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PubMedDate not supplied

A high rate of caesarean sections in an affluent section of Chennai: is it cause for concern?

BACKGROUND: While rising Caesarean section rates have been the subject of much attention and debate worldwide, there is not much information available on this rate and its potential adverse impact in India. METHODS: Our survey was a standard Expanded Programme on Immunization 30-cluster design, carried out in an urban educated, middle/upper class population in Chennai. Mothers of 210 children aged 12-36 months were interviewed and data collected on immunization and breast-feeding practices. Since the mode of delivery was one of the questions, we could generate population-based data on the Caesarean section rate and its influence on breast-feeding. RESULTS: Of the 210 babies, 95 (45%, 95% confidence interval: 39.1-51.3) had been delivered by Caesarean section. Two hundred and six of 210 babies (98%) had been breast-fed at some time. However, babies born by Caesarean section tended to be started late on breast-feeds were given prelacteal feeds more often, and colostrum less often when compared to babies delivered vaginally (all statistically significant). CONCLUSIONS: Our study revealed a very high rate of Caesarean section in the selected metropolitan population. On purely scientific grounds, a rate of 40% to 50% is extremely difficult to justify. Though not conclusive, the data also suggest that Caesarean section may be adversely affecting some aspects of breast-feeding. There is a need for more data and audits on Caesarean section rates in India, and a wider debate on its potential adverse impact on the health of mothers and newborns.

Cesarean Section↗
PubMed2000

[Clinical quality assurance at institutions according to a patterns of care study. Japanese PCS Working Group].

The clinical quality assurance (QA) of an institution is important in any multiinstitutional prospective study. Patterns of Care Study (PCS) is a well-known study for QA activity in the United States. PCS is a nationwide retrospective study done by two-staged cluster sampling of institutions and patients and external audits. After data are accumulated, National averages on various survey items are calculated as a QA measure. In 1996, PCS was imported into the radiation oncology field in Japan with the support of the Ministry of Health and Welfare. Preliminary results showed significant differences in treatment process, structure, and preliminary outcome according to the stratification of institutions. These data can be useful in improving the structure and process at the institutional as well as the national level. PCS will also clarify the dissemination of positive clinical results into national practice.

Esophageal Neoplasms↗
PubMed2004

Characteristics of Type 2 diabetic patients cared for by general practitioners either with medical nutrition therapy alone or with hypoglycaemic drugs.

The essential role of medical nutrition therapy (MNT) for people with diabetes is widely recognised, and its exclusive use is recommended in mild diabetes according to a stepwise therapeutic approach. We describe the characteristics of MNT-treated Type 2 diabetic patients (vs drugs) cared for by general practitioners (GPs) in order to check that appropriate differences did exist between the two groups, by auditing the data from our local shared-care program for diabetes. We had 16,000 diabetic patients (out of 630,000 inhabitants); 6,800 of them (42.5%) cared for by GPs. Thirty-one percent (2,079 out of 6,800 patients cared for by GPs) were treated with MNT and 69% with drugs. The MNT-treated patients (vs drugs) were younger (66.1 +/- 10.7 vs 67.7 +/- 11.0 yr, p<0.01), had shorter disease duration (8.2 +/- 6.6 vs 11.2 +/- 7.6 yr, p<0.01), lower HbA1c (7.0 +/- 1.1 vs 7.8 +/- 1.6%, p<0.01) and body mass index (BMI) (28.6 +/- 4.6 vs 29.0 +/- 4.9 kg/m2, p<0.01). They had less prevalence of high blood triglycerides (25.4% vs 29.0%, p<0.01). MNT-treated patients had less micro-albuminuria (5.3% vs 8.8%, p<0.01); less retinopathy both non-proliferant (6.5% vs 11.1%, p<0.01), and pre-proliferant (6.8% vs 12.7%, p<0.01), and proliferant (7.0% vs 12.9%, p<0.01); less peripheral neuropathy (3.9% vs 8.3%, p<0.01); and diabetic foot (1.0% vs 2.0%, p<0.01). They had less chronic heart failure (2.7% vs 4.6%, p<0.01), and claudicatio intermittens (3.3% vs 5.3%, p<0.01). In conclusion, the Type 2 diabetic patients cared for by GPs using MNT appropriately had a less severe form of diabetes.

