Search

Background: Assertive community treatment (ACT) teams have been implemented across England since 1999. Although successful at engaging clients, the model has failed to show the same clinical effectiveness in trials in Europe as in the US and Australia., Aim: To investigate current ACT provision in England, aims of treatment and team managers' views of the effectiveness of ACT and the most important interventions., Method: Postal survey of managers of all services in England identifying as ACT teams., Results: A total of 104/187 (56%) completed questionnaires were received. The majority of teams were in urban or mixed urban/rural areas. One third (36%) of teams had no psychiatrist, one half (48%) had no psychologist and less than a fifth (18%) had designated inpatient admission beds. The areas of intervention rated as most important by team managers could be delivered by non-professionally trained staff (engagement, accommodation, finances). The majority of managers reported positive clinical outcomes but only one third had collected data to support this. One third of teams were undergoing review or being reconfigured or closed., Conclusion: Successful client engagement is not being used as a vehicle to deliver evidence-based interventions. Many ACTs in England are not adequately staffed to deliver these.

The literature is littered with reports presenting the proportion of patients admitted with ischaemic stroke receiving thrombolysis. This gives some measure of activity and the efficiency of prehospital and hospital triage. Some stroke centres have reported rates of thrombolysis as high as 20%, but without knowing the population that such services serve, these proportions do not indicate how well or equitably the treatment is being delivered. Here, we explore various metrics to monitor our efforts to provide equitable access to stroke thrombolysis in Lothian, a region in the South East of Scotland., (© 2010 The Authors. International Journal of Stroke © 2010 World Stroke Organization.)

Effective communication is critical to providing quality health care and can be affected by a number of modifiable organizational factors. The authors performed a prospective multisite validation study of an organizational communication climate assessment tool in 13 geographically and ethnically diverse health care organizations. Communication climate was measured across 9 discrete domains. Patient and staff surveys with matched items in each domain were developed using a national consensus process, which then underwent psychometric field testing and assessment of domain coherence. The authors found meaningful within-site and between-site performance score variability in all domains. In multivariable models, most communication domains were significant predictors of patient-reported quality of care and trust. The authors conclude that these assessment tools provide a valid empirical assessment of organizational communication climate in 9 domains. Assessment results may be useful to track organizational performance, to benchmark, and to inform tailored quality improvement interventions.

The cumulative summation (CUSUM) test is increasingly being used in medicine to monitor a wide variety of processes such as cardiac surgery or disease outbreaks. The CUSUM sequentially tests the null hypothesis that the process is in control, i.e. its mean is equal to a given target. Thus, it detects when the process changes to an out of control state. Conversely, monitoring the learning curve requires detecting the time when the process reaches an in control state. In this work we develop an alternative to the CUSUM, the learning curve CUSUM (LC-CUSUM), that serves to detect when a process deviates from an out of control state to an in control state. The test is based on a two one-sided tests procedure where the null hypothesis is that the process is out of control. This can be written as H(0): |mu-mu(0)|> or =delta tested against H(1): |mu-mu(0)|< delta. The null hypothesis is thus the union of two one-sided hypotheses and is rejected when both are rejected. A CUSUM test statistic is then constructed for each hypothesis in a traditional way. The properties of the test are investigated through numerical simulations, and are illustrated on the learning curve of an endoscopist performing endoscopic retrograde cholangiopancreatographies for biliary tract disorders.

Objective: To determine the status of diabetes care among community pharmacy patients with diabetes., Design: Cross-sectional observational study., Setting: United States, 2005., Patients: 1,455 community pharmacy patients aged 18 years or older with diabetes who were diagnosed before 2005., Intervention: Analysis of the Medical Expenditure Panel Survey., Main Outcome Measures: Proportions of patients meeting American Diabetes Association (ADA) standards of medical care in diabetes., Results: In 2005, 1,455 patients with diabetes who were diagnosed before 2005 filled prescriptions through community pharmacies. Gaps occurred between the diabetes care of these patients and ADA standards. Examples include the following: ADA recommends at least two glycosylated hemoglobin (A1C) tests annually, but 19.52% of the study population reported less than two A1C tests in 2005; ADA recommends annual influenza vaccinations, but 42.46% of the study population reported not receiving an influenza vaccination in 2005; and ADA recommends weight control, but 83.74% of the study population was overweight or obese., Conclusion: The current results demonstrate that many patients with diabetes are not receiving adequate care and that pharmacists have an opportunity to improve diabetes management.

Objective: To compare self-reported (SR) medication use and pharmacy data for major psychoactive medications and three classes of medications used for different indications, and to determine the socio-economic factors associated with the congruence., Methods: Postal questionnaire data collected in 1997 were compared with the register of the Social Insurance Institution of Finland on the reimbursed prescriptions purchased during 1997. Altogether 7625 subjects were included in this study. Drugs were categorized according to the Anatomical Therapeutic Chemical (ATC) system., Results: Kappa values were 0.77, 0.68, 0.84, 0.92 and 0.55 for antipsychotics, antidepressants, antiepileptics, antidiabetics and beta-blocking agents, respectively. Prevalence-adjusted and bias-adjusted kappa values were almost perfect (0.98-1.00). Reliability of antipsychotics use was better for married subjects than for those who were not married; and of antidepressants use for highly educated and married subjects than for those who were less educated and were not married. Altogether 414 (5.4%) responders and 285 (7.1%) non-responders had used at least one of the selected medications., Conclusion: Agreement between the SR and pharmacy data was moderate for psychoactive medication use. Even though data collected by postal questionnaire may underestimate the prevalence of medication use due to non-participation it can be assumed accurate enough for study purposes.

Background: Controversy has attended the relationship between risk-adjusted mortality and process-of-care. There would be advantage in the establishment, at the data-base level, of global quantitative indices subsuming the diversity of process-of-care., Methods: A retrospective, cohort study of patients identified in the Australian and New Zealand Intensive Care Society Adult Patient Database, 1993-2003, at the level of geographic and ICU-level descriptors (n = 35), for both hospital survivors and non-survivors. Process-of-care indices were established by analysis of: (i) the smoothed time-hazard curve of individual patient discharge and determined by pharmaco-kinetic methods as area under the hazard-curve (AUC), reflecting the integrated experience of the discharge process, and time-to-peak-hazard (TMAX, in days), reflecting the time to maximum rate of hospital discharge; and (ii) individual patient ability to optimize output (as length-of-stay) for recorded data-base physiological inputs; estimated as a technical production-efficiency (TE, scaled [0,(maximum)1]), via the econometric technique of stochastic frontier analysis. For each descriptor, multivariate correlation-relationships between indices and summed mortality probability were determined., Results: The data-set consisted of 223129 patients from 99 ICUs with mean (SD) age and APACHE III score of 59.2(18.9) years and 52.7(30.6) respectively; 41.7% were female and 45.7% were mechanically ventilated within the first 24 hours post-admission. For survivors, AUC was maximal in rural and for-profit ICUs, whereas TMAX (>or= 7.8 days) and TE (>or= 0.74) were maximal in tertiary-ICUs. For non-survivors, AUC was maximal in tertiary-ICUs, but TMAX (>or= 4.2 days) and TE (>or= 0.69) were maximal in for-profit ICUs. Across descriptors, significant differences in indices were demonstrated (analysis-of-variance, P

