Improving the quality of perinatal and infant necropsy examinations: a follow up study.
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AIM: To compare the quality of perinatal and infant necropsy examinations in 1996 with those performed in 1993. METHODS: Cohort analysis, with data from the All Wales Perinatal Survey, of 1027 deaths (540 in 1993; 487 in 1996) of babies between 20 weeks' gestation and one year of age. The quality of the necropsy was assessed by scoring aspects identified as being part of the investigation. RESULTS: Necropsy was performed in 335 cases (62%) in 1993 and in 320 cases (66%) in 1996. The proportion done in a regional centre increased significantly from 39% (131/335) in 1993 to 76% (243/320) in 1996 (p < 0.0001). The quality of necropsy was above the minimum standard in 54% of cases in 1993 (171/314) compared with 93% in 1996 (289/312) (p < 0.0001). Improvement occurred in all categories. For stillbirths, 35% (46/133) were above the minimum standard in 1993 compared with 90% (104/116) in 1996 (p < 0.0001); for cases not classified as sudden unexpected death in infancy (SUDI), the improvement was from 62% in 1993 (40/65) to 97% in 1996 (73/75) (p < 0.0001); and for SUDI cases, the improvement was from 32% in 1993 (10/31) to 91% in 1996 (21/23) (p < 0.0001). The quality of both non-regional and regional necropsies improved. For non-regional cases, the score was above the minimum standard in 28% (51/183) in 1993 compared with 69% (52/75) in 1996 (p < 0.0001); for regional cases it improved from 92% (120/131) in 1993 to 100% (237/237) in 1996 (p < 0.0001). CONCLUSIONS: The quality of perinatal and infant necropsies improved considerably between 1993 and 1996, reflecting better awareness of the importance of good quality examination and an increase in referrals to paediatric centres. (+info)
Paediatric oncology and intensive care treatments: changing trends.
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OBJECTIVES: To review the outcome of patients with childhood malignancy requiring intensive care treatment and to assess whether there is any secular trend for improved outcome. DESIGN: Retrospective chart reviews of 74 consecutive admissions to a paediatric intensive care unit from a regional paediatric oncology centre between 1990 and 1997. During the same period there were 6419 admissions to the oncology unit, 814 of whom were new cases. RESULTS: The overall survival at discharge from the intensive care unit was 49 of 74. Patients with either systemic or respiratory infection requiring ventilation had the poorest survival (13 of 31) whereas postoperative patients had the best survival (15 of 15). However, patients with respiratory or systemic infection who required inotropic support with more than three agents all died compared with about one quarter of those needing no inotrope. All patients with systemic or respiratory infective illness were neutropenic and positive microbiological identification was possible in 13 of 21 and five of 18, respectively. Non-survivors had a higher mean acute physiology and chronic health evaluation system (APACHE-II) score than survivors (24.2 v 15.94, respectively) but no patient with a score of > 27 survived. CONCLUSION: Compared with previous series, there has been a great improvement in survival of oncology patients admitted to the intensive care unit especially those with either systemic or respiratory infection needing ventilation. Full intensive care treatment should be provided for these patients. (+info)
Anthem Blue Cross and Blue Shield's coronary services network: a managed care organization's approach to improving the quality of cardiac care for its members.
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OBJECTIVE: To describe a managed care organization's efforts to improve value for its members by forming a coronary services network (CSN). DESIGN: To identify high-quality facilities for its CSN, Anthem Blue Cross and Blue Shield reviewed claims data and clinical data from hospitals that met its general quality standards. An external firm measured and risk-adjusted applicant hospitals' mortality rates. Hospitals that demonstrated superior performance were eligible to join the CSN. In 1996, 2 years after the CSN was formed, clinical outcomes of participants and new applicants were analyzed again by the same external firm. PATIENTS AND METHODS: Data on more than 10,000 consecutive (all-payer) inpatients discharged after coronary bypass surgery in 1993 were collected from 16 applicant hospitals using a uniform format and data definitions. This analysis was expanded to 23 participating and applicant hospitals that discharged more than 13,000 patients who underwent either bypass surgery or coronary revascularization in 1995. We compared risk-adjusted routine length of stay (a measure of efficiency), mortality rates, and adverse outcome rates between CSN and non-CSN facilities. RESULTS: From 1993 to 1995, overall length of stay in the network decreased by 20%, from 12.3 to 9.8 days (P < or = 0.01) and severity-adjusted mortality rates decreased by 7.3%, from 2.9% to 2.7%. Initially, facilities outside the network had comparable efficiency but much higher mortality. However, they improved so much in both measures that their severity-adjusted mortality rate for bypass surgery in 1995 was no more than 10% higher than that of CSN hospitals. CONCLUSION: The creation of a statewide CSN that emphasized and improved the level of performance among providers ultimately benefited the carrier's managed care members. The desirability of participation was evidenced by an increase in the number of applicant hospitals over the 2 years. This may have stimulated quality improvement among competing providers in the region and among CSN facilities themselves. (+info)
Meta-manager: a requirements analysis.
