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PubMed1994

[Evaluation in gynecology and obstetrics. Propositions for routine evaluation of professional practices].

All the scientific prerequisites for auditing Gynaecology-Obstetrics clinics are currently available. Nevertheless, it is often difficult to usefully evaluate routine decision making. The aim of this paper was to offer matter for thought concerning the choice of methods and themes to be used in evaluating routine management in Gynaecology-Obstetrics clinics. Several methods are discussed, including monitoring synthetic indicators and complex evaluation of routine decision making (relationship between recruitment, practices and results). Details of this latter method were presented with several examples: prematurity prevention, perinatal mortality and morbidity, screening tests and antenatal diagnosis, cesarean section.

France↗

PubMed1997

The application of evidence-based priority setting in a District Health Authority.

BACKGROUND: Despite the current drive towards evidence-based medicine, it is not clear how commissioners actually use research findings in making decisions on priority setting. This study describes an attempt to directly introduce evidence on the effectiveness of interventions into the annual priority setting process of a District Health Authority (DHA). METHODS: Literature searches were undertaken on proposals for Health Authority funding. The identified literature was then critically appraised, and relevant information was used by members of the Department of Public Health to score the individual bids in terms of health gain. These scores were then fed into the priority setting process. RESULTS: A total of 144 proposals for funding were submitted. For 6.2 per cent of proposals there was strong evidence to support the intervention, for 21.2 per cent there was fair evidence in support, and for 38.1 per cent there was poor evidence. A search was not possible for 16.8 per cent of the proposals. There was a moderate correlation between the strength of evidence for the effectiveness of the proposal and initial scoring of the proposal for health gain (r = 0.41, p < 0.001). At the end of the priority setting process there was no correlation between strength of evidence and priority ranking (r = 0.01, p = 0.97). CONCLUSIONS: It is feasible, but difficult, to use information resources and critical assessment of research evidence as part of the priority setting process of a DHA. The research evidence did appear to influence the initial assessment of proposals. However, the strength of the research evidence was not associated with the priority choices made by the DHA in its purchasing plan.

Databases, Bibliographic↗

PubMed2004

Predictive value of blood cultures positive for coagulase-negative staphylococci: implications for patient care and health care quality assurance.

Interpretation of blood cultures that are positive for coagulase-negative staphylococci (CoNS) is often difficult. Predictive values for blood cultures positive for CoNS in patients with a central vascular line in place were calculated using the following rates: true bacteremia, 3%; blood culture contamination, 2%; detection of bacteremia, 80%; and catheter colonization, 2% (for blood samples obtained through a central vascular line). Positive predictive values were 55% for 1 positive culture result of 1 culture performed, 20% for 1 positive result of 2 performed, and only 5% for 1 positive result of 3 performed. For 2 positive culture results of 2 cultures performed, the positive predictive value was 98% if both samples were obtained through the vein, 96% if one sample was obtained through a catheter and the other was obtained by vein, and only 50% if both samples were obtained through a catheter. Use of this model with institution-specific values for input parameters would assist in clinical decision-making as well as hospital quality assurance.

Bacteremia↗

PubMed1993

How valuable is feedback of information on hospital referral patterns?

OBJECTIVES: To determine general practitioners' responses to and explanations for variation in rates of referral to hospital and how feedback of data on rates of referral could be used to facilitate practices in auditing their own referral behaviour. DESIGN: Visits by audit facilitators to general practices after feedback of details of rates of referral to hospital derived from annual reports in general practice. SETTING: 92 general practices in East Anglia. RESULTS: General practitioners judged that access to specialist care, the individual skill of general practitioners, patient demand, and fear of litigation were major determinants of referral behaviour. Because there was widespread scepticism about the accuracy of the data on which the feedback was based and because there is no clear relation between rates of referral and quality of care, it was extremely difficult to encourage doctors to use the feedback as a basis for auditing their own hospital referrals. CONCLUSION: If general practitioners are to contribute meaningfully to monitoring future changes in referral patterns it will be essential to develop reliable information systems in which doctors have confidence. Furthermore, audits need to be based on analysis of clinical cases rather than on rates of referral.

Attitude of Health Personnel↗

PubMed1998

Surgical treatment of the ruptured aneurysm. Timing.

