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Future plans for quality assurance in radiation oncology in the United States.

The Patterns of Care Study (PCS) is conducting continuing surveys in key disease sites that will monitor changes in processes and outcome of care from 1973 to 1985. The PCS will conduct a process survey in 1984 that will provide the baseline data for the quality assessment survey program available to individual facilities in the United States in 1985. This program will be conducted through the American College of Radiology and operated by the joint ACR-ASTR Quality Assessment Committee which includes representatives from the American Association of Physicists in Medicine. It will be a voluntary program that will be paid for by the facility requesting assessment. The feedback will be confidential and constructed in a manner as to maximally help the facility recognize areas where improvements can be made. We are continuing to work with licensing accrediting groups such as the Joint Commission on Accreditation of Hospitals (JCAH) and the American College of Surgeons' cancer accreditation program to advise them of the service we will be providing, and to obtain their recognition and recommendation of this service. This program will provide a means of meaningful quality assessment for the individual facility, and the opportunity for each facility to improve the quality of their care. In addition, through these surveys we will continue to monitor changes in the national benchmarks for processes and outcomes of care of key disease sites in which radiation therapy plays an important interventional role.

Female

Mammography quality assurance programs.

A quality assurance program is an integral part of a department of radiology, but certain examinations require a more specialized approach than others. The need for greater quality control in mammography was recognized by the American College of Radiology in 1987. The voluntary program developed by this organization has greatly improved the overall quality of mammography in almost three fourths of the facilities in this country. The principles of this initiative now have been adopted by various state and federal agencies, but a uniform approach has not yet been finalized. Optimally, the best aspects of all of these programs will be integrated, resulting in satisfactory image quality, acceptable dosimetry, and an appropriate level of interpretive accuracy in all mammography installations.

Accreditation

The impaired physician, Part II: Missouri State Physicians Health Program.

Missouri Physicians Health Program (MPHP) was established to help impaired physicians return to healthy personal and professional lives. One percent of Missouri physicians will suffer some sort of impairment; ie: substance abuse, or dependency of drugs or alcohol within a year. This is a confidential voluntary program. This program of early referral, intervention, treatment and monitoring advocacy has been highly successful. The average recovery rate in this study of 75 participants was 92%.

Female

Who comes to a voluntary depression screening program?

OBJECTIVE: The purpose of this study was to describe who comes to a voluntary depression screening program by analyzing findings from the 1992 National Depression Screening Day. METHOD: Survey results from 5,367 adult volunteers at 345 facilities were analyzed. The authors examined the prevalence of depression detected at the screening test and sociodemographic characteristics and treatment history of the respondents. They also estimated the percentage of these individuals who would actually have a diagnosis of major depression (positive predictive value). The main assessment measure was the Zung Self-Rating Depression Scale. RESULTS: Of all participants, 76.6% (N = 4,109) had at least minimal depressive symptoms (score of at least 50 on the Zung depression scale), 53.3% (N = 2,859) had at least moderate symptoms (score of at least 60), and 22.6% (N = 1,214) had severe symptoms (score of at least 70). Few of the depressed respondents were currently in treatment for a mental health problem. The positive predictive value of a screening test diagnosis of depression was between 92.5% and 95.5% when a cutoff score of 60 was used to indicate depression and between 88.7% and 92.3% when a cutoff score of 50 was used. CONCLUSIONS: Voluntary screening tests, as exemplified by results from the National Depression Screening Day, provide a good opportunity for identifying previously unidentified and untreated individuals with depression.

Adolescent

Feasibility study for neonatal neuroblastoma screening in the United States.

Urine was obtained from infants born at two large metropolitan Minneapolis/St. Paul, Minnesota hospitals to determine whether normal levels of urinary catecholamine metabolites in neonates can be used for subsequent neuroblastoma screening as well as to determine compliance with collecting such urine in a voluntary program. The results suggest that there are wide variations in raw values of urinary creatinine, homovanillic acid, and vanillylmandelic acid through the first 4 days of age, apparently because of maternal creatinine and catecholamine metabolite influences. Such maternal influences appear negligible by 3 weeks of age. Furthermore, the study suggests that voluntary compliance in the United States with collecting urine at home without rigorous public education and/or methods for reminding parents may be very poor.

Biomarkers, Tumor

The current status of screening for uterine cancer.

The screening program for cervix cancer in the Province of British Columbia appears to have reached a stable state. It has achieved a reduction in incidence of clinical squamous carcinoma in women over 20 of about 75% and reduction in mortality of about two thirds. Data has been presented to suggest that no further improvement in these rates should be forthcoming in a voluntary program such as ours. There has been a real increase in the numbers of in situ carcinomas found in our population but despite this increase clinical invasive carcinoma has not risen and we attribute this to the success of the program in intercepting disease before it becomes invasive. Endometrial carcinoma has not increased in our population and we do not feel that the current methods for early detection of this disease are applicable to a province-wide study. We intend to continue to emphasize the earliest possible investigation of abnormal peri- and postmenopausal bleeding by fractional curettage, as our mainstay of detection.

Adult

Improved perinatal knowledge in community hospitals through a self-instructional program.

