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PubMed1999

Implementation of nuchal translucency image-scoring method during ongoing audit.

OBJECTIVE: The aim of this study was to evaluate the contribution of an ongoing audit, using the image-scoring method, to the quality of nuchal translucency images and to set the basic standards required from the examiners. DESIGN: Evaluation of nuchal translucency images, before, during and after the implementation of an ongoing audit, without knowledge of the time period or the examiner. SUBJECTS: A total of 315 nuchal translucency scans were performed by three examiners. METHODS: Each of the retrospective, intermediate and prospective time periods included blind scoring of 105 images. The effect of the ongoing audit was examined by comparing the distribution of the quality groups and the mean final score between the time periods, for all cases and for each examiner separately. Improvement of the criteria was assessed by comparing the rate of scans meeting the demands between the time periods. RESULTS: The quality of the images improved significantly as the mean final score changed from 4.62 +/- 0.21 to 6.19 +/- 0.19 and to 6.91 +/- 0.16 (p < 0.0001) and the rate of obtaining acceptable scans rose from 72% to 88% and to 92% (p < 0.001), respective to the three time periods. Whereas the three major criteria improved significantly before and after implementation of the audit (mid-sagittal section from 48% to 94%, caliper placement from 60% to 75% and skin line from 19% to 77%), the minor criteria remained unchanged (image size 90%, amnion demonstration 25% and head position 77%). The average scores of two examiners, for whom improvement was more pronounced, were used to determine the basic standards required from examiners subjected to the audit as follows: unacceptable, none; intermediate, 5%; reasonable, 65%; excellent, 30%; with a mean final score of 7.25. CONCLUSIONS: Implementation of an ongoing audit, using the image-scoring method, proved to be an efficient method for surveillance and improving the quality of nuchal translucency images. We recommended centers or individuals practicing first-trimester ultrasound screening to consider its routine utilization, in an unbiased and strict manner.

Analysis of Variance↗

PubMed2001

Patient reported quality of care before vs. after the implementation of a diagnosis related groups (DRG) classification and payment system in one Swedish county.

Patient reported quality of care before vs. after the implementation of a diagnosis related groups (DRG) classification and payment system in one Swedish county. The purpose was to evaluate the effects of a diagnosis related groups (DRG)-intervention on the quality of care as perceived by patients at two surgical clinics in the County Council of Gävleborg, Sweden. The study was planned as a nonequivalent control groups design, but external factors turned it into a prospective longitudinal design. Changes in patient experiences of received care were evaluated for the period 1992-1996. Of the 40 included consecutive patients per year from each hospital, > 85% completed the questionnaire. The selection of patients was defined by diagnoses and surgical treatments, and by geographical area. The results demonstrated a decrease of the quality of care as seen from the patient perspective, especially with respect to treatment by staff. Previously stated DRG goals were partially fulfilled and the DRG-intervention was gradually implemented. Other presumed causal variables were: other reforms, restrained resources, quality assurance activities, organizational and structural changes within the county council. Further studies of the effects of health care reforms would yield more distinct conclusions, provided it would be possible to evaluate interventions prior to full-scale implementation.

Adolescent↗

PubMedDate not supplied

Local implementation of clinical practice guidelines and continuous quality improvement: challenges and opportunities.

Implementing clinical practice guidelines (CPGs), disease management programs, and quality improvement projects requires an understanding of the trends that will facilitate adoption at the local level. These trends include consumerism and the building of a national information technology infrastructure. The recommendations of the Presidential Advisory Commission on Consumer Protection and Quality in the Health Care Industry and the Institute of Medicine (IOM) report entitled "To Err Is Human: Building a Safer Health System" will frame developments and implementation. The relative roles and responsibilities of national entities, with coordination and integration of these activities with local efforts will need to be carefully orchestrated. Utilizing the Web to connect dialysis facilities, patients, and members of the health care delivery team has the potential to reap large benefits. Utilizing information technology at the point of care and retrospectively to improve decision making by all parties has the real potential to improve patient outcomes. Implementation of what at a local level? And what do we mean when local level is referred to? This article addresses these two questions and provides a framework for the engagement of patients, physicians, and members of the health care delivery team and organizations, at both the local and national levels, in improving patient outcomes. All have their roles, rights, and responsibilities. We are challenged to provide the right treatment, to the right patient, at the right time. And importantly, to provide the right information, to the right person, at the right time.