Timing of surgery is one of the most important and controversial aspects in the management of the patient with a ruptured aneurysm. For each patient with a ruptured aneurysm, the treating physician is faced with a difficult decision: to operate acutely in order to avoid rebleeding despite the swollen brain, or to wait until the effects of the initial hemorrhage subside. The decision of whether or not to perform surgery acutely after subarachnoid hemorrhage (SAH) strongly affects the ability to prevent and treat some of the complications of SAH. Either approach, early or delayed surgery, has pros and cons. This article reviews the numerous factors that play a role in this delicate decision-making process.

Age Factors↗

PubMed2000

The orthopaedic surgeon and industry. Ethics and industry incentives.

Physicians may receive various gifts and incentives from companies that make pharmaceuticals and medical devices. Although such incentives may benefit patients and physicians, they often pose serious conflicts of interest that violate a physician's professional responsibility. The physician-patient relationship is predicated on the physician acting in the best interest of the patient. The application of medical knowledge to complex clinical circumstances is difficult, even without biased sources of information and internal conflicts attributable to financial incentives. Yet, industry resources often are dedicated to the dissemination of information and incentives aimed to influence decisions not necessarily aimed at the goals of the patient. Physicians often are unaware of the nature of the incentives and commonly deny their demonstrated impact. Any incentive that is designed to impede, rather than enhance, the clinician's ability to make optimal patient care decisions is unethical for a physician to accept. These incentives should play no role in the practice of orthopaedic surgery.

Ethics, Medical↗

PubMed1992

Medical knowledge for clinical problem solving: a structural analysis of clinical questions.

Despite technological advances that support wide-ranging access to and transfer of knowledge, practicing physicians continue to underutilize current biomedical literature. This paper explores the nature of clinically applicable medical knowledge through a structural analysis of clinical questions. The author analyzed a set of sixty questions, based on actual online search requests of practicing physicians, for stated and unstated needs, certainty levels, implicit and explicit assumptions, decision-making processes, and type of answer required. As a result, four states of information valuable in patient care were identified: prediagnostic assessment, diagnosis, treatment choice, and learning. These states are presented in frame-like structures that integrate declarative and procedural components of medical decision making. It is concluded that clinical problem solving requires a blend of declarative and procedural knowledge. The ratio depends, in part, upon the reasoning process underway at the time of the request. Procedural knowledge required for clinical problem solving may be absent from current biomedical journal literature or difficult to identify.

Decision Making↗

PubMed1983

Government revamp of the health care system: effect on patient care and research.

Since the end of World War II, the United States has been in a golden age of medicine. Unprecedented advances in biomedical research have resulted in a fundamental understanding of many disease processes; pharmaceutical research and development has produced a host of new therapeutic agents; and new technology has opened new vistas in the areas of diagnosis and therapeutics. This new knowledge has been translated into the health care delivery system. The federal government made the crucial decision that new hospital construction and increased bed capacity were needed to upgrade medical care in the modern, high-technology era. Another crucial decision made by the government was that health care was a fundamental right of all its citizens, and access to the health care system for the elderly, poor, and middle class had to be assured. This decision was culminated by the enactment of the entitlement programs of Medicare and Medicaid in 1965. These policies helped to decrease the mortality rate of our population by 1.5 percent per year. Our elderly citizens are healthier as a group and living longer. During the past decade strains on the economy secondary to the inflationary spiral produced by the Arab Oil Embargo and the huge budget deficits of the Reagan Administration have led to broad-based efforts to decrease spending on health care. A complex system of cost limits has been initiated, including a prospective reimbursement system for Medicare and Medicaid based on diagnostic-related groups. This system will force hospitals to shift from direct medical care to ambulatory, lower-cost services, making it costlier and more difficult for individuals, particularly the poor, elderly, and middle class, to have access to the health care system.

Cost Control↗

PubMed1992

Assessment of dental health state utilities.

The term "health state utility" implies the assigning of a numerical value to a state of health. Assessment of the success of health care procedures, using health state utilities, enables evaluation of available treatments and procedures in terms of differing health outcomes and therefore facilitates cost-benefit analyses. Although measurement of general health state utilities has become increasingly common in medicine using a variety of techniques, few attempts have as yet been made in dentistry to place valuations on different dental health states. The absence of tried and tested methods for measuring tooth quality make the benefits gained from preventive and restorative dental programmes difficult to quantify. The aim of this study was to assess the average utility values, held by a group of dentists and a group of members of the general public, for four different tooth states which it was hypothesised would have different values. These were 1) a decayed and painful posterior tooth; 2) a decayed and non-painful posterior tooth; 3) a posterior tooth which had been restored and would need further restorative treatment and 4) a permanently restored posterior tooth. A standard gamble questionnaire was used to elicit the utility values which were then substituted as "weightings" in a modified version of the "T-health" index (1). The results show that it is possible to assess dental health state utility values using the standard gamble method and that the average utility values of the dentists in the study were consistently higher than those of the general public.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed2006

Effect of a dementia care management intervention on primary care provider knowledge, attitudes, and perceptions of quality of care.

