Stroke units in their natural habitat: can results of randomized trials be reproduced in routine clinical practice? Riks-Stroke Collaboration.
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BACKGROUND AND PURPOSE: Meta-analyses of randomized controlled trials of acute stroke care have shown care in stroke units (SUs) to be superior to that in conventional general medical, neurological, or geriatric wards, with reductions in early case fatality, functional outcome, and the need for long-term institutionalization. This study examined whether these results can be reproduced in clinical practice. METHODS: A multicenter observational study of procedures and outcomes in acute stroke patients admitted to designated SUs or general medical or neurological wards (GWs), the study included patients of all ages with acute stroke excluding those with subarachnoid hemorrhage, who were entered into the Riks-Stroke (Swedish national quality assessment) database during 1996 (14 308 patients in 80 hospitals). RESULTS: Patients admitted to SUs who had lived independently and who were fully conscious on admission to the hospital had a lower case fatality than those cared for in GWs (relative risk [RR] for death, 0.87; 95% confidence interval [CI], 0.79 to 0.96) and at 3 months (RR, 0.91; 95% CI, 0.85 to 0.98). A greater proportion of patients cared for in an SU could be discharged home (RR, 1.06; 95% CI, 1.03 to 1.10), and fewer were in long-term institutional care 3 months after the stroke (RR, 0.94; 95% CI, 0.89 to 0.99). No difference was seen in outcome in patients cared for in SUs or GWs if they had impaired consciousness on admission. CONCLUSIONS: The improvement in outcomes after stroke care in SUs compared with care in GWs can be reproduced in the routine clinical setting, but the magnitude of the benefit appears smaller than that reported from meta-analyses. (+info)
An epidemic of congenital syphilis in Jefferson County, Texas, 1994-1995: inadequate prenatal syphilis testing after an outbreak in adults.
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OBJECTIVES: After a syphilis epidemic in Jefferson County, Texas, in 1993 and 1994, congenital syphilis prevalence and risk factors were determined and local prenatal syphilis screening practices were assessed. METHODS: Medical records were reviewed, pregnant women with syphilis were interviewed, and prenatal care providers were surveyed. RESULTS: Of 91 women, 59 (65%) had infants with congenital syphilis. Among African Americans, the prevalence per 1000 live births was 24.1 in 1994 and 17.9 in 1995. Of the 50 women with at least 2 prenatal care visits who had infants with congenital syphilis, 15 (30%) had received inadequate testing. Only 16% of 31 providers obtained an early third-trimester syphilis test on all patients. CONCLUSIONS: Inadequate prenatal testing contributed to this outbreak of congenital syphilis. (+info)
Cancer mortality in Russia and Ukraine: validity, competing risks and cohort effects.
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BACKGROUND: The dramatic increase in mortality in Russia and Ukraine in the late 1980s and 1990s has been due to increases in certain causes of death, particularly cardiovascular disease and accidents and violence. In contrast, there has been a slight fall in mortality from cancer. METHODS: This paper presents an analysis of trends and patterns in cancer mortality and examines four possible explanations for its recent fall: changes in data collection; cohort effects; competing mortality from other causes of death; and improvements in health care. RESULTS: All contribute to some extent to the observed changes, with each affecting predominantly different age groups. There is evidence of a significant underrecording of cancer deaths among the elderly especially in rural areas and of significant changes in coding practices in the early 1990s. Competing mortality from cardiovascular diseases and accidents can explain some reduction in male deaths from cancer in middle age. Birth cohort effects can explain some reduction among males after early middle age and among females at all ages. The impact of changes in health care are more difficult to identify with certainty but there is evidence of reduced deaths from childhood leukaemia. IMPLICATIONS: Recent changes in mortality in Russia are complex and their understanding will require a multidisciplinary approach embracing demography, epidemiology and health services research. (+info)
The changing US health care system: challenges for responsible public policy.
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The "managed care backlash" arguably topped the list of media and policy concerns in 1998. Yet, against the background of the highly charged environment in which the future of our health care system continues to be debated, there is a dearth of concrete, "objective" facts on the nature of the changes, the reasons for them, and their meaning. An analysis of five important themes that emerged from a review of the recent literature on health system change concludes that an inherent tension exists between the interest in rapidly driving down health care costs through organizational change and the long time frames that are required to make fundamental changes in structure, process, and orientation. Unfortunately, in an environment in which purchasers are driven to seek cost savings and the political will supports a pluralistic and mixed public/private system, the health system may chart an alternative course, with the result that purchasers may rely increasingly on individual cost sharing and continue to cut back the amount of coverage they are willing to offer. The real challenge for public policy makers is to confront the issues directly, avoiding political incentives to adopt easy and fast solutions for these complex matters. (+info)
Assessment of management in general practice: validation of a practice visit method.