Age Factors↗
PubMed2004

The association of debt financing with not-for-profit hospitals' provision of uncompensated care.

Not-for-profit hospitals undertook unprecedented amounts of debt in the mid to late 1990s. Corporate finance theory and the literature on hospital financing suggest that debt may constrain hospitals' capacity to deliver uncompensated care. Using data from audited financial statements for a sample of hospitals, this article explores whether debt financing is associated with hospitals' provision of uncompensated care, an output central to many hospitals' service missions. Contrary to expectations, our analysis finds that higher debt is associated with higher levels of uncompensated care. However, the results may reflect the unusual economic and stock-market conditions prevailing in the mid 1990s, and they are consistent with the views of hospital financial managers and other practitioners whom we interviewed.

Empirical Research↗
PubMed2004

Management systems response to improving immunization coverage in developing countries: a case study from Cambodia.

INTRODUCTION: In contrast to the initial success following the establishment of the National Immunization Program (NIP) in Cambodia in 1986, infant vaccination coverage rates against the six expanded program immunization diseases have not improved since 1995. In response, the NIP of the Ministry of Health has undertaken a series of institutional initiatives to address the problem of static or declining rates of coverage. The aim of this paper is to describe and assess management strategies undertaken by the NIP in Cambodia in support of improved immunization coverage. METHODS: Sources of information used in preparing this report include international literature, national coverage and surveillance data, government policy documentation, information generated by national strategic planning and health centre microplanning processes, a functional analysis of human resources, and data quality audits. RESULTS: The NIP has implemented planning, organizational development and human resource development responses to the problem of low coverage. These have included: integration of the nip strategic and operational plans into the health sector plan; strengthening of needs-based microplanning; establishment of a national monitoring and management support strategy; and the introduction of performance-based agreements between levels of government for improved immunization coverage. CONCLUSIONS: Our analysis of these findings, in particular of the international literature, suggests that NIP's responses have been appropriate, and that the development of NIP management systems and capacity will increase the likelihood for sustained immunization coverage gains within a reform environment of health system decentralization. In 2003, there are early signs that the reform processes undertaken by the NIP have resulted in improved immunization coverage in targeted areas, and this should place the national program in a stronger position to lift immunization coverage in 2004.

Journal Article↗
PubMed1991

Patterns of use of chest physiotherapy in a teaching hospital.

Studies of chest physiotherapy in medical patients have consistently shown benefit only in patients who produce large amounts of sputum. Among surgical patients systematically repeated maximal inspiration is the only procedure that clearly reduces the incidence of post-operative pulmonary complications. Rationalization of the use of physiotherapy requires data on the pattern of its use. To obtain such data an audit was conducted on the use of physiotherapy in patients discharged from Royal Newcastle Hospital in October 1989. It was suspected that respiratory physicians would account for the bulk of chest physiotherapy. All patients admitted under respiratory physicians and random samples of patients admitted under other physicians and under surgical specialists were surveyed. Chest physiotherapy was ordered in 13/44 (30%) patients cared for by respiratory physicians, 5/45 (11%) other medical patients and 11/48 (23%) surgical patients (P = 0.049). Chest physiotherapy was ordered in 28 of 29 instances for conditions in which it is of no proven benefit. From the total numbers of medical and surgical patients it was estimated that 71% of chest physiotherapy referrals in October 1989 were for non-medical patients. About half of all referrals were initiated by junior medical staff. Much of the chest physiotherapy performed in the hospital was unlikely to have been of major clinical value and patients with respiratory illnesses were minor consumers of chest physiotherapy. Attempts to reduce wasteful overuse of chest physiotherapy may be most effective if directed at physiotherapists. If medical staff are targeted it would be essential to reach those attached to surgical units.

