Audit system on quality of breast cancer diagnosis and treatment (QT): results of quality indicators on screen-detected lesions in Italy in 2005 and preliminary results for 2006

Within this survey, conducted by the Italian Group of Mammography Screening (GISMa), individual data are collected yearly on more than 50% of all screen-detected operated lesions in Italy. In 2005, results showed overall good diagnosis and treatment quality, and an improving trend over time. Critical issues were identified in waiting times, compliance with the recommendations on not performing frozen section examination on small lesions and on performing specimen X-ray. Pre-operative diagnosis has reached the acceptable target, but room for improvement still exists. The sentinel lymph node technique (SLN) was performed on the axilla in more than 70% of screen-detected invasive cancers, avoiding a large number of potentially harmful dissections. On the other hand, potential overuse of SLN deserves further investigation. The detailed results have been distributed to local and regional screening programmes in order to allow multidisciplinary discussion and the identification of appropriate solutions to any problems documented by the data. Specialist Breast Units with adequate case volume would provide the best setting for making audit effective in producing quality improvement.

Bridging the gap between evidence and practice in venous thromboembolism prophylaxis: the quality improvement process

Venous thromboembolism (VTE) is considered to be the most common preventable cause of hospital-related death. Hospitalized patients undergoing major Surgery and hospitalized patients with acute medical illness have an increased risk of VTE. Although there is overwhelming evidence for the need and efficacy of VTE prophylaxis in patients at risk, only about a third of those who are at risk of VTE receive appropriate prophylaxis. To address the shortfall in VTE prophylaxis, the US Joint Commission and the National Quality Forum (NQF) endorse standardized VTE prophylaxis practices, and are identifying and testing measures to monitor these standards. Hospitals in the USA accredited by Centers for Medicare and Medicaid Services to receive medicare patients will need VTE prophylaxis programs in place to conform to these national consensus standards. This review aims to give background information on initiatives to improve the prevention of VTE and to identify key features of a successful quality improvement strategy for prevention of VTE in the hospital. A literature review shows that the key features of effective quality improvement strategies includes an active strategy, a multifaceted approach, and a continuous iterative process of audit and feedback. Risk assessment models may be helpful for deciding which patients should receive prophylaxis and for matching VTE risk with the appropriate intensity of prophylaxis. This approach should assist in implementing the NQF/Joint Commission-endorsed standards, as well as increase the use of appropriate VTE prophylaxis.

Inadequate analgesic prescription increases secondary post-tonsillectomy bleed rates: a completed audit loop

A significantly greater than normal secondary haemorrhage rate was noted in patients who had undergone tonsillectomy or adenotonsillectomy as waiting list 'initiative' cases within an alternative healthcare provider setting, compared with patients undergoing the same surgery within a primary healthcare trust (17.8 vs 3.9 per cent, respectively; p 0.1). We conclude that adequate analgesia, for the first week post-tonsillectomy, is essential in order to keep the secondary haemorrhage rate within an acceptable range.

Utility of the PFA-100 as a screening test of platelet function: an audit of haemostasis laboratories in Australia and New Zealand

The PFA-100 is a relatively new laboratory instrument, first described in 1995. There have since been numerous studies assessing its utility as a screening tool for platelet dysfunction and/or von Willebrand's disease (VWD). The PFA-100 displays variable sensitivity to different types of platelet disorders, as well as to antiplatelet medication (e.g. aspirin), with similar caveats for monitoring of primary haemostasis-promoting therapies in platelet dysfunction. There is therefore considerable uncertainty regarding its utility within this context, and we have accordingly performed an audit of usage among participants of the Royal College of Pathologists of Australasia Quality Assurance Program. Of 105 laboratories surveyed, 40 responded that they performed platelet function testing, with 26 (65%) further indicating they utilized the PFA-100. We report a wide variety of laboratory usage among these users, including numbers of tests performed [annual median (range) = 270 (15-6000)], sources of requests (clinical sources and localities), testing criteria and follow-up action. Most tests were completed within 4 h of collection, as recommended by the manufacturer, and most tests were performed as a replacement, or as a preliminary screen of platelet function (i.e. classical aggregation). Most abnormal findings, however, were attributed to antiplatelet medication such as aspirin.

Student dietitians? attitudes towards research and audit: a comparison with registered dietitians

BACKGROUND

Student dietitians' attitudes towards research and audit are important as they are likely to influence their subsequent involvement in such activities once qualified. The aim of this study was to investigate the attitudes of student dietitians towards research and audit and to compare them with those of registered dietitians previously reported.

