicing physicians do not routinely examine their outcomes.
OBJECTIVES: To set up a practical process for identifying problems in hospital practices of primary care physicians, examine their causes, and develop a quality improvement process that intimately involves practicing physicians in problem-solving.
DESIGN: All hospital admissions to the Primary Care Service were screened over a 14-month period using simple pre-specified criteria. Quality problems were verified by medical record reviews carried out by two physicians. These problems were discussed at monthly meetings of physicians to characterize the problems fully, identify their causes, and document adverse effects on patient outcomes.
SETTING: One community hospital.
PARTICIPANTS: Primary care physicians from three group practices and four solo practices who admit patients to the Primary Care Service.
INTERVENTIONS: Monthly group discussions plus discussions with individual physicians when time did not permit all quality problems to be discussed at group meetings. Certain issues of high sensitivity were also discussed with the individuals rather than in an open forum.
OUTCOME MEASURES: Missed or delayed diagnoses, inappropriate treatments, and complications and their root causes.
RESULTS: Quality problems were identified in 6% of all admissions. Of these, 60% were missed or delayed diagnoses, 22% were iatrogenic complications and 18% were inappropriate treatments. Root cause analysis suggested that physician behaviors led to 75% of problems; systems problems to 20% and inadequate knowledge to 5%. Process improvements included development of a call-in system to reduce delays in obtaining X-ray reports; implementation of an anticoagulation monitoring system in one group practice; and a protocol of regular feedback of errors in diagnosis to emergency room physicians. Participating physicians reported increased awareness of common errors and greater attention to detail in patient evaluations.
CONCLUSIONS: Knowledge of root causes of quality problems is essential for improving quality of care. A simple routine approach to examining adverse outcomes and how care might be improved in the future was set up. Active participation of practicing physicians is essential. Other organizations could use this process for routinely reviewing and improving quality.
Deuschele JM, Alvarez B, Logsdon DN, Stahl WM, Smith H. Physician performance in a prepaid health plan: results of the peer review program of the health insurance plan of greater New York. Med Care 1982;20(2):127-142.
Abstract
A peer review program to evaluate the quality of medical care was established by the Health Insurance Plan of Greater New York in 1973. Physician performance is assessed through application of explicit process criteria to medical care as recorded in the patient record. A total of 6,788 records were reviewed in terms of the clinical management of acute otitis media, hypertension and breast lesions. Follow-up procedures to bring about positive changes in delivery of health care were integrated into the program at the time of the initial audit. Re-audit of 715 records was used to measure change in physician compliance with medical care standards. Results of this audit/re-audit process demonstrated statistically significant improvement in quality of clinical practice as measured by the assessment parameters.
Stanford JR, Swaney-Berhoff L, Recht KE, Orsagh-Yentis DK. Improved cardiac surgical outcomes with use of total quality management. JCOM 2009;16(9):405-409.
http://www.turner-white.com/jc/abstract_new09.php?PubCode=jcom_sep09_cardiac
The M&M conference was one key forum for identifying and initiating work on opportunities for improvement, but the mainstay of the effort involved hiring a physician director for the surgery program, a nurse coordinator who made daily rounds, check lists for nursing care at each shift, use of EuroScore for operative risk assessment, and daily patient tracking on the director’s whiteboard.
Abstract
Objective: To describe a program to improve processes of care for coronary artery bypass graft (CABG) patients.
Methods: A director and clinical coordinator were appointed and system improvements were implemented, including use of checklists, Euroscore, monthly morbidity and mortality conferences, and daily patient progress tracking.
Results: There was a decrease in the 30-day mortality rate from 3.5% preintervention to 1.25% postintervention (P < 0.05).
Conclusion: A cardiac surgery clinical improvement program was successful in reducing the CABG mortality rate at our hospital.
Bertges DJ, Shackford SR, Cloud AK et al. Toward optimal recording of surgical complications. Surgery. 2007;141(1):19-31.
Describes Shakford’s Surgical Activity Tracking System and presents data on its effectiveness in identifying operative complications for inpatient procedures. The process relied heavily on surgical residents .
