Assessing discomfort after anaesthesia: should you ask the patient or read the record?
(9/2039)
OBJECTIVE: To assess the quality of anaesthesia care from the patients' viewpoint compared with the hospital record. DESIGN: Prospective study during 1988-9. SETTING: Four teaching hospitals (A-D) in Canada. PATIENTS: 15,960 inpatients receiving anaesthetic requiring at least an overnight stay, for whom an interview and review of hospital records within 72 hours of surgery were complete. MAIN MEASURES: Rates of postoperative symptoms of discomfort (nausea or vomiting, headache, back pain, sore throat, eye symptoms, and tingling) according to the hospital record versus interview and the relation between symptoms and patients' satisfaction with the anaesthetic experience. RESULTS: The preparation of completed interviews ranged from 31.0% to 72.7%, owing mainly to patients discharge (hospitals A and B) and severity of illness (C and D). Interviewed patients were similar to all inpatients in the hospitals but were younger and healthier and more had had effective operations and were general surgical than cardiovascular or neurosurgical patients. In all, 26% to 46% of patients at the four hospitals reported at least one symptom of discomfort. Agreement between interviews and hospital records was low, symptoms being more commonly reported by interview than in the record (for example, headache was reported for 5.8%-17% of patients compared with 0.3%-3.0% in hospital records). After controlling for case mix patients who reported at least one symptom were 2.91 times (95% confidence interval 1.89 to 4.50) more likely to be dissatisfied with their anaesthetic care than patients who did not. CONCLUSIONS: Anaesthesia services are typically neglected in studies of hospital quality, yet patients express considerable anxiety about anaesthetic care. Monitoring and recording patients' discomfort clearly need to be improved if the quality of anaesthesia is to be properly evaluated. (+info)
Comparison of short term outcomes of open and laparoscopic cholecystectomy.
(10/2039)
OBJECTIVE: To compare the three month outcome of open and laparoscopic cholecystectomy. DESIGN: Prospective assessment of outcome for a series of patients encompassing the introduction of the laparoscopic technique. SETTING: One teaching hospital. PATIENTS: 269 patients admitted for open cholecystectomy between January 1989 and March 1992 and 122 admitted for laparoscopic cholecystectomy between January 1991 and March 1992. MAIN MEASURES: Patients' reported symptoms and self assessed scores with the Nottingham health profile before operation and at three month follow up. Incidence of complications and adverse events after discharge. RESULTS: Similar improvements in symptom rates and health scores were seen regardless of surgical technique. A lower rate of postoperative complications was seen in the patients given laparoscopic surgery (6/95(6%) v 45/235(19%)), and their mean length of stay was lower (4.5 v 9.8 days). Similar results were obtained when the analysis was restricted to a subset of fairly uncomplicated cases (patients aged 60 or less without other illnesses on admission who were not undergoing emergency or urgent surgery), which constituted a larger proportion of the group given laparoscopy (35/95(37%) v 40/235(17%)). Between these two groups no significant difference was seen in the frequency of relevant readmissions to hospital or visits to general practitioners or accident and emergency departments. CONCLUSION: Ideally, a new surgical technique would be evaluated in a randomised trial. In the absence of such a trial, this observational study provides some evidence that the switch from open to laparoscopic cholecystectomy has brought benefits, particularly in terms of reduced length of stay in hospital. A range of clinical and patient derived indicators suggests that these gains have not been associated with a reduction in the quality of the outcome at three months. (+info)
How patients perceive the role of hospital chaplains: a preliminary exploration.
(11/2039)
OBJECTIVE: An exploratory study of the attitudes of hospital patients to the service provided by hospital chaplains. DESIGN: Questionnaire study of hospital inpatients in December 1992. SETTING: One large teaching hospital in London. PATIENTS: 180 hospital inpatients in 14 different general wards, 168 (93%) of whom agreed to take part. MAIN MEASURES: Attitudes to chaplains and their role contained in 12 questions developed during a pilot study on hospital inpatients (16) and staff (14) and their relation to patients' age, sex, length of hospital stay, and religious beliefs, according to Kendall rank order correlations. RESULTS: Of 168(93%) respondents, 72(43%) were women; mean age of patients was 63.1 (SD 16.8) years. Forty five (27%) were inpatients of three days or less and 22(13%) for one month or more. 136(81%) were Christian; 17(10%) atheist, agnostic, or had no religion; and 15(9%) were of other religions. In general, patients showed positive attitudes towards the role of hospital chaplains and to the services they provided. The correlation analysis showed that there was a significant tendency for older patients, those who had been inpatients for longer, and those with religious beliefs to be more sympathetic to the role of hospital chaplains. CONCLUSIONS: Hospital chaplains provide a service which is appreciated by patients. This study provides a simple instrument for assessing patients' attitudes to chaplains. (+info)
Effects of a computerised protocol management system on ordering of clinical tests.
