Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Process And Outcome In Medical Consultations Lawrence V. Perlman, Margot S. Kruskall, David Rosenzweig & Jack Kaufman To cite this article: Lawrence V. Perlman, Margot S. Kruskall, David Rosenzweig & Jack Kaufman (1975) Process And Outcome In Medical Consultations, Postgraduate Medicine, 57:4, 111-115, DOI: 10.1080/00325481.1975.11714015 To link to this article: https://doi.org/10.1080/00325481.1975.11714015
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 11 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20
Diagnostic and therapeutic process and outcome were assessed by chart review of 75 consecutive patients referred for chest consultation. Results show that clinical outcome is related in part to diagnostic and therapeutic processes. However, a number of factors not necessarily related to these processes can reduce the number of cases positively affected.
Peer review and quality care assurance have become significant medical issues because of the rise of health insurance plans and growing government participation in payment for health care. 1 - 7 Insurance and medical payment programs have led to increased regulation of services to assure that patients receive what the third party pays for, ie, medical care that is appropriate and of good quality. Quality of care may be judged by evaluation of process (most notably, physician performance employed in its delivery) or preferably by evaluation of outcome (the clinical results of care). Assessments of the quality of care can be made implicitly or explicitly. 8 Implicit judgments depend upon subjective assessments of process and outcome, while explicit techniques require fulfillment of certain prestated criteria. Currently, most professional peer review systems depend upon implicit analysis of process and outcome. While this will change with implementation of Professional Standards Review Organization (PSRO) legislation, criteria currently used are often not prestated and judgments are made on the basis of operational case review. Reviewers determine, by professional judgment, whether the clinical and laboratory data justify diagnoses and whether prescribed therapy affected the clinical outcome. The paucity of reports analyzing peer review and quality assurance at an operational level may be due to the means by which these procedures are performed. Yet, analysis of such procedures may give important insights into the process of medical care and factors affecting clinical outcome. Members of the medical chest service of the Milwaukee County General Hospital developed an operational program to determine implicitly the quality and effectiveness of diagnostic and
Vol. 57 • No. 4 • April 1975 • POSTGRADUATE MEDICINE
Process and Outcome in Medical Consultations EVALUATION ON A PULMONARY SERVICE LAWRENCE V. PERLMAN, MD MARGOT S. KRUSKALL, MD DAVID ROSENZWEIG, MD JACK KAUFMAN, MD Medical College of Wisconsin Milwaukee
therapeutic process and outcome on our consultation service. This study gave us information as to the relationship of process to outcome and the means by which clinical outcome could be improved. This report summarizes our findings. Definitions
The following definitions obtained throughout the study. Diagnostic process-Actions recommended by the consultant to make a diagnosis, including suggestions with regard to specific laboratory and clinical investigations. Diagnostic outcome-Accuracy of diagnosis. Therapeutic process-Actions recommended or taken by the consultant with regard to medical and surgical therapy and their implementation. Therapeutic outcome-Patient's state of health following and related to treatment recommended by the consultant.
111
TABLE 1. PULMONARY PROBLEMS REQUIRING CONSULTATION Problem
Number of patients
Percent of total
Infectious disorders
36
48
Neoplasms
13
17
Obstructive pulmonary disease
6
8
Pulmonary vascular disease
3
4
Miscellaneous Total
17
23
75
100
TABLE 2. DIAGNOSTIC OUTCOME OF CONSULTATION
Accuracy of diagnosis Accurate
Number Percent of Percent of diagnostic of diagnostic patients consultations* attempts* 51
69
75
Inaccurate
8
11
12
Judgment as to accuracy could not be made by reviewers
9
12
13
No diagnosis made by consu Ita nts
6
8
74
100
Total
100
*There were 68 diagnostic attempts in 74 diagnostic consultations.