Decision Support Systems, Clinical↗

PubMed2002

Disease management for chronic pain: barriers of program implementation with primary care physicians.

OBJECTIVE: This study investigated the implementation of a disease management (DM) program for chronic pain among primary care physicians. Its aim was the dissemination of guidelines for the treatment of chronic pain to help primary care physicians identify, treat, and manage patients highly impaired by pain. The goals of the program were: 1) To identify those pain patients who are at greatest disability due to pain; 2) To assess the impact of a DM program for pain on clinical practice; and 3) To evaluate the effect of the program on physician's use, compliance, and satisfaction with guidelines. METHODS: Thirty primary care physicians followed 82 patients who were identified as having chronic migraine headaches, back pain, or painful peripheral neuropathy. All patients were categorized according to their level of disability based on ratings of pain intensity, activity interference, emotional distress, perceived support, and work disability. Treatment algorithms developed for this study were placed in the charts of those patients considered to have moderate or high disability. Physicians completed pre- and poststudy questionnaires. RESULTS: Chronic pain patients could be successfully classified according to the disability from their pain and physicians were open to accepting guidelines for treatment. By the end of the study, primary care physicians reported improved confidence in treating chronic pain. Most felt that chronic pain management was a problem in their practice, and they recognized the benefit of treatment algorithms. Many of the physicians, however, expressed reluctance to regularly consult the algorithms when treating chronic pain. DISCUSSION: The identification of barriers for implementation of DM programs for pain is presented, and recommendations for future implementation are discussed.

Journal Article↗

PubMed2001

The reform of the Israeli health care system: a comparison between older and younger consumers, one year and three years after its implementation.

OBJECTIVE: One of the main objectives of the National Health Insurance Law, which was implemented in Israel in January 1995, was to increase equity among different population groups and improve services for weaker populations, such as older people. It is not clear, however, whether the law's goals are being achieved. This study aimed to examine changes in the satisfaction and perceived quality of healthcare services among older people one year and three years after enactment of the law, and to compare the satisfaction and perceptions of older people with those of young adults. DESIGN: Two cross-sectional telephone surveys conducted by the JDC-Brookdale Institute. SETTING: Israel. PARTICIPANTS: Two random samples of the adult residents of Israel at the end of 1995 and at the end of 1997. Two hundred and eighteen older people (of 1,116 respondents) were included in the first survey, and 198 older people (of 1,205 respondents) were included in the second survey. Sixty-seven percent of older respondents in both surveys were 65 to 74 years old and the remaining 33% were 75 years old and over. Forty-three percent were men. Sixty-four percent reported having had at least one chronic illness. There were no differences between the two samples, with the exception of a higher percentage of new immigrants in the second survey. MEASUREMENTS: Perception of changes in the level of services, satisfaction with services, and perceived quality of care (availability, accessibility, early detection procedures). RESULTS: Older people felt there had been an improvement in the level of sick fund (who operate as health maintenance organizations [HMOs] in the United States) services since implementation of the law. The proportion reporting improvement increased from 13% in 1995 to 28% in 1997. At the same time, the proportion of older people who sensed a decline in the level of services also increased, albeit at a much lower rate (4% in 1995 and 8% in 1997). The percentage of younger adults reporting an improvement in services and the percentage reporting a decline were greater than the percentages of older people, in both surveys. Regarding access to services, 69% waited up to 15 minutes to see their physician and 56% received an appointment to see a specialist within one week; this was an improvement. While a higher proportion of younger adults received an appointment within a shorter time span in 1995, the gap had diminished by 1997. Most of the older people felt that the office hours of their family physicians, specialists, administrative services, and laboratories were convenient. The proportion of elderly reporting so increased between 1995 and 1997, and in both surveys was higher than among younger adults. CONCLUSION: The study's findings show that older people perceived an improvement in a number of areas during the first three years of the law's implementation. Their experience was similar to that of younger adults and was even better in some areas. It is necessary to continue monitoring the impact of the law on the need for health services of vulnerable groups such as the chronically ill and disabled older people.

