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The Workshop . BACKGROUND AND CONDUCT To provide a context and some background materials for the committee, TOM and HCFA staff compiled a set of readings Hat was forwarded before the meeting. TOM staff developed a brief exercise, completed before He workshop, to identify a large set of clinical conditions grouped by major organ systems and disease categories and then to provide a means of narrowing the sets to be discussed at the workshop to a manageable few. HCFA staff compiled a large array of data tables on most of the conditions to be discussed, some of which were distributed before He meeting and some of which was made available the day of the workshop. The workshop began win presentations on the effectiveness research initiative by William L. Roper and Henry I. Krakauer (HCFA) and a general discussion of He criteria by which He clinical conditions should be selected. Kathleen N. Lohr (IOM) reviewed He homework exercise. The committee then discussed the preliminary list of conditions, selected an interim group of conditions, discussed that group in greater depth, and chose the final set to be recommended to HCEA. We also briefly discussed patient manage- ment options for He key conditions Hat we judged would be important to the Effectiveness Initiative. The executive session focused on the final recommendations to be made to HCFA. Homework Exercise The homework exercise was conducted as a modified Delphi process, in which committee members completed two questionnaire sheets to classify and Hen rate potential clinical conditions as to Heir probable importance for the Effectiveness Initiative. IOM staff generated a list of 42 diagnoses 4

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s judged to represent He primary conditions that should be considered (see Table 1~. We were then asked to assign each condition to one of three categories: (1) must be included in the workshop discussion, (2) probably important to the HCFA program, and (3) can be dropped from further discussion. The exercise restricted us from classifying more than 10 con- ditions in the first (highest priority) category. The third step was to take the 10 (or fewer) conditions we classified as highest priority and rate them on an "importance scale" ranging from 1 (highest importance to the Effective- ness Initiative) to 5 (lowest importance). We returned these sheets to IOM staff, who compiled the results and reported on them at the meeting. Of the 14 members of the committee, 13 resumed the classification and rating sheets. In our initial response, we collectively nominated 31 condi- tions as "must be included," including a 43rd condition (urinary incon- tinence). Based on a simple count of votes, we found that 10 conditions had been so classified by at least six of the committee: angina, breast cancer, acute myocardial infarction (10 votes each); prostatic hypertrophy (9 each); hip fracture and peripheral vascular disease (7 each); end transientischemic attack (TIA) without occlusion, Alzheimer's disease, cataracts, and oc- clusion/stenosis of precerebral arteries (6 each). When the importance ratings were analyzed, we determined with some simple scoring rules that 14 conditions had clearly higher importance than the others. They included all those listed above plus cardiovascular accident and stroke without TIA, depressive disorders, degenerative joint disease, and gastrointestinal bleeding. These conditions roughly one-~ird of He original list formed a core set on which initial discussions at He workshop were focused. A second round of voting on an intermediate listing was also conducted during the workshop. HCFA Data Additional background materials were made available by staff of the Health Standards and Quality Bureau (HSQB) of HCFA, both before and at the meeting, in the form of two sets of data Hat reflect the present capabilities of the HSQB/HCFA files. The first set of data concerned monitoring of outcomes of medical interventions. Specific topics examined for a number of disease categories are listed on Page 8:

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6 TABLE 1 Potential List of Clinical Conditions to Consider for HCFA Effectiveness Iniiiadve This list of clinical conditions to be considered at the Clinicians' Workshop for the Health Care Financing Administration's Effectiveness Initiative is based on the work already being done internally by HCFA or externally by researchers sponsored by HCFA or by the National Center for Health Services Research. The listing is organized by major diag- nosis or disease classes and, within those, more specific clinical condition areas. (No priority order should be inferred.) Specific procedures related to one or another of these diagnoses are not listed. DIAGNOSTIC CLASS I. CardiovasculartCirculatory Disease CLINICAL CONDITION 2. 3. 4. 5. 6. 7. 8. 1. Angina (stable and unstable) Acute myocardial infarction Valvular heart disease Congestive heart failure Hypertension Bradycardia and conduction defects Tachycardia Aortic Aneurysm 8.a Abdominal 8.b Thoracic 9. Peripheral vascular disease 10. Deep vein thrombophlebitis II. Cerebrovascular Disease 11. Cerebrovascular accident/stroke other than TIAs 12. Transient ischemia attack without occlusion 13. Occlusion/stenosis of precerebral arteries III. Disorders of Nervous System and Sense Organs 14. Pa~inson's disease 15. Alzheimer's disease 16. Cataracts 17. Glaucoma 18. Hearing loss IV. Diseases of the Respiratory System 19. Chronic obstructive pulmonary disease 20. Pneumonias 21. Respiratory failure

