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Attitude of Health Personnel↗
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Perinatal care in British Columbia: Diagnosis and management of hemolytic disease of the newborn.
We undertook to measure standards of perinatal care in British Columbia by studying the management of hemolytic disease of the newborn as the sample situation.Our data show that many isoimmunized pregnant women are delivered in hospitals that have infrequent experience with this problem, and by physicians who have little experience with this disease.The physician referral pattern, in regard to maternal isoimmunization, indicated that the more severely affected patients were managed by specialists, particularly those attached to teaching hospitals. However, 25% of the infants treated by exchange transfusion were managed by nonspecialists in nonteaching hospitals.Hospital record search, used as a method of medical audit and as a source of data for comparison with physician reports, did not result in dependable or complete information. Rates of disagreement between items from two data sources, physician report and hospital record, were frequently very high. Our experience suggests that comparison of these two data sources is not an ideal method of assessment of quality of care.A smaller caseload of isoimmunized pregnant women will result from the present prevention program. Nevertheless, cases will continue to occur. Our work supports the conclusion that a program of continuing education covering the diagnosis and management of hemolytic disease of the newborn is still necessary.
ABO Blood-Group System↗
Stimulus processing constraints in audition.
In 3 experiments, the authors tested performance in simple tone matching and classification tasks. Each tone was defined on location and frequency dimensions. In the first 2 experiments, participants completed a same-different matching task on the basis of one of these dimensions while attempting to ignore irrelevant variation in the other dimension. In Experiment 3, in which the tones were classified either by frequency or location, the authors explored intertrial repetition effects. The patterns of performance across these different tasks were remarkably similar and were taken to reveal basic characteristics of stimulus encoding processes. The data suggest a processing sequence in audition that reveals an early stage in which location and frequency are treated as being integral and a latter stage in which location and frequency are separable.
Adult↗
Audit of height measurement at age 3 years: results of a survey of Scottish health boards.
Height measurement at about the age of 3 years is accepted as a routine practice by all 15 Scottish health boards and is a recommendation of the Hall report Health for all Children. As part of a Scotland-wide project to assess the feasibility of audit of preschool surveillance programmes using routinely collected data, all boards were asked for information about this procedure. The results show that, while all boards confirmed its usefulness as a screening measure, only one board was realistically able to audit height measurement at this age at all stages using routinely available data. The whole screening process, including programme management, equipment validation, staff training and referral criteria, was examined using the quality standards defined in the Hall report. Results showed a wide variation between boards. For example, fewer than half of the boards provided guidelines for height measurement at age 3 to all professionals involved. The availability of even basic outcome data, such as numbers of children measured at this age was patchy, although this will improve with the introduction of the national computerised preschool surveillance system. Two boards have no plans to record such data routinely. In conclusion, before outcome data can be used and relied on, health boards and trusts need to develop local guidelines including quality standards such as age limits for measurement, programme management, provision of equipment, and review and referral criteria for inclusion into contracts.
Age Factors↗
An audit of drug prescribing practices of dentists.
OBJECTIVES: Data are scarce on the prescribing habits of dental practitioners. Drug use in dentistry and stomatology is undertaken to determine the pattern of drug use for patients seeking treatment. METHODS: 1820 prescriptions of dental patients attending the dental outpatient departments at Manipal Teaching Hospital, Nepal were collected by a random once weekly survey between March '01 to February '02. The information was compiled, scored and analyzed in consultation with dentists using WHO guidelines. RESULTS: Males numbered 801 (44%) and females 1019 (56%). Most of the patients were aged between 13-25 years. The dental disorders most frequently reported in our study were diseases of pulp and periapical tissue (36.5%), gingivitis and periodontal disease (28.5%), and dental caries (16%). The average number of drugs prescribed was 2.03 (3698 / 1820) and 66% prescriptions contained antimicrobials (1 or 2). 21% drugs were prescribed in generic names and 38% drugs were fixed dose combinations of 2 or more drugs. 4/5 of the prescribed drugs were systemic agents and 1/5 were local/topical agents. The most commonly prescribed systemic agents were analgesics (43.7%) followed by antimicrobials (39%). The most conmonly prescribed local / topical agents were anti-infectives (74%). In the present study, NSAID's (89.6%) were the preferred analgesics over narcotic analgesics (10.4%). The most frequently prescribed systemic analgesic and antimicrobials were ibuprofen and amoxycillin, respectively. CONCLUSIONS: This study may help in identifying the problems involved in therapeutic decision making. Also, there is a clear need for the development of prescribing guidelines and educational initiatives to encourage the rational and appropriate use of drugs in dentistry.
