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Clinical practice guidelines are an important tool for improving quality of care. This study determined whether and how guidelines are being used in nursing homes. We surveyed staff at 36 Department of Veterans Affairs (VA) nursing homes. Employees were asked whether they were familiar with guidelines as well as whether 5 specific guidelines had been read, were available, and had been adopted. Among 1065 respondents (60% of those surveyed), 79% reported familiarity with guidelines. The proportion of staff at a facility reporting adoption was generally less than 50%. Those nursing homes in which a high percentage of the staff reported adoption of one guideline were more likely to have adopted other guidelines. However, staff were not more likely to report adoption of a specific guideline when the nurse manager stated that it was adopted. We conclude that staff at VA nursing homes are familiar with guidelines. Guideline adoption at individual nursing homes, however, is not a systematic process involving the entire staff.

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BACKGROUND: Many patients with hypertension have inadequate control of their blood pressure. Improving the treatment of hypertension requires an understanding of the ways in which physicians manage this condition and a means of assessing the efficacy of this care. METHODS: We examined the care of 800 hypertensive men at five Department of Veterans Affairs sites in New England over a two-year period. Their mean (+/-SD) age was 65.5+/-9.1 years, and the average duration of hypertension was 12.6+/-5.3 years. We used recursive partitioning to assess the probability that antihypertensive therapy would be increased at a given clinic visit using several variables. We then used these predictions to define the intensity of treatment for each patient during the study period, and we examined the associations between the intensity of treatment and the degree of control of blood pressure. RESULTS: Approximately 40 percent of the patients had a blood pressure of > or =160/90 mm Hg despite an average of more than six hypertension-related visits per year. Increases in therapy occurred during 6.7 percent of visits. Characteristics associated with an increase in antihypertensive therapy included increased levels of both systolic and diastolic blood pressure at that visit (but not previous visits), a previous change in therapy, the presence of coronary artery disease, and a scheduled visit. Patients who had more intensive therapy had significantly (P<0.01) better control of blood pressure. During the two-year period, systolic blood pressure declined by 6.3 mm Hg among patients with the most intensive treatment, but increased by 4.8 mm Hg among the patients with the least intensive treatment. CONCLUSIONS: In a selected population of older men, blood pressure was poorly controlled in many. Those who received more intensive medical therapy had better control. Many physicians are not aggressive enough in their approach to hypertension.

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OBJECTIVES: The authors explored the role of casemix adjustment when profiling outcomes of ambulatory care. METHODS: The authors reviewed the medical records of 656 patients with hypertension, diabetes, or chronic obstructive pulmonary disease (COPD) receiving care at one of three Department of Veterans Affairs medical centers. Outcomes included measures of physiological control for hypertension and diabetes, and of exacerbations for COPD. Predictors of poor outcomes, including physical examination findings, symptoms, and comorbidities, were identified and entered into regression models. Observed minus expected performance was described for each site, both before and after casemix adjustment. RESULTS: Risk-adjustment models were developed that were clinically plausible and had good performance properties. Differences existed among the three sites in the severity of the patients being cared for. For example, the percentage of patients expected to have poor blood pressure control were 35% at site 1, 37% at site 2, and 44% at site 3 (P < 0.01). Casemix-adjusted measures of performance were different from unadjusted measures. Sites that were outliers (P < 0.05) with one approach had observed performance no different from expected with another approach. CONCLUSIONS: Casemix adjustment models can be developed for outpatient medical conditions. Sites differ in the severity of patients they treat, and adjusting for these differences can alter judgments of site performance. Casemix adjustment is necessary when profiling outpatient medical conditions.

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This study is unique in that it involved the efforts of several professional groups at eight medical centers to solve a common quality assurance problem. The study used a systematic approach to evaluate and improve the quality of care provided to veterans transferred from one facility to another. The initial survey of personnel identified perceived problems with the transfer process. Both the concurrent and the retrospective focused reviews substantiated these problems. As a result of the study, an inter-hospital transfer form was developed and implemented at eight VA medical centers with plans to expand its use to other facilities. An important benefit of the inter-hospital transfer form is the ability to use it to continuously monitor and improve the quality of inter-hospital transfers. The study was conducted by Medical District No. 1 MEDIPRO. The Medical District Initiated Peer Review Organization is a physician directed system of quality assurance within the Department of Veterans Affairs. In each geographic District, VA medical centers provide physician representatives to a medical peer review board. The MEDIPRO board, with staff support, identifies potential quality issues, designs studies, establishes standards and thresholds, and analyzes and reports study results to the medical centers. The goal of MEDIPRO is to assure and continuously improve the quality of medical care provided in VA medical centers.

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