Professional Documents
Culture Documents
should be investigated more fully; however, the absence of rates by census tract are subject to substantial variability
association between THM concentrations and incidence of since many rates are based on few cases and the occurrence
other cancers and the additional problem of lack of associa- of one or two tumor cases in a particular census tract greatly
tion between THM concentrations and pancreatic cancer in influences the incidence rate. Furthermore, use of adjusted
any other sex- or race-specific group raises doubts as to the rates glosses over associations that may be present in specif-
validity of this finding. Since ecological studies are theoreti- ic categories. Measurements of the independent variables
cally biased toward Type I error, there is the distinct possi- were taken after the appearance of the diseases and, al-
bility that this finding is a spurious product of confounding though chlorination practices in Erie County have not
by unmeasured variables. changed appreciably in four decades, this theoretically does
Concurrent with the Type I bias, is a lower probability not account for the long latency period usually associated
of missing a true association. Given a sound methodology, with cancer. Patterns of population migration out of Erie
this no-effect phenomenon could be due to the modest range County have not been quantified and differential migration
of THM values (71 ppb) or to factors actually inhibiting the by water quality could be a source of bias due to incomplete
disease process; an actual association might be masked by a cohort followup.
competing risk, (e.g., the population has a high incidence of On the other hand, this research does not present meth-
another disease which diminishes the susceptibility pool for odology inferior to previous research reporting positive as-
these cancers, or a competing exposure, or the environmen- sociations, and in some ways it may be considered more re-
tal "noise" in Erie County is too great to allow the surfacing fined.
of a modest THM effect).
One must also add that information gathered from dis- REFERENCE
ease registries is subject to biases such as differences in path- 1. Wilkins JR, Reiches, NA and Kruse CW: Organic chemical con-
ological diagnosis, and incomplete reporting or non- taminants in drinking water and cancer. Am J Epidemiology.
compliance, and that the site-specific age-adjusted incidence 110:420-448, 1979.
Methods
From the Departments of Medicine and Social Medicine, Mon- We reviewed the charts of every fifth adult visit over a
tefiore Hospital and Medical Center, Albert Einstein College of three-week period to the ER of a 700-bed teaching hospital.
Medicine. Address reprint requests to Zachary Bloomgarden, MD, Without reference to the results of the tests, a panel of six
Department of Social Medicine, Montefiore Hospital and Medical
Center, 111 East 210th Street, Bronx, NY 10467. This paper, sub- reviewers (three senior resident physicians and three attend-
mitted to the Journal April 4, 1979, was revised and accepted for ing physicians in the Department of Medicine) evaluated
publication December 26, 1979 each test performed with respect to: 1) necessity of the test
Classification of Tests
Assessment of
Quality of Care Necessary* Relevant" Not Indicated Total
X2 (for deviation from null hypothesis that per cent of tests necessary is independent of type of test) = 69.3; d.f. =
12; p < 0.001
*Includes tests "medico-legally required"
study was performed. Fifty such four-test "'surveys" were making, and 20 per cent were considered not indicated on
ordered, but in only two visits were all the survey tests con- any grounds; 42 per cent of tests considered not necessary
sidered necessary by both housestaff and attending review- were ordered as parts of screening surveys. These were clus-
ers. Twenty of the 50 surveys of four tests each were consid- tered in 44 patient visits, 20 per cent of the 218 visits eval-
ered by the reviewers to have included three or more unnec- uated and only 9 per cent of the total of 476 sampled visits.
essary tests. In all, 81 (41 per cent) of these 200 tests Unnecessary tests were correlated with the total number of
performed as surveys were considered "not necessary" tests per visit, and with the reviewers' judgment of quality of
compared with the 116 (23 per cent) unnecessary tests care delivered. These correlations may be confounded by
among the group of 430 tests not performed as surveys (X2 = the reviewers including the total number of tests as an ele-
5.76; p < .02). ment in judging necessity, despite instructions not to do so,
Of the 218 patient visits evaluated, the care was classi- or their view of the necessity of testing as an element in judg-
fied as "inadequate" in nine (4 per cent), and "less than opti- ing the overall quality of care.
mal" in 33 (15 per cent). Visits in which care was felt to be This study did not evaluate illness outcome or patient-
"'inadequate" or "less than optimal" had, respectively, physician interaction; it was designed to use reviewer judg-
means of 3.3 and 4.9 tests per visit, while those with "ade- ment as a normative standard. Such "'implicit" standards are
quate" care had 2.5 tests per visit. As shown in Table 1, 77 frequently used in evaluating diagnostic processes, although
per cent of tests done on patients with "optimal" care were they have not been shown to be directly relevant to improve-
considered necessary, compared to 48 per cent and 57 per ment of outcome.'2-'5 Since outcome may be remote or
cent of tests done on patients with "less than optimal" or unrelated to treatment, "implicit" criteria of the type em-
"inadequate" over-all care. ployed here'6 can be used to produce alterations in the
No clear differences emerged between the evaluation existing patterns of establishing diagnoses, specifically test-
patterns of housestaff and attending reviewers, with similar ordering behavior. Interventions to alter physician test-
judgments of necessity and relevance of the entire group of ordering might include requiring explicit presentation of the
laboratory tests. The attending physicians' evaluations are indications for the test and regular review of physicians'
compared with the housestaff members' evaluations on all of testing patterns.
the 630 tests in the study in Table 3. Both groups agreed on It is of interest that an assessment of care of adult wom-
their assessment of "necessity" in 531 instances (84 per en with symptoms of urinary tract infection in the same ER
cent). Of the 99 tests (16 per cent) in which there was dis- showed a significant correlation of physician performance
agreement, housestaff members were almost twice as likely
as attending physicians to assess a test as being necessary.