Materials and Methods
The medical records of 75 patients with pulmonary disorders for which consultations were performed during a three-month period (] anuary through March 1971) provided the basis for this investigation. The cases reviewed represent a consecutive unselected series. The consultations were requested by the house staff. Each request was answered by a member of the medical chest section who, after
112
TABLE 3. THERAPEUTIC OUTCOME OF CONSULTATION
Effect
Number Percent of Percent of all of therapeutic consultations* patients consultations*
Positive
22
51
29
None
19
44
25
Nerative
2
5
3
Total
43
100
57
*Therapeutic consultations were given in 43 of 75 total consultations.
analysis of the case, recorded on the patient's chart the evaluation and diagnostic and therapeutic suggestions. Consultants followed each patient's course during hospitalization or for as long as the pulmonary problem was active, offering further assistance as needed. After the patient's discharge, information was added to the chart if the patient continued to be seen in the outpatient department. When follow-up information was incomplete, the patient was contacted by telephone. If indicated, other hospitals were contacted for information; when necessary, death certificates and autopsy data were obtained. Three members of the medical chest section reviewed the medical records of the 75 patients. Each case was randomly assigned to one reviewer, who summarized the findings for the other two. Two of the reviewers had served as consultants on some of the cases. They did not review their own cases but occasionally provided clarifying information to the other reviewers. Only the reviewer who summarized the case knew the identity of the initial consultant. All reviews were made one year to 18 months after the initial consultation. Information was recorded on a specially designed form and included the patient's age and sex, the primary problem for which he was admitted, the pulmonary problem for which consultation was requested, the diagnostic process recommended, the consultant's diagnosis, the therapeutic recommendations, and the outcome.
POSTGRADUATE MEDICINE • April 1975 • Vol. 57 • No. 4
TABLE 4. EFFECTS OF DIAGNOSTIC OUTCOME ON THERAPEUTIC OUTCOME Patients accurately diagnosed
Total number of patients
Number
Percent of total
Positive
22
21
95
None or negative
21
12
57
Total therapeutic consultations
43
33
77
Therapeutic effect
In a given case, four elements could be judged: the adequacy of diagnostic process, the adequacy of therapeutic process, the nature of diagnostic outcome, and the nature of therapeutic outcome. Reviewers were asked whether diagnostic and therapeutic processes met professional standards with regard to appropriateness and completeness in the particular clinical context. Diagnostic outcome (accuracy) was judged on the basis of clinical, radiologic, microbiologic, and pathologic data (often obtained after the consultation) which had a significant bearing on corroborating the diagnosis. Therapeutic outcome was determined by assessment of the patient's health following and related to therapy, as judged by change in the clinical course with regard to such factors as symptoms, physical findings, physiologic measurements, ability to work or perform daily activities, and survival. Judgments as to the adequacy of process and the nature of outcome were made by consensus. When there was a dissenting view and discussion did not result in unanimity, the majority opinion was used. Results
Data from 75 consultations were reviewed and analyzed. The study population consisted of 49 men (65%) and 26 women (35%) ranging in age from 20 to 90 years, with an average age of 57 years. In 41 patients (55%), consultations were re-
Vol. 57 • No. 4 • April 1975 • POSTGRADUATE MEDICINE
Figure 1. Therapeutic outcome in 43 patients with pulmonary problems for which consultant suggested treatment.
TABLE 5. FAILURE OF CONSULTATION TO POSITIVELY AFFECT THERAPEUTIC OUTCOME*
Number of patients
Percent of total nonaffected or negatively affected patients
Disease severity
7
33
Consultant suggestions not followed
5
24
Reason for failure
Diagnostic error
4
19
Patient noncompliance
2
10
No chest problem
2
10
Therapeutic error
1
4
21
100
Total
*Analysis based on 21 cases in which therapeutic advice was sought but outcome was not positively affected.
