A comparative analysis of surveyors from six hospital accreditation programmes and a consideration of the related management issues

PURPOSE

To gather data on how accreditors manage surveyors, to compare these data and to offer them to the accreditors for improvement and to the scientific community for knowledge of the accreditation process and reinforcement of the credibility of these processes.

DATA SOURCE

The data were gathered with the aid of a questionnaire sent to all accreditors participating in the study.

RESULTS

An important finding in this comparative study is the different contractual relationships that exist between the accreditors and their surveyors.

CONCLUSION

Surveyors around the world share many common features in terms of careers, training, work history and expectations. These similarities probably arise from the objectives of the accreditors who try to provide a developmental process to their clients rather than an 'inspection'.

Accreditation programs for hospitals: funding and operation

Accreditation is a formal process by which an authorized body assesses and recognizes an individual, an organization (like a hospital), a program, or a group as complying with requirements such as standards or criteria. This article analyses and compares the activity and funding of six health care accrediting bodies which operate in five different countries, and which in 1994, accredited over 5000 health centres. The data included in this article could be useful for other institutions who wish to commence accreditation programmes for health care organizations.

Randomized phase II study of single-agent epirubicin +/- verapamil in patients with advanced metastatic breast cancer. An AIO clinical trial. Arbeitsgemeinschaft Internistische Onkologie of the German Cancer Society

BACKGROUND

Anthracyclines are the most active cytostatic agents in patients with metastatic breast cancer. Drug resistance and dose intensity are relevant issues in the treatment of cancer.

METHODS

A randomized phase II study in 51 patients with advanced progressive metastatic breast cancer was performed. Twenty-six were treated with epirubicin (EPI) 120 mg/m2 i.v. bolus injection divided over three days combined with a daily dose of 480 mg verapamil (VPL) orally administered one day before and during EPI. Twenty-five patients received the same dose and schedule of EPI without VPL. Evaluation of response was carried out after three 21-day cycles. Study endpoints were objective response rate and overall survival.

RESULTS

Among the 24 evaluable patients treated with EPI+VPL 1 CR (4%), 7 PR (29%), 9 NC (38%) and 7 PD (29%) were observed. Two patients were excluded because of toxicity. Among the 24 evaluable patients treated with EPI alone 8 PR (28%), 6 NC (24%) and 10 PD (40%) were observed, and one patient was excluded because of toxicity. Myelotoxicity was the major side effect followed by alopecia, stomatitis/mucositis and nausea. The patient group treated with VPL had lower blood pressure levels during therapy, with complete normalization after discontinuation of VPL. The median overall survival times were similar: 7.4 month in the EPI group and 8.9 month in the EPI+VPL group.

CONCLUSION

In both treatment groups the objective response rate was about 30% and the overall survival rates were also the same. No clinical relevance could be demonstrated for the hypothesized resistance modifying action of VPL. Furthermore, VPL did not increase the toxicity of EPI.

Cyclic alternating chemotherapy of high-grade malignant non-Hodgkin lymphomas with VIM-Bleo and CHOP

Between 1986 and 1988, 81 patients with high grade malignant non-Hodgkin lymphoma according to the Kiel classification were treated with the VIM-Bleo/CHOP-regimen: etoposide 100 mg/m2 intravenously on days 1-3, ifosfamide 1.5 g/m2 intravenously days 1-5 with mesna for prophylaxis of cystitis, methotrexate 30 mg/m2 intravenously on days 3, bleomycin 10 mg intravenously on days 8 and 15, cyclophosphamide 750 mg/m2 day 22, doxorubicin 50 mg/m2 day 22, vincristine 1.4 mg/m2 on day 22, and prednisolone 100 mg postoperatively on days 1-5 and 22-26. Cycles were repeated four times beginning on day 43. Regions with bulky disease were irradiated after chemotherapy. 36 patients (44%) had stage II, 12 (15%) stage III and 33 (41%) stage IV disease. B-symptoms were present in 49% of patients. Serum lactate dehydrogenase activity was elevated in 53%. Overall, 59 patients (73%) achieved a complete and 14 (17%) a partial remission. 8 (9%) had stable or progressive disease. After a median follow up of 30 months thus far, probability of long-term relapse free survival is 66% for patients in complete remission. Overall survival is 72% at 24 months. Toxicity from treatment was very low with leukopenia being the main side effect. Major infections were observed in only 2% of cycles with one treatment related death. VIM-Bleo/CHOP is a well tolerated regimen with remission rates in the range of other, more toxic regimens. However, cyclic alternating treatment did not improve results as compared with repeated treatment with a single standard protocol.

