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The Newbury Maternity Care Study: a randomized controlled trial to assess a policy of women holding their own obstetric records.

To assess a policy of women holding and thus having constant access to their own obstetric records, 290 women attending a peripheral consultant clinic in Newbury, West Berkshire, were randomly allocated to hold either their full case notes, or the more usual co-operation card. Women holding their full records were significantly more likely to feel in control of their antenatal care (rate ratio 1.45; 95% confidence interval 1.08-1.95) and to feel it was easier to talk to doctors and midwives (rate ratio 1.73; 95% confidence interval 1.16-2.59). No other beneficial effects were detected. Asked about their preferences for any subsequent pregnancies, women holding their own records in the index pregnancy were more likely to say they would prefer to hold the same kind of record again in a subsequent pregnancy than were women holding a co-operation card (rate ratio 1.56; 95% confidence interval 1.34-1.81). There was no evidence of negative effects. In particular, women holding their case notes did not feel more anxious than co-operation card holders. The policy of women holding their notes resulted in savings in clerical time, without evidence of an increase in the rate of lost notes.

Clinical Trials as Topic↗

Financial impact of elimination of routine chest radiographs in a pediatric intensive care unit.

OBJECTIVE: To determine the change in chest radiograph use if each chest radiograph requires a separate order and clinical indication. DESIGN: Prospective, nonrandomized, controlled design with an intervention. SETTING: The pediatric intensive care unit (PICU) at Primary Children's Medical Center, Salt Lake City, UT. PATIENTS: The study comprised 3,727 PICU patients treated between 1992 and 1996. INTERVENTIONS: A change in ordering practice: There will be no standing orders for routine daily morning chest radiographs. Each radiograph requires a written order and a clinical indication. MEASUREMENTS AND MAIN RESULTS: During a 29-month control phase when routine daily chest radiographs were obtained for all intubated patients, 1.026 chest radiographs per patient day were performed. After the intervention, the ratio dropped to 0.653 chest radiographs per patient day, a decrease of 36.4%. This resulted in a (projected) variable cost savings of $45,476. Data were also collected for quality assurance purposes. CONCLUSIONS: These results demonstrate the impact of an evaluation and subsequent change in radiology ordering practice in our PICU. The change resulted in decreased variability in ordering practice, fewer chest radiographs per patient, and an accompanying cost savings to our patients and payors.

Cost Savings↗

Smart cards and their opportunities for controlling health information systems.

The specification for a Chip Card-Based Medical Information System (CCMIS) for the treatment of patients with chronic diseases was developed to improve the communication in Health Care. Diabetes, which is a 'typical' chronic disease was chosen as an example. Patients with chronic diseases are treated at all levels of health care and in various health care sectors. Having a Portable Personal Medical Record (PPMR) on a chip card means that the necessary information of the patient is available at any time. Such a communication tool will thus have an important impact on the quality of health care and also contribute to cost reduction of European health budgets. As the main issues of the CCMIS the data security, data protection and privacy have been integrated. The system architecture allows an implementation into different networking environments and is covered by approved standards. A demonstrator has been developed to show medical applications and the security aspects.

Computer Communication Networks↗

Film labels: a new look.

Every diagnostic image should be properly labeled. To improve the labeling of radiographs in the Department of Radiology at the University Medical Center, Tucson, Arizona, a special computer program was written to control the printing of the department's film flashcards. This program captures patient data from the hospital's radiology information system and uses it to create a film flashcard that contains the patient's name, hospital number, date of birth, age, the time the patient checked into the radiology department, and the date of the examination. The resulting film labels are legible and aesthetically pleasing. Having the patient's age and date of birth on the labels is a useful quality assurance measure to make certain the proper study has been performed on the correct patient. All diagnostic imaging departments should institute measures to assure their film labeling is as legible and informative as possible.

Forms and Records Control↗

[Recording of drug prescriptions in medical records. How to improve the quality?].