Drainage, Postural↗
PubMed1985

Correlation between clinical and autopsy diagnoses in a community hospital.

Forty-six consecutive autopsies performed in 1 year on patients who died in a 120-bed urban community hospital were analysed with respect to clinical-pathological correlation. The mean age of the patients was 71 years. Errors in clinical diagnosis were assigned to one of four classes: class I, a missed major diagnosis, the detection of which before death would probably have changed management and resulted in longer survival or possible cure; class II, a major missed diagnosis that, if detected before death, would probably not have altered management; and classes III and IV, minor missed diagnoses. Six (13%) class I and 10 (22%) class II errors were found, as well as a number of class III and IV errors. Suggestions are made regarding the use of such data in audit procedures.

Adult↗
PubMed1993

[Obstetric health care offered to Turkish immigrant women--a quality assessment].

The object of this investigation was to make a quality-assessment of the care offered to pregnant and delivering Turkish immigrant women by the Danish health care system. The quality-assessment was made as a Medical Audit using data obtained from relevant medical records as well as from semi-structured interviews with the women. Thirteen cases were evaluated among the 65 Turkish women included in the project by having delivered at Aarhus Kommunehospital in the period between April 1 and December 15 1989. In this material no severe obstetrical deficiencies were found, but other types of deficiencies were observed. Bad communication due to insufficient use of trained interpreters and to the health personnel's lack of knowledge about cultural background often resulted in mutual misunderstandings. Most of the women were examined by many different doctors and midwives during pregnancy and delivery. It is demonstrated, that the lack of continuity was an additional strain of these women. It is concluded that the difficulties in communication are potentially dangerous, increasing the risk of delayed or missing obstetrical intervention. The insufficient communication demonstrated causes insecurity and inappropriate care.

Adolescent↗
PubMedDate not supplied

Is a pre-discharge checklist useful?

A pre-discharge checklist of requirements for equipment, services, benefits and follow-up has been developed in a general rehabilitation unit. An analysis of 66 inpatients discharged after rehabilitation following a stroke or amputation within the past 2 years suggests that such a checklist is a useful tool in ensuring that patients are sent home with optimum services and support. It is also a simple way of recording discharge data for audit and quality control purposes. It may be of benefit to a wider range of hospital services.

Amputation, Surgical↗
PubMed1997

A virtual repository approach to clinical and utilization studies: application in mammography as alternative to a national database.

A national mammography database was proposed, based on a centralized architecture for collecting, monitoring, and auditing mammography data. We have developed an alternative architecture relying on Internet-based distributed queries to heterogeneous databases. This architecture creates a "virtual repository", or a federated database which is constructed dynamically, for each query and makes use of data available in legacy systems. It allows the construction of custom-tailored databases at individual sites that can serve the dual purposes of providing data (a) to researchers through a common mammography repository and (b) to clinicians and administrators at participating institutions. We implemented this architecture in a prototype system at the Brigham and Women's Hospital to show its feasibility. Common queries are translated dynamically into database-specific queries, and the results are aggregated for immediate display or download by the user. Data reside in two different databases and consist of structured mammography reports, coded per BIRADS Standardized Mammography Lexicon, as well as pathology results. We prospectively collected data on 213 patients, and showed that our system can perform distributed queries effectively. We also implemented graphical exploratory analysis tools to allow visualization of results. Our findings indicate that the architecture is not only feasible, but also flexible and scaleable, constituting a good alternative to a national mammography database.

Computer Communication Networks↗
PubMed1998

A novel method for the assessment of the accuracy of diagnostic codes in general surgery.