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The digital imaging network-picture-archiving and communications system (DIN-PACS) will be implemented in ten sites within the Great Plains Regional Medical Command (GPRMC). This network of PACS and teleradiology technology over a shared T1 network has opened the door for round the clock radiology coverage of all sites. However, the concept of a virtual radiology environment poses new issues for military medicine. A new workflow management system must be developed. This workflow management system will allow us to efficiently resolve these issues including quality of care, availability, severe capitation, and quality of the workforce. The design process of this management system must employ existing technology, operate over various telecommunication networks and protocols, be independent of platform operating systems, be flexible and scaleable, and involve the end user at the outset in the design process for which it is developed. Using the unified modeling language (UML), the specifications for this new business management system were created in concert between the University of Arizona and the GPRMC. These specifications detail a management system operating through a common object request brokered architecture (CORBA) environment. In this presentation, we characterize the Meta-Manager management system including aspects of intelligence, interfacility routing, fail-safe operations, and expected improvements in patient care and efficiency. (+info)
Study of a patient referral system in the Republic of Honduras.
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The first nationwide study on a patient referral system was conducted in Honduras. It covered all 25 public hospitals (six National, five Regional and 14 Area Hospitals) and 24 major health centres. Based on 46,739 reviews of patient records, 226 'received referral' and 1072 'sent referral' cases were analyzed by age and sex of the patient, diagnosis on referral, institution from or to which the case was referred, use of proper referral form, and reception of reply for referrals. At the same time, the study team supervised the function of the registry and management of patient records at each institution. The average referral rate by the level of health facility was 15.8% at National, 4.0% at Regional, 2.8% at Area Hospitals, and 0.8% at health centres. The referral rate was observed to be higher when institutional managers emphasized the importance of the referral system. Only 1.4% of referrals received a reply from upper level institutions. The most common cases for referral were neurological at National, obstetric at Regional and respiratory cases at Area Hospitals. The use rate of the standard referral form was 70 to 80% at hospitals and 60% at health centres. There was no norm to duplicate referral letters for record keeping. The patient referral system has not developed satisfactorily in Honduras. The main problems were: 1) low referral rate at all levels of institution, 2) evident by-pass phenomenon at intermediate hospitals, 3) inadequate health information system for patient referral, and 4) misunderstanding of the terminology of referral by health personnel. The following recommendations were made: guarantee of essential health services at peripheral institutions, development of an effective information system for patient referral, facilitation of frequent reply for referrals, elaboration of referral case discussion between institutions, patient education on proper use of health facilities, and restructuring the health service network in the two major cities. (+info)
Changes in Canadian women's mammography rates since the implementation of mass screening programs.
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OBJECTIVES: This study reports on Canadian mammography rates between 1990, when mass screening programs were launched, and 1994/95. METHODS: Mammography rates from 2 national surveys were compared according to the presence of a provincial screening program. RESULTS: Mammography rates among women aged 50 to 69 years (the targeted group) increased significantly, by 16%; increases were twice as high in provinces with screening programs. Among women in their 40s (nontargeted group), the changes were insignificant and independent of screening program status. CONCLUSIONS: Screening programs appear to have influenced the mammography rates of targeted women aged 50 to 69 years. (+info)
Surveillance of problem drug use in the UK: a review of a Regional Drug Misuse Database.
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BACKGROUND: We report detailed findings of the first systematic validation of a Regional Drug Misuse Database (RDMD); such databases constitute the main investment in routine drug statistics in the UK by the Department of Health. METHODS: A retrospective case-finding study in a stratified random sample of one in three specialist drug agencies was carried out. Agency records of clients attending during 1994 were matched with reports (episodes) to the North Thames RDMD to assess the level of under-reporting, and the relationship between RDMD reports (episodes) and the number of problem drug users in contact with agencies. Under-ascertainment of cases was estimated using two-sample capture-recapture. RESULTS: Under-reporting was associated with agency records missing full date of birth or initials (attributers), and agency type. Compared with drug dependency units (DDU) the odds of under-reporting were 3-18 times higher by the other specialist drug agencies. Even after excluding episodes with missing attributers the odds ratio (OR) of not being reported was significantly higher among needle exchanges (OR 2.7), non-statutory community based drug teams (OR 3.2), statutory community based drug teams (OR 4.9) and residential rehabilitation units (OR 8.7) compared with DDUs. Overall database episodes represented 60 per cent of the number of clients attending specialist agencies as a result of a mixture of under-reporting and the proportion of clients retained in treatment, which also varied by agency type. A total of 727 individuals (16 per cent) had never been reported. CONCLUSIONS: Surveillance of drug misuse through RDMDs does not yet fulfil its objectives. It is essential that a system of following up reports is introduced to improve their utility, and to contribute to the monitoring of the UK Government's new drugs strategy, and wider European surveillance. (+info)
A new architecture for enterprise information systems.
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Irresistible economic and technical forces are forcing healthcare institutions to develop regionalized services such as consolidated or virtual laboratories. Technical realities, such as the lack of an enabling enterprise-level information technology (IT) integration infrastructure, the existence of legacy systems, and non-existent or embryonic enterprise-level IT services organizations, are delaying or frustrating the achievement of the desired configuration of shared services. On attempting to address this matter, we discover that the state-of-the-art in integration technology is not wholly adequate, and itself becomes a barrier to the full realization of shared healthcare services. In this paper we report new work from the field of Co-operative Information Systems that proposes a new architecture of systems that are intrinsically cooperation-enabled, and we extend this architecture to both the regional and national scales. (+info)