OBJECTIVES: To evaluate the effect of a multicomponent dementia care management program on primary care provider knowledge, attitudes, and perceptions of quality of dementia care. DESIGN: A clinic-level randomized, controlled trial of a comprehensive care management program for patients with dementia and their nonprofessional caregivers. The program included provider education and protocols for care managers to communicate with patients' medical providers. SETTING: Eighteen clinics (nine intervention, nine [corrected] usual care) in three healthcare systems in San Diego, California. PARTICIPANTS: Two hundred thirty-two medical providers; 129 from nine [corrected] intervention clinics; 103 from nine [corrected] usual-care clinics. MEASUREMENTS: Providers were surveyed 9 months after intervention onset on knowledge (five items on four topics), attitudes about dementia (three items), and perception of quality of dementia care in their practice setting (three items). Multivariable linear and logistic regression models were used to evaluate the differences between intervention and usual-care providers, adjusting for covariate effects across groups and clustering by clinic. RESULTS: One hundred sixty-six of 232 (72%) providers responded. Intervention providers had better knowledge about assessing decision-making capacity than usual-care providers (adjusted difference in percentage correct = 12%; adjusted odds ratio = 2.4, 95% confidence interval = 1.2-4.8). Intervention providers viewed dementia patients as more difficult to manage in primary care than usual-care providers (P = .03). There were no other differences in knowledge, attitudes, or care quality perceptions across intervention and usual-care providers. CONCLUSION: A comprehensive dementia care management model resulted in few differences in provider knowledge or attitudes favorable to dementia care, suggesting that this care model's effects on quality were primarily mediated through other components of the care management program.

Aged↗

PubMed2026

Examining gaps in institutional policies for clinical genomic data sharing: A cross-jurisdictional study.

The sharing of data generated by clinical genetic and genomic testing without explicit consent is important for timely diagnosis and treatment. While many jurisdictions permit the sharing of identifiable data for direct clinical care, institutional policies vary in how clearly they specify key elements, including when sharing is permitted, what data are covered, and what safeguards apply. Greater clarity around these elements may support responsible data sharing while balancing timely care with transparency and appropriate protections. We conducted a mixed-methods content analysis of data-sharing and privacy policies from 33 clinical genomic institutions across 17 countries and regions. Using a predefined analytical framework, we assessed how policies document key governance elements relevant to sharing without explicit consent. Two independent reviewers extracted information about clinical contexts, data types, justifications, and protections. Although 70% of institutions described circumstances permitting data sharing without explicit consent, most policies did not clearly define the scope or governance of such sharing. Policies also rarely distinguished clinical from research or secondary use and inconsistently specified privacy and security safeguards. While sharing was commonly justified for clinical care (78.3%) or testing services (43.5%), data recipient roles and onward-sharing expectations were often left undefined. This uneven documentation could make it difficult for clinical teams and institutional decision-makers to identify and justify decisions about what is permitted and under what conditions. A guidance framework specifying core governance elements and corresponding protections could help institutions communicate their governance choices more clearly and support comparable baseline practices for responsible data sharing.

Information Dissemination↗

PubMed2002

Serial assessment of mortality in the neonatal intensive care unit by algorithm and intuition: certainty, uncertainty, and informed consent.