The aim of this study was to describe the accuracy of diagnostic coding in general surgery in a district general hospital, the North Staffordshire Hospital NHS Trust (NSHT), Stoke-on-Trent. An assessment was carried out by comparison between codes ascribed by hospital coders and expert external coders. Patients who had a finished consultant episode (FCE) in the specialty of general surgery at NSHT were included in the study. The sampling frame was general surgery FCEs at NSHT purchased by North Staffordshire Health Authority (NSHA) with an episode end date between 1 May 1995 and 31 December 1995. Every 15th record was sampled. Of 455 records sampled, 157 (35%) were in active use and were excluded but not replaced; therefore, 298 (65%) records were studied in detail. Outcome was measured by the accuracy of primary diagnostic codes ranked 1, 2, 3, 4, from highest to lowest levels of inaccuracy; a description of where errors occurred in the data cycle was recorded. Errors were found in 87/298 (29%) records; 25/298 (8%) records had an error at the highest level (i.e. wrong ICD-10 chapter), and 44/298 (15%) at the third level. Of the errors, 68/87 (78%) occurred between the medical record and the admission form. A substantial percentage (29%) of records had inaccurate diagnostic codes. It is concluded that coding should be carried out from the medical record rather than from the admission form (KMR1). The proportion of records with errors suggests that a routine data coding audit would be useful to improve the accuracy of routine diagnostic codes.

Abstracting and Indexing↗
PubMedDate not supplied

Prognostic factors for patients with esophageal cancer treated with radiation therapy in PCS: a preliminary study.

PURPOSE: We investigated the prognostic factors, with special reference to age, for esophageal cancer patients, who did not receive surgery but were treated with radiation in the context of a Patterns of Care Study (PCS) in Japan. PATIENTS AND METHODS: The fifth PCS database format employed in the United States was used to collect information on 455 esophageal cancer patients by external audit. The data of patients who had not received surgery (n=252) were further selected and divided into two age groups, patients 75 years old or older (n=90) and patients younger than 75 years (n=162). Cox's proportional hazards model was used for the statistical analysis, with crude survival as the endpoint. Variables tested were age; Karnofsky performance status (KPS); history of pulmonary disease, cardiovascular disease, and diabetes; AJCC stage; external dose; treatment period; combination with chemotherapy; utilization of brachytherapy, and stratification of institutions. RESULTS: Statistically significant prognostic factors for all patients in the non-surgery group were KPS p=.0001), stage (p=.0001), and utilization of brachytherapy (p=.0102). For younger patients, KPS (p=.0001), stage (p=.0007), external dose (p=.0001), and utilization of brachytherapy (p=.0034) were significant, and for the elderly, stage (p=.0001) and external dose (p=.0006). CONCLUSION: Although this was a preliminary study, age was not a significant prognostic factor for esophageal cancer patients in the non-surgery group, and making the external dose more than 60 Gy appears to be effective for improving survival of elderly as well as younger patients.

Adenocarcinoma↗
PubMed1999

Quality through metrics.

The Quality Assurance Unit analyzed 18 months of departmental data regarding the report-audit cycle. Process mapping was utilized to identify milestones in the cycle for measurement. Five milestones were identified in the audit cycle, as follows: (1) time from report receipt in quality assurance to start of audit, (2) total calendar days to audit a report, (3) actual person-hours to perform a report audit, (4) time from completion of audit to issuance of report, and (5) total time a report is in quality assurance. An interrelationship diagraph is a quality tool that is used to identify what activities impact the overall report-auditing process. Once the data collection procedure is defined, a spreadsheet is constructed that captures the data. The resulting information is presented in time charts and bar graphs to visually aid in interpretation and analysis. Using these quality tools and statistical analyses, the Quality Assurance Unit identified areas needing improvement and confirmed or dispelled previous assumptions regarding the report-auditing process. By mapping, measuring, analyzing, and displaying the data, the overall process was examined critically. This resulted in the identification of areas needing improvement and a greater understanding of the report-audit cycle. A further benefit from our increased knowledge was the ability to explain our findings objectively to our client groups. This sharing of information gave impetus to our clients to examine their report-generation process and to make improvements.

Data Collection↗
PubMed2001

Use of clinical audit for revalidation: is it sufficiently accurate?