quested for pulmonary problems that were the reason for hospitalization; in the remainder, they were requested for pulmonary problems detected after admission. Problems for which consultations were requested were categorized as infectious disorders, neoplasms, obstructive pulmonary disease, pulmonary vascular disease (pulmonary emboli and infarction), and miscellaneous (sarcoidosis, chest trauma, differential
113
LAWRENCE V. PERLMAN Dr. Perlman was formerly assistant professor of medicine, Medical College of Wisconsin, Milwaukee. He is now associate professor of medicine and community medicine, University of Pittsburgh. Dr. Margot S. Kruskall, formerly a senior medical student at Medical College of Wisconsin, is now an intern at Mount Auburn Hospital, Mount Auburn, Massachusetts. Drs. David Rosenzweig and Jack Kaufman are associate professors of medicine, Medical College of Wisconsin.
diagnosis of abnormal chest films, differential diagnosis of chest symptoms) (table 1). Consultations were requested solely for diagnosis in 39 patients (52%), for diagnosis and therapy in 35 patients (47%), and for therapy alone in 1 patient ( 1%). The diagnostic process was judged to be adequate in 68 of the 74 cases (92%) in which diagnostic assistance was sought. The diagnostic process was judged to be inadequate in one case in which a consultant's lack of knowledge of a particular clinical syndrome led to the performance of unnecessary laboratory examinations, one in which the consultant misinterpreted findings of pleural fluid analysis, one in which the consultant misdiagnosed the cause of shock, one in which the consultant did not consider the diagnosis of a subdiaphragmatic abscess, one in which the consultant misinterpreted a chest roentgenogram, and one in which the consultant did not consider the diagnosis of pulmonary emboli and infarction in a patient with a classic history who was later found to have pulmonary infarction. Diagnostic accuracy was assessed in 68 cases (table 2). No diagnosis was made by the consultants in six cases. Therapeutic suggestions were made in 43 cases and judged appropriate in 41 cases (95 %) (table 3). The clinical status of 22 patients was judged to have improved because of the consultant's recommendations, while the status of 19 patients was unchanged. Therapeutic process was judged inadequate in two cases in which the clinical status was adversely affected: (1)
114
a 60-year-old woman with a subdiaphragmatic abscess which the consultant did not consider or treat because he mistakenly concentrated on findings of pleural fluid analysis and (2) a 66year-old woman in hemorrhagic shock who died within minutes after the consultant ordered intravenous administration of thorazine. Effect on therapeutic outcome was not related to age, sex, or reason for admission. A higher proportion of the patients who benefited from therapeutic consultation had received an accurate diagnosis as compared with those who did not benefit or who were adversely affected (table 4). Of the 51 patients in whom diagnosis was accurate, 22 (43%) had a positive therapeutic outcome as compared with only 1 (4%) of the remaining 23 patients, in whom the diagnosis was inaccurate, could not be judged as to accuracy, or could not be made. A larger proportion of patients with infectious disorders benefited from the consultation process as compared with patients with other pulmonary problems (figure 1). Reasons for failure to positively affect therapeutic outcome are listed in table 5. Disease severity (usually end-stage malignant disease), failure of staff to follow the consultant's suggestions, and diagnostic error were the principal reasons why the proportion of favorable outcomes was not higher. Discussion
The method of analysis used in this study was implicit judgment of diagnostic and therapeutic process and outcome. This technique is closely related to methods traditionally used in peer review. 9 While there are a number of methods which seek to objectively analyze process and outcome, such techniques require commitments of resources and personnel often not available.10-12 Implicit judgments usually demonstrate a higher proportion of cases with acceptable and favorable processes than explicit judgments, because criteria are less rigidly defined. In the study reported by Brook and Appel, 8 only a very small proportion of cases analyzed according to explicit criteria fulfilled projected standards of process and outcome. In our study, diagnostic process was judged to be adequate in all but six cases. Seventy-five
POSTGRADUATE MEDICINE • April 1975 • Vol. 57 • No. 4