[Therapeutic aspects of advanced high risk breast cancer]

In the treatment of metastatic breast cancer patients, remission rates and survival are determined by prognostic criteria and not by the choice of treatment. It remains to be proven whether or not the intensification of chemotherapy leads to a higher complete remission rate and/or prolongs survival. Generally, patients derive benefit from achieving a "no change" status. Therefore, milder treatment regimens are preferred except in clinical trials. However, additional research is mandatory to analyze treatment results in clearly defined prognostic subgroups to determine if specific subgroups benefit with prolonged survival and/or improved quality of life. Aggressive treatment with severe side effects should only be administered in such studies or if milder treatment regimes are no longer effective. The aim of palliation has to be kept in mind.

Randomized clinical trial comparing mitoxantrone with epirubicin and with doxorubicin, each combined with cyclophosphamide in the first-line treatment of patients with metastatic breast cancer

Two hundred and twenty-four patients with advanced breast cancer were enrolled in a multicenter prospective randomized clinical study and received either doxorubicin (40 mg/m2), or epirubicin (40 mg/m2) or mitoxantrone (12 mg/m2) each combined with cyclophosphamide (600 mg/m2) i.v. In the patient collective the following response rates were observed: complete response 12.1%; partial response 30.6%; stable disease 40.5%; progressive disease 16.8%. A complete response was observed significantly less often in patients where more than one organ site was involved as compared to those patients with only one metastatic site. The mean time period required to reach a best response was 3.7 months. There was no significant difference between the response rates in the three arms. In comparing the observed toxicities in 1,434 treatment cycles, there was a significant difference with regard to leukocytopenia (mitoxantrone arm exhibiting more than either epirubicin and doxorubicin) although infections did not occur more frequently in the mitoxantrone arm; with regard to alopecia, mitoxantrone and epirubicin arms both exhibited less than doxorubicin. It is noteworthy that no patient who had previously received adjuvant chemotherapy achieved a complete response (p = 0.006). The overall significance of these findings can only be clearly evaluated when survival times can be measured.

[Sequential alternating chemotherapy of highly malignant non-Hodgkin's lymphomas with VIM-Bleo and CHOP. Initial results]

54 patients with high grade malignant NHL (stage II 19, stage III 10, stage IV 25 patients, medium age 56 years) were treated in an ongoing study with the VIM-Bleo/CHOP-regimen: Etoposide 100 mg/m2 i.v. days 1-3, Ifosfamide 1.5 g/m2 i.v. days 1-5 with Mesna for prophylaxis of cystitis, Methotrexate 30 mg/m2 i.v. day 3, Bleomycin 10 mg i.v. days 8 and 15, Cyclophosphamide 750 mg/m2 day 22, Adriamycin 50 mg/m2 day 22, Vincristine 1.4 mg/m2 day 22 and prednisolone 100 mg po days 1-5 and 22-26. Cycles were repeated on day 43. After completion of therapy (4 cycles of VIM-Bleo/CHOP), 27 out of 35 patients (77%) were in complete remission. 6 patients (17%) had a partial remission and 2 (6%) progressive disease. After a median follow up of 8 months so far, 6 relapses occurred. Probability of survival at 12 months is 82%. Toxicity of treatment was very low with leukopenia being the main side effect. Only in 2 cycles (3%), major infections were observed. Nausea and vomiting were severe only in 4% of patients. We conclude that VIM-Bleo/CHOP is a well tolerated regimen with good remission rates in high grade malignant NHL. However, longer follow up is necessary for a final evaluation.

Reactivity of the allysine aldehyde group

Allysine is a very important crosslink precursor in connective tissue proteins. We describe the reactions of Phthalyl-Allysine-p-Nitrobenzylester, which is a suitable compound to investigate the reactions of the aldehyde group in vitro. Crosslinked compounds are synthesized by mixing suitable stoichiometric amounts of Phthalyl-Allysine-p-Nitrobenzylester and nucleophiles in aqueous organic solvents. The results are compared with the reaction pathways which have been proposed for crosslink synthesis in vivo.

