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The Pan American Health Organization (PAHO) supports performance evaluation programs in clinical chemistry, Caribbean. Much more work remains to be done before many labs in this part of the world can be certified as providing accurate results, but PAHO has taken an important first step toward establishing benchmarks and rallying for labs to improve test quality.
The intraoperative injury of the external branch of the Superior Laryngeal Nerve (SLN) is a disregarded complication of thyroid surgery that becomes a serious one for particular professional groups. The Authors retrospectively evaluate 124 cases of total thyroidectomies performed by the same surgeon from 1999 to 2002. Clinically evaluated SLN lesions (hypomobility of the vocal cord) was registered in six patients (4.8%). Routine identification of SLN and meticulous dissection of the superior thyroid vessels must be the technical benchmark to avoid nerve injury, even if bulky disease, anatomic variations and previous surgery may increase the chance of nerve damaging.
In summary, the Wisconsin Head and Neck Cancer Control Network was formulated with the primary charge of improving the management of patients with head and neck cancer throughout the State. Detailed data on over 1500 patients representing 80 percent of all head and neck cancer patients in the State of Wisconsin was gathered, reviewed for quality, and analyzed. The data base consisted of information on the symptoms, signs, physical findings, treatment, complications, morbidity, and outcome. Although it was the impression of Network members that lesions were being noted earlier and treatment perhaps more effective, it was not possible to document this impression with the available data. The benchmarks of success of the overall project were numerous, however, particularly in the areas of public and professional education. The individuals reached were extremely receptive to new information. Several patients indicated that their dentist and dental hygienists, for example, were performing more thorough oral examinations. The effort was successful in establishing a network of physicians and institutions throughout the State cooperating with a common interest. It is hoped that in the future we can continue to build on the experience of the Network. Follow-up data has continued to accumulate through a largely voluntary effort of the coinvestigators, and this will enhance the value of the data base. Such follow-up data will certainly facilitate ongoing and future research projects based on this comprehensive information. To date, one publication has been prepared since termination of the project using the data base.
BACKGROUND: Journal usage studies, which are useful for budget management and for evaluating collection performance relative to library use, have generally described a single library or subject discipline. The Southern Chapter/Medical Library Association (SC/MLA) study has examined journal usage at the aggregate data level with the long-term goal of developing hospital library benchmarks for journal use. METHODS: Thirty-six SC/MLA hospital libraries, categorized for the study by size as small, medium, or large, reported current journal title use centrally for a one-year period following standardized data collection procedures. Institutional and aggregate data were analyzed for the average annual frequency of use, average costs per use and non-use, and average percent of non-used titles. Permutation F-type tests were used to measure difference among the three hospital groups. RESULTS: Averages were reported for each data set analysis. Statistical tests indicated no significant differences between the hospital groups, suggesting that benchmarks can be derived applying to all types of hospital libraries. The unanticipated lack of commonality among heavily used titles pointed to a need for uniquely tailored collections. CONCLUSION: Although the small sample size precluded definitive results, the study's findings constituted a baseline of data that can be compared against future studies.
The growing use of classification and coding of patient data in medical information systems has resulted in increased dependence on the accuracy of coding practices. Information maintained on systems must be trusted by both providers and managers in order to serve as a viable tool for the delivery of healthcare in an evidence-based environment. A national survey of health information managers was employed here to assess observed levels of coder agreement with physician code selections used in classifying patient data. Findings from this survey suggest that, on a national level, the quality of coded data may suffer as a result of disagreement or inconsistent coding within healthcare provider organizations, in an era where physicians are increasingly called upon to enter and classify patient data via computerized medical records. Nineteen percent of respondents report that coder-physician classification disagreement occurred on more than 5% of all patient encounters. In some cases disagreement occurs in 20% or more instances of code selection. This phenomenon occurred to varying degrees across regions and market areas, suggesting a confounding influence when coded data is aggregated for comparative purposes. In an evidence-based healthcare environment, coded data often serves as a representation of clinical performance. Given the increasing complexity of medical information classification systems, reliance on such data may pose a risk for both practitioners and managers without consistent agreement on coding practices and procedures.
In 2004, the Canadian Cardiovascular Society formed an Access to Care Working Group with a mandate to use the best science and information available to establish reasonable triage categories and safe wait times for common cardiovascular services and procedures through a series of commentaries. The present commentary discusses the rationale for access benchmarks for urgent cardiac catheterization and revascularization, including hospital transfer in the setting of non-ST elevation acute coronary syndromes. The literature on standards of care, wait times, wait list management and clinical trials was reviewed. A survey of all cardiac catheterization directors in Canada was performed to develop an inventory of current practices in identifying and triaging patients. The Working Group recommended the following medically acceptable wait times for access to diagnostic catheterization and revascularization in patients presenting with acute coronary syndromes: for diagnostic catheterization and percutaneous coronary intervention, the target should be 24 h to 48 h for high-risk, three to five days for intermediate-risk and five to seven days for low-risk patients; for coronary artery bypass graft surgery, the target should be three to five days for high-risk, two to three weeks for intermediate-risk and six weeks for low-risk patients. All stakeholders must affirm the appropriateness of these standards and work continuously to achieve them. However, some questions remain around what are the best clinical risk markers to delineate the triage categories and the utility of clinical risk scores to assist clinicians in triaging patients for invasive therapies.