percent of diagnoses offered were correct according to the reviewer's criteria. It is not known how the proportion of correct diagnoses compares with that in other specialty consultations or with that of chest consultations in other contexts, nor is it known how the proportion of positively affected cases compares with that of chest consultations in private hospitals or private offices. The ability to affect clinical outcome was not related to process itself, since process was frequently adequate, but was related to the ability to use process to achieve an accurate diagnosis. In the Brook and Appel 8 study, outcome had no significant correlation with either implicit or explicit process indicators. Brook and Appel did not study diagnostic accuracy; ·all patients had specific conditions diagnosed before entry into the study. In addition, most patients had certain basic therapeutic maneuvers after diagnosis. Under those conditions, process may well be unrelated to outcome. In our study, consultation led to improvement, according to the reviewer's criteria, in about half of the cases in which therapy was sugg~sted (29% of the total group). At first glance, these figures seem quite low, but the potential for favorable outcome must also be considered. Certain problems, such as advanced malignant disease or overwhelming sepsis, may not be solvable by current methods and standards of medical practice. In our study, such
insolvable problems led to failure to affect outcome in many cases, lowering the percentage of positive outcomes. However, some possibly remediable factors, such as diagnostic error, failure to follow consultant's recommendations, and inadequate patient follow-up, also reduced the proportion of favorable outcomes. Certainly, the outcome appears much more favorable when an accurate diagnosis can be reached. Physician as well as patient education is probably the key to improvement in outcome in some patients in this series. Conclusion
This study, based upon an operational analysis of the consultative process, has given insights into the relationship between process and outcome. Therapeutic outcome is related to diagnostic process if that process results in an accurate diagnosis. However, a number of factors, many of them beyond the consultant's control, reduce the proportion of cases positively affected. A higher proportion of positively affected cases might be achieved through educational effort. Presented in part at Scientific Assembly on Clinical Problems, Annual Meeting of the American Thoracic Society/ American Lung Association, May 13-15, 1974, Cincinnati. Address reprint requests to Lawrence V. Perlman, MD, University Health Center of Pittsburgh, Ambulatory Care Program, 3601 Fifth Ave, Pittsburgh, PA 15213.
REFERENCES 1. Gonnella JS, Goran MJ, Williamson ]W, er al: Evaluation of patient care: An approach. JAMA 214:2040, 1970 2. Kessner DM, Kalk CE, Singer J: Assessing health quality-the case for tracers. N Engl J Med 288: 189, 1973 3. Brook RH, Appel FA, Avery C, et al: Effectiveness of inpatient follow-up care. N Engl J Med 285: 1509, 1971 4. Helbig DW, O'Hare D, Smith NW: The carecomponent score--a new system for evaluating quality of inpatient care. Am ] Public Health 62: 540, 1972 5. Sanazaro PJ, Goldstein RL, Roberts JS, et al: Research and development in quality assurance. N Engl ] Med 287:1125, 1972 6. Brook RH: Critical issues in the assessment of quality of care and their relationship to HMOs. J Med Educ 48 (Suppl):114-134, 1973 7. Williamson JW: Evaluating quality of patient care.
Vol. 57 • No. 4 • April 1975 • POSTGRADUATE MEDICINE
8. 9.
10. 11. 12.
A strategy relating outcome and process assessment. JAMA 218:564, 1971 Brook RH, Appel FA: Quality-of-care assessment: Choosing a method for peer review. N Engl J Med 288:1323, 1973 Brown C: How to evaluate models and mechanisms in evaluation of care in the university and community hospitals. In Walker JE, Douglas D, Vietzke W (Editors): Proceedings of the University of Connecticut School of Medicine Conference. Conn Health Serv Res Ser 2:13, 1971 Slee VN: PSRO and the hospital's quality control. Ann Intern Med 81:97, 1974 Goetzl EJ, Cohen P, Downing E, et al: Quality of diagnostic examinations in a university hospital outpatient clinic. Ann Intern Med 78:481, 1973 Sackett DL, Spitzer WO, Gent M, et al: The Burlington randomized trial of the nurse practitioner: Health outcomes of patients. Ann Intern Med 80: 137, 1974
115
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Process And Outcome In Medical Consultations Lawrence V. Perlman, Margot S. Kruskall, David Rosenzweig & Jack Kaufman To cite this article: Lawrence V. Perlman, Margot S. Kruskall, David Rosenzweig & Jack Kaufman (1975) Process And Outcome In Medical Consultations, Postgraduate Medicine, 57:4, 111-115, DOI: 10.1080/00325481.1975.11714015 To link to this article: https://doi.org/10.1080/00325481.1975.11714015
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 11 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20
Diagnostic and therapeutic process and outcome were assessed by chart review of 75 consecutive patients referred for chest consultation. Results show that clinical outcome is related in part to diagnostic and therapeutic processes. However, a number of factors not necessarily related to these processes can reduce the number of cases positively affected.
