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Objective: To determine how accurately preventive care reported in the medical record reflects actual physician practice or competence.Design: Scoring criteria based on national guidelines were developed for 7 separate items of preventive care. The preventive care provided by randomly selected physicians was measured prospectively for each of the 7 items. Three measurement methods were used for comparison: (1) the abstracted medical record from a standardized patient (SP) visit; (2) explicit reports of physician practice during those visits from the SPs, who were actors trained to present undetected as patients; and (3) physician responses to written case scenarios (vignettes) identical to the SP presentations.Setting: The general medicine primary care clinics of two university-afflliated VA medical centers.Participants: Twenty randomly selected physicians (10 at each site) from among eligible second- and third-year general internal medicine residents and attending physicians.Measurements and Main Results: Physicians saw 160 SPs (8 cases x 20 physicians). We calculated the percentage of visits in which each prevention item was recorded in the chart, determined the marginal percentage improvement of SP checklists and vignettes over chart abstraction alone, and compared the three methods using an analysis-of-variance model. We found that chart abstraction underestimated overall prevention compliance by 16% (P < .01) compared with SP checklists. Chart abstraction scores were lower than SP checklists for all seven items and lower than vignettes for four items. The marginal percentage improvement of SP checklists and vignettes to performance as measured by chart abstraction was significant for all seven prevention items and raised the overall prevention scores from 46% to 72% (P < .0001).Conclusions: These data indicate that physicians perform more preventive care than they report in the medical record. Thus, benchmarks of preventive care by individual physicians and institutions that rely solely on the medical record may be misleading, at best. [ABSTRACT FROM AUTHOR]

Objective: To determine if the medical record might overestimate the quality of care through false, and potentially unethical, documentation by physicians. Design: Prospective trial comparing two methods for measuring the quality of care for four common outpatient conditions: (1) structured reports by standardised patients (SPs) who presented unannounced to the physicians' clinics, and (2) abstraction of the medical records generated during these visits. Setting: The general medicine clinics of two veterans affairs medical centres. Participants: Twenty randomly selected physicians (10 at each site) from among eligible second and third year internal medicine residents and attending physicians. Main measurements: Explicit criteria were used to score the medical records of physicians and the reports of SPs generated during 160 visits (8 cases x 20 physicians). Individual scoring items were categorised into four domains of clinical performance: history, physical examination, treatment, and diagnosis. To determine the false positive rate, physician entries were classified as false positive (documented in the record but not reported by the SP), false negative, true positive, and true negative. Results: False positives were identified in the medical record for 6.4% of measured items. The false positive rate was higher for physical examination (0.330) and diagnosis (0.304) than for history (0.166) and treatment (0.082). For individual physician subjects, the false positive rate ranged from 0.098 to 0.397. Conclusions: These data indicate that the medical record falsely overestimates the quality of important dimensions of care such as the physical examination. Though it is doubtful that most subjects in our study participated in regular, intentional falsification, we cannot exclude the possibility that false positives were in some instances intentional, and therefore fraudulent, misrepresentations. Further research is needed to explore the questions raised but... [ABSTRACT FROM AUTHOR]

Context: Better health care quality is a universal goal, yet measuring quality has proven to be difficult and problematic. A central problem has been isolating physician practices from other effects of the health care system.Objective: To validate clinical vignettes as a method for measuring the competence of physicians and the quality of their actual practice.Design: Prospective trial conducted in 1997 comparing 3 methods for measuring the quality of care for 4 common outpatient conditions: (1) structured reports by standardized patients (SPs), trained actors who presented unannounced to physicians' clinics (the gold standard); (2) abstraction of medical records for those same visits; and (3) physicians' responses to clinical vignettes that exactly corresponded to the SPs' presentations. Setting Outpatient primary care clinics at 2 Veterans Affairs medical centers.Participants: Ninety-eight (97%) of 101 general internal medicine staff physicians, faculty, and second- and third-year residents consented to be randomized for the study. From this group, 10 physicians at each site were randomly selected for inclusion.Main Outcome Measures: A total of 160 quality scores (8 cases x 20 physicians) were generated for each method using identical explicit criteria based on national guidelines and local expert panels. Scores were defined as the percentage of process criteria correctly met and were compared among the 3 methods.Results: The quality of care, as measured by all 3 methods, ranged from 76.2% (SPs) to 71.0% (vignettes) to 65.6% (chart abstraction). Measuring quality using vignettes consistently produced scores closer to the gold standard of SP scores than using chart abstraction. This pattern was robust when the scores were disaggregated by the 4 conditions (P<.001 to <.05), by case complexity (P<.001), by site (P<.001), and by level of physician training (P values from <.001 to <.05). The pattern persisted, although less dominantly, when we assessed the component domains of the clinical encounter--history, physical examination, diagnosis, and treatment. Vignettes were responsive to expected directions of variation in quality between sites and levels of training. The vignette responses did not appear to be sensitive to physicians' having seen an SP presenting with the same case.Conclusions: Our data indicate that quality of health care can be measured in an outpatient setting by using clinical vignettes. Vignettes appear to be a valid and comprehensive method that directly focuses on the process of care provided in actual clinical practice. Vignettes show promise as an inexpensive case-mix adjusted method for measuring the quality of care provided by a group of physicians. INSET: Coronary artery disease scenarios.. [ABSTRACT FROM AUTHOR]