Adolescent↗
A model of practice for the management of velopharyngeal dysfunction.
This paper reviews normal speech production, the speech characteristics associated with velopharyngeal dysfunction, the investigations required and treatment options. A model of service delivery is proposed which has been in place over the past 4 years. This model highlights multidisciplinary management by a specialist team. An audit of the service has been undertaken. Of the 225 patients audited, some interesting findings are presented on aetiology, diagnosis and trends in management. Systematic and comprehensive collection of data on large numbers of patients permits meaningful audit of process and outcome.
Articulation Disorders↗
Quality assurance--guaranteeing a high level of care.
The quality assurance process in long-term care focuses on solving resident care problems and monitoring compliance with established standards of practice. An effective quality assurance monitoring system for long-term care includes the audit design steps of study design, criteria development, data retrieval, data interpretation, and definitive action. To assure that a clinical change in nursing practice results from quality assurance audit findings, it is imperative that organizational systems and structures be designed to disseminate these findings and follow through with identified courses of action. A formalized link between the quality assurance committee and nursing administration establishes the legitimate authority and accountability for follow-through to successfully integrate findings into actual practice.
Humans↗
An audit of upper gastrointestinal endoscopy in Australian facilities--results of a pilot study.
OBJECTIVE: To test the endoscopy audit protocol for larger prospective study. METHOD: Prospective medical audit. RESULTS: Sixty two endoscopies provided both patient data and suggestions for improvement in the protocol.
Adult↗
Clinical audit, related cycles and types of health care quality: a preliminary model.
This paper is drawn from a study carried out in England, funded by the Department of Health. The aims of the study were to explore clinical audit in the four health professions of clinical psychology, occupational therapy, physiotherapy and speech and language therapy and to develop a model of clinical audit and guidelines for use by practitioners and managers. The focus in this paper is the model development. Included are examples of audits relevant to different types of health care quality that illustrate the process of clinical audit using the model. The modelling process involved interrogating the clinical audit cycle and related cycles against the data and identifying their inter-connecting links. The model was refined and reformulated to include guidelines for the professions on what is needed to make clinical audit work. The position of the professional service manager is crucial. A mandate that includes creating machinery at provider unit level, mobilizing the principal working groups and promoting internalization of audit by practitioners, is essential for audit to be effective.
England↗
Emergency department access to a longitudinal medical record.
Our goal is to assess how clinical information from previous visits is used in the emergency department. We used detailed user audit logs to measure access to different data types. We found that clinician-authored notes and laboratory and radiology data were used most often (common data types were used up to 5% to 20% of the time). Data were accessed less than half the time (up to 20% to 50%) even when the user was alerted to the presence of data. Our access rate indicates that health information exchange projects should be conservative in estimating how often shared data will be used and the wide breadth of data accessed indicates that although a clinical summary is likely to be useful, an ideal solution will supply a broad variety of data.
Emergency Service, Hospital↗
[Acceptance and practicability of a guideline for rehabilitation in coronary artery disease].