Peer review and quality care assurance have become significant medical issues because of the rise of health insurance plans and growing government participation in payment for health care. 1 - 7 Insurance and medical payment programs have led to increased regulation of services to assure that patients receive what the third party pays for, ie, medical care that is appropriate and of good quality. Quality of care may be judged by evaluation of process (most notably, physician performance employed in its delivery) or preferably by evaluation of outcome (the clinical results of care). Assessments of the quality of care can be made implicitly or explicitly. 8 Implicit judgments depend upon subjective assessments of process and outcome, while explicit techniques require fulfillment of certain prestated criteria. Currently, most professional peer review systems depend upon implicit analysis of process and outcome. While this will change with implementation of Professional Standards Review Organization (PSRO) legislation, criteria currently used are often not prestated and judgments are made on the basis of operational case review. Reviewers determine, by professional judgment, whether the clinical and laboratory data justify diagnoses and whether prescribed therapy affected the clinical outcome. The paucity of reports analyzing peer review and quality assurance at an operational level may be due to the means by which these procedures are performed. Yet, analysis of such procedures may give important insights into the process of medical care and factors affecting clinical outcome. Members of the medical chest service of the Milwaukee County General Hospital developed an operational program to determine implicitly the quality and effectiveness of diagnostic and
Vol. 57 • No. 4 • April 1975 • POSTGRADUATE MEDICINE
Process and Outcome in Medical Consultations EVALUATION ON A PULMONARY SERVICE LAWRENCE V. PERLMAN, MD MARGOT S. KRUSKALL, MD DAVID ROSENZWEIG, MD JACK KAUFMAN, MD Medical College of Wisconsin Milwaukee
therapeutic process and outcome on our consultation service. This study gave us information as to the relationship of process to outcome and the means by which clinical outcome could be improved. This report summarizes our findings. Definitions
The following definitions obtained throughout the study. Diagnostic process-Actions recommended by the consultant to make a diagnosis, including suggestions with regard to specific laboratory and clinical investigations. Diagnostic outcome-Accuracy of diagnosis. Therapeutic process-Actions recommended or taken by the consultant with regard to medical and surgical therapy and their implementation. Therapeutic outcome-Patient's state of health following and related to treatment recommended by the consultant.
111
TABLE 1. PULMONARY PROBLEMS REQUIRING CONSULTATION Problem
Number of patients
Percent of total
Infectious disorders
36
48
Neoplasms
13
17
Obstructive pulmonary disease
6
8
Pulmonary vascular disease
3
4
Miscellaneous Total
17
23
75
100
TABLE 2. DIAGNOSTIC OUTCOME OF CONSULTATION
Accuracy of diagnosis Accurate
Number Percent of Percent of diagnostic of diagnostic patients consultations* attempts* 51
69
75
Inaccurate
8
11
12
Judgment as to accuracy could not be made by reviewers
9
12
13
No diagnosis made by consu Ita nts
6
8
74
100
Total
100
*There were 68 diagnostic attempts in 74 diagnostic consultations.