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7 TABLE 1 (Continued) V. Diseases of the Gastrointestinal/Digestive System 22. Gastrointestinal bleeding 23. Peptic ulcer disease 24. Diverticular disease 25. Cholecystitis 26. Cholelithiasis 27. Hernia (inguinal) 28. Hiatal hernia VI. Disorders of the Endocrine System VII. Musculoskeletal Disease VIII. Genitourinary Diseases IX. Neoplastic Disease (Primary) 29. Diabetes mellitus 30. Osteoporosis 31. Degenerative joint disease (osteoarthritis/osteoarthrosis) 32. Hip fracture 33. Kidney/urinary tract infection (pyelonephritis, cystitis) 34. Kidney stones 35. Prostatic hyperplasia/trophy Breast cancer Uterine cancer Colorectal cancer Stomach cancer 40. Leukemia/lymphoma X. Psychological and Psychiatric Disorders 41. Anxiety states 42. Depressive states

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8 1. demographics and mortality rates; 2. patterns of morbidity: time to first readmission within 12 months (e.g., readmissions and relative risk of readmissions); 3. patterns of morbidity: prior admissions within 12 months; 4. patterns of morbidity: readm~ssions within 30 days of first discharge (e.g., percentage of persons at risk; readmissions for specific causes; length of stay and charges in readmissions); 5. patterns of morbidity: readmissions within 31-180 days of first discharge (e.g., percentage of persons at risk; readmissions for specific causes; length of stay and charges in readmission); 6. patterns of morbidity: readmissions within 181-360 days of first discharge (e.g., percentage of persons at risk; readmissions for specific causes; length of stay and charges in readmissions); 7. charges for medical care (e.g., total, hospital charges, and charges for various other providers or settings); 8. cumulative mortality rates; 9. population-based mortality rates, 10. year-to-year relative risks of dying after hospitalization; and 11. time trends in mortality rates and use of coronary revascularization. The second set of data illustrated HCFA's efforts to acquire and analyze data from hospital medical records in special studies being done Trough the Medicare PROB. It focused specifically on coronary artery bypass graft surgery and balloon angioplasty, win special emphasis on risk factors predictive of dead or of rehospitalization. PREMISES OF THE CLINICAL WORKSHOP In discharging its responsibilities, the committee based its deliberations on several premises and understandings Mat form the context for our specific recommendations. 1. The workshop marks tile beginning of a planning and implementa- tion process blat will involve other clinical and research experts. 2. Many different points of view will be involved in the planning and implementation of He Effectiveness Initiative. These will include the major units of HCFA, over federal agencies, and all appropriate private sector constituencies, such as the physician and other provider communizes, insurance carriers, and academic and other research teams.

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9 3. The development of information on ambulatory care, long-term care, and quality of care Trough He Medicare PROs and Trough external investigator-initiated research is crucial to He effort to expand He relevant data bases and to address He issues that tine Effectiveness Initiative is intended to examine. We assume existing HCFA data alone cannot answer all questions that might arise from the Initiative; Hey can, however, identify many problems warranting greater investigation. Thus, we expect that HCFA will undertake to gamer information on outpatient encounters on a diagnosis-speci~c basis. 4. Data will need to be managed in a careful and responsible way. This includes He publication of findings in peer-reviewed journals and He avoidance of premature release of information. We assume that external review groups will be used extensively at all stages planning, implemen- tation, and review-of He Effectiveness Initiative program.