The Perinatal Continuing Education Program (PCEP) was conducted throughout South Carolina. The program was well received and greatly valued; however, participants requested more information covering obstetrics. To meet this need, we developed the Perinatal Education Program for Community Hospitals (PEPCH), patterned after and similar to PCEP, and tested it in South Carolina and southern California. In the South Carolina trial, the posttest was found reliable (Kuder-Richardson index = .77). In the California trial, the pretest/posttest reliability was confirmed. Learning for nurses was documented (pretest = 30.8 +/- 5.3, posttest = 36.8 +/- 5.5, P less than .001). Completion rate for this voluntary program was 84%. We conclude that a self-study program based in the community hospital can improve knowledge of perinatal professionals.

California

Measurement of physicians' performance using existing techniques.

Existing techniques permit objective and valid measurement of limited elements of physicians' performance. These limited aspects, however, are of considerable importance to patients. The basic components of performance in medicine and surgery can be defined and used as the basis of organized programs for such evaluation. Interhospital comparisons can provide an effective impetus for assessing and improving performance of individual staff members when this is indicated. Professional auspices are needed for the development and application of methods that can provide continuing assurance that the clinical activity of physicians corresponds to contemporary standards.A system of incentives should be provided to physicians to promote their participation in voluntary programs of self-assessment. The incentives should be in the form of performance assessment credits, comparable in definition to continuing medical education credits, but granted for participation in an accredited program that objectively measures physicians' performance against national standards of the respective specialty.

Clinical Competence

Strength increases from the motor program: comparison of training with maximal voluntary and imagined muscle contractions.

1. This study addressed potential neural mechanisms of the strength increase that occur before muscle hypertrophy. In particular we examined whether such strength increases may result from training-induced changes in voluntary motor programs. We compared the maximal voluntary force production after a training program of repetitive maximal isometric muscle contractions with force output after a training program that did not involve repetitive activation of muscle; that is, after mental training. 2. Subjects trained their left hypothenar muscles for 4 wk, five sessions per week. One group produced repeated maximal isometric contractions of the abductor muscles of the fifth digit's metacarpophalangeal joint. A second group imagined producing these same, effortful isometric contractions. A third group did not train their fifth digit. Maximal abduction force, flexion/extension force and electrically evoked twitch force (abduction) of the fifth digit were measured along with maximal integrated electromyograms (EMG) of the hypothenar muscles from both hands before and after training. 3. Average abduction force of the left fifth digit increased 22% for the Imagining group and 30% for the Contraction group. The mean increase for the Control group was 3.7%. 4. The maximal abduction force of the right (untrained) fifth digit increased significantly in both the Imagining and Contraction groups after training (10 and 14%, respectively), but not in the Control group (2.3%). These results are consistent with previous studies of training effects on contralateral limbs. 5. The abduction twitch force evoked by supramaximal electrical stimulations of the ulnar nerve was unchanged in all three groups after training, consistent with an absence of muscle hypertrophy. The maximal force of the left great toe extensors for individual subjects remained unchanged after training, which argues against strength increases due to general increases in effort level. 6. Increases in abduction and flexion forces of the fifth digit were poorly correlated in subjects of both training groups. The fifth finger abduction force and the hypothenar integrated EMG increases were not well correlated in these subjects either. Together these results indicate that training-induced changes of synergist and antagonist muscle activation patterns may have contributed to force increases in some of the subjects. 7. Strength increases can be achieved without repeated muscle activation. These force gains appear to result from practice effects on central motor programming/planning. The results of these experiments add to existing evidence for the neural origin of strength increases that occur before muscle hypertrophy.

Adult

Initiation of a goal-directed movement in the monkey. Role of the cerebellar dentate nucleus.

The participation of the dentate nucleus (DN) in the initiation of a voluntary movement was investigated in five baboons (Papio papio). In these experiments, we have analyzed the effects of excluding the DN on the latency (reaction time, RT) of a learned goal-directed movement. Two techniques were for excluding the DN. In three animals, the structure was cooled with a probe, stereotaxically implanted on the side ipsilateral to the active hand. In two others, a partial electrolytic destruction of the DN ipsilateral to the operant hand was undertaken. In one further animal, both DNs were destroyed electrolytically. A comparison was made of the effect of DN inactivation on the latency of stereotyped goal-directed movements of constant amplitude and direction, and of goal-directed movements whose amplitude and/or direction were varied in random fashion. The exclusion of DN brought about a prolongation of RTs in all animals. This prolongation was not accentuated by variation of different characteristics (amplitude and/or direction) of the impending goal-directed movement. A recovery of the RTs to their prelesion values was observed after irreversible unilateral DN lesion, but no so easily after bilateral destruction. These results show that in the monkey DN is concerned with the initiation of a goal-directed movement, but is not critically implicated in the encoding of direction and amplitude parameters. These findings are discussed in view of the role that is usually attributed to the neocerebellum in programming voluntary movements.

Animals

Nonprofessionals in the rehabilitation of mentally disordered sex offenders.