Background: This study aims to describe the development, testing and optimization of a new standard instrument, the Consumer Quality Index (CQ-index) Long-term Care, for measuring client experiences with long-term care in the Netherlands., Methods: Three versions of the CQ-index questionnaires and protocols for study sampling and data collection were developed, designed for interviews with residents of nursing or residential care homes and postal surveys among representatives of psychogeriatric residents and homecare clients. From July to November 2006 a pilot study was conducted among 2,697 clients of 68 nursing or residential care homes, 2,164 representatives of clients in 57 psychogeriatric care institutions, and 1,462 clients of 19 homecare organizations. We performed psychometric analyses and descriptive analyses, and evaluated the pilot study., Results: The pilot study showed the feasibility and usability of the instruments, supported the multidimensionality of the questionnaires and showed first findings on client experiences and possibilities for quality improvement. Nine scales applied to all care settings: shared decision making, attitude and courtesy, information, body care, competence and safety of care, activities, autonomy, mental well-being, and availability of personnel. The pilot resulted in three optimized questionnaires and recommendations for nationwide implementation., Conclusions: The CQ-index Long-term Care provides a good basis to investigate the quality of nursing homes, residential care homes and homecare from the clients' perspective. This standardized instrument enables a nationwide comparison of the quality of long-term care for the purpose of transparency and quality assurance.

Background: Because hot flashes usually persist for years after menopause, a clinically meaningful hot flash therapy needs to have long-term efficacy; however, it is unclear for how long a therapy needs to be compared with a placebo before long-term efficacy can be reasonably deduced. The Food and Drug Administration (FDA) requires a 12-week treatment period for industry-initiated hot flash trials, whereas most academic-initiated trials have ranged from 4 to 12 weeks. We have focused on reviewing nonhormonal hot flash trials to identify inadequate trial durations as a guide toward deducing adequate trial duration to reasonably assess for long-term efficacy., Methods: An electronic database search of MEDLINE, Web of Science, and PsycINFO was performed from 1966 to May 2009 to identify target studies showing a nonhormonal hot flash therapy to be effective at early time points only to become ineffective at later time points (i.e., showing short-term but not long-term efficacy) in a randomized controlled trial (RCT). The longest early time point of efficacy from the target studies plus 1 additional week would be considered the minimum treatment duration necessary to assess for long-term efficacy., Results: Of 2518 citations, 54 RCTs met our inclusion criteria, from which 3 target studies were identified. These 3 target studies evaluated Bellergal Retard (Sandoz, East Hanover, NJ), soy, and venlafaxine and showed times of 2, 6, and 7 weeks, respectively, when the nonhormonal compound last demonstrated efficacy before subsequently losing efficacy in a single RCT., Conclusions: This analysis supports a hot flash RCT duration of at least 8 weeks to reasonably assess a nonhormonal compound's long-term efficacy.

Background: Women's primary-care services are frequently dispensed to HIV-infected women through HIV specialty clinics. Our objective was to evaluate cervical cancer and breast cancer screening practices in a county-based HIV clinic in San Mateo, California., Methods: This was a retrospective cohort study of medical records of HIV-infected women obtaining HIV care at this site., Results: Between January 1, 2002 and December 31, 2006, 69 women were documented to have at least 12 months of medical care at the clinic. Median followup time was 51 months. Over 253 person-years of followup, there were 656 pap smears performed per 1,000 person-years; 77.9% of women had at least one Pap smear during the study time period. A total of 59.5% (47/79) of normal pap smears had a followup pap smear within 18 months; 62.0% of abnormal pap smears had a followup pap smear within 12 months. A CD4 count of less than 200 cells/mm(3) was associated with not receiving a pap smear in multivariable analysis. Mammogram screening was performed on 64.7% of women aged 40 or older., Conclusions: Based on the results of this study, the majority of HIV-infected women at this clinic received cervical and breast cancer screening at some point during their care. Only two-thirds of abnormal pap smear results had followup pap smear screening within a year. With the increased risk of cervical cancer in HIV-infected women, efforts should be made to promote cervical cancer screening, particularly in high-risk women.

Background: Few quality of care evaluations examine the relationship between clinical processes and patient outcomes., Objective: To determine the association between health plan performance on Healthcare Effectiveness Data and Information Set (HEDIS) clinical processes and intermediate outcome measures and Health Outcomes Survey (HOS) self-reported physical and mental health scores among Medicare plan enrollees with diabetes., Research Design: Secondary data analysis of 2002 HEDIS and 2001-2003 HOS data., Subjects: This study focused on Medicare plan enrollees with self-reported diabetes (N = 8184)., Measures: Plan-level HEDIS diabetes care measures for 2002 and longitudinal, patient-level 2001-2003 HOS physical and mental health outcomes scores. Hierarchical linear models estimated the relationship between plan HEDIS performance on diabetes process of care and intermediate outcome measures and 2-year changes in enrollee HOS physical and mental health scores., Results: Each 10% point improvement in plan performance on HEDIS intermediate outcomes (ie, the proportion of well-controlled diabetes) was related to significant positive increase in the probability of being healthy as measured by both enrollee physical health scores (7 percentage point increase, P < 0.05) and mental health scores (11 percentage point increase, P < 0.01). Similar increases in plan process of care measures were associated with increases in the probability of being healthy as measured by enrollee mental health scores (11 percentage point increase, P < 0.001)., Conclusions: This study represents one of the first attempts to link plan HEDIS performance to changes in enrollee health. The results suggest that improved quality of care, as measured by process and intermediate outcomes measures for diabetes, can result in better health among patients with diabetes. Further research should address whether this relationship exists in other quality measures, clinical conditions, and populations.

Background: Process measures have been developed and implemented to evaluate the quality of care patients receive in the hospital. This study examines whether there is an association between the quality of in-hospital cardiac care and a hospital's proportion of low-income patients., Methods and Results: A retrospective analysis of 1979 hospitals submitting information on 12 quality of care (QoC) process measures for acute myocardial infarction (AMI) and congestive heart failure (CHF) patients to the Hospital Quality Alliance during 2005 and 2006 and meeting all study inclusion criteria. Mean hospital performance ranged from 84.2% (ACE inhibitor for left ventricular systolic dysfunction) to 95.9% (aspirin on arrival) for AMI QoC process measures and from 64.4% (discharge instructions) to 92.4% (left ventricular function assessment) for CHF QoC process measures. Regression analyses indicated a statistically significant negative association between the proportion of low-income patients and hospital performance for 10 of the 12 cardiac QoC process measures, after controlling for selected hospital characteristics., Conclusions: Hospital adherence to QoC process measures for AMI and CHF patients declined as the proportion of low-income patients increased. Future research is needed to examine the role of community characteristics and market forces on the ability of hospitals with a disproportionate share of low-income patients to maintain the staffing, equipment, and policies necessary to provide the recommended standards of care for AMI and CHF patients.