Adult↗

PubMed2002

Assessing the accuracy of three viral risk models in predicting the outcome of implementing HIV and HCV NAT donor screening in Australia and the implications for future HBV NAT.

BACKGROUND: Risk modeling is now the most practical method of estimating the residual risk of viral transmission in developed countries. One method of assessing the accuracy of a risk model is to measure the observed against the predicted outcome after implementing a new screening method. The primary objective of this paper is to assess the accuracy of three published models in predicting the impact of implementing HIV and HCV NAT in Australia. STUDY DESIGN AND METHODS: Viral screening data on Australian donors for 2000 and 2001 were retrospectively analyzed. The data were applied to the three models to estimate the risk of transmission and predicted NAT yield for HIV, HCV, and HBV. RESULTS: The median risk estimates for the three models were 1 in 3,415,000 for HIV NAT, 1 in 911,000 for HCV NAT, and 1 in 483,000 for HBsAg. The predicted NAT yield for the three models ranged from 0.17 to 0.30 per million donations for HIV, 1.20 to 5.55 for HCV, and 0.47 to 1.01 for HBV. The observed NAT yield was not significantly different from the expected yield with any of the three models for either HIV or HCV. CONCLUSIONS: First, the residual risk in Australian donors is small in comparison with other transfusion complications and comparable to or lower than the risk in US and European nonremunerated donors. Second, mathematical risk modeling has sufficient precision to be used as a predictive tool for risk-benefit assessments of novel screening procedures. Finally, in relation to the case for implementing HBV NAT and/or anti-HBc in Australia, we conclude that at present, there is inadequate information about our donor population to perform an evidence-based risk-benefit analysis.

Adult↗

PubMed2002

[Randomised controlled trials in mental health services research: practical problems of implementation].

This article outlines problems of implementation and clinical practice of randomised controlled trials in mental health services. Furthermore, it offers practical solutions taking into account the experiences with a randomisation process in a multi-site EC-funded (EDEN-) study on the evaluation of acute treatment in psychiatric day hospitals. Identification of the problems follows the time-course of a research project: 1. Problems to be solved prior to the study's commencement: Definition of the eligibility criteria, information of clinically working colleagues. 2. Problems referring to the process of randomisation: Influence of clinical experience of the research fellows, precise time-point of implementing the randomisation into the process of admission, assessment of the patient's ability to give informed consent, patient's refusal of randomisation but agreement to study participation, availability of treatment places. 3. Problems which might occur after randomisation: Early break-off of treatment, transfer from one treatment setting to another. General conclusion: Detailed definitions of the randomisation procedure do not guarantee high performance quality and randomisation rates. Continuous precise assessment of the implementation into the clinical routines of every study centre, adaptation according to specific conditions and personal discussions with all participants are obligatory to establish and maintain a high quality of this important research procedure.

Humans↗

PubMed1988

The care of elderly patients with hip fracture. Changes since implementation of the prospective payment system.

We hypothesized that the care provided to elderly patients with hip fracture in community hospitals has changed since the implementation of prospective payment systems (PPS) in 1983. We reviewed records of elderly patients admitted with hip fracture to a large community hospital from 1981 to 1986. During that period, the mean length of hospitalization decreased (from 21.9 to 12.6 days; P less than 0.0001), inpatient physical therapy decreased (from 7.6 to 6.3 sessions; P less than 0.04), and the maximal distance walked before discharge fell (from 27 to 11 m [93 to 38 ft]; P less than 0.0001). Concomitantly, the proportion of patients discharged to nursing homes rose (from 38 to 60 percent; P less than 0.0001), as did the proportion remaining in nursing homes one year after hospitalization (from 9 to 33 percent; P less than 0.0001). Neither in-hospital mortality nor one-year mortality changed significantly. As compared with beneficiaries of conventional Medicare after the implementation of PPS, HMO enrollees had shorter hospitalizations (7.3 vs. 14.0 days; P less than 0.0001), received less physical therapy (3.5 vs. 7.1 sessions; P less than 0.0001), walked shorter distances at discharge (3 vs. 13 m [11 vs. 44 ft]; P less than 0.01), and were more frequently transferred to nursing homes (83 vs. 55 percent; P less than 0.01). One year later, however, fewer HMO patients remained in nursing homes (16 vs. 35 percent; P less than 0.07). We conclude that since the implementation of PPS, hospitals have reduced the amount of care given to patients with hip fracture and have shifted much of the rehabilitation burden to nursing homes. The increase in the number of such patients remaining in nursing homes one year after the fracture suggests that the overall quality of care for these patients may have deteriorated.