OBJECTIVE: To describe the evaluation of a program to improve the recording of drug prescribing in medical records. DESIGN: Experimental study with before and after measurements, without a control group, of the medical files of all patients who consulted during 2 different weeks, 9 months apart. SETTING: Family Medicine Unit of Centre hospitalier de l'Université Laval. PARTICIPANTS: Teachers and residents in the Family Medicine Unit. MAIN OUTCOME MEASURE: Proportion of prescriptions for drugs having a systemic effect (n = 206 for week before, n = 257 for week after) for which the following information was recorded: concentration, dosage, quantity prescribed or length of treatment, number of renewals. RESULTS: After the program, recording frequency increased from 86% to 97% for concentration, 80% to 95% for dosage, 52% to 79% for the quantity prescribed, and 20% to 71% for number of renewals. Both groups of doctors showed a notable improvement, except for the recording of quantity prescribed by residents, which remained stable. CONCLUSION: We observed an improvement in the recording of drug prescriptions in medical files. The program had a greater effect on teachers who had been exposed to activities that are known to be effective in improving recording.

Drug Prescriptions↗

Recommended framework for presenting injury mortality data.

Injuries are a substantial and preventable public health problem and account for approximately 6% of deaths in the United States. Many injury epidemiology and injury control programs depend on injury mortality and morbidity data aggregated by external cause of injury codes (E codes) for program planning and evaluation. This report provides a framework for the uniform tabulation and analysis of injury mortality data classified by the Ninth Revision of the International Classification of Diseases (ICD-9) (a subsequent report will address the application of this framework to injury morbidity data). Standard ICD-9 E-code groupings are presented in the form of a matrix and are depicted as mechanism by intent of injury. All cells in the matrix are mutually exclusive. Injury mortality data from the National Center for Health Statistics (NCHS) are presented in the matrix for 1993 to illustrate numbers of deaths within each cell Justifications are given for assigning E codes to major categories and subcategories within the matrix. The groupings of external causes presented in this framework were developed by CDC (National Center for Injury Prevention and Control [NCIPC] and NCHS) in collaboration with members of the American Public Health Association's Injury Control and Emergency Health Services Section (ICEHS). These groupings are intended to assist persons involved in planning and evaluating injury control programs at national, state, and local levels and are relevant for all persons who collect, code, analyze, and report injury data. Public health researchers and other public health professionals are encouraged to adopt or adapt these groupings as a minimum framework for tabulating injury deaths and death rates. For historical continuity, vital statistics programs will continue to use tabulation standards based on both the guidelines of the World Health Organization and derivative lists developed by CDC (NCHS) for presentation of national mortality statistics. The proposed framework can be used to supplement these tabulation standards by providing more detailed presentations of injury deaths and death rates, which are useful for making policy decisions and planning injury prevention activities.

Cause of Death↗

Validity of International Classification of Diseases, Ninth Revision, Clinical Modification Codes for Acute Renal Failure.

Administrative and claims databases may be useful for the study of acute renal failure (ARF) and ARF that requires dialysis (ARF-D), but the validity of the corresponding diagnosis and procedure codes is unknown. The performance characteristics of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for ARF were assessed against serum creatinine-based definitions of ARF in 97,705 adult discharges from three Boston hospitals in 2004. For ARF-D, ICD-9-CM codes were compared with review of medical records in 150 patients with ARF-D and 150 control patients. As compared with a diagnostic standard of a 100% change in serum creatinine, ICD-9-CM codes for ARF had a sensitivity of 35.4%, specificity of 97.7%, positive predictive value of 47.9%, and negative predictive value of 96.1%. As compared with review of medical records, ICD-9-CM codes for ARF-D had positive predictive value of 94.0% and negative predictive value of 90.0%. It is concluded that administrative databases may be a powerful tool for the study of ARF, although the low sensitivity of ARF codes is an important caveat. The excellent performance characteristics of ICD-9-CM codes for ARF-D suggest that administrative data sets may be particularly well suited for research endeavors that involve patients with ARF-D.

Acute Kidney Injury↗

Application of microcomputers in the emergency department: experience with a computerized logbook.

The regulations of the Joint Commission on Accreditation of Hospitals stipulate that every emergency department must maintain a control register or logbook of patients seen. The retrieval of handwritten logbook data characteristically is a slow and tedious task that is prone to error. A computerized logbook has been developed for use on personal microcomputers using an economical database management system. Each patient record consists of 16 fields, including basic identifying data, chief complaint, diagnosis, physicians involved, and disposition. The daily log of patients seen is a computer-generated printout containing nearly four times the number of patients per printed page as our handwritten log system. It is now possible to obtain listings of admissions, mortalities, daily radiographs, laboratory cultures, and physicians patient lists 24 hours a day. The system is a valuable resource in an emergency medicine residency, and allows our program to generate interesting case and radiograph listings. Research data can be obtained in a fraction of the time and with a fraction of the effort usually required by manual methods.