Background: Recent efforts to improve care for patients hospitalized with heart failure have focused on process-based performance measures. Data supporting the link between current process measures and patient outcomes are sparse., Objective: To examine the relationship between adherence to hospital-level process measures and long-term patient-level mortality and readmission., Research Design: Analysis of data from a national clinical registry linked to outcome data from the Centers for Medicare and Medicaid Services (CMS)., Subjects: A total of 22,750 Medicare fee-for-service beneficiaries enrolled in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure between March 2003 and December 2004., Measures: Mortality at 1 year; cardiovascular readmission at 1 year; and adherence to hospital-level process measures, including discharge instructions, assessment of left ventricular function, prescription of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker at discharge, prescription of beta-blockers at discharge, and smoking cessation counseling for eligible patients., Results: Hospital conformity rates ranged from 52% to 86% across the 5 process measures. Unadjusted overall 1-year mortality and cardiovascular readmission rates were 33% and 40%, respectively. In covariate-adjusted analyses, the CMS composite score was not associated with 1-year mortality (hazard ratio, 1.00; 95% confidence interval, 0.98-1.03; P = 0.91) or readmission (hazard ratio, 1.01; 95% confidence interval, 0.99-1.04; P = 0.37). Current CMS process measures were not independently associated with mortality, though prescription of beta-blockers at discharge was independently associated with lower mortality (hazard ratio, 0.94; 95% confidence interval, 0.90-098; P = 0.004)., Conclusion: Hospital process performance for heart failure as judged by current CMS measures is not associated with patient outcomes within 1 year of discharge, calling into question whether existing CMS metrics can accurately discriminate hospital quality of care for heart failure.

Objective: The objective of this research was to examine differences in patterns of statin prescribing between Northern Ireland and England both before and after the introduction of the Quality and Outcomes Framework (QOF)., Setting: Primary care practices in Northern Ireland and England. Method Northern Ireland practices were matched with practices in England, statin prescribing data and QOF achievement scores (for the first year post-QOF) were obtained. Crude prescribing data from matched practices were manipulated to provide a data set of Defined Daily Doses (DDDs)/1,000 patients and cost/DDD/1,000 patients for each statin drug entity covering 1 year before and after the introduction of QOF. QOF achievements were converted into percentage scores for matched practices., Main Outcome Measure: Cost per defined daily dose (DDD) per 1,000 patients., Results: Significantly less statins (DDD/1,000 patients) were dispensed in Northern Ireland compared with the matched region in England both before and after the introduction of QOF (P < 0.001). However, significantly more statins were dispensed in both regions after the introduction of QOF. As a result of the introduction of QOF, the cost/DDD/1,000 patients rose by pound13.17 in NI, but fell by pound3.76 in the matched region in England., Conclusion: Strategies should be considered to educate prescribers on cost-effectiveness by increasing their awareness of the negative budgetary impact resulting from early adoption of new and expensive statins and by encouraging generic prescribing.

Purpose: The current wars in Iraq and Afghanistan have led to an increasing number of female veterans seeking medical and mental healthcare in the Department of Veterans Affairs (VA) healthcare system. To better understand gender differences in healthcare needs among recently returned veterans, we examined the prevalence of positive screenings for depression, posttraumatic stress disorder (PTSD), military sexual trauma (MST), obesity, and chronic pain among female and male veterans of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) receiving care at the VA Connecticut Healthcare System., Methods: We performed a retrospective, cross-sectional data analysis of OEF/OIF veterans at VA Connecticut who received services in either Primary Care or the Women's Health Clinic between 2001 and 2006., Results: In this study, 1129 electronic medical records (1032 men, 197 women) were examined. Female veterans were more likely to screen positive for MST (14% vs. 1%, p < 0.001) and depression (48% vs. 39%, p = 0.01) and less likely to screen positive for PTSD (21% vs. 33%, p = 0.002). There was no significant gender difference in clinically significant pain scores. Men were more likely than women to have body mass index (BMI) >30 kg/m(2) (21% vs. 13%, p = 0.008)., Conclusions: These results suggest that important gender differences exist in the prevalence of positive screenings for MST, depression, obesity, and PTSD. As the VA continues to review and improve its services for women veterans, clinicians, researchers, and senior leaders should consider innovative ways to ensure that female veterans receive the health services they need within the VA system.

Aim: It has been established that patients with severe mental illness are at increased risk of physical illness and that physical health screening should be performed when an individual experiences a first episode of psychosis. The aim of the audit was to examine how physical health screening was achieved in the real world of an early intervention in psychosis (EIP) service in Scotland. Of particular interest was considering if primary or secondary care were more effective in providing specific physical health assessment for those presenting to the service., Methods: A case note audit was performed., Results: The audit shows that physical examination and blood tests were being completed in the majority of service users under the care of the Esteem service. However, an unacceptably high number were not undergoing sufficient initial screening for metabolic syndrome or having baseline monitoring prior to commencing antipsychotic medication., Conclusions: Our results suggest that relying on primary care to provide physical health screening was not an effective approach in a population experiencing first-episode psychosis. Having a psychiatrist motivated to perform physical health screening within the EIP team may help to improve the uptake of physical health screening. Strategies to improve physical health screening in EIP services are discussed., (© 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Asia Pty Ltd.)

Background: Minimizing delays to coronary reperfusion is critical in the management of acute myocardial infarction (AMI)., Aims: To determine delays in in-hospital management and factors associated with delays of over 45min., Methods: We analysed data from the Observatoire Régional Breton sur l'Infarctus, a registry of AMI patients admitted within 24h of symptom onset (July 2007 to December 2008) to an interventional cardiology centre in Brittany. Prehospital delay was defined as time between first responder arrival at the patient and patient arrival at an interventional cardiovascular centre. In-hospital delay was defined as time between admission to the interventional cardiovascular centre and first balloon inflation. Patients were grouped according to duration of in-hospital delay (>45 vs

Local public health agencies are challenged to continually improve service delivery, yet they frequently operate with constrained resources. Quality improvement methods and techniques such as statistical process control are commonly used in other industries, and they have recently been proposed as a means of improving service delivery and performance in public health settings. We analyzed a quality improvement project undertaken at a local Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinic to reduce waiting times and improve client satisfaction with a walk-in nutrition education service. We used statistical process control techniques to evaluate initial process performance, implement an intervention, and assess process improvements. We found that implementation of these techniques significantly reduced waiting time and improved clients' satisfaction with the WIC service.