Aged↗

PubMed2004

"Spectral implementation" for creating a labeled pseudo-pure state and the Bernstein-Vazirani algorithm in a four-qubit nuclear magnetic resonance quantum processor.

A quantum circuit is introduced to describe the preparation of a labeled pseudo-pure state by multiplet-component excitation scheme which has been experimentally implemented on a 4-qubit nuclear magnetic resonance quantum processor. Meanwhile, we theoretically analyze and numerically investigate the low-power selective single-pulse implementation of a controlled-rotation gate, which manifests its validity in our experiment. Based on the labeled pseudo-pure state prepared, a 3-qubit Bernstein-Vazirani algorithm has been experimentally demonstrated by spectral implementation. The "answers" of the computations are identified from the split peak positions in the spectra of the observer spin, which are equivalent to projective measurements required by the algorithms.

Journal Article↗

PubMed1999

Practical implementation of nonlinear time series methods: The TISEAN package.

We describe the implementation of methods of nonlinear time series analysis which are based on the paradigm of deterministic chaos. A variety of algorithms for data representation, prediction, noise reduction, dimension and Lyapunov estimation, and nonlinearity testing are discussed with particular emphasis on issues of implementation and choice of parameters. Computer programs that implement the resulting strategies are publicly available as the TISEAN software package. The use of each algorithm will be illustrated with a typical application. As to the theoretical background, we will essentially give pointers to the literature. (c) 1999 American Institute of Physics.

Journal Article↗

PubMed2004

Spectral implementation of some quantum algorithms by one- and two-dimensional nuclear magnetic resonance.

Quantum information processing has been effectively demonstrated on a small number of qubits by nuclear magnetic resonance. An important subroutine in any computing is the readout of the output. "Spectral implementation" originally suggested by Z. L. Madi, R. Bruschweiler, and R. R. Ernst [J. Chem. Phys. 109, 10603 (1999)], provides an elegant method of readout with the use of an extra "observer" qubit. At the end of computation, detection of the observer qubit provides the output via the multiplet structure of its spectrum. In spectral implementation by two-dimensional experiment the observer qubit retains the memory of input state during computation, thereby providing correlated information on input and output, in the same spectrum. Spectral implementation of Grover's search algorithm, approximate quantum counting, a modified version of Berstein-Vazirani problem, and Hogg's algorithm are demonstrated here in three- and four-qubit systems.

Journal Article↗

PubMed2006

New formulation and implementation for volume polarization in dielectric continuum theory.

In the use of dielectric continuum theory to model bulk solvation effects on the electronic structure and properties of a solute, volume polarization contributions due to quantum mechanical penetration of the solute charge density outside the cavity nominally enclosing it are known to be significant. This work provides a new formulation and implementation of methods for solution of the requisite Poisson equation. In previous formulations the determination of the surface polarization contribution required evaluation of the difficult to calculate electric field generated by the volume polarization. It is shown that this problematic quantity can be eliminated in favor of other more easily evaluated quantities. That formal advance also opens the way for a more efficient apparatus to be implemented for calculation of the direct contribution of volume polarization to the solvation energy. The new formulation and its practical implementation are described, and illustrative numerical results are given for several neutral and ionic solutes to study the convergence and precision in practice.

Journal Article↗

PubMed2005

Using a set of strategic indicator systems as a decision-making support implement for establishing a recycling-oriented society. A Taiwanese case study.