This article explains how a primary care team transformed a run down general practice into a leading edge healthcare organisation by adopting the principles of the EFQM excellence model. The decisions surrounding the choice of approach, challenges faced, benefits achieved and lessons learned are all described in such a way that the reader may appreciate the issues which faced the members of the 15-man team. In particular, the practice team found that describing indicators of quality and gathering evidence to test out assumptions regarding performance were vital elements in the pursuit of a continuous improvement culture that was to benefit patients, staff and key stakeholders alike. Whilst an increase in workload was experienced in the early days, the knowledge that this was associated with improved performance made the efforts worthwhile and the team eager to adopt a regular, never-ending cycle of self-assessment and improvement.
In today's managed care healthcare environment, there is a need for hospitals and physician groups alike to know the true quality and costs of healthcare services provided to patients. As the movement toward having providers accept risk via financial capitation escalates, quality improvement professionals involved in outcomes management are increasingly being asked to investigate information sources and systems that can prove helpful in managing effectively within these limitations. As a result, there is a high degree of interest in comparative performance outcomes measurement data based on risk-adjusted and severity-adjusted data. This article explains the key features of performance outcomes measurement systems and notes concerns that should be considered when evaluating these software systems for selection.
As with any health care process, the efficiency with which outputs are produced in general practice is of considerable importance. Using data from Lincolnshire, this study utilizes data envelopment analysis to examine the relationships between practice costs and outputs, measured not only as the number of patients treated, but also on the basis of performance indicators. The technique permits the construction of an efficiency ranking, facilitating the accurate targeting of monitoring resources.
The Balanced Scorecard concept, which aims to translate an organization's mission and strategy into a set of concrete performance measures, may have been developed for use in other industries, but a growing number of hospital quality directors and administrators have begun to make the concept their own.
Disease management is a strategy of organizing care and services for a patient population across the continuum. It is characterized by a population database, interdisciplinary and interagency collaboration, and evidence-based clinical information. The effectiveness of a disease management program has been measured by a combination of clinical, financial, and quality of life outcomes. In early 1997, driven by a strategic planning process that established three Centers of Excellence (COE), we implemented disease management as the foundation for a new approach to performance improvement utilizing five key strategies. The five implementation strategies are outlined, in addition to a review of the key elements in outcome achievement.
The Balanced Budget Act (BBA) of 1997 directed CMS to implement a system to measure and report the quality of dialysis services under Medicare by 2000. Because of this tight timeframe, a rapid-cycle measurement development process was initiated to develop dialysis facility-specific measures that could be released to the public. The result was "Dialysis Facility Compare" which has served as a template for the development of public reporting initiatives for other providers in the Medicare Program. This article describes the process used for developing and reporting these performance measures and the lessons learned for future work in this area.
Leapfrog has designed its program to reward improvers as well as best performers. Key areas represent approximately 33% of admissions and 20% of commercial payers' inpatient expenditures. Local market conditions, employer groups, and health plans will dictate incentive structures.
Much discussion has taken place over the relative merits of various platforms and operating systems for real-time data collection. Most would agree that, provided great care is taken, many are capable of millisecond timing precision. However, to date, much of this work has focused on the theoretical aspects of raw performance. It is our belief that researchers would be better informed if they could place confidence limits on their own specific paradigms in situ and without modification. To this end, we have developed a millisecond precision test rig that can control and time experiments on a second presentation machine. In this paper, we report on the specialist hardware and software used. We elucidate the importance of the approach in relation to real-world experimentation.