Using Medicare inpatient claims and Hospital Compare process of care quality data from the period 2004-2006, we estimate two model specifications to test for the presence of correlational and causal relationships between hospital process of care performance measures and risk-adjusted (RA) 30-day mortality for heart attack, heart failure, and pneumonia. Our analysis indicates that while Hospital Compare process performance measures are correlated with 30-day mortality for each diagnosis, after we account for unobserved heterogeneity, process of care performance is no longer associated with mortality for any diagnosis. This suggests that the relationship between hospital-level process of care performance and mortality is not causal. Implications for pay-for-performance are discussed.

Objective: To analyze patient complaints in a Primary Health Care District (PHCD) using statistical process control methods compared to multivariate methods, as regards their results and feasibility of application in this context., Material and Method: Descriptive study based on an aggregate analysis of administrative complaints., Setting: Complaints received between January 2005 and August 2008 in the Customer Management Department in the 3rd PHCD Management Office, Madrid Health Services. Complaints are registered through Itrack, a computer software tool used throughout the whole Community of Madrid., Main Variables: Total number of complaints, complaints sorted by Reason and Primary Health Care Team (PHCT), total number of patient visits (including visits on demand, appointment visits and home visits) and visits by PHCT and per month and year., Statistical Analysis: Multivariate analysis and control charts were used., Results: 44-month time series with a mean of 76 complaints per month, an increasing trend in the first three years and decreasing during summer months. Poisson regression detected an excess of complaints in 8 out of the 44 months in the series. The control chart detected the same 8 months plus two additional ones., Conclusions: Statistical process control can be useful for detecting an excess of complaints in a PHCD and enables comparisons to be made between different PHC teams. As it is a simple technique, it can be used for ongoing monitoring of customer perceived quality.

Most hospital work can be seen as linked processes. Designed to examine process performance, control charts allow distinction between two types of variation. While processes that exhibit special cause variation are unstable and should be improved by eliminating special causes, processes exhibiting only common cause variation are predictable and should be improved by fundamental redesign. Control charts are also key tools to monitor such intended changes. This paper provides an overview of the most common types of control charts and the most important interpretation rules.

In 2003 the Royal College of Radiologists Clinical Radiology Audit Sub-Committee began an audit process evaluating the standards of provision of magnetic resonance imaging (MRI) services. This was prompted by the publication of the 2002 Audit Commission Report, which had identified that lack of MRI provision was responsible for more than half of the total waiting times for diagnostic imaging investigations. The audit found that the time from request to report did not meet the standard for cancer staging examinations, but nationally, was within the target set for routine orthopaedic examinations. However, national mean waiting times were longer than recommended for both cancer and orthopaedic MRI. Since then, there has been massive investment in MRI capacity, both from installation of MRI systems in NHS Trusts, and in England, from outsourcing of routine MRI cases through the Department of Health contract with an independent provider. A re-audit in 2006/7 shows that there has been a significant improvement in waiting times for routine orthopaedic examinations, but the position with cancer staging examinations has deteriorated. Control chart methodology shows that underperformance is due to common cause variation, i.e., improvements need to be made to the overall process from receiving the request for MRI to the issue of the report. Follow-up with participating departments demonstrated there were some common themes for underperformance, and suggestions for improvement are made from departments with best performance.

Background: Statistical Process Control (SPC), a sub-area of Statistical Quality Control (SQC) has been widely used in the manufacturing industry for a long time to monitor and improve processes. However, the use of SPC in other application areas in particular healthcare has been met with resistance due to lack of evidence or lack of conviction regarding their power of utility., Method: Literature and computer programmes (Medline and PsychoInfo databases) were searched for relevant information., Conclusion: This paper provides an overview of SPC, and its primary tool- the control chart, the challenges and the benefits of the application of SPC as tool for health care improvement.

Objective: To determine whether imputed data can be used to produce unbiased hospital quality measures., Background: Different methods for handling missing data may influence which hospitals are designated as quality outliers., Methods: Monte-Carlo simulation study based on 63,020 patients with no missing data in 68 hospitals using the National Trauma Data Bank (NTDB, version 6.1). Patients were assigned missing data for the motor component of the Glasgow coma scale (GCS) conditional on their observed clinical risk factors. Multiple imputation was then used to "fill in" the missing data. Hospital risk-adjusted quality measures (observed-to-expected mortality ratio) based either on (1) imputed data, (2) excluding patients with missing data (complete case analysis), or (3) excluding the predictor with missing data were compared with hospital quality based on the true data (no missing data). Pair-wise comparisons of hospital quality were performed using the intraclass correlation coefficient (ICC) and the kappa statistic., Results: With 10% of the data missing, the level of agreement between multiple imputation and the true data (ICC = 0.99 and kappa = 0.87) was better compared with the level of agreement between complete case analysis and the true data (ICC = 0.93 and kappa = 0.62). Excluding the predictor (motor GCS) with missing data from the risk adjustment model resulted in the least amount of agreement with quality assessment based on the true data (ICC = 0.88 and kappa = 0.46)., Conclusion: Multiple imputation can be used to impute missing data and yields hospital quality measures that are nearly identical to those based on the true data. Simply excluding patients with missing data or excluding risk factors with missing data from hospital quality assessment yields substantially inferior quality measures.

This was a descriptive, exploratory, documental study of trends that aimed to analyze process indicators in the Program for Humanization of Prenatal Care and Childbirth in Ceará State, Brazil, from 2001 to 2006. The authors analyzed data from 312,507 pregnant women. In 2001, the year the program was implemented in the State, the system tabulated data for three of the seven process indicators; beginning in 2002, all indicators were tabulated. Total enrollment of pregnant women was the only indicator that increased every year until 2006, while the other indicators increased from 2002 until 2005, but declined from 2005 to 2006. When combining the completion of six prenatal visits with a postpartum visit, routine laboratory tests, or both, the percentages declined. Tetanus immunization reached the highest percentage in 2002 (68.34%), decreasing to 60.86% in 2006. The combination of six prenatal visits, a postpartum visit, laboratory tests, tetanus immunization, and HIV test was the indicator with the lowest percentage for the State (15.67%), although it was higher than the national average. Even considering flaws in the use of the Prenatal Care Information System, it is unacceptable that prenatal care still lacks complete coverage for such basic elements as routine laboratory tests and tetanus immunization.

