The feasibility and cost of a large multicentre audit of process and outcome of prostatectomy.
(73/14168)
Objective--To determine the feasibility of performing multicentre process and outcome audits of common interventions taking prostatic procedures as an example. Design--Prospective, cohort study. Setting--All National Health Service and independent hospitals in Northern, Wessex, Mersey, and South West Thames health regions. Patients--5361 men undergoing prostatectomy identified by 103 of the 107 urologists and general surgeons performing prostatectomy in the study regions. Main measures-- Rates of participation by surgeons and patients; completeness of clinical data provided by surgeons; patient response rate and completeness of patient derived data; and cost. Results--Most surgeons (103,96%) agreed to participate. Overall, the proportion of eligible patients invited to take part was high (89%), although this was only measured in South West Thames, where dedicated data collectors were employed. Few men (80, 1.5%) declined to participate. Of those surviving for three months after surgery, 82.4% (4226) completed and returned the postal questionnaire. The response rate was higher in South West Thames (86.7%) than in the other regions (80.6%-80.8%). The audit was well received: 91% of patients found the questionnaire easy to complete and only 2.3% of them disapproved. Completeness of data was high with both the hospital and patient questionnaires. Missing data occurred in less than 5% of responses to most questions. The attributable cost was 34.50 pounds per patient identified or 44 pounds for patients in whom either the treatment outcome or vital status was known three months after their prostatectomy. Conclusions--This multicentre audit of process and outcome of prostatectomy proved feasible in terms of surgeon participation, patient identification, and the quantity and quality of data collection. Whether the cost was warranted will depend on how surgeons use the audit data to modify their practice. (+info)
Management of primary antibody deficiency by consultant immunologists in the United Kingdom: a paradigm for other rare diseases.
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Variation in clinical practice and its effect on outcome is little known for rare diseases such as primary antibody deficiency. As part of a national audit a survey of all 30 consultant immunologists in the United Kingdom dealing with primary antibody deficiency syndromes in adults and children was carried out in 1993 to ascertain their practices in diagnosis and management. Consensus guidelines were published after the survey was completed. Comparison of the survey results of clinical practice at the time the guidelines were published with the standards identified highlighted that the practice of a minority of specialists was at variance with their peers and with the consensus document, particularly in the use of intramuscular immunoglobulin, the dose and frequency of intravenous immunoglobulin, and target trough immunoglobulin G concentration, which has implications for the quality of patient care. However, much closer agreement existed in the key areas of management, such as diagnosis and selection of intravenous immunoglobulin. The approach and the problems identified are relevant to the management of other rare diseases, in which diagnosis and management is complex and there are few specialists with the necessary knowledge to undertake such care. This survey, the first attempted audit of practice, shows that within a motivated group of specialists highly significant differences in practice may exist and the authors emphasise the importance of setting clear guidelines against which care can be assessed. (+info)
Screening for mild hypertension: costs and benefits.
(75/14168)
It is important to understand the full implications of introducing a new screening and treatment programme into the National Health Service. In this paper, we calculate, for mild hypertension, the cost of community-based screening and the cost of case-finding in general practice. We show that case-finding in general practice is both less expensive and more efficient. We calculate the cost of running a programme in general practice for five years and divide that cost by an estimate of the number of deaths that might be prevented as a result of introducing such a programme. This calculation give a minimum cost for extending a life by the programme. (+info)
Indicators of the quality of general practice care of patients with chronic illness: a step towards the real involvement of patients in the assessment of the quality of care.
(76/14168)
OBJECTIVE: To develop a list of indicators of the general practice care of people with chronic illnesses considered important by both patients and practitioners and to identify the indicators that are considered relevant for patient assessment of health care quality. DESIGN: Qualitative study with focus group interviews and a written consensus procedure. SETTING: General practice in the Netherlands in 1993. SUBJECTS: 34 patients with chronic illness, mostly members of patient organisations, and 19 general practitioners with expertise in either chronic disease management or experience with patient surveys. MAIN MEASURES: Aspects of general practice care considered important for the delivery of good quality care that emerged from focus group interviews; the relevance of evaluations of 41 aspects of care for patients explored through the written consensus procedure. Those aspects of general practice care agreed to be both important and relevant by patients and general practitioners were considered to be suitable indicators for patient assessment of the quality of care. RESULTS: Patients and general practitioners differed to some extent in their assessment of the aspects of care that they considered important for quality. They agreed that most indicators of care that related to the inverted question markdoctor-patient relation inverted question mark and to inverted question markinformation and support inverted question mark were relevant and therefore suitable as indicators for patient assessment of health care quality. There was less agreement about the relevance of indicators of inverted question markmedical and technical care, inverted question mark inverted question markavailability and accessibility, inverted question mark and inverted question markorganisation of services. inverted question mark CONCLUSIONS: Several indicators of the quality of general practice care of patients with chronic illness were thought to be suitable for the patient assessment of healthcare quality, but other indicators were not, mainly because of reservations by general practitioners. IMPLICATIONS: Qualitative methods can contribute to the selection of indicators for assessment of the quality of health care in areas where scientific evidence is limited or where patients' and providers' preferences are particularly important. (+info)
Understanding the basis of treatment choices for varicose veins: a model for decision making with the repertory grid technique.
