Background. Randomized, controlled trials have shown that prophylactic antibiotics are effective in preventing surgical-wound infections. However, it is uncertain how the timing of antibiotic administration affects the risk of surgical-wound infection in actual clinical practice. Methods. We prospectively monitored the timing of antibiotic prophylaxis and studied the occurrence of surgical-wound infections in 2847 patients undergoing elective clean or "clean—contaminated" surgical procedures at a large community hospital. The administration of antibiotics 2 to 24 hours before the surgical incision was defined as early; that during the 2 hours before the incision, as preoperative; that during the 3 hours after the incision, as perioperative; and that more than 3 but less than 24 hours after the incision, as postoperative. Results. Of the 1708 patients who received the prophylactic antibiotics preoperatively, 10 (0.6 percent) subsequently had surgical-wound infections. Of the 282 patients who recei...

https://www.nejm.org/doi/pdf/10.1056/NEJM199201303260501

The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection.

An estimated 2 million patients develop nosocomial infections in the United States annually. The increasing number of antimicrobial agent-resistant pathogens and high-risk patients in hospitals are challenges to progress in preventing and controlling these infections. While Escherichia coli and Staphylococcus aureus remain the most common pathogens isolated overall from nosocomial infections, coagulase-negative staphylococci (CoNS), organisms previously considered contaminants in most cultures, are now the predominant pathogens in bloodstream infections. The growing number of antimicrobial agent-resistant organisms is troublesome, particularly vancomycin-resistant CoNS and Enterococcus spp. and Pseudomonas aeruginosa resistant to imipenem. The active involvement and cooperation of the microbiology laboratory are important to the infection control program, particularly in surveillance and the use of laboratory services for epidemiologic purposes. Surveillance is used to identify possible infection problems, monitor infection trends, and assess the quality of care in the hospital. It requires high-quality laboratory data that are timely and easily accessible.

An overview of nosocomial infections, including the role of the microbiology laboratory.

The Medical Outcomes Study was designed to (1) determine whether variations in patient outcomes are explained by differences in system of care, clinician specialty, and clinicians' technical and interpersonal styles and (2) develop more practical tools for the routine monitoring of patient outcomes in medical practice. Outcomes included clinical end points; physical, social, and role functioning in everyday living; patients' perceptions of their general health and well-being; and satisfaction with treatment. Populations of clinicians (n = 523) were randomly sampled from different health care settings in Boston, Mass; Chicago, Ill; and Los Angeles, Calif. In the cross-sectional study, adult patients (n = 22 462) evaluated their health status and treatment. A sample of these patients (n = 2349) with diabetes, hypertension, coronary heart disease, and/or depression were selected for the longitudinal study. Their hospitalizations and other treatments were monitored and they periodically reported outcomes of care. At the beginning and end of the longitudinal study, Medical Outcomes Study staff performed physical examinations and laboratory tests. Results will be reported serially, primarily inThe Journal. (JAMA. 1989;262:925-930)

https://www.rand.org/content/dam/rand/pubs/notes/2009/N3038.pdf

The Medical Outcomes Study. An application of methods for monitoring the results of medical care

Background and Methods Optimal decisions about the use of antibiotics and other antiinfective agents in critically ill patients require access to a large amount of complex information. We have developed a computerized decision-support program linked to computer-based patient records that can assist physicians in the use of antiinfective agents and improve the quality of care. This program presents epidemiologic information, along with detailed recommendations and warnings. The program recommends antiinfective regimens and courses of therapy for particular patients and provides immediate feedback. We prospectively studied the use of the computerized antiinfectives-management program for one year in a 12-bed intensive care unit. Results During the intervention period, all 545 patients admitted were cared for with the aid of the antiinfectives-management program. Measures of processes and outcomes were compared with those for the 1136 patients admitted to the same unit during the two years before the interve...