Background: Hospitals use time-motion studies to monitor process effectiveness and patient waiting. Manual tracking is labor-intensive and potentially influences system performance. New technology known as indoor positioning systems (IPS) may allow automatic monitoring of patient waiting and progress. The authors tested whether an IPS can track patients through a multistep preoperative process., Methods: The authors used an IPS between October 14, 2005, and June 13, 2006, to track patients in a multistep ambulatory preoperative process: needle localization and excisional biopsy of a breast lesion. The process was distributed across the ambulatory surgery and radiology departments of a large academic hospital. Direct observation of the process was used to develop a workflow template. The authors then developed software to convert the IPS data into usable time-motion data suitable for monitoring process efficiency over time., Results: The authors assigned tags to 306 patients during the study period. Eighty patients never underwent the procedure or never had their tag affixed. One hundred seventy-seven (78%) of the remaining 226 patients successfully matched the workflow template. Process time stamps were automatically extracted from the successful matches, measuring time before radiology (mean +/- SD, 77 +/- 35 min), time in radiology (105 +/- 35 min), and time between radiology and operating room (80 +/- 60 min), which summed to total preoperative time (261 +/- 67 min)., Conclusions: The authors have demonstrated that it is possible to use a combination of IPS technology and sequence alignment pattern matching software to automate the time-motion study of patients in a multidepartment, multistep process with the only day-of-surgery intervention being the application of a tag when the patient arrives.

There is considerable interest in the use of statistical process control (SPC) in healthcare. Although SPC is part of an overall philosophy of continual improvement, the implementation of SPC usually requires the production of control charts. However, as SPC is relatively new to healthcare practitioners and is not routinely featured in medical statistics texts/courses, there is a need to explain the issues involved in the selection and construction of control charts in practice. Following a brief overview of SPC in healthcare and preliminary issues, we use a tutorial-based approach to illustrate the selection and construction of four commonly used control charts (xmr-chart, p-chart, u-chart, c-chart) using examples from healthcare. For each control chart, the raw data, the relevant formulae and their use and interpretation of the final SPC chart are provided together with a notes section highlighting important issues for the SPC practitioner. Some more advanced topics are also mentioned with suggestions for further reading.

Objectives: We evaluated whether appropriateness and baseline risk of cardiac catheterization varied according to regional intensity of invasive therapy after acute myocardial infarction (AMI), and whether AMI mortality varied according to invasive intensity regions., Background: Marked regional variations exist in cardiac invasive procedure use after AMI within the U.S., Methods: We performed an analysis of 44,639 Medicare fee-for-service beneficiaries hospitalized with AMI between 1998 and 2001. Invasive procedure intensity was determined based on overall cardiac catheterization rates for Medicare enrollees. Cardiac catheterization appropriateness was determined by the American College of Cardiology/American Heart Association classification and baseline risk was estimated using the GRACE (Global Registry of Acute Coronary Events) risk score. The primary outcomes of the study were cardiac catheterization use within 60 days and 3-year mortality after hospital admission., Results: Higher invasive intensity regions were more likely to perform cardiac catheterizations on class I patients (appropriate) (RR 1.38, 95% confidence interval [CI] 1.27 to 1.48), class II patients (equivocal) (RR 1.42, 95% CI 1.31 to 1.53), and class III patients (inappropriate) (RR 1.29, 95% 0.97 to 1.67) compared with low-intensity regions after adjusting for patient and physician characteristics. The overall cardiac catheterization use was 5.2% lower for each increase in GRACE risk decile, and this relationship was observed similarly in all regions. Risk-standardized mortality rates of AMI patients at 3 years were not substantially different between regions., Conclusions: Although higher-risk patients and those with more appropriate indications may have the most to benefit from an invasive strategy after AMI, we found that higher-invasive regions do not differentiate procedure selection based on the patients' appropriateness or their baseline risks.

With the purpose of contributing to the evaluation of primary care, a study was conducted based on the quality of patients' health charts, considering the records for care provided in 4 municipalities with more than 100 thousand inhabitants each in the State of Rio de Janeiro, Brazil, in 2004. This was a cross-sectional study based on primary data collected from direct consultation of patient charts. A two-stage, probabilistic cluster sample was selected from primary care facilities and consultations/patient charts. We checked the completeness of attributes pertaining to the identification of users receiving care and the characteristics of the care itself (weight, blood pressure, Pap tests, and blood glucose) on the charts of women over 19 years of age with hypertension and/or diabetes. User identification showed a low presence of social attributes, and only half of the charts had recorded the opening date. Records of process characteristics in care provided to women with hypertension and diabetes failed to conform to Brazilian Ministry of Health guidelines. Analysis of completeness suggests dubious quality in the continuity of the care provided and difficulties in management practice for primary care and implementation of the Family Health Strategy.

Objectives: To assess the quality of care for hospitalized vulnerable elders using measures based on Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs)., Design: Prospective cohort study., Setting: Single academic medical center., Participants: Subjects aged 65 and older hospitalized on the University of Chicago general medicine inpatient service who were defined as vulnerable using the Vulnerable Elder Survey-13 (VES-13), a validated tool based on age, self-reported health, and functional status., Measurements: Inpatient interview and chart review using ACOVE-based process-of-care measures referring to 16 QIs in general hospital care and geriatric-prevalent conditions (e.g., pressure ulcers, dementia, and delirium); adherence rates calculated for type of care process (screening, diagnosis, and treatment) and type of provider (doctor, nurse)., Results: Six hundred of 845 (71%) older patients participated. Of these, 349 (58%) were deemed vulnerable based on VES-13 score. Three hundred twenty-eight (94%) charts were available for review. QIs for general medical care were met at a significantly higher rate than for pressure ulcer care (81.5%, 95% confidence interval (CI)=79.3-83.7% vs 75.8%, 95% CI=70.5-81.1%, P=.04) and for delirium and dementia care (81.5%, 95% CI=79.3-83.7 vs 31.4% 95% CI=27.5-35.2%, P<.01). According to standard nursing assessment forms, nurses were responsible for high rates of adherence to certain screening indicators (pain, nutrition, functional status, pressure ulcer risk; P<.001 when compared with physicians), although in patients with functional limitations, nurse admission assessments of functional limitations often did not agree with reports of limitations by patients on admission., Conclusion: Adherence to geriatric-specific QIs is lower than adherence to general hospital care QIs. Hospital care QIs that focus on screening may overestimate performance by detecting standard nursing or protocol-driven care.

Background: The Measure of Processes of Care (MPOC) is a 56-item self-administered measure designed to examine what parents of a child with a chronic health problem think of the services they and their child receive, and to measure the extent to which these services are family-centred. Reliability and validity of the MPOC were established in prior studies. The aim of the present study was to assess the 1-year stability of the MPOC to justify its use as an evaluative tool., Methods: Nine paediatric rehabilitation centres in the Netherlands participated in this short longitudinal survey study. Subjects were 205 parents (response rate 74.8%) of children aged 1-18 years who received care in one of the participating paediatric rehabilitation centres. All subjects filled out two MPOCs with a 1-year interval., Results: All correlations between the scale scores of the MPOC at the first and second administration were relatively high and significant (range: 0.443-0.609, all P < 0.001), demonstrating high inter-individual stability. However, all mean scale scores, except for Providing General Information, significantly reduced after 1 year., Conclusions: The MPOC has a moderate 1-year stability. However, because of its tendency to score lower when repeated after 1 year, its use as an evaluative follow-up instrument to assess the effectiveness of a programme intervention is restricted.