(12/2039)
OBJECTIVE: To assess the effects of a computerised protocol management system on the number, cost, and appropriateness of laboratory investigations requested. DESIGN: A before and after intervention. SETTING: A supraregional liver unit in a teaching hospital. PATIENTS: 1487 consecutive patients admitted during 1990 and 1991 (one year before and one year after introduction of the system). INTERVENTION: Introduction of a computerised protocol management system on 1 January 1991. MAIN MEASURES: The number and cost of clinical chemistry tests requested per patient day. RESULTS: The total number of clinical chemistry tests requested per patient day by the unit declined 17% (p < 0.001, Student's t test) and of out of hours tests requested per patient day from 0.31 to 0.16, 48% (p < 0.001; Mann-Whitney U test), resulting in a 28% reduction (p < 0.001) in direct laboratory expenditure per patient-day. Overall, the number of tests per admission decreased by 24% (p < 0.001; Mann-Whitney U test). CONCLUSION: Use of the computerised protocol management system resulted in closer compliance with the protocols and a significant reduction in the overall level of requesting. IMPLICATIONS: Although similar systems need to be tested in other clinical settings, computerised protocol management systems may be important in providing appropriate and cost effective health care. (+info)
Trauma emergency unit: long-term evaluation of a quality assurance programme.
(13/2039)
OBJECTIVE: Long-term evaluation of a quality assurance programme (after an assessment in 1993). DESIGN: Review of medical records. SETTING: Emergency area of an orthopaedic, trauma, and plastic surgery unit in a French teaching hospital (Besancon). SUBJECTS: 1187 consecutive ambulatory patients' records, from July 1995. MAIN MEASURES: Occurrence of near adverse events (at risk events causing situations which could lead to the occurrence of an adverse event). RESULTS: 71 near adverse events were identified (5.9% of the ambulatory visits). There was a significant decrease in the rate of near adverse events between 1993 (9.9% (2056 ambulatory visits, 204 near adverse events)), and 1995 (5.9% (1187 ambulatory visits, 71 near adverse events)), and significant change in the proportion of each category of adverse event (decrease in departures from prevention protocols). CONCLUSIONS: Despite their limitations, the effectiveness and efficiency of quality assurance programmes seem to be real and valuable. Maintaining quality improvement requires conditions which include some of the basic principles of total quality management (leadership, participatory management, openness, continuous feed back). The organisation of this unit as a specialised trauma centre was also a determining factor in the feasibility of a quality assurance programme (specialisation and small size, high activity volume, management of the complete care process). Quality assurance is an important initial step towards quality improvement, that should precede consideration of a total quality management programme. (+info)
Physicians' views on capitated payment for medical care: does familiarity foster acceptance?
(14/2039)
Physicians' attitudes toward capitated payment have not been quantified. We sought to assess physicians' views on capitated payment and to compare the views of those who did and did not participate in such payment. A written survey was given to 200 physicians with admitting privileges at a 600-bed Ohio hospital; 82 (41%) responded and were included in this study. Among respondents, 21 (26%) were primary care physicians, 18 (22%) were medical subspecialists, and 18 (22%) were surgeons. Fifty-eight (71%) were providers for managed care plans, and 35 (43%) participated in capitated payment arrangements. Among physicians who did not participate in capitated care, 100% believed that there was a conflict of interest in capitated payment, and 77% (23 physicians) believed that participation in plans that reduce physician income in proportion to medical expenditures is not acceptable. Among those who did participate in capitated payment contracts, 95% (41 physicians) believed these plans posed a conflict of interest, and 72% (31 physicians) said this was not acceptable (P = 0.4 and 0.66 for each comparison). There was no trend toward the opinion that capitated payment arrangements are acceptable with greater levels of experience in capitated care (P = 0.5 by Spearman test). There were trends suggesting that compared with those who were not receiving capitated payments, those who received capitated payment were 50% more likely to have never discussed capitated payment with any patient (63% versus 42%, P = 0.08), were 70% more likely to very strongly oppose the use of capitation to pay their own family's physicians (49% versus 29%, P = 0.07), and were 30% more likely to believe that it is impossible to stay in the practice of medicine without participating in capitated payment plans (84% versus 65%, P = 0.06). None of the respondents reported that they had a contractual "gag clause," but 34% (27 physicians) said they would not speak publicly about any perceived risks of capitated payments anyway. Among this sample of physicians, those who participated in existing capitated payment managed care plans had views that were as negative, or more negative, on the acceptability of capitated payment as did those of nonparticipating physicians. Many were participating in capitated payment plans in spite of these negative views because they feared that to do otherwise would force them out of medical practice. The hypotheses generated by this study must be tested in larger, national studies. (+info)
Evaluation of "solitary" thyroid nodules in a community practice: a managed care approach.