METHODS

A questionnaire survey of final-year student dietitians' attitudes towards research and audit was conducted. Students indicated their agreement with 12 statements relating to research and audit and the results were compared with those from an identical survey of registered dietitians.

RESULTS

A total of 110 questionnaires were completed (87% response rate). In general, students had positive attitudes towards research and audit. The majority (91%) agreed that 'all dietitians should be able to act on research', whilst only a small minority agreed that research (6%) and audit (4%) was 'not part of a dietitian's role'. In general, students had more positive attitudes towards research, and less positive attitudes towards audit, than dietitians from a previously published survey.

DISCUSSION

Final year student dietitians have positive attitudes towards research and audit. These should be nurtured throughout the early years of their career in order to maximize on their research potential.

Comparison of Clinical and Administrative Data Sources for Hospital Coronary Artery Bypass Graft Surgery Report Cards

Background— Regardless of statistical methodology, public performance report cards must use the highest-quality validated data, preferably from a prospectively maintained clinical database. Using logistic regression and hierarchical models, we compared hospital cardiac surgery profiling results based on clinical data with those derived from contemporaneous administrative data.

Methods and Results— Fiscal year 2003 isolated coronary artery bypass grafting surgery results based on an audited and validated Massachusetts clinical registry were compared with those derived from a contemporaneous state administrative database, the latter using the inclusion/exclusion criteria and risk model of the Agency for Healthcare Research and Quality. There was a 27.4% disparity in isolated coronary artery bypass grafting surgery volume (4440 clinical, 5657 administrative), a 0.83% difference in observed in-hospital mortality (2.05% versus 2.88%), corresponding differences in risk-adjusted mortality calculated by various statistical methodologies, and 1 hospital classified as an outlier only with the administrative data–based approach. The discrepancies in volumes and risk-adjusted mortality were most notable for higher-volume programs that presumably perform a higher proportion of combined procedures that were misclassified as isolated coronary artery bypass grafting surgery in the administrative cohort. Subsequent analyses of a patient cohort common to both databases revealed the smoothing effect of hierarchical models, a 9% relative difference in mortality (2.21% versus 2.03%) resulting from nonstandardized mortality end points, and 1 hospital classified as an outlier using logistic regression but not using hierarchical regression.

Conclusions— Cardiac surgery report cards using administrative data are problematic compared with those derived from audited and validated clinical data, primarily because of case misclassification and nonstandardized end points.

The utility of an automated electronic system to monitor and audit transfusion practice

BACKGROUND AND OBJECTIVES

Transfusion laboratories with transfusion committees have a responsibility to monitor transfusion practice and generate improvements in clinical decision-making and red cell usage. However, this can be problematic and expensive because data cannot be readily extracted from most laboratory information systems. To overcome this problem, we developed and introduced a system to electronically extract and collate extensive amounts of data from two laboratory information systems and to link it with ICD10 clinical codes in a new database using standard information technology.

MATERIALS AND METHODS

Three data files were generated from two laboratory information systems, ULTRA (version 3.2) and TM, using standard information technology scripts. These were patient pre- and post-transfusion haemoglobin, blood group and antibody screen, and cross match and transfusion data. These data together with ICD10 codes for surgical cases were imported into an MS ACCESS database and linked by means of a unique laboratory number. Queries were then run to extract the relevant information and processed in Microsoft Excel for graphical presentation. We assessed the utility of this data extraction system to audit transfusion practice in a 600-bed adult tertiary hospital over an 18-month period.

RESULTS

A total of 52 MB of data were extracted from the two laboratory information systems for the 18-month period and together with 2.0 MB theatre ICD10 data enabled case-specific transfusion information to be generated. The audit evaluated 15,992 blood group and antibody screens, 25,344 cross-matched red cell units and 15,455 transfused red cell units. Data evaluated included cross-matched to transfusion ratios and pre- and post-transfusion haemoglobin levels for a range of clinical diagnoses. Data showed significant differences between clinical units and by ICD10 code.

CONCLUSION

This method to electronically extract large amounts of data and linkage with clinical databases has provided a powerful and sustainable tool for monitoring transfusion practice. It has been successfully used to identify areas requiring education, training and clinical guidance and allows for comparison with national haemoglobin-based transfusion guidelines.