The aim of the present study was to develop an index specifically for the measurement of treatment complexity. Input factors were directly related to complexity, and the output was a score measuring the degree of treatment complexity. The sample comprised 120 sets of dental casts, 30 for each of the four main malocclusion classes. Sixteen orthodontists graded the study casts for perceived treatment complexity on a six-point scale and then listed, in order of importance, up to three occlusal features which they felt contributed to complexity from a pre-determined list. Multiple regression analysis was used to derive weightings for each occlusal feature, which would reflect the relevant treatment complexity. In order to obtain an overall treatment complexity score for each case, weightings were then multiplied by the corresponding occlusal feature scores and summed. The relationship between treatment complexity scores and perceived complexity was examined using Spearman's ranked correlation coefficient. The regression equation explained 49.5 per cent of the variance in treatment complexity of the whole sample. Regression analysis on the basis of malocclusion produced R (2) values of 90.7 per cent for Class I, 42.6 per cent for Class II division 1, 62.3 per cent for Class II division 2, and 79.5 per cent for Class III malocclusions. The index of orthodontic treatment complexity (IOTC) scores showed a moderate but highly significant association with the orthodontists' perceived complexity assessments (rho = 0.42, P = 0.000). The proposed IOTC shows sufficient promise to warrant further development.

Objective: The paper reviews the experience with the EmOC process indicators, and evaluates whether the indicators serve the purposes for which they were originally created - to gather and interpret relatively accessible data to design and implement EmOC service programs., Method: We review experience with each of the 6 process indicators individually, and monitoring change over time, at the level of the facility and at the level of a region or country. We identify problems encountered in the field with data collection and interpretation., Result: While they have strengths and weaknesses, the process indicators in general serve the purposes for which they were developed. The data are easily collected, but some data problems were identified. We recommend several relatively minor modifications to improve data collection, interpretation and utility., Conclusions: The EmOC process indicators have been used successfully in a wide variety of settings. They describe vital elements of the health system and how well that system is functioning for women at risk of dying from major obstetric complications.

This study evaluated daily trends of hospitalisations in public and privately-owned hospitals in the Lombardy region (Italy). Discharge abstract data for 2004-2005 and data regarding bed capacity were used to evaluate number of admissions, discharges, inpatients, and bed occupancy rates. Daily trends were uniform within all weeks of the year with some seasonal fluctuations observed (e.g. during holiday season). Average occupancy rates were found to vary according to the size of the hospital (greater average occupancy rates in larger hospitals) and the level of emergency care services provided.

Objective: Benchmarks, representing the level of performance achieved by the best-performing providers, can be used to set achievable goals for improving care, but they have not heretofore been available for mental health care. This article describes the application of a method for developing statistical benchmarks for 12 process measures of quality of care for mental and substance use disorders., Methods: Twelve quality measures--taken from a core measure set selected by a multistakeholder panel through a formal consensus process--were constructed from 1994-1995 administrative data on care received by Medicaid beneficiaries in six states. Conformance rates were calculated at the provider level and presented as means, 90th-percentile results, and statistical benchmarks. Sample sizes for each measure ranged from 356 to 4,494 providers and from 1,205 to 78,627 cases. Three measures involved antidepressant treatment, two involved antipsychotic treatment, and one involved mood stabilizers for bipolar disorder. Six other measures involved follow-up treatment visits., Results: Benchmarks for provider-level performance ranged from 59.7 percent to 97.7 percent, markedly higher than the mean results, which ranged from 9.4 percent to 65.4 percent. Benchmark results varied widely-in contrast to results for these measures at the 90th percentile of providers and in contrast to performance standards that apply the same numerical goal across varied clinical processes., Conclusions: Statistical benchmarks can be applied to results from quality assessment of mental health care. Further research should examine whether incorporating benchmarks into quality improvement activities leads to better mental health care and substance-related care and improved outcomes.

A cross-sectional population-based study was carried out among individuals aged 20 to 69 years in the urban area of Pelotas, Rio Grande do Sul, Brazil. The objective was to analyze characteristics of hypertensive patients in relation to management of arterial hypertension. Among the 1,968 interviewees, 380 were hypertensive (19.3%), and 44.1% of these always consulted the same physician. Of the entire sample, 85.5% were sedentary, 48.2% showed excessive fat consumption, and 47.4% smoked. Most physicians recommend the following: lowering salt consumption (98.4%), cessation of alcohol consumption (93.7%), for losing weight, diet and consumption of low-fat food (88.2%), smoking cessation (73.2%), and physical activity (68.9%). The clinical management was classified as inadequate in 284 individuals (74.7%). Increased probability of adequate management was found among: women, individuals > 50 years, upper and middle-class patients, non-smokers, and patients with diabetes mellitus. Some findings showed positive aspects, but differences according to socioeconomic status evidenced lack of equity in care.

Interpersonal psychotherapy (IPT) research has addressed outcome more than mechanism. This study used the novel Interpersonal Psychotherapy Outcome Scale (IPOS) to test the theoretical axiom that symptomatic improvement in IPT reflects resolution of interpersonal problem areas. The IPOS rates change in focal interpersonal problem areas on a 5-point scale. Patients (N = 24) and therapists (N = 7) in a time-limited IPT outcome study of dysthymic disorder, and patients (N = 11) in an open trial for posttraumatic stress disorder, completed the IPOS at treatment termination. All responding dysthymic subjects (N = 24) and therapists (N = 21) reported interpersonal gains: dysthymic patients scored 4.39 (SD = 0.52) out of 5, therapists 4.27 (0.53). Posttraumatic stress disordered patients rated 4.75 (0.34). Patient and therapist IPOS ratings correlated with objectively measured symptomatic improvement with full or trend statistical significance. Despite methodological limitations, initial testing of the IPOS supports the theorized link between resolving interpersonal crises and improvement in IPT.