Abstract
BACKGROUND: Information extracted from the hospital discharge data set is used increasingly for outcomes research and for benchmarking hospital and provider performance. The accuracy of these data in detecting vascular complications has never been validated.
METHODS: We compared morbidity and mortality data derived from the hospital discharge data set to similar data recorded concurrently by our Surgical Activity Tracking System (SATS) for 1 year on the vascular surgery service.
RESULTS: Of 798 total admissions, no complications were detected by either system in 598 admissions (75%). In 200 admissions (25%), there were 335 complications, including 24 deaths (3.0%), that occurred either in-hospital or within 30 days of the date of operation or the date of discharge for nonoperative admissions. Of the 335 complications, 180 (53.7%) were recorded by both systems; the SATS missed 59 complications recorded in the hospital discharge data set (17.6%), whereas the hospital discharge data set missed 96 complications recorded in the SATS (28.7%, P = .003). Of the 289 in-hospital complications, the SATS recorded 230 (79.5%), whereas the hospital discharge data set recorded 229 (79.2%). Of the 24 deaths, the hospital discharge data set missed 6 that occurred after discharge but within the 30-day reporting period.
CONCLUSIONS: Both systems are not completely accurate for tracking inpatient complications. The SATS was more representative than the hospital discharge data set in capturing 30-day morbidity and mortality. An amalgamation of the 2 systems would provide more optimal tracking of complications.
Graber ML. Physician participation in quality management: Expanding the goals of peer review to detect both practitioner and system error. Jt Comm J Qual Improv. 1999;25(8):396-407.
A very important paper that presages the QI Model for peer review. Graber showed that broadening the scope of peer review to include system issues quadrupled the number of problems identified and greatly magnified the number of quality improvement projects initiated. The program also enhanced reviewer participation. While the effort was successfully sustained for several years after this report, unfortunately the program did not spread to other services or to other VA hospitals and was ultimately replaced by national administrative mandates (personal communication from Mark Graber).
Abstract
BACKGROUND: The goals of peer review are to improve the quality of medical care and to provide fair review of individual practitioner actions, judged against the local standard of medical care. A new system for conducting peer review was evaluated which included in every case a root cause analysis to identify latent system flaws and a consideration of performance improvement projects to remedy these flaws.
METHODS: The peer review committee of the medical service in a tertiary care, affiliated Department of Veterans Affairs Medical Center, which conducted the evaluation, was familiar with the local standards of care and the systems issues relevant to each case. Four questions were answered for each case: Was the quality of care less than ideal? If so, was the practitioner negligent? What system flaws contributed to the error or to the severity of injury? How could the system flaws be eliminated?
RESULTS: Compared with the prior method of peer review, expanding the scope of review identified four times as many system problems (in 46% of cases versus 11%) without changing the incidence of finding provider negligence (21% preintervention versus 25% postintervention). Performance improvement projects were generated in 36 of 89 of these cases during the three-year period.
DISCUSSION: Expanding the scope of peer review to include both root cause analysis and performance improvement thinking increased the detection of latent system flaws and the number of performance improvement projects without compromising the peer review committee's ability to identify negligence.
Olcott C IV, Mitchell RS, Steinberg GK, Zarins CK. Institutional peer review can reduce the risk and cost of carotid endarterectomy. Arch Surg. 2000;135(8):939-942.
http://jamanetwork.com/journals/jamasurgery/article-abstract/390670
Virtually eliminated stroke complications and mortality for carotid surgery, while simultaneously reducing cost and length of stay, through annual review and discussion of complication profiles among all involved surgeons. Improvement in case selection may have been an important leverage point for the improvement.
Abstract
HYPOTHESIS: Surgeon-directed institutional peer review, associated with positive physician feedback, can decrease the morbidity and mortality rates associated with carotid endarterectomy.
DESIGN: Case series.
SETTING: Tertiary care university teaching hospital.
PATIENTS/INTERVENTIONS: All patients undergoing carotid endarterectomy at our institution during a 5-year period ending August 1998.
RESULTS: Stroke rate decreased from 3.8% (1993-1994) to 0% (1997-1998). The mortality rate decreased from 2.8% (1993-1994) to 0% (1997-1998). Length of stay decreased from 4.7 days (1993-1994) to 2.6 days (1997-1998). The total cost decreased from $13,344 (1993-1994) to $9548 (1997-1998).