Behandlungsfehler im Zusammenhang mit der Bestimmung des prostataspezifischen Antigens

Advances in prostate specific antigen (PSA) diagnosis are accompanied by deficits in realization. The justification of claims by affected patients against their doctors are reviewed by commissions of experts and mediation by medical councils out of court, impartial and free of charge. The objectivity of the review is ensured by the independence of the commission and its members as well as the determination of facts and their assessment. Criteria are professional standards and required care. Since 1995, 21 requests by affected patients have been reviewed. In 15 cases (71.4%), treatment errors were ascertained. This involved either a delayed or an insufficient diagnosis (prostatic biopsy). In ten of the patients, a mostly early prostate cancer would have be diagnosed and treated at the time of the first finding of PSA values between 3.3 and 10.4 ng/ml. In ten of 13 patients, the tumor was diagnosed late, having PSA values between 6.8 and 1251 ng/ml with no chance of curative therapy. As in other life threatening diseases, time of recognition is most important for the diagnosis and treatment of patients with prostate cancer. Particularly for early recognition, PSA is much more sensitive then digital rectal examination, and in cases without a digital finding is the only parameter for early diagnoses. In men with suspicious PSA values (>4.0 ng/ml) suitable a diagnostic test (prostate biopsy) is required early, until cancer is detected or excluded.

Six-year prospective audit of chest reopening after cardiac arrest

OBJECTIVE

To identify which patients benefit from chest reopening after cardiac arrest.

SETTING

Cardio-thoracic hospital undertaking full range of adult cardio-thoracic surgery.

METHODS

In-hospital arrests were prospectively audited over a 6-year period. Information was collected for every patient whose chest was reopened following cardiac arrest: location of arrest, type of arrest, specialty, time since surgery, time to chest reopening, location of chest opening, surgical findings on reopening, time to cardiopulmonary bypass (if used) and patient outcomes.

EXCLUSIONS

Arrests in theatre and chest openings for reasons other than cardiac arrest.

RESULTS

There were 818 confirmed in-hospital arrests following 'cardiac arrest calls'. Chest reopening was undertaken in 79 surgical patients. Overall survival to discharge was 20/79 (25%). Favourable determinants of outcome were: arrest on intensive care unit (ICU), arrest within 24 h of surgery and reopening within 10 min of arrest. Nineteen of 58 (33%) chest openings following arrests on the ICU survived to discharge compared to one of 21 (5%) patients whose initial arrest was outside the ICU (P=0.017). One of nine ward arrests scooped to ICU for chest reopening survived whereas all 12 patients reopened on the ward died. Fifteen of 40 patients (38%) reopened within 24 h surgery survived compared to five of 39 patients where reopening was undertaken more than 24 h after surgery (P=0.02). Fourteen of 29 (48%) patients opened within 10 min of arrest survived to discharge compared to six of 50 (12%) patients where time to reopening was more than 10 min (P=<0.001). Seven of 22 patients (32%) patients where emergency bypass was utilised survived to discharge.

CONCLUSION

This study strongly confirms the benefit of chest reopening after cardiac arrest in the cardiac surgical ICU. Patients who arrest within 24 h of surgery and in whom reopening is instituted within 10 min are particularly likely to benefit. The value of chest reopening in arrests outside the ICU remains unresolved. All patients reopened on the ward died, suggesting that this practice should be discontinued. Early 'scoop and run' resulted in one solitary survivor though it should probably be restricted to patients who arrest within 72 h of surgery as surgically remediable problems are unlikely after this time.

The involvement, understanding and attitudes of dietitians towards research and audit

AIM

To investigate the involvement of dietitians in research and audit and to assess their understanding of and attitudes towards these activities.

METHODS

A postal questionnaire was used to investigate the knowledge, attitude towards and involvement in research and audit of State Registered Dietitians practising in the National Health Service (NHS) in the UK.

RESULTS

A response rate of 64% was achieved. Few respondents (15%) were currently involved in research, although more (65%) were currently involved in audit. Involvement in audit rose significantly with increasing grade and managerial responsibility. Dietitians qualifying more recently were more likely to believe that their college training prepared them to undertake research, but felt less confident about undertaking audit. Experience of audit made respondents more confident about auditing their work and improved their belief that they understood audit terminology. Higher grade dietitians were more likely to see audit as an important part of their role than were their more junior colleagues. Understanding of the terms 'research' and 'audit' was poor, although 48% of respondents identified the link between the two activities. Perceived constraints to involvement in research and audit were identified.