This explores the applicability of Sen's capability approach to the economic evaluation of health care programmes. An individual's 'capability set' describes his freedom to choose valuable activities and states of being ('functionings'). Direct estimation and valuation of capability sets is not feasible at present. Standard preference-based methods such as willingness to pay are feasible, but problematic due to the adaptive and constructed nature of individual preferences over time and under uncertainty. An alternative is to re-interpret the QALY as a cardinal and interpersonally comparable index of the value of the individual's capability set. This approach has limitations, since the link between QALYs and capabilities is not straightforward. Nevertheless, the QALY approach is recognisable as an application of the capability approach since it pays close attention to functionings, through the use of survey-based multi-attribute health state valuation instruments, and permits conceptions of value other than the traditional utilitarian ones of choice, desire-fulfilment and happiness. Furthermore, suitably re-interpreted, it can account for (i) non-separability between health and non-health components of value; and suitably modified it can also account for (ii) process attributes of care, which may have a direct effect on non-health functionings such as comfort and dignity, and (iii) sub-group diversity in the value of the same health functionings., ((c) 2005 John Wiley & Sons, Ltd.)

Statistical process control (SPC) can be thought of as the frequent monitoring of processes using inferential statistics. The feature that distinguishes SPC from the typical use of inferential statistics for analyzing populations is that in the former frequent samples are taken over time, whereas in inferential statistics a single sample is generaLLy taken before and after some intervention or treatment. An x-s control chart is used to monitor a continuous variable that reflects the output of a process. The x-s control chart is a graph that includes serial sample means (x) as the variables of interest, a centerline that represents the grand mean of the samples (x), and upper control limit (UCL) and lower control limit (LCL) that represent three standard errors (SEx) above and below the centerline. An x-s control chart is used to estimate with 99.7% confidence that the population mean of a continuous output variable was within the interval defined by the UCL and LCL during a period of baseline monitoring. It is further assumed that if the process remains stable, future population means wiLL remain between the control Limits for additional process outputs. Control charts allow the evaluation of both common- and special-cause variation. AnaLysis of the common-cause variation aLLows an assessment of the current process performance. Special-cause variation is identified when there is a sample mean that is beyond the UCL or LCL.

A p control chart is used to monitor a proportion from a binomial variable that reflects the output of a process. The p control chart is a graph that includes serial sample proportions (p) as the variables of interest, a centerline that represents the overall proportion of the samples (p), and upper control limits (UCLs) and Lower control Limits (LCLs) that represent three standard errors (SEp) above and below the centerline. We use a p control chart to estimate with 99.7% confidence that the population proportion of an output variable was within the interval defined by the UCLs and LCLs during a period of baseline monitoring. We further assume that if the process remains stable, the values of future population proportions will remain between the established control limits. An np control chart simply plots the numerators of the sample proportions as the variables of interest. A u control chart is used to monitor ratios. In u control charts, ratios are quantities in which the numerator can have one or more occurrences in reference to the denominator. A c control chart is analogous to an np control chart in that it graphs the numerators from the ratios.

Cigarette smoking among adolescents remains one of the most important public health challenges. Despite much attention to research on the etiology of smoking, notably the examination of factors that differentiate adolescent smokers from never smokers, much less is known about factors that predict the development of dependence once an adolescent tries smoking. This paper reviews individual and contextual influences on the progression of smoking among adolescents. Highlights include a consideration of multiple levels of influence, from intra-individual factors, such as genetics, demographics, temperament and comorbidities, to social influences, such as families and peers, to the more macro, societal/cultural levels of influence, including advertising and tobacco-related policies. More recent work examining microcontextual influences through the use of Ecological Momentary Assessments is also discussed. Finally, the need to consider both developmental and transdisciplinary approaches to understanding the development of nicotine dependence in adolescents is emphasized.

Background: Despite the substantive literature from survey research that has accumulated on complementary and alternative medicine (CAM) in the United States and elsewhere, very little research has been done to assess conceptual domains that CAM and conventional providers would emphasize in CAM survey studies. The objective of this study is to describe and interpret the results of concept mapping with conventional and CAM practitioners from a variety of backgrounds on the topic of CAM., Methods: Concept mapping, including free sorts, ratings, and multidimensional scaling was used to organize conceptual domains relevant to CAM into a visual "cluster map." The panel consisted of CAM providers, conventional providers, and university faculty, and was convened to help formulate conceptual domains to guide the development of a CAM survey for use with United States military veterans., Results: Eight conceptual clusters were identified: 1) Self-assessment, Self-care, and Quality of Life; 2) Health Status, Health Behaviors; 3) Self-assessment of Health; 4) Practical/Economic/ Environmental Concerns; 5) Needs Assessment; 6) CAM vs. Conventional Medicine; 7) Knowledge of CAM; and 8) Experience with CAM. The clusters suggest panelists saw interactions between CAM and conventional medicine as a critical component of the current medical landscape., Conclusions: Concept mapping provided insight into how CAM and conventional providers view the domain of health care, and was shown to be a useful tool in the formulation of CAM-related conceptual domains.

There is an increasing need of a model for the process-based performance measurement of multispecialty tertiary care hospitals for quality improvement. Analytic hierarchy process (AHP) is utilized in this study to evolve such a model. Each step in the model was derived by group-discussions and brainstorming sessions among experienced clinicians and managers. This tool was applied to two tertiary care teaching hospitals in Barbados and India. The model enabled identification of specific areas where neither hospital performed very well, and helped to suggest recommendations to improve those areas. AHP is recommended as a valuable tool to measure the process-based performance of multispecialty tertiary care hospitals.

Background and Purpose: Telemedicine is emerging as a potential timesaving, efficient means for evaluating patients experiencing acute stroke. In areas where local stroke care specialists are not available, telemedicine can link an emergency department physician with a specialist in a stroke treatment center. This consultation provides an opportunity for administration of thrombolytic drugs within the short therapeutic time window associated with ischemic stroke. Here, we describe our stroke treatment center experiences and report safe administration of recombinant tissue plasminogen activator (rtPA) during telemedicine consultation., Methods: The University of Maryland Medical Center uses a triplexed integrated services digital network line providing a 30--frames-per-second video link to St Mary's Hospital >100 miles away. The system uses a pan, tilt, and zoom camera with remote site control, allowing 2-way, real-time, audiovisual communication and CT image transfer. We retrospectively reviewed all acute stroke consultations provided to St Mary's Hospital between 1999 and 2001., Results: We reviewed 50 consultations. Of the 50, 23 were attempted through telemedicine linkage, and 27 were by traditional telephone conversation, followed by transfer. Of the 23 telemedicine consultations, 2 were aborted because of technical difficulties. Of the patients evaluated by traditional means, 1 of 27 (3.8%) received intravenous rtPA; 5 of 21 (23.8%) received rtPA after telemedicine consultation. No patients experienced complications., Conclusions: Telemedicine consultation provided treatment options not previously available at the remote hospital. Administration of rtPA during telemedicine consultation was feasible and safe, and the system was well received. Lack of reimbursement for telemedicine services will hinder widespread adaptation of this promising technology for remote acute stroke treatment.