In order to provide better patient care, clinicians will be subject to revalidation and re-certification. This may be partially based on existing and ongoing data collection, yet many units fail to incorporate mechanisms that validate the data that may be used. The accuracy of audit data was evaluated in a unit that has been using commercially available audit software for over 10 years. A total of 655 consecutive surgical admissions were documented over a 6-month period and errors in data collection and entry were gathered and analyzed. An overall accuracy of 90.5% was confirmed but examination of the data found them to be open to misinterpretation. Moreover, 13% of errors were made during a single week when locum staff were involved. The study highlights the fallibility of data collection during audit, and urges caution if using such data when judging performance-related issues as part of the process of appraisal.

Certification↗
PubMed1992

How accurate is a computerized surgical audit when resident medical staff collect the data?

Since July 1988 all eight general surgeons at Fremantle Hospital have used a computer-based surgical audit and discharge system. At the time of writing (September 1991) 10,919 computer-generated discharge letters have been produced by the system. This paper describes the system and reports a series of quality control assessments carried out between 1 July 1988 and 30 June 1990 during which 30 pre-registration surgical residents completed 5,716 data collection forms. It was found that: (1) data collection for 23 of 24 monthly surgical audits was at least 95% complete; (2) outstanding surgical discharge summaries were reduced by 89%; (3) the residents recorded 17/19 wound infections and identified 15 (79%) of these as a surgical complication; and (4) the residents tended to under-record complications in patients who had more than one complication during their hospital stay. It was concluded that the system was robust, and that resident staff collected data in such a way that good quality computer-generated discharge letters were produced in a timely manner. Closer attention to aspects of data collection will be required before the optimum surgical audits of the QX system can be generated.

Abstracting and Indexing↗
PubMed2002

Variations in implementation of current national guidelines for the treatment of acute pancreatitis: implications for acute surgical service provision.

OBJECTIVES: The aim of this study was to explore the implementation of the current national guidelines for the treatment of acute pancreatitis. By taking pooled data from all available individual and regional audits, the study aimed to identify areas of consistent variance from the 'best practice' stipulated in the guidelines. METHODS: All published audits of the management of acute pancreatitis where treatment was compared to the current British Society of Gastroenterology guidelines for the treatment of acute pancreatitis were identified from a search of MEDLINE and the published abstracts of relevant specialty meetings. RESULTS: Five audits providing pooled data on 545 patients were identified. Overall mortality from severe disease was 8% (range, 4-17%). Definitive treatment of gallstone disease within 4 weeks of index attack was performed in 49% (range, 16-65%). High dependency or intensive care facilities for severe disease were available in 52% (range, 20-100%). CONCLUSION: This study demonstrates the presence of striking variations in the implementation of the current national guidelines for the treatment of acute pancreatitis.

Acute Disease↗
PubMed2005

Quality and variability of osteoporosis data in general practice computer records: implications for disease registers.

OBJECTIVE: To determine the extent to which routinely collected general practitioner computer data could be used to create disease registers of patients with osteoporosis, and to report any improvement in data quality since previous studies. STUDY DESIGN: Audit using anonymized data extracted from general practice computer records from across England. METHODS: Morbidity Query Information and Export Syntax (MIQUEST) software was used to extract structured data from the 78 volunteer practices that participated in the study. The data were aggregated and analysed. RESULTS: There were 100-fold differences in the rates of recording of relevant data. Many patients receiving treatment had no diagnostic codes. Data about secondary causes of osteoporosis and fractures were more consistently recorded than data relating to falls. There were no data to indicate whether fractures were low impact. T-scores, the gold-standard measure of bone density, were very infrequently recorded. CONCLUSIONS: Sufficient data about secondary causes of osteoporosis exist, and these could be searched to identify patients at risk. Meanwhile, fracture recoding could be improved, including likely fragility fractures, and T-scores could be added to computer records. A systematic approach is needed to raise the computer records to a standard where they can be used as valid and reliable disease registers.

Accidental Falls↗