A Computer-Assisted Management Program for Antibiotics and Other Antiinfective Agents

Self-care is advocated as a method of improving outcomes from heart failure (HF), the final common pathway for several prevalent illnesses, including hypertension and coronary artery disease. HF is widespread in aging populations across the world.1 The burden of HF is manifested in poor quality of life (QOL)2,3 and early mortality.4 In addition, there are >3 million ambulatory care and emergency department visits5 and well over 1 million hospitalizations for HF in the United States annually,6 which contributes to the exorbitant costs associated with HF. Much of this healthcare utilization is thought to be preventable if patients engage in consistent self-care.7,8

This scientific statement seeks to highlight concepts and evidence important to the understanding and promotion of self-care in persons with HF. Specifically, the document describes what is known about (1) the self-care behaviors required of HF patients, (2) factors that make self-care challenging for patients, (3) interventions that promote self-care, and (4) the effect of self-care on HF outcomes. The review ends with evidence-based recommendations for clinicians and direction for future research.

Self-care is defined as a naturalistic decision-making process that patients use in the choice of behaviors that maintain physiological stability (symptom monitoring and treatment adherence) and the response to symptoms when they occur.9 The term naturalistic decision making is used to describe how people make decisions in real-world settings. Naturalistic decision makers focus on process rather than outcomes, make decisions based on the situation, let the context influence their decision-making processes, and base practical decisions on the information available at the moment.10

In HF, self-care maintenance requires following the advice of providers to take medications, eat a low-sodium diet, exercise, engage in preventive behaviors, and actively monitor themselves for signs and symptoms. Self-care management refers to decision making in …

State of the science: Promoting self-care in persons with heart failure: A scientific statement from the american heart association

ALTHOUGH modern medicine provides great benefits to large numbers of people, medical professionals and clinical researchers have expressed concern about the effectiveness and appropriateness of many current and emerging medical practices. For example, the evidence substantiating the effectiveness of many such practices is frequently questionable and in many instances entirely lacking.1 Research on medical interventions is often poorly designed and methodologically flawed.2 , 3 Many physicians lack the skills to interpret and critically evaluate medical literature,4 and they approach the same clinical problem with different theoretical assumptions, contributing to wide variations in practice patterns.5 , 6 Furthermore, physicians have difficulty incorporating information about probabilities . . .

Effectiveness in health care. An initiative to evaluate and improve medical practice.

In their June report, the Medicare Payment Advisory Commission (MedPAC) made 3 recommendations intended to create collective accountability across providers for selected hospital episodes. Glenn Hackbarth, Robert Reischauer, and Anne Mutti hope that this set of policies will create an environment that encourages and enables providers to accept bundled payments while also testing the feasibility of this payment design.

Collective accountability for medical care--toward bundled Medicare payments.

To provide high-value care, physicians will need skills in such domains as quality improvement, cost-aware practice, and care coordination. Medicare can speed graduate medical education (GME) reform by linking some funding to programs' performance on relevant measures.

https://www.medpagetoday.com/upload/2011/2/11/nejmp1012691.pdf

Transforming graduate medical education to improve health care value.

Physicians should recognize that a more competitive health-care market would provide the best defense against government regulation. Aside from group-practice health-maintenance organizations, the cost-containment steps that might be taken in such a market are not well understood. In particular, little attention has been paid to how private health insurers might redefine their coverage to limit the cost-increasing effects of third-party payment. Insurer-provider agreements negotiated in a competitive environment would seem to be especially promising. Competing insurance plans would be variously organized and operated according to provider and consumer preferences. Traditional doctor-patient relations as well as fee-for-service payment could be preserved. The antitrust laws, while curbing concerted effort to prevent change, should assure that physicians are not exploited by dominant buyers. Lucrative opportunities already exist for enterprising and efficient providers.

Glenn M. Hackbarth

Papers

Effectiveness in health care. An initiative to evaluate and improve medical practice.

Collective accountability for medical care--toward bundled Medicare payments.

Transforming graduate medical education to improve health care value.

Private Cost Containment

Pursuit of an expanded physician supply.