BACKGROUND: Developed within the German Pension Insurance scheme's Guidelines programme, the Guideline for Rehabilitation in Coronary Artery Disease has been publicly available since January 2005. Pension Insurance routine data on the therapeutic benefits and services provided (based on the Classification of Therapeutic Procedures, KTL) were analyzed to assess the extent to which rehabilitation facilities had complied with Guideline requirements already in 2004. In January 2005, the results were disseminated together with the Guideline to the rehabilitation facilities which had participated in Pension Insurance rehabilitation of patients with coronary artery disease in 2004. In an accompanying survey information was requested concerning acceptability and applicability of the Guideline, of the presentation of KTL data, as well as reasons for non-adherence to Guideline requirements. METHODS: In February 2005 a written, anonymous survey was conducted among 72 clinical directors of rehabilitation facilities. The survey instrument contained three standardized questionnaires covering the aspects cited above. The response rate was 73.6 % (n = 53). Descriptive analyses were performed. RESULTS: Views of the Guideline: The Guideline fulfils most of the seven quality attributes surveyed (completely fulfilled: 11.3-32.7 %, basically fulfilled: 49.1-64.2 %). Volume, structure and clarity of the guideline are judged to be "very good" by 62.3 %, 50.9 % and 36.5 % of the respondents. The KTL-procedure codes forming part of the Guideline to be used to assess guideline adherence, were considered appropriate by 88.5 % to 98 %. Consent to Guideline requirements varies between 80.8 and 34.6 %. Views of the audit feedback based on KTL-data: Depending on the various data table types, 37.7 % to 20.0 % of the respondents stated that the tables should remain unchanged in future evaluations. 28.0 % to 39.0 % consider the tables to be very useful for quality management. Reasons for non-adherence to Guideline recommendations: according to the clinicians, the most important reason for deviation from Guideline requirements is incomplete or incorrect coding of therapeutic procedures. DISCUSSION: The Guideline for Rehabilitation in Coronary Artery Disease basically fulfils the formal, methodological and content-related quality criteria considered to be most relevant by the clinical directors. As expected, the greatest need for discussion is focussed on the actual Guideline requirements. Form and content of the KTL-feedback are well accepted, and the feedback itself is considered relevant for everyday practice. The main reason given for non-adherence to guideline requirements (i. e., inaccurate coding) should not be overstated as the KTL-analyses was based on data from 2004, when the guideline had not yet been published. CONCLUSION: The Guideline for Rehabilitation in Coronary Artery Disease is acceptable and practicable, and it is moreover tied in with external quality assurance activities in place (i. e., the quality assurance programme of the statutory Pension Insurance scheme). The audit feedback given in this framework provides rehabilitation facilities participating in the programme not only with comparative analyses but also with input for their internal quality management actions. Future activities within the external quality assurance programme should inter alia focus on more targeted implementation activities and repeated KTL-based appraisals.
Attitude of Health Personnel↗
[Audit procedure of radiology reports in a hospital service].
PURPOSE: Presentation of a clinical audit of the radiology reports in our institution. MATERIAL: and methods: This audit has been performed in several steps: launching the project, elaboration of the reference book, elaboration of the protocol, analysis of the results, improvements made. RESULTS: Several dysfunctions were detected: typing errors, the lack of sentences explaining the procedure of examination, the lack of negative pertinent elements, the lack of synthesis. Several interventions were made: checking on the screen of the computer the report before signing it, purchase of personal voice recorders, restructuring the interpretation room. Other interventions are considered: structured data entry, P.A.C.S. systems CONCLUSION: This audit has allowed the modification of the process for realisation of the radiology reports and the stimulation of the medical team, thus improving the quality of our work.
Clinical Protocols↗
Spending on medicines in Israel in an international context.
BACKGROUND: Like most developed countries, in the last decade Israel's healthcare system has been subject to cost-containing measures in the drug sector. OBJECTIVES: To provide comparative information in an international context on the level of outpatient drug expenditures in Israel, both total and those publicly financed, and to analyze how these have changed with time during the last decade. METHODS: Using definitions of the OECD (Organization of Economic Cooperation and Development), internationally comparable data on total expenditure and public expenditure on medicines in Israel are provided. The Israeli estimates are based on data from the Ministry of Health audited reports of financial activities of the health management organizations and from the family expenditure surveys carried out by the Central Bureau of Statistics. Per capita total and public expenditures in Israel are analyzed over time, as are their share of national expenditure on health and of gross domestic product. Israel expenditures are then compared with those for individual member countries of the OECD, as well as a 21 country average, from 1992 to 2002. RESULTS: Analysis of the Israeli expenditure data shows a considerable reduction in growth of per capita total and public expenditures on medicines since 1997. Growth in the share of total drug expenditure of NEH and of GDP has also been constrained since 1997. In an international context, per capita expenditure on medicines in Israel, particularly what is publicly financed, is one of the lowest. Furthermore, its share of NEH and GDP is also very low compared to other countries. This substantive gap in spending on medicines between Israel and other countries has increased since 1997. CONCLUSIONS: Israel, a medium-income country with a lower than average level of expenditure on health compared to OECD countries, has a particularly low level of expenditure on medicines. Whereas the share of health expenditure of GDP in Israel is similar to the international average, the share of drug expenditure of GDP is well below the average. In addition to structural and longer-term factors contributing to Israel's low per capita spending on medicines, such as the young population and the apparently low level of actual prices paid by most institutional purchasers, recent years are witness to the growing impact of National Health Insurance budgetary pressures on HMOs as well as continual increases in prescription cost sharing by patients. The impact is felt both on the demand side (higher copayments, administrative and prescribing restrictions) and perhaps more crucially on the supply side (price competition, mainly from generics). Substantial extra public funding for the addition of new drugs to the NHI basket in recent years has had no overall impact on these longer-term spending patterns.