TABLE 3-Comparison of Attending Physician and House Staff
Evaluation of Tests Performed
Discussion Attending Physician Evaluations
House Staff
Of 630 laboratory tests evaluated by the reviewers, 32 Evaluations "Necessary" "Not Necessary" Total
per cent were considered not necessary for clinical decision-
"Necessary" 389 60 449
X2 for deviation from the null hypothesis that per cent neces- "Not Necessary" 39 142 181
sary is independent of the number of tests done = 69.1; d.f. = 6; TOTAL 428 202 630
p < 0.0001.
with outcome.'9 It would appear useful, based on the results 10. Edwards LD, Levin S, Balagtus R, et al: Ordering patterns and
of this study, to isolate the relatively small number of pa- utilization of bacteriologic culture reports. Ann Internal Med
tient-visits which led to inappropriate use of laboratory tests, 132:678-682, 1973.
11. Dixon RH and Lazzio J: Utilization of clinical chemistry serv-
and, by making a determined effort to alter testing behavior ices by medical house staff: An analysis. Ann Internal Med
in these visits in a controlled experiment, determine the rela- 134:1064-1067, 1974.
tionship between change in this aspect of the diagnostic pro- 12. Sidel VW: Evaluation of the quality of medical practice. JAMA
cess and change in the outcome of care. 198:763-764, 1966.
13. Lewis CE: The state of the art of quality assessment-1973.
Medical Care 12:799-806, 1974.
14. Sidel, VW: Quality for whom? Effects of professional responsi-
bility for quality of health care on equity. Bull NY Acad Med
REFERENCES 52:164-176, 1976.
1. Weinerman ER, Ratner RS, Robbins R, et al: Yale studies in 15. Eyes B and Evans AF: Post-traumatic skull radiographs: Timn
ambulatory medical care: V. Determinants of use of hospital for a reappraisal. Lancet 2:85-86, 1978.
emergency service. Am J Public Health 56:1037-1056, 1966. 16. Donabedian A: The quality of medical care. Science 200:856-
2. Garfield S: The delivery of medical care. Scientific American 864, 1978.
222:15-23, 1970. 17. Donabedian A: Promoting quality through evaluating the pro-
3. Gibsen G: Status of urban services. Hospitals JAHA 45:49-54, cess of patient care. Medical Care 6:181-202, 1968.
1971. 18. Brook RH and Appel FA: Quality-of-care assessment: Choosing
4. Jonas S, Flesh R, Brook R, et al: Maintaining utilization of a a method for peer review. N Engl J Med 288:1323-1329, 1973.
municipal hospital emergency department. Hospital Topics 19. Rubenstein L, Mates S and Sidel VW: Quality of care assess-
54:43-48, 1976. ment by process and outcome scoring: Use of weighted algorith-
5. Carter PM, Davison AJ, Wickens I, et al: The horns of the path- mic assessment criteria for evaluation of emergency room care
ological dilemma. Hosp and Health Serv Rev, pp 346-350, Oc- of women with symptoms of urinary tract infection. Ann Inter-
tober 1975. nal Med 86:617-625, 1977.
6. Scitovsky AA and McCall N: Changes in the Costs of Treatment
of Selected Illnesses, 1951-1964-1971. U.S. DHEW, U.S. Pub-
lic Health Service, DHEW Publication No. (HRA) 77-3161, ACKNOWLEDGMENTS
1977. The authors are grateful to: Drs. David Hamerman, David
7. Griner PF and Liptziu B: Use of the laboratory in a teaching Kindig, and Isidore Levine for their advice on and support of this
hospital: Implications for patient care, education, and hospital study; Dr. Herbert Levine for help with the statistical evaluation;
costs. Ann Internal Med 75:157-163, 1971. Drs. Harold Keltz, Stephen Brenner, Philip Lief, Michael Seidman,
8. Griner PF: Treatment of acute pulmonary edema: Conventional Mary Ann Chase, and James Bradof for acting as reviewers; Drs.
or intensive care? Ann Internal Med 77:501-506, 1972. Lewis Goldfrank, Leo Koss, Susan Mates, and Thomas Ben-
9. Griner PF: Medical intensive care in the teaching hospital: eventano, and Daniel Drosness and Mo Katz for reviewing the
Costs versus benefits: The need for an assessment. Ann Internal manuscript; and Jean Nardelli, Eve Teitelbaum, and Edythe Weber
Med 78:581-585, 1973. for their patient and meticulous work on the manuscript.
Although the importance of continuity in primary care is The extent to which physicians in primary care training
intuitively accepted by many authorities in medical educa- programs achieve continuity with their patients is not well
tion and health services, its value in terms of outcomes is not established.
well proven. In spite of the relative lack of evidence, resi- This study, undertaken at the Family Practice Center at
dency training programs in primary care are committed by the University of North Carolina, was designed to measure
accreditation boards to the implementation of a continuous the degree of continuity of care achieved by resident and
clinical experience.' faculty physicians over a one year period (July 1976 to June
1977).
The Family Practice Center served an enrolled popu-
Address reprint requests to Dr. Peter Curtis, Assistant Profes- lation of 5,020 patients (1,980 families) over the 12 months.
sor, Department of Family Medicine, School of Medicine, Universi- Each physician was responsible for a specific "practice" of
ty of North Carolina, Chapel Hill, NC 27514. Dr. Rogers is a Fellow,
Department of Family Medicine, University of Washington School assigned patients or families on a continuing basis. In addi-
of Medicine. This paper, submitted to the Journal August 1, 1979, tion, the physicians worked within three defined medical
was revised and accepted for publication December 26, 1979. teams.