Computers↗

[Methologic contribution to blood transfusion materials surveillance].

To reduce seriousness and frequency of iatrogenic risk implies prevention policies and efficient operational systems for vigilance. This risk management implies definition of precise organizations and procedures able to locate and to notify quickly undesirable events. This is the case about single use medical devices (SUMD) used in blood transfusion. This article is a contribution to the organisation of the implemented material vigilance in blood transfusion, collectively carried out with actors concerned (users, manufacturers, National Commission for Material Vigilance). It presents a lot of tools and methods to favour practices harmonization, as well as preventive a curative (specifications before purchase, main part of the quality contract between customer and supplier; internal control plan; index for medical device used in transfusion; illustrated glossaries for three main families of medical devices; index about symptomatic events; definitions of seriousness levels with their operational consequences; methods to manage a single use medical device judged as defective; tool for the review of incidents according to reference and batch). Then, the management of incidents about SUMD is presented within a material vigilance system integrated into the quality system of the institution, for user as for manufacturer. This is done in a chronological order with successively description of the incident, the assessment of the impact, the management of the associated risk, the periodical review of incidents and management of matters in dispute.

Algorithms↗

Development and implementation of clinical pathways for the management of four trauma diagnoses.

Clinical pathways are similar to the production algorithms developed by industry. They are being adapted for use in healthcare to reduce resource utilization, decrease variability, and control expenditures. At Boston Medical Center we identified four trauma diagnoses that we believed to be amenable to the design and implementation of clinical pathways: closed head injury, penetrating wound to the abdomen, penetrating wound to the chest, and penetrating wound to an extremity. Upon implementation of these pathways, appropriate nonoperative, single-system, short-stay trauma patients were enrolled in them. This article details the process by which the four diagnoses were identified and the pathways designed, implemented, and evaluated. Preliminary data demonstrate a significant decrease in resource utilization following implementation of the pathways, without an adverse impact on readmission rates, length of stay, or mortality.

Algorithms↗

A randomized controlled trial to increase cancer screening among attendees of community health centers.

BACKGROUND: We assessed the efficacy of the Cancer Screening Office Systems (Cancer SOS), an intervention designed to increase cancer screening in primary care settings serving disadvantaged populations. METHODS: Eight primary care clinics participating in a county-funded health insurance plan in Hillsborough County, Fla, agreed to take part in a cluster-randomized experimental trial. The Cancer SOS had 2 components: a cancer-screening checklist with chart stickers that indicated whether specific cancer-screening tests were due, ordered, or completed; and a division of office responsibilities to achieve high screening rates. Established patients were eligible if they were between the ages of 50 and 75 years and had no contraindication for screening. Data abstracted from charts of independent samples collected at baseline (n = 1,196) and at a 12-month follow-up (n = 1,237) was used to assess whether the patient was up-to-date on one or more of the following cancer-screening tests: mammogram, Papanicolaou (Pap) smear, or fecal occult blood testing (FOBT). RESULTS: In multivariate analysis that controlled for baseline screening rates, secular trends, and other patient and clinic characteristics, the intervention increased the odds of mammograms (odds ratio [OR] = 1.62, 95% confidence interval [CI], 1.07-9.78, P = .023) and fecal occult blood tests (OR = 2.5, 95% CI, 1.65-4.0, P <.0001) with a trend toward greater use of Pap smears (OR = 1.57, 95% CI, 0.92-2.64, P = .096). CONCLUSIONS: The Cancer SOS intervention significantly increased rates of cancer screening among primary care clinics serving disadvantaged populations. The Cancer SOS intervention is one option for providers or policy makers who wish to address cancer related health disparities.

Aged↗

[Compatibility of different quality control systems].

Management of the good laboratory practice (GLP) quality system presupposes its linking to a basic recognized and approved quality system, from which it can draw on management procedures common to all quality systems, such as the ISO 9000 set of norms. A quality system organized in this way can also be integrated with other dedicated quality systems, or parts of them, to obtain principles or management procedures for specific topics. The aim of this organization is to set up a reliable, recognized quality system compatible with the principles of GLP and other quality management systems, which provides users with a simplified set of easily accessible management tools and answers. The organization of this quality system is set out in the quality assurance programme, which is actually the document in which the test facility incorporates the GLP principles into its own quality organization.