CONCLUSIONS: An objective, confidential peer review process that provides ongoing feedback of performance to surgeons and documents that performance in relationship with that of peers seems to be effective in reducing the morbidity and mortality rate associated with carotid endarterectomy. In addition, the review process lowered the hospital cost of performing carotid endarterectomy.
Agee C. Professional review committee improves the peer review process. Physician Executive. 2007;33(1):52-55.
A descriptive report that claims benefits from a centralized, multispecialty review process based on the short-term experience at 1 hospital. Outcomes data are weak. Review volume was less than 1% of hospital inpatient volume.
Antonacci AC, Lam A, Lavarias V, Homel P, Eavey RA. A morbidity and mortality conference-based classification system for adverse events: surgical outcome analysis, part I. J Surg Res. 2008:147(2):172-177.
Abstract
BACKGROUND: We hypothesized that an archive database in conjunction with Morbidity and Mortality (M&M) review could be used to define a systematic list of post-surgical adverse events and identify areas for performance improvement.
STUDY DESIGN: Adverse event data following surgery were prospectively collected at the Beth Israel Medical Center in NYC from academic, specialty, community hospital, and ambulatory care settings over a 5-year period from September 2000 through April 2005. A classification system and analysis methodology was developed to guide and maximize the effectiveness of M&M review.
RESULTS: A total of 1618 adverse events, including 219 deaths, were analyzed following 29,237 operative procedures according to the analysis method described. A list of 245 adverse events was classified among 15 groups, and a subgroup of 25 adverse events accounted for over 80% of total adverse events. Five categories of adverse events were associated with death in surgical patients and 4 of 5 categories were post-operative events. Used in conjunction with M&M review, data derived from this analysis highlighted those adverse events with the greatest clinical frequency to the department's quality profile.
CONCLUSIONS: We present a classification system for surgical adverse events and propose a specific analysis method which may be used in conjunction with Morbidity and Mortality Conference to standardize the profiling of surgical performance.
Antonacci AC, Lam A, Lavarias V, Homel P, Eavey RA. A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II. J Surg Res. 2009;153(1):95-104.
These 2 papers describe a rigorous program to identify, review, classify, track, and provide regular feedback on surgical adverse events. An average of 9.6 cases were reviewed each week during M&M conferences that ran up to 4 hours. The authors claim reduced mortality resulted from this activity in a University hospital, but not in an affiliated community hospital. I don’t find the claim fully satisfactory as it is dependent on an uncertain baseline and virtually all the benefit was achieved in the first year. Also, one wants to better understand why the method didn’t work in both settings. Regardless, the expanded focus of review to include system process issues was productive.
Abstract
BACKGROUND: An effective report card system for adverse outcome error analysis following surgery is lacking. We hypothesized that a memorialized database could be used in conjunction with error analysis and management evaluation at Morbidity & Mortality conference to generate individualized report cards for Attending Surgeon and System performance.
STUDY DESIGN: Prospectively collected data from September 2000 through April 2005 were reported following Morbidity & Mortality review on 1618 adverse outcomes, including 219 deaths, following 29,237 operative procedures, in a complete loop to approximately 60 individual surgeons and responsible system personnel.
RESULTS: A 40% reduction of gross mortality (P < 0.001) and 43% reduction of age-adjusted mortality were achieved over 4 years at the Academic Center. Quality issues were identified at a rate three times greater than required by New York State regulations and increased from a baseline 4.96% to 32.7% (odds ratio 1.94; P < 0.03) in cases associated with mortality. A detailed review demonstrated a significant increase (P < 0.001) in system errors and physician-related diagnostic and judgment errors associated with mortality highlighted those practices and processes involved, and contrasted the results between academic (43% mortality improvement) and community (no improvement) hospitals.
CONCLUSIONS: The findings suggest that structured concurrent data collection combined with non-punitive error-based case review and individualized report cards can be used to provide detailed feedback on surgical performance to individual surgeons and possibly improve clinical outcomes.