OBJECTIVES: Does predictive power for outcomes of neonatal intensive care unit (NICU) patients get better with time? Or does it get worse? We determined the predictive power of Score for Neonatal Acute Physiology (SNAP) scores and clinical intuitions as a function of day of life (DOL) for newborn infants admitted to our NICU. METHODS: We identified 369 infants admitted to our NICU during 1996-1997 who required mechanical ventilation. We calculated SNAP scores on DOL 1, 3, 4, 5, 7, 10, 14, 21, 28, and weekly thereafter until either death or extubation. We also asked nurses, residents, fellows, and attendings on each day of mechanical ventilation: "Do you think this child is going to live to go home to their family, or die before hospital discharge?" RESULTS: Two thousand twenty-eight SNAP scores were calculated for 285 infants. On DOL 1, SNAP for nonsurvivors (24 +/- 8.7 [standard deviation]) was significantly higher than SNAP for survivors (13 +/- 6.1). However, this difference diminished steadily and by DOL 10 was no longer statistically significant (12.7 +/- 4.9 vs 10.0 +/- 4.8). On each NICU day, at all ranges of SNAP scores, there were at least as many infants who would ultimately survive as would die. Consequently, the positive predictive value of any SNAP value for subsequent mortality was <0.5 on all NICU days. Prediction profiles were obtained for 230 ventilated infants reflecting over 11 000 intuitions obtained on 2867 patient days. One hundred fifty-seven (81%) of 192 survivor profiles displayed consistent accurate prediction profiles-at least 90% of their NICU ventilation days were characterized by 100% prediction of survival. Twenty-five (13%) of 192 surviving infants survived somewhat unexpectedly; that is, after at least 1 day characterized by at least 1 estimate of "death." Thirty-three (60%) of the 55 nonsurvivors died before DOL 10. Eighty-two percent of the prediction profiles for these early dying infants were homogeneous, dismal, and accurate. Twenty-two (40%) of the 55 nonsurvivors died after DOL 10. Seventeen (78%) of these 22 late-dying infants were predicted to live by many observers on many hospital days. Sixty-one (30%) of 230 profiled patients had at least 1 NICU day characterized by at least 1 prediction of death; 26/61 (43%) of these patients were incorrectly predicted; that is, they survived. Seventeen infants who were predicted to die during but survived nonetheless were assessed neurologically at 1 year. Fourteen (82%) of these 17 were not neurologically normal-8 were clearly abnormal, 1 suspicious, and 5 had died. CONCLUSIONS: If absolute certainty about mortality is the only criterion that can justify a decision to withhold or withdraw life-sustaining treatment in the NICU, these data would make such decisions difficult on the first day of life, and increasingly problematic thereafter. However, if we acknowledge that medicine is inevitably an inexact science and that clinical predictions can never be perfect, we can ask the more interesting question of whether good but less-than-perfect predictions of imprecise but ethically relevant clinical outcomes can still be useful. We think that they can-and that they must.

Age Factors↗

PubMed2006

When do tissues and cells become products? Regulatory oversight of emerging biological therapies.

Although therapeutics derived from biological sources have been subjected to regulatory oversight for some time, the products used in transplantation procedures have historically been exempt from this oversight. These products have been viewed as being part of medical practice rather than as the result of mainstream pharmaceutical manufacture. Furthermore, their unique source makes them difficult to assess in traditional regulatory systems based on the tenets of pharmaceutical quality control. With the increasing use of transplantation therapies to both replace dysfunctional organs and to influence genetic and metabolic processes, public health concerns on these therapies have increased. In addition, it is recognized that therapeutic claims for some of these interventions need to be properly assessed. These considerations have led the established regulatory agencies of the developed world to develop new regulatory paradigms for the products of transplantation practice. While a number of concerns have driven these developments, the minimization of infectious disease risk remains the paramount driver for introducing these regulatory systems. More than the regulation of medicines and medical devices manufactured in traditional pharmaceutical modes, the regulation of cell and tissue products is intimately linked to areas of public health policy and funding. This places regulators in a challenging position as they attempt to reconcile their roles as independent assessors with the needs of the overall public health framework. This is particularly difficult when considering measures which may affect access to life saving therapies. Regulators have recognized the need to assess these therapies through systems which incorporate consideration of risk-benefit ratios and include mechanisms for transparent and accountable release of products when full compliance to traditional concepts of manufacturing practice is not possible.

Biological Therapy↗

PubMed1995

Contemporary quality management in mental health.