BACKGROUND. Infants awaiting heart transplantation for congenital heart disease frequently require prostaglandin E1 (PGE1) infusion for prolonged periods. As a result, complications of prolonged PGE1 infusion, such as cortical hyperostosis, are being encountered more commonly. OBJECTIVE. To determine the incidence and severity of cortical hyperostosis in newborns requiring prolonged PGE1 infusion. METHODS. Chest radiographs of 86 infants receiving PGE1 infusion awaiting heart transplantation were reviewed. The chest radiographs were graded for the severity of cortical hyperostosis (no bony changes, minimal hyperostosis, or severe hyperostosis). Duration of PGE1 infusion, total PGE1 dose, and highest alkaline phosphatase were recorded for each patient. Infants were arbitrarily divided into three groups according to the duration of PGE1 infusion (< 30 days, 30 to 60 days, > 60 days). RESULTS. Fifty-three of the 86 infants (62%) had radiologic evidence of cortical hyperostosis. Forty-two of 80 infants (53%) had elevated alkaline phosphatase. The percentage of infants with hyperostosis increased with increasing duration of PGE1 infusion (42% at < 30 days; 87% at 30 to 60 days; 100% at > 60 days). The incidence and severity of cortical hyperostosis were related (by Kruskal-Wallis) to the duration of PGE1 infusion (P < .0001) and the total dose of PGE1 received (P < .0001). The highest alkaline phosphatase levels were observed in infants with the most severe grades of hyperostosis (P < .0001). The percentage of infants with elevated alkaline phosphatase increased with greater severity of hyperostosis (26% of infants with no bony changes, 59% with minimal changes, and 85% with severe changes). Two infants had symptomatic bone tenderness or swelling mimicking osteomyelitis. CONCLUSION. It is concluded that cortical hyperostosis is a frequent, often asymptomatic, side effect of prolonged PGE1 infusion that should be evaluated in any infant on long-term PGE1 therapy. When symptoms occur in infants awaiting transplantation, osteomyelitis must be excluded rapidly to avoid an unnecessary delay in transplantation. [ABSTRACT FROM AUTHOR]

Previous research suggests that the moment arm of the m. triceps surae tendon (i.e., Achilles tendon), is positively correlated with the energetic cost of running. This relationship is derived from a model which predicts that shorter ankle moment arms place larger loads on the Achilles tendon, which should result in a greater amount of elastic energy storage and return. However, previous research has not empirically tested this assumed relationship. We test this hypothesis using an inverse dynamics approach in human subjects (n = 24) at speeds ranging from walking to sprinting. The spring function of the Achilles tendon was evaluated using specific net work, a metric of mechanical energy production versus absorption at a limb joint. We also combined kinematic and morphological data to directly estimate tendon stress and elastic energy storage. We find that moment arm length significantly determines the spring-like behavior of the Achilles tendon, as well as estimates of mass-specific tendon stress and elastic energy storage at running and sprinting speeds. Our results provide support for the relationship between short Achilles tendon moment arms and increased elastic energy storage, providing an empirical mechanical rationale for previous studies demonstrating a relationship between calcaneal length and running economy. We also demonstrate that speed and kinematics moderate tendon performance, suggesting a complex relationship between lower limb geometry and foot strike pattern. [ABSTRACT FROM AUTHOR]