Materials and Methods
The medical records of 75 patients with pulmonary disorders for which consultations were performed during a three-month period (] anuary through March 1971) provided the basis for this investigation. The cases reviewed represent a consecutive unselected series. The consultations were requested by the house staff. Each request was answered by a member of the medical chest section who, after
112
TABLE 3. THERAPEUTIC OUTCOME OF CONSULTATION
Effect
Number Percent of Percent of all of therapeutic consultations* patients consultations*
Positive
22
51
29
None
19
44
25
Nerative
2
5
3
Total
43
100
57
*Therapeutic consultations were given in 43 of 75 total consultations.
analysis of the case, recorded on the patient's chart the evaluation and diagnostic and therapeutic suggestions. Consultants followed each patient's course during hospitalization or for as long as the pulmonary problem was active, offering further assistance as needed. After the patient's discharge, information was added to the chart if the patient continued to be seen in the outpatient department. When follow-up information was incomplete, the patient was contacted by telephone. If indicated, other hospitals were contacted for information; when necessary, death certificates and autopsy data were obtained. Three members of the medical chest section reviewed the medical records of the 75 patients. Each case was randomly assigned to one reviewer, who summarized the findings for the other two. Two of the reviewers had served as consultants on some of the cases. They did not review their own cases but occasionally provided clarifying information to the other reviewers. Only the reviewer who summarized the case knew the identity of the initial consultant. All reviews were made one year to 18 months after the initial consultation. Information was recorded on a specially designed form and included the patient's age and sex, the primary problem for which he was admitted, the pulmonary problem for which consultation was requested, the diagnostic process recommended, the consultant's diagnosis, the therapeutic recommendations, and the outcome.
POSTGRADUATE MEDICINE • April 1975 • Vol. 57 • No. 4
TABLE 4. EFFECTS OF DIAGNOSTIC OUTCOME ON THERAPEUTIC OUTCOME Patients accurately diagnosed
Total number of patients
Number
Percent of total
Positive
22
21
95
None or negative
21
12
57
Total therapeutic consultations
43
33
77
Therapeutic effect
In a given case, four elements could be judged: the adequacy of diagnostic process, the adequacy of therapeutic process, the nature of diagnostic outcome, and the nature of therapeutic outcome. Reviewers were asked whether diagnostic and therapeutic processes met professional standards with regard to appropriateness and completeness in the particular clinical context. Diagnostic outcome (accuracy) was judged on the basis of clinical, radiologic, microbiologic, and pathologic data (often obtained after the consultation) which had a significant bearing on corroborating the diagnosis. Therapeutic outcome was determined by assessment of the patient's health following and related to therapy, as judged by change in the clinical course with regard to such factors as symptoms, physical findings, physiologic measurements, ability to work or perform daily activities, and survival. Judgments as to the adequacy of process and the nature of outcome were made by consensus. When there was a dissenting view and discussion did not result in unanimity, the majority opinion was used. Results
Data from 75 consultations were reviewed and analyzed. The study population consisted of 49 men (65%) and 26 women (35%) ranging in age from 20 to 90 years, with an average age of 57 years. In 41 patients (55%), consultations were re-
Vol. 57 • No. 4 • April 1975 • POSTGRADUATE MEDICINE
Figure 1. Therapeutic outcome in 43 patients with pulmonary problems for which consultant suggested treatment.
TABLE 5. FAILURE OF CONSULTATION TO POSITIVELY AFFECT THERAPEUTIC OUTCOME*
Number of patients
Percent of total nonaffected or negatively affected patients
Disease severity
7
33
Consultant suggestions not followed
5
24
Reason for failure
Diagnostic error
4
19
Patient noncompliance
2
10
No chest problem
2
10
Therapeutic error
1
4
21
100
Total
*Analysis based on 21 cases in which therapeutic advice was sought but outcome was not positively affected.