Clinical Laboratory Techniques↗

Evaluation of patients' knowledge about anticoagulant treatment.

OBJECTIVE: To develop a questionnaire to evaluate patients' knowledge of anticoagulation. DESIGN: Anonymous self completed questionnaire study based on hospital anticoagulant guidelines. SETTING: Anticoagulant clinic in a 580 bed district general hospital in London. SUBJECTS: 70 consecutive patients newly referred to the anticoagulant clinic over six months. MAIN MEASURES: Information received by patients on six items of anticoagulation counselling (mode of action of warfarin, adverse effects of over or under anticoagulation, drugs to avoid, action if bleeding or bruising occurs, and alcohol consumption), the source of such information, and patients' knowledge about anticoagulation. RESULTS: Of the recruits, 36 (51%) were male; 38(54%) were aged below 46 years, 22(31%) 46-60, and 10(14%) over 75. 50 (71%) questionnaires were returned. In all, 40 respondents spoke English at home and six another language. Most patients reported being clearly advised on five of the six items, but knowledge about anticoagulation was poor. Few patients could correctly identify adverse conditions associated with poor control of anticoagulation: bleeding was identified by only 30(60%), bruising by 23(56%), and thrombosis by 18(36%). Only 26(52%) patients could identify an excessive level of alcohol consumption, and only seven (14%) could identify three or more self prescribed agents which may interfere with warfarin. CONCLUSION: The questionnaire provided a simple method of determining patients' knowledge of anticoagulation, and its results indicated that this requires improvement. IMPLICATIONS: Patients' responses suggested that advice was not always given by medical staff, and use of counselling checklists is recommended. Reinforcement of advice by non-medical counsellors and with educational guides such as posters or leaflets should be considered. Such initiatives are currently being evaluated in a repeat survey.

Aged↗

A comprehensive set of coded chief complaints for the emergency department.

OBJECTIVE: To develop a generally applicable set of coded chief complaints for the computerized patient records of emergency departments (EDs). METHODS: At an urban teaching ED the chief complaints of more than 50,000 patients were analyzed retrospectively during a 29-month period (June 1995-October 1997). Applying continuous quality improvement methods, a multidisciplinary team examined the current process documenting the patient's chief complaint. During two prospective periods (November 1997-December 1998; January 1999-June 1999), more than 34,000 chief complaints were analyzed. To reduce free-text charting practices, a variety of interventions on individual and team level were applied. Quantitative analysis was performed with statistical process control charts, and a qualitative evaluation was performed with a questionnaire. RESULTS: The charting of chief complaint in free-text format decreased from 23% to 1%. The range among individual ED staff members narrowed from 45% to 9%. During the refinement of the set of coded chief complaints, six infrequently charted items were removed. Five new chief complaints identified by analysis of free-text entries during the second study period were added. The current set of chief complaints consists of 54 codable and the three original free-text items. The ED staff members perceived all the interventions beneficial. A poster displaying all available terms as a visual aid, however, had the largest impact on charting the patient's chief complaint in coded format. CONCLUSIONS: Applying continuous quality improvement methods, the authors created a clinically developed and applicable set of codable chief complaints that can be easily integrated into a computerized patient record of an ED.

Emergency Service, Hospital↗

[Quality control of 135 histopathological reports of colo-rectal carcinoma].

OBJECTIVE: To evaluate the information content in our surgical pathology reports of colon and rectum carcinoma. SETTING: A third level hospital. DESIGN: Consecutive surgical reports from 1988 to 1994 were retrieved. The gross and histological variables with prognostic relevance according to the TNM system were registered using a checklist with standardized variables as proposed by two groups of pathologists. The adequacy of our reports was surveyed counting the number of histopathological variables in relation to the 11 prognostic parameters that must be included in routine surgical reports of large colon carcinomas. RESULTS: The surgical reports were 135. The histologic type, tumor grade and histological tumor invasion were provided in most of the reports. In 90% the lymph node characteristics were described and 85% had gross and histologic margin assessment. But other variables were poorly informed, i.e. vascular invasion was informed in one case (0.7%). CONCLUSIONS: Our surgical reports were considered adequate as 113/135 (84%) recorded more than eight prognostic variables. Insufficient data were: 1) a poor gross description; 2) lack of tumor grading in 12%; and 3) omission of anatomic site in 29%.