Eighty-six sex offenders were exposed to a 6-month voluntary program of either group encounters (experimental group) or hobbies and games (control group) led by nonprofessionals. Pre- and posttests included a personality test, an introspective report, and a behavior rating scale. Written ward records were assessed as were the results of a postexperimental prisoner evaluation of the experience. Significant changes were evidenced by encounter subjects in improved feelings of approval of the prison-hospital experience, lessened hostility, and better attendance at the meetings. Encounter subjects were improved in the predicted direction on 55 of the 74 treatment dimensions. Community volunteers were judged moderately successful as lay therapists.

Adult

The Australian development of national quality indicators in health care.

BACKGROUND: The Australian Council on Healthcare Standards (ACHS) conducts a voluntary program of health facility accreditation modeled along the lines of the Joint Commission. To increase clinician involvement in the accreditation process and in quality assurance programs and to enable some assessment of the outcome of care in a facility at the time of survey, the ACHS, together with the medical colleges, is developing objective measures of care (clinical indicators). METHODS: Ten medical colleges are now involved in the program. The first set of measures, the Hospital-Wide Medical Indicators (HWMIs) developed in conjunction with the Royal Australian College of Medical Administrators, was formally introduced into the accreditation process in January 1993. These indicators were developed by a combined working party of the Care Evaluation Program and the Royal Australian College of Medical Administrators. The HWMIs address the areas of trauma, postoperative pulmonary embolism, readmissions to hospital, returns to the operating room, hospital-acquired infection, medication errors, and hospital throughout. CONCLUSION: It is hoped that the development of objective measures of care (clinical indicators) will facilitate the accreditation process. The development of these measures also enables Australian physicians to compare patient care throughout the hospital with national indicators of quality of care.

Accreditation

Client interests in premarital counseling: a further analysis.

A survey was conducted of over 150 college students concerning their attitudes toward premarital preparation. In general, the students valued brief, high-quality, low-cost, voluntary programs led by well-trained clergy or mental health professionals. However, females, students with more supportive family backgrounds, and religious students were more willing to participate in longer-than-average programs. Students with more supportive family backgrounds were also willing to pay more for such programs and to participate earlier in their relationship's development and were more willing to accept mandatory programs. Religious students were more interested in those led by clergy and less interested in those led by mental health or social workers. Female students were more interested in in-depth programs that focus on awareness and skill-building.

Adolescent

Standardization of image quality and radiation dose in mammography.

Image quality is the cornerstone to the practice of high-quality mammography. To ensure high quality in the practice of mammography, the American College of Radiology has established a voluntary program for the accreditation of mammographic screening sites. Between August 15, 1987, and February 1, 1989, 647 mammography units completed the accreditation program. Data collected from those units are presented, demonstrating that broad ranges of image quality and dose currently exist among mammographic screening sites. Reasons are discussed for the wide ranges observed, and steps are proposed to narrow the ranges of image quality and dose in the practice of mammography.

Accreditation

Voluntary public health insurance for low-income families: the decision to enroll.

A dominant issue in the health reform debate is whether insurance coverage should be voluntary or mandatory. Clearly, the factors that determine who will seek voluntary coverage are relevant to this policy issue. This article uses experience from Washington State's Basic Health Plan to examine the enrollment choices of low-income families in a state-subsidized voluntary insurance plan offered through managed care organizations. We hypothesize that the decision to enroll, which encompasses the decisions to purchase insurance coverage and to select a particular plan, is influenced by four factors: the family's financial vulnerability, their risk perception, the price of coverage, and the transition costs of enrolling. Our enrollment model is supported by the data and has important implications for the design of voluntary programs. Families who choose to enroll are more likely to have a female head of household, young children, and a family member who has a part-time job and some college education. Higher premiums and availability of other insurance coverage decrease the probability of enrolling.

Adult

Education for AIDS prevention: not our only voluntary weapon.

Authorities frequently state that education is the "only" method we have to stop the AIDS (acquired immunodeficiency syndrome) epidemic until a vaccine and/or curative therapy is available. We suggest that education, while critically important to our efforts to stop transmission of the human immunodeficiency virus (HIV), needs to be bolstered by additional voluntary approaches. Control of parenteral drug use, prevention of ulcerative sexually transmitted diseases, provision of expanded contraceptive services to seropositive reproductive age women, and reinforcement of risk-reduction behaviors through extended follow-up interventions are required as well. The support of these voluntary programs is a necessary complement to educational approaches which impact on HIV transmission and eventually on the AIDS epidemic.

Acquired Immunodeficiency Syndrome

Peer instruction of home glucose monitoring.

During a 2-wk summer camp for insulin-dependent children aged 9-15 yr, a voluntary program of home glucose monitoring using an Ames' Dextrometer was offered. The primary instructors were campers who had mastered the procedure and who, with limited staff assistance, tutored naive campers. By camp's end, 96% of all naive campers had practiced this new home glucose monitoring procedure. Procedural errors were infrequent and decreased as a function of practice. No significant differences were found in error rates as a function of either the age or sex of the user. The data suggest that home glucose monitoring could be incorporated into the treatment regimen of many young patients and that peer instruction is an effective method of introducing the procedure to young children.

Adolescent