UNLABELLED: BACKGROUND, SCOPE AND AIMS: To realize the vision of sustainable development (SD) originating from the 'only one earth' philosophy, and to integrate the conceptions of ecology and sustainability into the planning and decision-making criteria of urban growth management, the establishment of a recycling-oriented society (ROS) is essential. However, before the above intention can be achieved, it is indispensable to develop a system of strategic indicators for supporting a radical reformation of the urban development plan. Therefore, this study, based on the conception of the new urban development pattern ROS, attempted to carefully choose a sample city in Taiwan for launching a preliminary case study, and furthermore designed and proposed a concise and strategy-oriented assessment indicator system termed ROSAIS. ROSAIS, on the one hand, can act as a compass for understanding resource using efficiency and recycling status during city development and, on the other hand, can serve as an implement supporting decision-making for ROS construction. METHODS: According to the definition and spirit of ROS, the structure of ROSAIS should clearly represent the relationship between resources and environment in human activities. The eco-efficiency indicator system (EEIS) and environmental symbiosis indicator system (ESIS) can be considered two key subindicator systems, and are the necessary components of ROSAIS. EEIS chooses the dominant production sectors in urban economic activities to calculate their eco-efficiency (EE). Separately, for obtaining a consensus regarding the framework of ESIS, the questionnaire approaches and expert consultation, together with the research experience and foundation of current relevant studies and indicator systems, are applied when crucial resource and environmental issues and respective indicators are selected. RESULTS AND DISCUSSION: The calculation results of EEIS in this case study indicated that among the three dominant production activities (agricultural, fishery, and animal husbandry sector) the fishery sector has the highest EE, which indicates that the fishery activities and resources significantly influence the sustainability of the economic-environmental system of the sample city. Furthermore, according to a consensus achieved in ESIS, local green spaces, resource recovery, energy consumption pattern change, freshwater conservation and greenhouse effect abatement were considered as the five crucial issues influencing how the case study city can develop into an ES-city. The rate of local green spaces, resource recycling, freshwater conservation and the rate of reduction of nonrenewable energy use as well as carbon dioxide (CO2) emissions were used to evaluate the above five issues. CONCLUSION: This case study is unparalleled in Taiwan. Even in Japan, where ROS legislation has been implemented, this kind of study remains in the preliminary stages. Furthermore, when communicating the indicator results, it is essential to provide the context and countermeasures of the crucial issues that are faced. The two sub-indicator systems proposed in this case study could comply completely with the above-mentioned requirements. For example, the EEIS provides information for achieving a balance between environmental burden and economic benefits among dominant production sectors; the ESIS provides information for setting strategies for overcoming the crucial issues faced. RECOMMENDATION AND OUTLOOK: This study recommends that urban planers should consider the construction of the corresponding strategic indicator system to be indispensable, and makes further use of the indicator results related to the environmental education of residents for identifying and promoting participation with ROS, and turning them into implements for supporting urban SD decision-making. Furthermore, a successful indicator system depends on data availability and quality. This study recommends that urban planers should pay considerable attention to constructing relevant data collection channels, databases and the data quality.

Cities↗

PubMed2000

Design and implementation of a controlled trial of pediatric endotracheal intubation in the out-of-hospital setting.

This article describes the design and implementation of the Pediatric Airway Management Project. The project was completed January 1, 1997, and evaluated the effectiveness of endotracheal intubation relative to bag-valve-mask ventilation in improving survival to hospital discharge and neurologic outcome in children, the effect of training on paramedic airway management skills and self-efficacy, the length of time the skills can be retained, and the costs of training and retraining. The main focus of project design was the implementation of a controlled trial comparing methods of airway management for acutely ill and injured pediatric patients in the out-of-hospital setting. To date, this project is the largest prospective, controlled, out-of-hospital study of the care of children ever reported. Barriers to implementation of a study of this size are described.

Airway Obstruction↗

PubMed2000

Association between implementation of CDC recommendations and ventilator-associated pneumonia at selected US hospitals.

