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The assessment of pollutant effects on health status requires the mergence and analysis of two different databases: pollution measurements and health care information. This paper compares two subsets of these data: Ohio Environmental Protection Agency data on ambient air pollutants and Ohio Medicare data on respiratory diseases. Small area analysis was performed to assess statewide variations in hospital admission rates for respiratory diseases. The ambient air pollutant levels for each small area were compared to the variations in respiratory disease rates. Five groups of diseases correlated with pollutant levels. In addition, pollutant levels were significantly associated with medical complications. This study demonstrates the feasibility and benefit of linking environmental and health care databases and suggests the need for a more comprehensive, automated analysis of more pollutants and diseases.

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In conclusion, these results suggest that pattern analysis may provide a flexible and dynamic tool with which to sort cases prior to review, and evaluate changing medical practice patterns. Patterns analysis may also provide a way to avoid spending time and resources on cases with a low probability of quality problems. Lastly, pattern analysis promises to increase timely information and feedback to health care professionals and organizations.

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Quality problems occur throughout the health care system, regardless of the disease or diagnosis. Peer review groups and health care organizations can take advantage of this finding to design quality improvement programs that will have a greater impact on health care quality than traditional quality assurance programs. Problems associated with high volume diagnoses or high risk procedures can be analyzed with the understanding that lessons learned in those examinations can be applied to many other aspects of health care. Continuous quality improvement can be implemented, using specific indicators and criteria as models for the overall factors contributing to quality in the health care system. Quality improvement experts estimate that the majority of all quality problems originate in the system, rather than in the performance of individuals. An in-depth analysis of our hospital and health care systems, complementing the performance-based quality assurance programs already in place, will facilitate the comprehensive improvement of quality throughout our health care institutions.

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An analysis of Ohio's Medicare data base by the state's Peer Review Organization, using the most common diagnosis-related group in the Medicare population (heart failure and shock), from January 1, 1989 to January 1, 1991, identified 72 cases with confirmed quality-of-care problems. The analysis was performed to determine whether the majority of quality-of-care problems are related to systems or performance deficiencies. Study results indicated that health care workers are being inappropriately blamed for problems that are inherent in the health care system--74% of problems were related to inefficiencies in the health care delivery system, and 26% were determined to reflect performance problems.

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Peer review organizations (PRO) review the health care given to Medicare beneficiaries. If a PRO determines that a hospital admission was unnecessary, the hospital is not reimbursed for the medical care and the case is "denied." The average hospital denial rate on Ohio is 2%; however, the denial rate for hospital admissions of one day or less is 7.5%. An analysis of hospitals and diagnoses for one-day hospital admission denials was performed, showing that urban hospitals and disorders of the circulatory and digestive systems predominate. The inappropriate utilization of health care resources costs millions of dollars per year in Ohio and could be costing the nation billions of dollars. There is an urgent need to research why resources are used less effectively by some hospitals and for some diseases.

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Adjusted admission rates for respiratory distress (COPD, asthma, bronchitis, and pneumonia) varied up to 3.09-fold between the highest and lowest hospital market areas in 1986 for the state of Ohio. Reasons for the variability can be determined through small area analysis techniques with the help of area physicians. Substantial improvements in the availability, delivery, and cost of respiratory care would reasonably be anticipated as a result of such analysis and feedback.

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One Ohio hospital underwent three years of 100% focused review of admissions for medical back problems (DRG 243) due to excessive numbers of admissions previously noted. On cessation of the focused review, the volume of admissions rose at this hospital, and the admission denial rate increased. Reinstitution of focused review appeared to decrease the number of admissions, but did not affect the rate of admission denials.

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