Developed Countries↗
National survey of radiotherapy fractionation practice in 2003.
AIMS: To document UK practice in radiotherapy fractionation. METHODS: All radiotherapy centres in the UK participated in a 1-week audit from 29 September 2003. Fractionation data were collected for all patients starting external beam radiotherapy. This included 2498 patients who were prescribed 32 547 fractions. RESULTS: For the radical treatment of non-skin malignancy (n = 708), the prescribed dose ranged from a single fraction of 8 Gy for total-body irradiation to 75 Gy in 43 fractions for prostate cancer. Postoperative treatment for breast cancer was dominated by three regimens: 40 Gy in 15 fractions; 45 Gy in 20 fractions; and 50 Gy in 25 fractions. Palliative treatment was given in a single fraction to 393 patients (36%) with doses of up to 15 Gy. Three hundred and ninety patients (36%) received four to seven fractions delivering 20-25 Gy. Only 89 patients (8%) received more than 10 fractions with palliative intent but used 29% of such fractions. In the treatment of bone metastases, the most common prescriptions were 8-10 Gy in a single fraction and 20 Gy in five fractions. CONCLUSION: UK radiotherapy practice has become more uniform and moved closer to practice in North America and Europe over the past 15 years. For radical radiotherapy, 54% of prescriptions were for a fraction size of 1.8-2.0 Gy but the distribution was bi-modal and 20% of patients were prescribed fraction sizes of 2.7-3.0 Gy. Evidence-based practice now supports hypo-fractionated palliative treatment favouring single fractions for bone metastases and one or two fractions for many patients with advanced lung cancer. Two fractions are advised for some patients with brain metastasis. If these guidelines had been applied uniformly, then the number of treatments prescribed for palliation could have fallen by 36% from 5197 to 3313. This would have represented a 6% reduction in the overall radiotherapy workload. Not all patients are suitable for such hypo-fractionated treatments, but this is an area in which resource use can be improved. In the postoperative management of breast cancer, a change in practice to use 15 fractions uniformly would reduce overall radiotherapy workload by 4%. By contrast, a change to 25 fractions would increase overall workload by 7%.
Data Collection↗
No magic bullets: a systematic review of 102 trials of interventions to improve professional practice.
OBJECTIVE: To determine the effectiveness of different types of interventions in improving health professional performance and health outcomes. DATA SOURCES: MEDLINE, SCISEARCH, CINAHL and the Research and Development Resource Base in CME were searched for trials of educational interventions in the health care professions published between 1970 and 1993 inclusive. STUDY SELECTION: Studies were selected if they provided objective measurements of health professional performance or health outcomes and employed random or quasi-random allocation methods in their study designs to assign individual subjects or groups. Interventions included such activities as conferences, outreach visits, the use of local opinion leaders, audit and feedback, and reminder systems. DATA EXTRACTION: Details extracted from the studies included the study design; the unit of allocation (e.g., patient, provider, practice, hospital); the characteristics of the targeted health care professionals, educational interventions and patients (when appropriate); and the main outcome measure. DATA SYNTHESIS: The inclusion criteria were met by 102 trials. Areas of behaviour change included general patient management, preventive services, prescribing practices, treatment of specific conditions such as hypertension or diabetes, and diagnostic service or hospital utilization. Dissemination-only strategies, such as conferences or the mailing of unsolicited materials, demonstrated little or no changes in health professional behaviour or health outcome when used alone. More complex interventions, such as the use of outreach visits or local opinion leaders, ranged from ineffective to highly effective but were most often moderately effective (resulting in reductions of 20% to 50% in the incidence of inappropriate performance). CONCLUSION: There are no "magic bullets" for improving the quality of health care, but there are a wide range of interventions available that, if used appropriately, could lead to important improvements in professional practice and patient outcomes.
Humans↗
Effect of a community health center intervention on breast cancer screening among Hispanic American women.