(15/2039)
Evaluation of thyroid nodules remains a challenge for primary care physicians. To include or exclude the presence of malignancy in a thyroid nodule, radioisotope scan, ultrasound, and fine-needle aspiration biopsy of the thyroid generally are used. The objectives of this study were to determine the utility and cost effectiveness of fine-needle aspiration biopsy of solitary thyroid nodules in a community setting; to compare the cost of fine-needle aspiration biopsy with that of radioisotope scan and ultrasound; and to determine whether the practice of obtaining radioisotope scans and ultrasound has changed in the 1990s compared with the 1980s. Patients were referred by community physicians to university-based endocrinologists for evaluation of thyroid nodules. Many of the patients had previously undergone radioisotope scans and ultrasound scans at the discretion of their primary care physicians. All patients underwent fine-needle aspiration biopsy. The biopsy results were evaluated prospectively, and the practice of community physicians' obtaining radioisotope scans and ultrasound scans was compared for the 1980s and 1990s. Eighty-three patients underwent 104 biopsies. In 20 biopsies the specimens were inadequate; the others showed 70 benign, 9 suspicious, and 4 malignant lesions. All four patients with biopsy findings read as malignant were found to have malignant growth at surgical procedures. Two benign biopsy findings were false-negative results. Malignant growth was correctly diagnosed later for one patient at a second biopsy and for the other because of growth of the nodule. The cost of 104 biopsies was $20,800. The cost of radioisotope scans was $22,400, and the cost of ultrasound scans was $10,640. The frequency of obtaining radioisotope scans (84.5% vs 77%) and ultrasound scans (65% vs 45%) was slightly higher in the 1990s compared with the 1980s. Fine-needle aspiration biopsy is a safe and cost effective initial evaluation modality for smaller community-based centers, as it is at large tertiary centers. The cost incurred ($33,040) in obtaining the radioisotope scans and ultrasound scans could have been saved if fine-needle aspiration biopsy had been used as the initial diagnostic procedure for evaluation of these nodules. Although radioisotope scan and ultrasound scan are of little diagnostic help in the evaluation of thyroid nodules, they continued to be obtained at a high frequency during the last decade. (+info)
Economic consequences of early inpatient discharge to community-based rehabilitation for stroke in an inner-London teaching hospital.
(16/2039)
BACKGROUND AND PURPOSE: In an inner-London teaching hospital, a randomized trial of "conventional" care versus early discharge to community-based therapy found no significant differences in clinical outcomes between patient groups. This report examines the economic consequences of the alternative strategies. METHODS: One hundred sixty-seven patients received the early discharge package, and 164 received conventional care. Patient utilization of health and social services was recorded over a 12-month period, and cost was determined using data from provider departments and other published sources. RESULTS: Inpatient stay after randomization was 12 days (intervention group) versus 18 days (controls) (P=0.0001). Average units of therapy per patient were as follows: physiotherapy, 22.4 (early discharge) versus 15.0 (conventional) (P=0.0006); occupational therapy, 29.0 versus 23.8 (P=0.002); speech therapy, 13. 7 versus 5.8 (P=0.0001). The early discharge group had more annual hospital physician contacts (P=0.015) and general practitioner clinic visits (P=0.019) but fewer incidences of day hospital attendance (P=0.04). Other differences in utilization were nonsignificant. Average annual costs per patient were pound sterling 6800 (early discharge) and pound sterling 7432 (conventional). The early discharge group had lower inpatient costs per patient (pound sterling 4862 [71% of total cost] versus pound sterling 6343 [85%] for controls) but higher non-inpatient costs (pound sterling 1938 [29%] versus pound sterling 1089 [15%]). Further analysis demonstrated that early discharge is unlikely to lead to financial savings; its main benefit is to release capacity for an expansion in stroke caseload. CONCLUSIONS: Overall results of this trial indicate that early discharge to community rehabilitation for stroke is cost-effective. It may provide a means of addressing the predicted increase in need for stroke care within existing hospital capacity. (+info)