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Institute of Medicine (US) Division of Health Care Services. Effectiveness Initiative: Setting Priorities for Clinical Conditions. Washington (DC): National Academies Press (US); 1989.
Effectiveness Initiative: Setting Priorities for Clinical Conditions.
Show detailsBACKGROUND AND CONDUCT
To provide a context and some background materials for the committee, IOM and HCFA staff compiled a set of readings that was forwarded before the meeting. IOM staff developed a brief exercise, completed before the 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 the meeting and some of which was made available the day of the workshop.
The workshop began with presentations on the effectiveness research initiative by William L. Roper and Henry J. Krakauer (HCFA) and a general discussion of the criteria by which the clinical conditions should be selected. Kathleen N. Lohr (IOM) reviewed the 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 HCFA. We also briefly discussed patient management options for the key conditions that 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 then rate potential clinical conditions as to their probable importance for the Effectiveness Initiative. IOM staff generated a list of 42 diagnoses judged to represent the 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 conditions 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 Effectiveness Initiative) to 5 (lowest importance). We returned these sheets to IOM staff, who compiled the results and reported on them at the meeting.
TABLE 1
Potential List of Clinical Conditions to Consider for HCFA Effectiveness Initiative.
Of the 14 members of the committee, 13 returned the classification and rating sheets. In our initial response, we collectively nominated 31 conditions as “must be included,” including a 43rd condition (urinary incontinence). 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); and transient ischemic attack (TIA) without occlusion, Alzheimer's disease, cataracts, and occlusion/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-third of the original list—formed a core set on which initial discussions at the 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 that 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:
- 1.
demographics and mortality rates;
- 2.
patterns of morbidity: time to first readmission within 12 months (e.g., readmissions and relative risk of readmissions);
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patterns of morbidity: prior admissions within 12 months;
- 4.
patterns of morbidity: readmissions 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);
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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);
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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 through the Medicare PROs. It focused specifically on coronary artery bypass graft surgery and balloon angioplasty, with special emphasis on risk factors predictive of death or of rehospitalization.
PREMISES OF THE CLINICAL WORKSHOP
In discharging its responsibilities, the committee based its deliberations on several premises and understandings that form the context for our specific recommendations.
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The workshop marks the beginning of a planning and implementation process that will involve other clinical and research experts.
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Many different points of view will be involved in the planning and implementation of the Effectiveness Initiative. These will include the major units of HCFA, other federal agencies, and all appropriate private sector constituencies, such as the physician and other provider communities, insurance carriers, and academic and other research teams.
- 3.
The development of information on ambulatory care, long-term care, and quality of care through the Medicare PROs and through external investigator-initiated research is crucial to the effort to expand the relevant data bases and to address the issues that the Effectiveness Initiative is intended to examine. We assume existing HCFA data alone cannot answer all questions that might arise from the Initiative; they can, however, identify many problems warranting greater investigation. Thus, we expect that HCFA will undertake to gather information on outpatient encounters on a diagnosis-specific basis.
- 4.
Data will need to be managed in a careful and responsible way. This includes the publication of findings in peer-reviewed journals and the avoidance of premature release of information. We assume that external review groups will be used extensively at all stages—planning, implementation, and review—of the Effectiveness Initiative program.
- The Workshop - Effectiveness Initiative: Setting Priorities for Clinical Conditi...The Workshop - Effectiveness Initiative: Setting Priorities for Clinical Conditions
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