quested for pulmonary problems that were the reason for hospitalization; in the remainder, they were requested for pulmonary problems detected after admission. Problems for which consultations were requested were categorized as infectious disorders, neoplasms, obstructive pulmonary disease, pulmonary vascular disease (pulmonary emboli and infarction), and miscellaneous (sarcoidosis, chest trauma, differential
113
LAWRENCE V. PERLMAN Dr. Perlman was formerly assistant professor of medicine, Medical College of Wisconsin, Milwaukee. He is now associate professor of medicine and community medicine, University of Pittsburgh. Dr. Margot S. Kruskall, formerly a senior medical student at Medical College of Wisconsin, is now an intern at Mount Auburn Hospital, Mount Auburn, Massachusetts. Drs. David Rosenzweig and Jack Kaufman are associate professors of medicine, Medical College of Wisconsin.
diagnosis of abnormal chest films, differential diagnosis of chest symptoms) (table 1). Consultations were requested solely for diagnosis in 39 patients (52%), for diagnosis and therapy in 35 patients (47%), and for therapy alone in 1 patient ( 1%). The diagnostic process was judged to be adequate in 68 of the 74 cases (92%) in which diagnostic assistance was sought. The diagnostic process was judged to be inadequate in one case in which a consultant's lack of knowledge of a particular clinical syndrome led to the performance of unnecessary laboratory examinations, one in which the consultant misinterpreted findings of pleural fluid analysis, one in which the consultant misdiagnosed the cause of shock, one in which the consultant did not consider the diagnosis of a subdiaphragmatic abscess, one in which the consultant misinterpreted a chest roentgenogram, and one in which the consultant did not consider the diagnosis of pulmonary emboli and infarction in a patient with a classic history who was later found to have pulmonary infarction. Diagnostic accuracy was assessed in 68 cases (table 2). No diagnosis was made by the consultants in six cases. Therapeutic suggestions were made in 43 cases and judged appropriate in 41 cases (95 %) (table 3). The clinical status of 22 patients was judged to have improved because of the consultant's recommendations, while the status of 19 patients was unchanged. Therapeutic process was judged inadequate in two cases in which the clinical status was adversely affected: (1)
114
a 60-year-old woman with a subdiaphragmatic abscess which the consultant did not consider or treat because he mistakenly concentrated on findings of pleural fluid analysis and (2) a 66year-old woman in hemorrhagic shock who died within minutes after the consultant ordered intravenous administration of thorazine. Effect on therapeutic outcome was not related to age, sex, or reason for admission. A higher proportion of the patients who benefited from therapeutic consultation had received an accurate diagnosis as compared with those who did not benefit or who were adversely affected (table 4). Of the 51 patients in whom diagnosis was accurate, 22 (43%) had a positive therapeutic outcome as compared with only 1 (4%) of the remaining 23 patients, in whom the diagnosis was inaccurate, could not be judged as to accuracy, or could not be made. A larger proportion of patients with infectious disorders benefited from the consultation process as compared with patients with other pulmonary problems (figure 1). Reasons for failure to positively affect therapeutic outcome are listed in table 5. Disease severity (usually end-stage malignant disease), failure of staff to follow the consultant's suggestions, and diagnostic error were the principal reasons why the proportion of favorable outcomes was not higher. Discussion
The method of analysis used in this study was implicit judgment of diagnostic and therapeutic process and outcome. This technique is closely related to methods traditionally used in peer review. 9 While there are a number of methods which seek to objectively analyze process and outcome, such techniques require commitments of resources and personnel often not available.10-12 Implicit judgments usually demonstrate a higher proportion of cases with acceptable and favorable processes than explicit judgments, because criteria are less rigidly defined. In the study reported by Brook and Appel, 8 only a very small proportion of cases analyzed according to explicit criteria fulfilled projected standards of process and outcome. In our study, diagnostic process was judged to be adequate in all but six cases. Seventy-five