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BACKGROUND: Practice management (PM) in general practice is as yet ill-defined; a systematic description of its domain, as well as a valid method to assess it, are necessary for research and assessment. AIM: To develop and validate a method to assess PM of general practitioners (GPs) and practices. METHOD: Relevant and potentially discriminating indicators were selected from a systematic framework of 2410 elements of PM to be used in an assessment method (VIP = visit instrument PM). The method was first tested in a pilot study and, after revision, was evaluated in order to select discriminating indicators and to determine validity of dimensions (factor and reliability analysis, linear regression). RESULTS: One hundred and ten GPs were assessed with the practice visit method using 249 indicators; 208 of these discriminated sufficiently at practice level or at GP level. Factor analysis resulted in 34 dimensions and in a taxonomy of PM. Dimensions and indicators showed marked variation between GPs and practices. Training practices scored higher on five dimensions; single-handed and dispensing practices scored lower on delegated tasks, but higher on accessibility and availability. CONCLUSION: A visit method to assess PM has been developed and its validity studied systematically. The taxonomy and dimensions of PM were in line with other classifications. Selection of a balanced number of useful and relevant indicators was nevertheless difficult. The dimensions could discriminate between groups of GPs and practices, establishing the value of the method for assessment. The VIP method could be an important contribution to the introduction of continuous quality improvement in the profession. (+info)
Deliberate departures from good general practice: a study of motives among Dutch general practitioners.
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BACKGROUND: When general practitioners (GPs) act contrary to their own standards of good practice, they usually cite patient demands as the main reason. However, up until now, studies have relied on doctors' recollections of departures from their own norms, which may be unreliable. AIM: To systematically explore GPs' motives for deliberate departures from their own conception of good practice. METHOD: Forty-nine GPs, over five days, registered to what extent they had deviated from their own norms, and recorded the motives underlying any deviation. RESULTS: Of the 6087 consultations registered, 10% contained some departure from 'good' general practice, the majority (75%) of which was perceived by the doctor concerned as 'slight'. Doctors underpinned their departures mostly by referring to the doctor-patient relationship: the wish to be nice was used, on average, in 42% of deviations, and the wish to prevent a conflict in 30%. The most important non-relational motive was clinical uncertainty, which doctors used in 11% of their cases. DISCUSSION: Contrary to common belief, GPs often comply with patient requests because they wish to, and not because they feel forced to. Whether or not this behaviour affects the quality of care is largely dependent on the model of 'good' general practice used. (+info)
Impact of a DRG-based hospital financing system on quality and outcomes of care in Italy.
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OBJECTIVE: To examine potential changes in quality of care associated with a recent financing system implementation in Italy: in 1995, hospital financing reform implemented in Italy included the introduction of a DRG-based hospital financing system with the goals of controlling the growth of hospital costs and making hospitals more accountable for their productivity. DATA SOURCES: Hospital discharge abstract data from 1993 through 1996 for all hospitals (N=32) in the Friuli-Venezia-Giulia region of Italy. Regional population data were used to calculate rates. STUDY DESIGN: Changes between 1993 and 1996 in hospital admissions, length of stay, mortality rates, severity of illness, and readmission rates were studied for nine common medical and surgical conditions: appendicitis, diabetes mellitus, colorectal cancer, cholecystitis, bronchitis/chronic obstructive pulmonary disease (COPD), bacterial pneumonia, coronary artery disease, cerebrovascular disease, and hip fracture. PRINCIPAL FINDINGS: The total number of ordinary hospital admissions decreased from 244,581 to 204,054 between 1993 and 1996, a population-based decrease of 17.3 percent (p<.001). The mean length of stay decreased from 9.1 days to 8.8 days, resulting in a 21.1 percent decrease in hospital bed days (p<.001). Day hospital use increased sevenfold from 16,871 encounters in 1993 to 108,517 encounters in 1996. The largest decrease in hospital admissions among study conditions was a 41 percent decrease for diabetes (from 2.25 per 1,000 in 1993 to 1.31 in 1996, p<.001). For eight of the nine conditions, severity of illness increased. Differences between severity-adjusted expected and observed in-hospital mortality rates were small. CONCLUSIONS: Observed trends showed a decrease in ordinary hospital admissions, an increase in day hospital admissions, and a greater severity of illness among hospitalized patients. There was little or no change in mortality and readmission rates. Administrative data can be used to track changes in patterns of care and to identify potential quality problems deserving further review. (+info)
Clinical practice guidelines in end-stage renal disease: a strategy for implementation.
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Clinical practice guidelines (CPGs) for end-stage renal failure (ESRD) were recently published, and represent a comprehensive review of available literature and the considered judgment of experts in ESRD. To prioritize and implement these guidelines, the evidence underlying each guideline should be ranked and the attributes of each should be defined. Strategies to improve practice patterns should be tested. Focused information for each high priority guideline should be disseminated, including a synopsis and assessment of the underlying evidence, the evidence model used to develop that guideline, and suggested strategies for CPG implementation. Clinical performance measures should be developed and used to measure current practice, and the success of changing practice patterns on clinical outcomes. Individual practitioners and dialysis facilities should be encouraged to utilize continuous quality improvement techniques to put the guidelines into effect. Local implementation should proceed at the same time as a national project to convert high priority CPGs into clinical performance measures proceeds. Patients and patient care organizations should participate in this process, and professional organizations must make a strong commitment to educate clinicians in the methodology of CPG and performance measure development and the techniques of continuous quality improvement. Health care regulators should understand that CPGs are not standards, but are statements that assist practitioners and patients in making decisions. (+info)