BACKGROUND: To assess whether selected recommendations in the Centers for Disease Control and Prevention "Guideline for Prevention of Nosocomial Pneumonia" were being implemented and having an impact on the occurrence of ventilator-associated pneumonia (VAP) at US hospitals, we surveyed hospitals participating in the National Nosocomial Infections Surveillance (NNIS) system. METHODS: We mailed a questionnaire to the infection control practitioner of each NNIS hospital in 1995 and used data from the NNIS system to calculate annual rates of VAP. RESULTS: Of the 188 hospitals surveyed, 179 (95%) returned completed questionnaires. Of these, 175 (98%) had implemented the recommended change of mechanical-ventilator breathing circuits at 48-hour or greater intervals. Of 110 hospitals using the hygroscopic condenser-humidifiers or heat-moisture exchangers with ventilators, 102 (93%) changed the hygroscopic condenser-humidifiers or heat-moisture exchangers routinely, and of 98 hospitals using bubbling humidifiers, 96 (98%) used sterile water to fill these humidifiers. Other practices for which the guideline provides no recommendation and their frequency of use by NNIS hospitals include use of hygroscopic condenser-humidifiers or heat-moisture exchangers (110/179 [61%]) and use of bacterial filters in anesthesia machines (128/171 [61%]). There was a significant decrease in the VAP rate from 1987 to 1998. CONCLUSION: Most NNIS hospitals had implemented selected recommendations in the Centers for Disease Control and Prevention "Guideline for Prevention of Nosocomial Pneumonia" before the final publication of the revised guideline. Further studies are needed to assess the impact of these recommendations on the occurrence of VAP.

Anesthesiology↗

PubMed2002

The implementation of a surgical antibiotic prophylaxis program: the pivotal contribution of the hospital pharmacy.

BACKGROUND: Although surgical site infection rates have decreased with the prophylactic use of antibiotics, the inappropriateness of surgical antibiotic prophylaxis is still a worldwide problem. Various strategies have been used to address this problem. This study describes the implementation of a perioperative antibiotic prophylaxis protocol that emphasizes the contribution of the pharmacist. METHODS: A descriptive study design was used to evaluate the impact of the protocol on the appropriateness of prophylaxis in a private university hospital. The surgical antibiotic prophylaxis of all surgeries was evaluated for 1 month before and 1 month after the implementation of the protocol. RESULTS: The appropriateness of the indication for prophylaxis rose from 56.4% to 100% and that of the postoperative maintenance prophylactic antibiotics rose from 21.9% to 95.7%. The cost of the perioperative antibiotic prophylaxis per surgery decreased 40.5%. CONCLUSION: The implementation of a cost-effective perioperative antibiotic prophylaxis protocol was the result of a multidisciplinary effort. The hospital pharmacist participated in education activities as part of the discussion groups on the perioperative antibiotic prophylaxis protocol that involved all participants and in managerial actions that optimized the process of ordering, dispensing, administering, and documenting the perioperative antibiotic prophylaxis.

Adolescent↗

PubMed2003

Hospital health care worker (HCW) vaccination coverage after implementation of an HCW vaccination policy.

The purpose of this study was to assess knowledge, attitudes, practices, and self-reported vaccination status of HCWs at a tertiary Australian hospital, one year after implementation of a HCW vaccination policy. Two cross-sectional telephone surveys were conducted with HCWs at the hospital prior to and one year after HCW vaccination policy implementation. There was a 95% (272/287) response rate from eligible HCWs in the follow-up survey. Despite 96% (260/272) of HCWs indicating a willingness to update their vaccination status, only 24% (65/272) reported being fully vaccinated. Successful policy implementation requires adequate resource allocation and organisational commitment. Ongoing evaluation can inform the success of this process.

Cross-Sectional Studies↗

PubMed1998

Clinical trials and tribulations: implementation processes in schizophrenia research outcome.

This article focuses on an area in clinical drug trials for new antipsychotic medications for the treatment of schizophrenia which has not received sufficient attention in the literature: the day-to-day implementation tasks performed by research staff which have potential effects on study results. Implementation tasks are viewed as dynamic processes involving interactions among research and nonresearch staff, patients, families, and pharmaceutical company staff. Research-related demands and possible sources of stress for all participants in the process, such as recruiting and maintaining patients in studies, are discussed. Suggestions are offered for increasing the ease of participation. Further investigation is called for in several areas including variability in the effectiveness of research teams and in the rarely discussed interactions between site staff and pharmaceutical company personnel, as they may affect research outcomes. It is posited that increased knowledge about implementation processes in schizophrenia drug development is needed to more fully understand study results and to enhance patients' and their families' willingness to participate.

Antipsychotic Agents↗