Help a Brother Out! Outcome Studies

Hi Dr. Keller,

I was hoping I could pick your brain (and those of your readers) for ideas regarding Outcome studies.

We are an NCCHC accredited facility with a population of less than 500 inmates. We are required as part of our accreditation to complete 1 Outcome and 1 Process study annually. Outcome studies are more patient specific and Process studies are more global, referring to the process by which we deliver care.

I don’t usually have problems developing Process Studies, but always seem to get stuck on the Outcome studies. I am wondering if you or your viewers might share any suggestions on topics for Outcome studies or comment on topics they have studied in the past.

Thanks for your help–Bryan19970521

Hi Bryan!  I am a big fan of NCCHC, but I have to admit right at the beginning that I have no expertise in NCCHC processes, including Outcome and Process Studies.  In my experience, the difference between the two is evidently subtle enough that many people, including site surveyors, are sometimes not completely sure whether a particular study is “outcome” or “process.”

I will give you my (limited) understanding of the difference, but I also invite anyone from NCCHC to please comment!  My understanding is this:  Process studies are roughly equivalent to the older “Continuous Quality Improvement” programs.  You identify something you are doing such as, say, 14-day health assessments (the “process”).  You set a goal, such as doing the health assessment on 90% of all inmates within 14 days, and then you track your progress.  Since we all do so many different things, process studies are easy to design and to do.

An Outcome Study, on the other hand, deals with specific patients.  You identify patients who are not meeting some treatment goal, you change their therapy and you track how well they do.  It is easiest to give examples by tracking an outcome in one individual patient.  Let’s say one of your patients takes two different hypertension medications but still has a blood pressure of 170/100.  You decide to add a third agent and a month later the patient’s blood pressure is 136/88. Voila!  An individual patient’s outcome has been studied!

Unfortunately, this will not count as a formal NCCHC Outcome Study because it only contains one patient—you need more.  I’m not sure what the absolute minimum acceptable number for an Outcome Study is, though our last site surveyor told us to shoot for ten patients.  But in a jail like yours, with less than 500 beds, it may be impossible to find ten patients with uncontrolled hypertension who will all be treated the exact same way. However, you still can do Outcome Studies even if you are a small jail.  Here’s how:

One way to find at least ten patients for an Outcome Study is to track patient outcomes anytime you change your formulary.  For example, let’s say you used to prescribe doxycycline for MRSA, but now doxycycline is $3.78 a pill (!) and so you are going to use minocycline (25 cents a pill) instead.  Pull out the first ten patients who get minocyline and track how they do.  Did they have the same MRSA clearance rate as before?  Another example: some prisons have stopped prescribing bupropion (Wellbutrin) due to its abuse potential.  If your facility had done that, you could track ten patients who had their bupropion changed to something else.  How well did they do?  Any change in formulary is an invitation for an outcome study.

Any other change in treatment practice will serve as well.  We recently had a new vendor take over food services in one of my jails.  We could track ten patients prescribed diabetic diets.  Is there any change in their blood sugars?  Are more (or less) refusing the diabetic diet?

Another of my jails just added a medical commissary program.  We could track ten patients who had previously been prescribed omeprazole, say, in the medical clinic.  Are they buying omeprazole from the commissary instead?  Have their clinic visits gone down?  Are they happy with the change?

Help a brother out!  What cool Outcome Study have you done at your facility?  NCCHC site surveyors—Please Comment!

Help a Sister Out!  (I certainly don’t know the answer)

Angie Watson writes

“I am curious about something and wondered if anyone has any information on this subject. I realize that this is may be a legal question so I am just asking opinions, not for legal advice. If a jail or prison staff member is assaulted in some way by an inmate who has been released, is that covered under workers compensation? I was thinking that it would be covered as long as the person (staff member) isn’t doing something against regulations such as contacting the inmate outside of the facility. But, I actually do not know. Hopefully, I will never need to know. Anyway, I was curious. Thanks for any info on the subject! 🙂 “

This question brings to mind the tragic slaying of Tom Clements, the executive director of the Colorado Department of Corrections .  If Mr. Clements had survived, would this have been a workman’s comp claim?  I’m afraid that I do not know the answer for sure.

It seems to me that since the injury is directly related to the victim’s activities at work, that it would be a valid workman’s compensation claim.  On the other hand, I suspect that smart lawyers could come up with good arguments on either side of this issue, so it may not be decided until such a case is adjudicated. And I am not aware that such a workman’s comp claim has ever been filed

 Help a sister out!  Do any correctional attorneys wish to weigh in on this question?  Does anyone else have an opinion?

Maximum Insecurity: A Doctor in the Supermax.  An update

Approximately 50 people (so far) have requested copies of Dr. Wright’s wonderful book.  Hopefully, all 50 have successfully downloaded the books PDF.

We do have one concise review of the book from Julie, who writes,

“I haven’t laughed out loud this much since I read M.A.S.H. 100 years ago!”

Well put, Julie!  I entirely agree!

Dr Wright recently posted this:

Just a note for anyone who requested a copy and didn’t receive the link, please let me know (through Dr. Keller) and I’ll get it to you. Also, if you know someone who would like an advance copy, let me know that too. To everyone: thanks so much for your comments and warm reception. I’ll let you know when it’s published on Amazon!

Do you have any critique, comment or just a good story to share?  Please comment!

6 thoughts on “Help a Brother Out! Outcome Studies

  1. Outcome studies are the current vogue – however they are often confounded by uncontrollable factors. Non-medical example: Teachers are upset about application of improvements in standard tests (outcome study) as a factor in their assessments – there are so many uncontrolled factors in that issue.
    Hypertension, hyperglycemia, etc. are so dependent upon compliance – one thought how about withdrawal related seizures as an outcome study. My other thought would be to factor in compliance scales such that elevated glucometer readings would be correlated with HgbA1c and structure the study to note – those who complied with A1c of x.x had glucometer readings that were within appropriate range etc. etc. (probably should include calculated ideal weights v activity v medication compliance too)

  2. I’m sorry, but I haven’t yet received any link for the PDF version of Maximum Insecurity as you mentioned in your update. Can you please try again. I would love to read a copy.
    Thank you

  3. Having been a Doctor in a Supermax, I would love to compare notes with Dr. Wright. This may be the answer to something I find myself saying a lot: “I could write a book”.

    Please send me the link.

    All the best,
    Dr. Jim Cheverie

  4. Just did 6 months study of the Li+. tegretol, and VPA labs we did. How many refused, how many “None Detected,” etc. Very interesting outcomes! Should work for you if you have enough subjects–we have 3,400 inmates and a MH caseload of 470.

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