Objective To assess the quality of medical treatment by disaggregating quality into components that distinguish between insufficient and unnecessary care. Design Randomly selected doctors were asked how they would treat a sick child. Their responses were disaggregated into how much of an evidence-based essential treatment plan was completed and the number of additional non-essential treatments that were given. Key variables included the expected cost, the health consequences of insufficient and unnecessary care and comparisons between public and private physicians. Responses to 160 clinical performance vignettes (CPVs) were analysed. Setting Philippines. Participants One hundred and forty-three public and private physicians in the Philippines, collected in November 2003–December 2004 and September 2006–June 2007. Interventions CPVs administered to physicians. Main outcome measures Process quality measures (accounting for the possibility of both over-treatment and under-treatment). Results Based on CPVs, doctors gave both insufficient and unnecessary treatment to under-five children in 69% of cases. Doctors who provided the least sufficient care were also the most likely to give costly or harmful unnecessary care. Insufficient care typically had potentially worse health consequences for the patient than unnecessary care, though unnecessary care remains a concern because of overuse of antibiotics (47%) and unnecessary hospitalization (34%). Conclusions Quality of care is complex, but over- and under-treatment coexist and, in our analysis physicians that were more likely to under-treat a sick child were also those more likely to over-treat. [ABSTRACT FROM PUBLISHER]

In 2001–2003, a team of researchers from the United States and China performed an independent, multidisciplinary review of China's National Improved Stove Program carried out since the 1980s. As part of a 3500-household survey, a subsample of 396 rural households were monitored for particulate matter less than 4 μm (PM4) in kitchens and living rooms over 24 h, of which 159 were measured in both summer and winter. Carbon monoxide was measured in a 40% subsample. The results of this indoor air quality (IAQ) component indicate that for nearly all household stove or fuel groupings, PM4 levels were higher than – and sometimes more than twice as high as – the national PM10 standard for indoor air (150 μg PM10/m3). If these results are typical, then a large fraction of China's rural population is now chronically exposed to levels of pollution far higher than those determined by the Chinese government to harm human health. Further, we observed highly diverse fuel usage patterns in these regions in China, supporting the observations in the household survey of multiple stoves being present in many kitchens. Improved stoves resulted in reduced PM4 from biomass fuel combinations, but still not at levels that meet standards, and little improvement was observed in indoor pollution levels when other unimproved stoves were present in the same kitchen. As many households change fuels according to daily and seasonal factors, resulting in different seasonal concentrations in living rooms and kitchens, assessing health implications from fuel use requires longitudinal evaluation of fuel use and IAQ levels, combined with accurate time-activity information. Practical Implications Leaving aside the difficult issue of enforcement, it is uncertain whether Chinese household IAQ standards represent realistic objectives for current attainment given current patterns of energy consumption in rural China, which rely so heavily on unprocessed solid fuels. Even when used with chimneys, these fuels emit substantial pollution into the household environment. It is probable that low-emission technologies involving gaseous/liquid fuels or high combustion - efficiency biomass stoves need to be promoted in order to achieve these standards for the greater part of the population. [ABSTRACT FROM AUTHOR]

Purpose: Despite widespread reliance on chart abstraction for quality measurement, concerns persist about its reliability and validity. We prospectively evaluated the validity of chart abstraction by directly comparing it with the gold standard of reports by standardized patients.Subjects and Methods: Twenty randomly selected general internal medicine residents and attending faculty physicians at the primary care clinics of two Veterans Affairs Medical Centers blindly evaluated and treated actor-patients (standardized patients) who had one of four common diseases: diabetes, chronic obstructive pulmonary disease, coronary artery disease, or low back pain. Charts from the visits were abstracted using explicit quality criteria; standardized patients completed a checklist containing the same criteria. For each physician, quality was measured for two different cases of the four conditions (a total of 160 physician-patient encounters). We compared chart abstraction with standardized-patient reports for four aspects of the encounter: taking the history, examining the patient, making the diagnosis, and prescribing appropriate treatment. The sensitivity and specificity of chart abstraction were calculated.Results: The mean (+/- SD) chart abstraction score was 54% +/- 9%, substantially less than the mean score on the standardized-patient checklist of 68% +/- 9% (P <0.001). This finding was similar for all four conditions and at both sites. "False positives"-chart-recorded necessary care actions not reported by the standardized patients-resulted in a specificity of only 81%. The overall sensitivity of chart abstraction for necessary care was only 70%.Conclusions: Chart abstraction underestimates the quality of care for common outpatient general medical conditions when compared with standardized-patient reports. The medical record is neither sensitive nor specific. Quality measurements derived from chart abstraction may have important shortcomings, particularly as the basis for drawing policy conclusions or making management decisions. [ABSTRACT FROM AUTHOR]