HYPOTHESIS: Anastomotic leakage is the most important cost driver in patients who undergo low anterior resection (LAR) for rectal cancer. Creating defunctioning stomas to protect colorectal anastomoses may also have a major effect on the overall costs. Unselected creation of defunctioning stomas in most of these patients may be associated with higher overall costs compared with a program that has a low rate of defunctioning stomas and an acceptable anastomotic leakage rate. DESIGN: Cost-effectiveness analysis. SETTING: Secondary referral center. PATIENTS: Performing a cost analysis from the viewpoint of a hospital provider, we reviewed data of 70 consecutive patients who underwent LARs with (n = 19) or without (n = 51) a defunctioning colostomy. A scenario analysis was performed using data derived from the medical literature to assess a plausible range of leakage and stoma rates. MAIN OUTCOME MEASURE: Costs per treatment option and incremental cost-effectiveness ratio according to various treatment scenarios. RESULTS: Performing an LAR without a stoma and no anastomotic leakage is associated with significantly lowest costs (8.400 euro; P<.001) compared with patients with a stoma (13.985 euro) and patients with anastomotic leakage (42.250 euro). The most important cost drivers were anastomotic leakages and defunctioning stomas. A leakage rate of 16.5% in patients without a stoma would be necessary to balance the overall costs of patients with stomas. The incremental cost-effectiveness ratio would be 158.705 euro and 60.915 euro per leak, respectively, avoided in patients with defunctioning stomas assuming a leakage rate lower than 3% and 6%, respectively, in patients who did not undergo a colostomy. A 1-way sensitivity analysis revealed that duration and costs of intensive care unit care were the only factors that may considerably alter our results. CONCLUSIONS: A suggested benchmark for an LAR should be a rate of 10% or less for defunctioning stomas and anastomatic leaks; that would limit the overall costs to 12,000 euro per patient treated. Against the background of a lack of universally valid criteria for the creation of defunctioning stomas, our aim should be to reduce the rate of defunctioning stomas because of their major effect on the overall costs especially in programs with a lower leakage rate. Higher leakage rates despite higher stoma rates depend more on the skill of the surgeon than on the characteristics of the patient and higher leakage should lead to a change in surgical technique strategy.
An extension of the SIBFA polarizable molecular mechanics procedure to flexible oligopeptides is reported. The procedure is evaluated by computing the relative conformational energies, deltaE(conf), of the alanine tetrapeptide in 10 representative conformations, which were originally derived by Beachy et al. (J Am Chem Soc 1997, 119, 5908) to benchmark molecular mechanics procedures with respect to ab initio computations. In the present study, a particular emphasis is on the separable nature of the components of the energy and the particular impact of the polarization energy component on deltaE(conf). We perform comparisons with respect to single-point HF, DFT, LMP2, and MP2 computations done at the SIBFA-derived energy minima. Such comparisons are made first for the 10 conformers derived from phi/psi torsional angle energy-minimization (the rigid rotor approach), and, in a second step, after allowing additional relaxation of the C(alpha) centered valence angles. In both series of energy-minimization, the SIBFA deltaE(conf) compared best with the LMP2 results using the 6-311G** basis set, the rms being 1.3 kcal/mol. In the absence of the polarization component, the rms is 3.5 kcal/mol. In both series of minimizations, the magnitudes of deltaE(conf), computed as differences with respect to the most stable conformer taken as energy zero, decrease along the series: HF > DFT > LMP2 > SIBFA > MP2, indicative of increasing stabilization of the most highly folded conformers.
The Space Elevator (SE) concept has begun to receive an increasing amount of attention within the space community over the past couple of years and is no longer widely dismissed as pure science fiction. In light of the renewed interest in a, possibly sustained, human presence on the Moon and the fact that transportation and logistics form the bottleneck of many conceivable lunar missions, it is interesting to investigate what role the SE could eventually play in implementing an efficient Earth to Moon transportation system. The elevator allows vehicles to ascend from Earth and be injected into a trans-lunar trajectory without the use of chemical thrusters, thus eliminating gravity loss, aerodynamic loss and the need of high thrust multistage launch systems. Such a system therefore promises substantial savings of propellant and structural mass and could greatly increase the efficiency of Earth to Moon transportation. This paper analyzes different elevator-based trans-lunar transportation scenarios and characterizes them in terms of a number of benchmark figures. The transportation scenarios include direct elevator-launched trans-lunar trajectories, elevator launched trajectories via L1 and L2, as well as launch from an Earth-based elevator and subsequent rendezvous with lunar elevators placed either on the near or on the far side of the Moon. The benchmark figures by which the different transfer options are characterized and evaluated include release radius (RR), required delta v, transfer times as well as other factors such as accessibility of different lunar latitudes, frequency of launch opportunities and mission complexity. The performances of the different lunar transfer options are compared with each other as well as with the performance of conventional mission concepts, represented by Apollo.
A comparative study of two self-organizing clustering neural network algorithms, Dignet and ART2, has been conducted. The differences in architecture and learning procedures between the two models are compared. Comparative computer simulations on data clustering and signal detection problems with Gaussian noise were used for investigating the performance of Dignet and "fast learning" ART2. The study shows that Dignet, with a simple architecture and straightforward dynamics, is more flexible with the choice of different metrics for the measure of similarity. The system parameters in Dignet can be analytically determined from a self-adjusting process; moreover, the initial threshold value used in Dignet is directly determined from a lower-bound of the desirable operational signal-to-noise ratio. Simulations show that Dignet generally exhibits faster learning and better clustering performance on statistical pattern recognition problems. A simplified ART2 model (SART2) is derived by adopting the structural concepts from Dignet. SART2 exhibits faster learning and eliminates a "false conviction" problem that exists in the "fast learning" ART2. The comparative study is benchmarked against statistical data clustering and signal detection problems. Copyright 1997 Elsevier Science Ltd.