POSTGRADUATE MEDICINE • April 1975 • Vol. 57 • No. 4
percent of diagnoses offered were correct according to the reviewer's criteria. It is not known how the proportion of correct diagnoses compares with that in other specialty consultations or with that of chest consultations in other contexts, nor is it known how the proportion of positively affected cases compares with that of chest consultations in private hospitals or private offices. The ability to affect clinical outcome was not related to process itself, since process was frequently adequate, but was related to the ability to use process to achieve an accurate diagnosis. In the Brook and Appel 8 study, outcome had no significant correlation with either implicit or explicit process indicators. Brook and Appel did not study diagnostic accuracy; ·all patients had specific conditions diagnosed before entry into the study. In addition, most patients had certain basic therapeutic maneuvers after diagnosis. Under those conditions, process may well be unrelated to outcome. In our study, consultation led to improvement, according to the reviewer's criteria, in about half of the cases in which therapy was sugg~sted (29% of the total group). At first glance, these figures seem quite low, but the potential for favorable outcome must also be considered. Certain problems, such as advanced malignant disease or overwhelming sepsis, may not be solvable by current methods and standards of medical practice. In our study, such
insolvable problems led to failure to affect outcome in many cases, lowering the percentage of positive outcomes. However, some possibly remediable factors, such as diagnostic error, failure to follow consultant's recommendations, and inadequate patient follow-up, also reduced the proportion of favorable outcomes. Certainly, the outcome appears much more favorable when an accurate diagnosis can be reached. Physician as well as patient education is probably the key to improvement in outcome in some patients in this series. Conclusion
This study, based upon an operational analysis of the consultative process, has given insights into the relationship between process and outcome. Therapeutic outcome is related to diagnostic process if that process results in an accurate diagnosis. However, a number of factors, many of them beyond the consultant's control, reduce the proportion of cases positively affected. A higher proportion of positively affected cases might be achieved through educational effort. Presented in part at Scientific Assembly on Clinical Problems, Annual Meeting of the American Thoracic Society/ American Lung Association, May 13-15, 1974, Cincinnati. Address reprint requests to Lawrence V. Perlman, MD, University Health Center of Pittsburgh, Ambulatory Care Program, 3601 Fifth Ave, Pittsburgh, PA 15213.
REFERENCES 1. Gonnella JS, Goran MJ, Williamson ]W, er al: Evaluation of patient care: An approach. JAMA 214:2040, 1970 2. Kessner DM, Kalk CE, Singer J: Assessing health quality-the case for tracers. N Engl J Med 288: 189, 1973 3. Brook RH, Appel FA, Avery C, et al: Effectiveness of inpatient follow-up care. N Engl J Med 285: 1509, 1971 4. Helbig DW, O'Hare D, Smith NW: The carecomponent score--a new system for evaluating quality of inpatient care. Am ] Public Health 62: 540, 1972 5. Sanazaro PJ, Goldstein RL, Roberts JS, et al: Research and development in quality assurance. N Engl ] Med 287:1125, 1972 6. Brook RH: Critical issues in the assessment of quality of care and their relationship to HMOs. J Med Educ 48 (Suppl):114-134, 1973 7. Williamson JW: Evaluating quality of patient care.
Vol. 57 • No. 4 • April 1975 • POSTGRADUATE MEDICINE
8. 9.
10. 11. 12.
A strategy relating outcome and process assessment. JAMA 218:564, 1971 Brook RH, Appel FA: Quality-of-care assessment: Choosing a method for peer review. N Engl J Med 288:1323, 1973 Brown C: How to evaluate models and mechanisms in evaluation of care in the university and community hospitals. In Walker JE, Douglas D, Vietzke W (Editors): Proceedings of the University of Connecticut School of Medicine Conference. Conn Health Serv Res Ser 2:13, 1971 Slee VN: PSRO and the hospital's quality control. Ann Intern Med 81:97, 1974 Goetzl EJ, Cohen P, Downing E, et al: Quality of diagnostic examinations in a university hospital outpatient clinic. Ann Intern Med 78:481, 1973 Sackett DL, Spitzer WO, Gent M, et al: The Burlington randomized trial of the nurse practitioner: Health outcomes of patients. Ann Intern Med 80: 137, 1974
115