Colonic Neoplasms↗

A cluster randomised controlled trial of patient-held medical records for people with schizophrenia receiving shared care.

BACKGROUND: Patient-held records can improve communication across the primary-secondary interface. There has been no previous rigorous assessment of the utility of patient-held records for people with schizophrenia from a primary care perspective and their value for this population is unclear. AIM: To evaluate the effectiveness of a patient-held record for patients with schizophrenia receiving shared care. DESIGN OF STUDY: Cluster randomised controlled trial. SETTING: Seventy-four general practices and six community mental health localities in Birmingham, England between June 1998 and June 1999. METHOD: A sample of 201 patients with schizophrenia (ICD-10 classification F20) was recruited; of these, 100 were intervention and 101 were control. Patient-held records were given to the intervention patients. At 12-month follow-up, all patients were accounted for and 191 (95%) were revisited. Primary outcomes were the Verona Service Satisfaction Scale-54 (VSSS-54) and the Krawiecka and Goldberg (K & G) rating scale of psychopathology at 12-month follow-up. Secondary outcomes were use of primary and secondary care services. RESULTS: A total of 63/92 (68.5%) patients still had the patient-held record, 64/92 (69.6%) had used it, and 39 (60.9%) of the 64 who had used it said the patient-held record was regularly used by their keyworker. However the patient-held record had no significant effect on primary outcomes (VSSS-54: F1,116 = 0.06, P = 0.801, K & G: F1,116 = 0.6, P = 0.439) or on use of services. A higher symptom score was associated with not using the patient-held record. CONCLUSIONS: The trial provides no good evidence to suggest that patient-held records should be introduced as part of routine shared care for all patients with schizophrenia. However, the patient-held record was acceptable to patients with schizophrenia and acted as a communication tool, particularly between patients and keyworkers.

Adolescent↗

A utilization management intervention to reduce unnecessary testing in the coronary care unit.

BACKGROUND: There have been no studies of interventions to reduce test utilization in the coronary care unit. OBJECTIVE: To determine whether a 3-part intervention in a coronary care unit could decrease utilization without affecting clinical outcomes. METHODS: Practice guidelines for routine laboratory and chest radiographic testing were developed by a multidisciplinary team, using evidence-based recommendations when possible and expert opinion otherwise. These guidelines were incorporated into the computer admission orders for the coronary care unit at a large teaching hospital, and educational efforts were targeted at the house staff and nurses. Utilization during the 3-month intervention period was compared with utilization during the same 3 months in the prior year. The hospital's medical intensive care unit, which did not receive the specific intervention, provided control data. RESULTS: During the intervention period, there were significant reductions in utilization of all chemistry tests (from 7% to 40%). Reductions in ordering of complete blood counts, arterial blood gas tests, and chest radiographs were not statistically significant. After controlling for trends in the control intensive care unit, however, the reductions in arterial blood gas tests (P =.04) and chest radiographs (P<.001) became significant. The reductions in potassium, glucose, calcium, magnesium, and phosphorus testing, but not other chemistries, remained significant. The estimated reduction in expenditures for "routine" blood tests and chest radiographs was 17% (P<.001). There were no significant changes in length of stay, readmission to intensive care, hospital mortality, or ventilator days. CONCLUSION: The utilization management intervention was associated with significant reductions in test ordering without a measurable change in clinical outcomes.

Adult↗

Evaluation of a visual layering methodology for colour coding control room displays.

Eighteen people participated in an experiment in which they were asked to search for targets on control room like displays which had been produced using three different coding methods. The monochrome coding method displayed the information in black and white only, the maximally discriminable method contained colours chosen for their high perceptual discriminability, the visual layers method contained colours developed from psychological and cartographic principles which grouped information into a perceptual hierarchy. The visual layers method produced significantly faster search times than the other two coding methods which did not differ significantly from each other. Search time also differed significantly for presentation order and for the method x order interaction. There was no significant difference between the methods in the number of errors made. Participants clearly preferred the visual layers coding method. Proposals are made for the design of experiments to further test and develop the visual layers colour coding methodology.

Adult↗