Contemporary approaches to quality management in mental health utilize methods derived from traditional quality assurance and industrial quality improvement. Quality assurance involves the use of measurable indicators to monitor and evaluate care. Sentinel event indicators refer to high risk events that require review each time they occur. Rate indicators refer to events that are reviewed in the context of trends and patterns. The process of choosing and developing indicators should involve identification of the indicator topic, the monitoring objectives, data collection mechanisms, and responsible staff. As well, indicator data must be evaluated, actions taken, and communication of results must occur. Positive results, like positive diagnostic findings, point to a probability of the presence of a quality related issue. Quality improvement methods have led to a further evolution of efforts to promote quality care. A major goal of quality management is to utilize data to improve clinical decisions. Reaching this important goal is difficult in mental health due to the uncertain relationship between interventions and outcomes of care. In the effort described,, interventions were initiated to improve decisions relating to clinical risk management and resource utilization. Administrative restructuring enabled real-time review procedures and retrospective data analysis focused on decisions related to clinical instability and on permissive and restrictive clinical decisions. Permissive decisions were defined as decisions to allow off-ward privileges for patients whose level of functioning scores suggested the need for greater restriction. Restrictive decisions involved extending hospitalization of low risk patients. Inappropriate permissive or restrictive decisions are undesirable from both risk management and quality-of-care perspectives.(ABSTRACT TRUNCATED AT 250 WORDS)

Decision Making↗

PubMed1990

Dissemination of research findings: who wants what?

There is growing concern to ensure that the results of health services research reach, and are understood by, those who plan and provide health services. Because of the complexity and variability of services, it is often difficult to translate findings from one setting to another. This paper discusses an attempt to disseminate the findings of one study, Patterns and Pathways of Care of Old People, by visiting local health services on request. The main conclusion is that, for a qualitative study such as this, considerable effort is needed to predetermine which relevant research aspects and local people to bring together to make the exercise useful to either party. If dissemination of National Health Service (NHS) funded research is to be promoted, a central issue to be addressed is who is responsible for initiating and funding this stage. The paper raises a number of options.

Aged↗

PubMed2006

Experiences and demands of families with mentally ill people at home in Botswana.

PURPOSE: To describe the experiences and demands of families who care for their mentally ill relatives at home in Botswana. DESIGN: Grounded theory design with triangulated data sources. METHODS: A convenience sample was drawn from both urban and rural areas and composed of both men and women. Data-collection methods included in-depth interviews, focus group discussions and field observations. Data were collected using an interview protocol in the local language. Interviews were audiotaped, transcribed, and translated into English. Analysis was done by open and axial coding and grouping like data together to generate core categories, using the constant comparison method. FINDINGS: The interview data revealed a myriad of experiences and problems that families encountered in providing care to their relatives. The situation was perceived as difficult and burdensome because of lack of control and inadequate resources. The complexity of the situation required negotiation between the family members, their ill relatives, and health professionals. CONCLUSIONS: This study indicated some of the difficulties caregivers encounter and the coping mechanisms they use to deal with the day-to-day care of their ill relatives. Community resources are needed to assist families to effectively care for their relatives.

Adaptation, Psychological↗

PubMed2002

Ethics in perioperative practice--duty to foster an ethical environment.

Though often difficult, ethical decision making is necessary when caring for surgical patients. Perioperative nurses have to recognize ethical dilemmas and be prepared to take action based on the ethical code outlined in the American Nurses Association's (ANA's) Code of Ethics for Nurses with Interpretive Statements. In this sixth of a nine-part series that will help perioperative nurses relate the ANA code to their own area of practice, the author looks at the sixth statement, which emphasizes the nurse's duty to promote a working environment that enhances quality patient care and fosters the values and behaviors that form the foundation of ethical practice.

American Nurses' Association↗

PubMed2001

Strategies for promoting equity: experience with community financing in three African countries.

Although the need for a pro-poor health reform agenda in low and middle income countries is increasingly clear, implementing such policy change is always difficult. This paper seeks to contribute to thinking about how to take forward such an agenda by reflection on the community financing activities of the UNICEF/WHO Bamako Initiative. It presents findings from a three-country study, undertaken in Benin, Kenya and Zambia in 1994/95, which was initiated in order to better understand the nature of the equity impact of community financing activities as well as the factors underlying this impact. The sustained relative affordability gains achieved in Benin emphasise the importance of ensuring that financing change is used as a policy lever for strengthening health service management in support of quality of care improvements. All countries, however, failed in protecting the most poor from the burden of payment, benefiting this group preferentially and ensuring that their views were heard in decision-making. Tackling these problems requires, amongst other things, an appropriate balance between central and local-level decision-making as well as the creation of local decision-making structures which have representation from civil society groups that can voice the needs of the most poor. Leadership, strategy and tactics are also always important in securing any kind of equity gain-such as establishing equity goals to drive implementation. In the experiences examined, the dominance of the goal of financial sustainability contributed to their equity failures. Further research is required to understand what equity goals communities themselves would prefer to guide financing policy.

Benin↗