Comparative in vitro toxicity of mitoxantrone and adriamycin in human granulocyte-macrophage progenitor cells

Mitoxantrone (MIT) has recently been introduced into cancer therapy as a possible substitute for the structurally related drug, adriamycin (ADR), because it causes less cardiotoxicity and fewer gastrointestinal side effects. However, the dose-limiting toxicity of MIT is pronounced neutropenia. The in vitro hematoxicity of both drugs in granulocyte-macrophage precursor cells (GM-CFCs) was analyzed using drug-exposure schedules analogous to the principles of the in vivo pharmacokinetics of MIT. Bone-marrow and peripheral-blood cells were exposed to 0.075-20 ng/ml MIT or ADR for 5, 20, 60, and 120 min, and for 14 days. The 14-day exposure resulted in Do values of 0.95 and 0.68 ng/ml for bone-marrow and peripheral-blood GM-CFCs subjected to MIT. Exposure to ADR resulted in Do values of 5.43 and 5.13 ng/ml, respectively. As was the case after 14-day exposure to MIT or ADR, short-term exposure again revealed that peripheral-blood GM-CFCs were more sensitive to both drugs. Moreover, at low concentrations, ADR was less toxic than MIT in both types of GM-CFCs, but was more toxic than MIT when a concentration of 20 ng/ml was used. The intracellular concentration of MIT, as measured by high-performance liquid chromatography, was constantly below 1 ng per 2 X 10(7) cells, even when it was applied at a concentration of 20 ng/ml for an exposure time of 2 h. The fact that such low concentrations of MIT are toxic for hemopoietic precursor cells may explain the myelotoxicity of this drug. However, the difference between the precursor-cell toxicity of MIT and that of ADR was small when their respective therapeutic doses were taken into consideration. Further analyses of their toxicity in stem cells and/or the microenvironment would appear to be needed.

Recombinant interferon alpha 2 stimulation of target-binding by natural killer cells

Even though the enhancement of the lyitc capacity and the kinetics of lysis of natural killer cells (NK) by interferon has been well documented, an increase of the target-effector cell binding percentage is still disputed. We, therefore, modified the Grimm-Bonavida single-cell assay so that 400 to 600 cells per individual determination could be reliably evaluated. Using this assay, which makes possible separate determination of effector-target cell binding and target lysis, we demonstrated that, in addition to lytic capacity, target-effector cell binding is also increased by preincubating NK with 100 to 1,000 IU interferon alpha 2 per 10(6) cells. Our data indicate that interferon alpha 2 induces pre-NK cells to bind target cells and that it activates these pre-NK cells to kill the targets.

Natural killer cell activity against a thymoma cell line Thy 121 in bone marrow transplant recipients

Twenty-one patients with acute and chronic leukemia or severe aplastic anemia were studied for NK activity against a thymoma cell line (Thy 121) before and after allogeneic bone marrow transplantation. The means of the pretransplant and post-transplant levels did not differ from the mean of 134 NK determinations in 67 healthy donors. There was no correlation between pretransplant NK levels and the appearance of graft-versus-host disease. Three weeks following bone marrow transplantation, pretransplant NK levels were observed. The sensitivity of NK cells to interferon was the same as in normal donors both before and after bone marrow transplantation. In contrast to methotrexate, cyclosporin A inhibited NK activity in patients and controls in vitro. In vivo cyclosporin A treatment, however, did not decrease NK levels in bone marrow recipients.

Diagnosis and treatment of meningeal carcinomatosis in ten patients with breast cancer

Clinical and radiological findings of 10 breast cancer patients with meningeal carcinomatosis were recorded. Special attention was drawn to CSF findings. Initial CSF cytology revealed malignant cells in all cases with a background of inflammatory cells in 7. Oligoclonal bands were found in the CSF of 3 out of 5 cases examined. Repeated CSF control under therapy showed elevation of lactate to be a better diagnostic parameter than lowered glucose. Six patients responded well to CNS radiation therapy and intrathecal chemotherapy. Median duration of survival was 6.4 months.

Mitoxantrone in the treatment of relapsed and refractory acute leukemia

Twenty-four patients with acute leukemia or blast crisis (BC) of chronic myelocytic leukemia (CML) in relapse or refractory to standard chemotherapy, were eligible for treatment with mitoxantrone. Mitoxantrone (Novantrone; dihydroxyanthracenedione) was administered in a dose of 8-13 mg/m2 on five consecutive days. Five of 20 evaluable patients were induced into complete remission, one patient achieved a partial remission. Side-effects included moderate to severe bone marrow suppression, moderate mucositis and hair loss. No cardiotoxicity was observed. We believe that mitoxantrone is an active agent in the treatment of acute leukemia and suggest further studies in combination chemotherapy.