(77/14168)
OBJECTIVES: To use the repertory grid technique as a method for identifying and rating the criteria that clinicians use to make a choice between the different treatment options for patients with a common condition such as varicose veins. DESIGN: The "expert panel" consensus method for rating the appropriateness of clinical procedures was modified with an existing psychometric method, the repertory grid technique. To identify the criteria used to decide about treatment, the panel members compared and contrasted a range of nine "treatment prototypes". They were then required to rate each criterion for its relevance to each treatment prototype. SETTING: The panel was selected from different geographical locations in the South Western Regional Health Authority. SUBJECTS: The expert panel was composed of six vascular surgeons, three from teaching and three from non-teaching hospitals; two general practitioners who were also clinical assistants in vascular surgery; and one honorary senior lecturer in general practice. MAIN MEASURES: Decision making criteria were categorised according to their content. Their frequency of replication was noted-that is, how many clinicians used the same criterion. Computer analysis of the rating scores for the nine panel members identified the relative importance of each treatment criterion for each treatment option. RESULTS: 161 criteria for the treatment of varicose veins were elicited from the nine participants. These criteria were wide ranging, from clinical indications (48% of those used), to social (32%), and organisational factors (20%). Clinical indications were more likely to be used when deciding about surgery as a high priority, whereas social and organisational criteria were more likely to be applied in decisions about surgery as a low priority, day case surgery, and cosmetic surgery. CONCLUSIONS: The repertory grid technique proved to be effective in modelling decision making for a condition such as varicose veins: its use enabled both the identification of the wide range of criteria underlying the decision to treat and the exploration of the relative importance of these criteria in relation to several treatment options. Its potential as a method for reducing variation in clinical decision making and thus improving distribution of high quality care lies in its ability to pinpoint dilemmas of decision making rather than as the basis for drawing up guidelines to regulate decision making practice. (+info)
Organisation of asthma care: what difference does it make? A systematic review of the literature.
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OBJECTIVES: To evaluate the effectiveness of different forms of organisation (delivery) of asthma care. METHODS: A systematic review of the published evidence of effectiveness organisational methods of asthma management. Searches on computerised databases including Medline, CINAHL, and HELMIS, and relevant citations and letters to experts were used to identify relevant studies. RESULTS: 27 studies were identified that evaluated different organisational methods of delivery across both primary and secondary sectors, such as shared care, general practice asthma clinics, outpatient programmes, inpatient admissions policies, and the use of specialists. Only one third of the studies used a randomised controlled trial and many had small sample sizes. No conclusive evidence was found to favour any particular organisational form, although limited evidence would suggest that specialist care is better than general care and that shared care can be as effective as hospital led care. CONCLUSIONS: There is little good published research evaluating different ways of organising the delivery of asthma care. There is need for quality research on organisational methods of delivery of asthma care that could be used to inform policy makers, in particular examining whether patients treated by healthcare professional with expertise and interest in asthma will experience better outcomes. (+info)
Patients' satisfaction with care after stroke: relation with characteristics of patients and care.
(79/14168)
OBJECTIVES: To evaluate stroke patients' satisfaction with care received and to identify characteristics of patients and care which are associated with patients' dissatisfaction. DESIGN: Cross sectional study. SETTING: Sample of patients who participated in a multicentre study on quality of care in 23 hospitals in the Netherlands. PATIENTS: 327 non-institutionalised patients who had been in hospital six months before because of stroke. MAIN MEASURES: Data were collected on (a) characteristics of patients: socio-demographic status, cognitive function (mini mental state examination), disability (Barthel index), handicap (Rankin scale), emotional distress (emotional behavior subscale of the sickness impact profile) and health perception; (b) characteristics of care: use of various types of formal care after stroke, unmet care demands perceived by patients, unmet care demands confirmed by their general practitioners, continuity of care, and secondary prevention, and (c) patients' satisfaction with care received. RESULTS: 40% of the study sample were dissatisfied with at least one type of care received. Multivariate analyses showed that unmet care demands perceived by patients (odds ratio (OR) 3.2, 95% confidence interval (95% CI) 1.8-5.7) and emotional distress (OR 1.8, 95% CI 1.1-3.0) were the main variable associated with dissatisfaction. CONCLUSIONS: Patients' satisfaction was primarily associated with emotional distress and unmet care demands perceived by patients. No association was found between patients' satisfaction on the one hand and continuity of care or secondary prevention on the other; two care characteristics that are broadly accepted by professional care givers as important indicators of quality of long term care after stroke. IMPLICATIONS: In view of these findings discussion should take place about the relative weight that should be given to patients' satisfaction as an indicator of quality of care, compared with other quality indicators such as continuity of care and technical competence. More research is needed to find which dimensions of quality care are considered the most important by stroke patients and professional care givers. (+info)
Aid instruments and health systems development: an analysis of current practice.
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There has been a clear shift in the policy of many donors in the health sector-away from discrete project assistance towards more broad-based sectoral support. This paper, based on interviews with officials in a number of bilateral and multilateral agencies, explores whether this shift in policy has been matched by similar changes in the form or range of aid instruments. The paper develops a framework for examining current practice in relation to the different objectives that donors seek to promote through technical and financial assistance. In particular, it looks in some detail at the advantages and disadvantages of budgetary support compared to more traditional forms of project assistance. It concludes that the debate should not be about whether one form of aid is better than another. Ideally, they should be complementary and the forms, channels and systems used for managing aid need to be assessed in relation to how they help to achieve the mix of development objectives that are most appropriate to the country concerned. The review demonstrates that this is a complex task and that to achieve an effective balance is not easy. The final section summarizes the main themes emerging from the discussion and suggests some preliminary conclusions and proposals for future action. (+info)