The purpose of this study was to determine the nature of swallowing evaluation practices in western Washington, specifically in terms of (a) components of the clinical examination most commonly used, (b) consistency of clinical examination practices across clinicians, and (c) consistency of clinical decision-making (instrumental vs. noninstrumental) given specific patient scenarios. A 21-question survey was sent to 150 speech-language pathologists who provide services to dysphagia patients. Of the 72 (48%) surveys that were returned, 64 provided the data for the study. The results revealed that clinicians who responded to the survey differ somewhat regarding which components they include in a clinical examination of swallowing. There was a high degree of consistency for 11 of the 19 components. Inconsistency across clinicians was revealed in four areas: assessment of sensory function, assessment of the gag reflex, cervical auscultation, and assessment of trial swallows using compensatory techniques. Clinicians agreed in their recommendations on two of the six clinical case scenarios. In general, participating clinicians varied widely in their clinical decision-making. These findings are compared with other studies where variability in clinical practice has raised concerns.

We undertook the current survey-based study to assess clinicians' views on the determinants of effective inpatient consultation and the existing process of inpatient consultation at the Cleveland Clinic Hospital. A 25-question survey developed for this study using Likert scale responses was completed by 181 (of 404 eligible addressees, a 45% response rate) members of the Cleveland Clinic staff in the divisions of medicine, surgery, and pediatrics. Ratings of the overall value of inpatient consultation reflected moderate satisfaction (mean 6.9 of possible 10). Types of consults that were most valued were those requesting a procedure and those seeking assistance in establishing a diagnosis and in interpreting data. Features deemed most important in making a consult excellent were legibility of the consultant's note, timeliness of the response (i.e., within 24 hours), and direct communication of the consult question. The data showed a trend indicating that physicians regarded the value of direct physician-to-physician communication more highly than they personally practiced such direct communication when requesting a consult. Study findings indicate the opportunity to improve the process of inpatient consultation by implementing measures that enhance direct physician-to-physician communication about the consult, ensure timeliness, facilitate identification of the appropriate consultants, and allow easier auditing. We propose a novel process for requesting inpatient consultations that extends currently available hospital information systems but offers a process improvement that warrants development.

Introduction: Automated and/or electrical twitch-obtaining intramuscular stimulation (ATOIMS & ETOIMS) evoke twitches at/or near motor end plate zones to relieve muscle pain., Objectives: To demonstrate that pain levels recorded daily by patients enable statistical process control (SPC) analysis of ATOIMS & ETOIMS effects over time., Methods: Four chronic fibromyalgic patients received ATOIMS & ETOIMS treatments to bilateral C3-C8 and L3-S1 myotomes and recorded daily pain on a visual analogue scale. Mechanical stimulation with ATOIMS involved a custom device to insert, oscillate and retract a monopolar needle (MN) at 2 Hz x2s. ETOIMS involved manual insertion of the MN and stimulating with 5 Volts, 0.5 ms pulse duration at 2 Hz for 2s to multiple sites. Positive outcome measures include two pain scales reduction., Results: Patient 1-4 had 89, 38, 40, 36 treatments during a follow-up time of 625, 1018, 378, 466 days with 5.4 +/- 3.7, 8.0 +/- 4.9, 4.2 +/- 2.4 and 4.6 +/- 2.7 days between treatments (DBT) during the first 6 months and 4.7 +/- 3.0, 21.8 +/- 15.6, 6.2 +/- 4.4 and 4.3 +/- 2.5 DBT respectively in the latter phase of the therapy. The average pain level (APL) in 1st week of treatment for patient 1-4 were 6.4 +/- 1.1, 3.7 +/- 1.1, 6.6 +/- 2.8 and 7.5 +/- 0.4 and in the last week of treatment were 4.5 +/- 0.4, 1.2 +/- 0.1, 4.2 +/- 1.0 and 4.7 +/- 0.7 respectively. APL correlated negatively with time during the first 6 months for patients 2-4 and also after 6 months for patients 4 & 1 who had unchanged and reduced DBT respectively. APL correlated positively with time for patient 2 with no correlation for patient 3 (both had increased DBT) after 6 months., Conclusions: Patients will chronically record their pain scales daily enabling analysis by SPC. ATOIMS & ETOIMS applied periodically can be helpful in relieving fibromyalgic pain.

Background and Purpose: Integrated care pathways (ICP) may not reduce disability, institutionalization, or duration of hospitalization compared with conventional multidisciplinary team (MDT) care in organized stroke rehabilitation. Their potential to improve patient heath status or satisfaction with care is not known., Methods: A comparison of quality of life, caregiver strain, and patient/caregiver satisfaction at 6 months after stroke was undertaken in 152 stroke patients randomized to receive ICP or MDT care. Differences in processes of care were recorded with the use of a predefined schedule. Multivariate analyses were undertaken to identify the effect of age, sex, stroke severity, functional status, mood, and use of care pathway on quality of life score., Results: The 2 groups were comparable for baseline characteristics of age, sex, stroke severity, and initial disability. MDT care was characterized by greater emphasis on return of higher function and caregiver needs compared with ICP. EuroQol Visual Analogue Scale (EQ-VAS) scores were higher in the MDT group (median, 72 versus 63; P<0.005), who also had higher scores for EuroQol dimension of social functioning (P=0.014). Higher EQ-VAS scores were independently related to MDT care (P=0.04), Rankin score (P=0.01), and psychological function (P<0.0001) but not to age, sex, or stroke severity. There were no significant differences in patient or caregiver satisfaction between the 2 settings., Conclusions: Better quality of life in patients receiving conventional MDT care may be attributable to improved social functioning and greater attention to higher function and caregiver needs during rehabilitation.

Objective: Although acute complications of diabetes account for approximately 3% of all emergency calls, clinically relevant indicators of structural and process quality in the management of diabetic emergencies have not yet been studied. The purpose of this investigation was, therefore, to collect representative data on these indicators for the whole of Germany., Methods: Standardized questionnaires comprising 20 items were sent to all 312 emergency medical services in Germany. Apart from demographic data, information was obtained about the diagnostic materials and drugs carried by the ambulances, methods of blood glucose measurement, the level of qualification of the emergency teams, the frequency of diabetic emergencies, and the need for further training., Results: The return rate of the questionnaires was 55%, corresponding to 172 emergency medical service districts serving a total population of 45.3 million. The data revealed deficits with regard to structural and process quality. Thus, only 6% of ambulances carried glucagon and only 11% ketone test strips. In 57% capillary blood was used for glucose determination, in 17% visually read test strips were still used. While in some districts hospital admission after hypoglycaemic episodes was mandatory even for patients well educated about their diabetes, in other districts multimorbid patients on oral antidiabetics were sometimes only treated at the emergency scene. Emergency medical technicians increasingly carried out both the diagnosis and treatment of diabetic emergencies., Conclusions: The structural and process quality of the management of diabetic emergencies in Germany is in need of improvement. The most important factor is continuing education of the entire emergency team.