OBJECTIVE: A multiple component intervention in a community health center is presented, and its effect on breast cancer screening participation by Hispanic American women between the ages of 45 and 75 years is discussed. DATA SOURCES/STUDY SETTING: In 1990, data were collected through a retrospective audit (at least as far back as 1987) of community health center medical records, as well as from a client referral log. The health center, located in a small Massachusetts city, primarily serves clients of Latino heritage. STUDY DESIGN: The study used a nonexperimental pretest-posttest intervention design to document clients' screening activities. To control for uneven length of enrollment, aging of the population, and sporadic utilization, the unit of analysis chosen for the principle study variables was an "eligible year." DATA COLLECTION: Variables of interest included screening (clinical breast exam and mammography), periodicity of screening, and compliance with referrals. PRINCIPAL FINDINGS: Postintervention, considerably greater screening mammography occurred among all age groups, more women had at least one screening mammogram during the period, more clinical breast exams included a mammogram referral, and the compliance rate improved. The rate of clinical breast exam did not significantly improve, showing a downward trend.
Age Factors↗
Audit of reflux oesophagitis at 4 years.
BACKGROUND: Data on the natural history of reflux oesophagitis are few and conflicting: it is not clear whether in the long-term, patients still require therapy for controlling symptoms and preventing endoscopic relapse. AIMS: To assess, in reflux oesophagitis patients followed up for a median period of 4 years: a) clinical conditions throughout follow-up period (i.e., frequency of relapses, need and type of treatment, satisfaction with therapy; b) present state, including quality of life, mode of treatment, presence of residual symptoms or invalidity. PATIENTS: A series of 288 consecutive outpatients, diagnosed as having reflux oesophagitis during the period 1986-1990, and followed up for at least 48 months. METHODS: The study was carried out in two parts. The first, retrospective, assessing the outcome throughout follow-up during which it was suggested that patients assume a maintenance therapy with H2-receptor antagonists, proton pump inhibitors or other drugs for the first year, and to continue only if desired. Patients returned for follow-up every six months, and endoscopy was repeated after the first year or in the case of symptom recurrence. In the second part, after a median follow-up of 4 years, patients were submitted to a telephone interview by means of a structured questionnaire, assessing type and severity of current symptoms (if any), type of current therapy, degree of satisfaction with treatment, and overall evaluation of quality of life. RESULTS: Data are available from 132 patients (M/F = 85/47) of whom 119 (90%) were still on treatment and 31% still presented symptoms. During follow-up, 21% had more than 3 endoscopic relapses, 23% between 2 and 3, 28% one, and 28% zero, respectively and 79% were still adopting non-pharmacological measures (diet, posture, etc.). Only two (1.5%) had been submitted to surgery to control untractable symptoms/mucosal lesions. Finally, 64% and 11%, respectively, considered the present quality of life as good or excellent. CONCLUSIONS: Contrary to many reports, the prognosis of reflux oesophagitis is not favourable showing a marked trend to chronicity; the disease leads to almost continuous drug assumption for symptom control, and is associated with a high relapse risk after treatment withdrawal. Despite (or due to) these unfavourable features, patient compliance to both pharmacological and non-pharmacological therapy is excellent and, correspondingly, also the quality of life is acceptable or improved.
Adult↗
Issues in perceptual speech analysis in cleft palate and related disorders: a review.
BACKGROUND: Perceptual speech assessment is central to the evaluation of speech outcomes associated with cleft palate and velopharyngeal dysfunction. However, the complexity of this process is perhaps sometimes underestimated. AIMS: To draw together the many different strands in the complex process of perceptual speech assessment and analysis, and make recommendations for practice. MAIN CONTRIBUTION: This review examines issues such as data sampling, data collection/recording, archiving, the advantages and disadvantages of lay and specialist listeners, approaches to data analysis, reliability, and data interpretation. CONCLUSIONS: The need to capture meaningfully the sound of speech based on detailed phonetic analysis is argued. Also described are some of the differences in measuring speech for clinical, audit and research activities. Blind independent analysis of speech data by specialist therapists is recommended as the gold standard methodological approach when reporting audit and research outcomes. The requirement for ongoing training in listening skills for specialist therapists is advocated. The limitations of an impairment-based-only approach to measurement are also illustrated, indicating the need to develop outcome measures that incorporate more functional issues that affect quality of life.
Cleft Palate↗