CONCLUSION

The present level of involvement of dietitians in research and audit activities falls below that recommended in the BDA's (1997a) National Professional Standards for Dietitians Practising in Healthcare. This study identifies factors that influence dietitians' involvement in, understanding of and attitudes towards research and audit and recommends ways of increasing their involvement in these activities.

An audit of fresh frozen plasma usage in a tertiary referral centre in a developing country

This paper evaluates the practice of fresh frozen plasma (FFP) transfusion at the University Hospital, Kuala Lumpur, and analyses its usage by the various clinical departments. The aim of this study is to identify where it is inappropriately used and the clinical indications in which such misuse is common. A retrospective analysis of the blood bank request forms and work sheets during a 6-month period between January 1998 and June 1998 formed the basis of this study. Overall, 40% of 2665 units transfused were considered appropriate. However, out of the 931 episodes of FFP transfusions only 31% were for appropriate indications. The average FFP requirement when used for appropriate indication was about 4 units per episode, whereas for inappropriate indication it was 2.5 units per episode. Inappropriate use in terms of the number of units was highest by the surgical services (68%) and Orthopaedics (64%), while the Department of Paediatrics had the lowest incidence of inappropriate use (40%). When Paediatrics was used as the benchmark, the incidence of inappropriate use by other departments was significantly higher (p < 0.01). As for FFP usage in common clinical indications, there was a high incidence of inappropriate use in burns (82%), perioperative period (73%), cardiac surgery (68%), massive bleeding (62%) and trauma (60%). The findings in this study, specifically the use of FFP for volume support in trauma, massive bleeding and burns, routine requests without identified indication in cardiac bypass surgery, and prophylactic use in the perioperative period can be the basis for recommendations to minimize the inappropriate use of FFP in the future.

Quality measures of antimicrobial drug use

Antimicrobial use is the major determinant in the development of resistance. Many parameters of importance for optimal quality of antimicrobial therapy have already been defined. Maximal efficacy of the treatment should be combined with minimal toxicity at the lowest cost. Quality of antimicrobial drug use is dependent on knowledge of many aspects of infectious diseases. Considering efficacy, many of our indications for antimicrobial use need critical evaluation. Irrational use should be discouraged. Avoidance of the development of resistance is a quality parameter that will need increasing attention. This paper reviews the well-established factors that may influence the appropriateness of pharmacotherapy with antimicrobial drugs. It cites recent evidence supporting principles of prudent prescribing and gives an overview of audits that have addressed these parameters. Measures relating to resistance are discussed.

The problem-based medical audit program: influence on family practice residents' knowledge and skills

BACKGROUND AND OBJECTIVES

Family physicians need to possess the skills to conduct audits in their own clinical settings to ensure that their patients receive exemplary clinical care. Residency offers an important opportunity for physicians to develop these auditing skills. This study describes the introduction of a problem-based medical audit program at three teaching units in the Department of Family Medicine at McMaster University and the program's effect on learner knowledge, skills, and attitudes toward the practice audit.

METHODS

A survey designed to assess residents' self-rated knowledge, skills, and attitudes toward practice audits was distributed before and after residents participated in the audit program.

RESULTS

Forty-three residents were surveyed; 33 (76.7%) completed the initial questionnaire and follow-up questionnaire. Residents reported significant improvements in their understanding of the relevance of audits, ability to develop a practice audit question, skills in designing methodology, and skills needed to conduct an audit independently. Residents also reported a moderate increase in their knowledge of statistics needed to complete an audit.

CONCLUSIONS

The practice audit program at McMaster University uses a problem-based model to introduce learners to the concept of the clinical audit. The practice audit program successfully improved the residents' self-reported ability to conduct an audit and heightened their understanding of the importance and relevance of the audit process.

Assessment of Guillain-Barré syndrome mortality and morbidity in the United States: implications for acute flaccid paralysis surveillance

To estimate age-specific incidences and assess the national morbidity and mortality burden for Guillain-Barre syndrome (GBS) in the United States, a national hospital discharge database compiled by the Commission on Professional and Hospital Activities (CPHA) and national death certificate data reported to the National Vital Statistics System were reviewed. During 1985-1991, 10,453 patients with GBS were discharged from CPHA-participating hospitals (estimated annual incidence, 3.0/100,000 population). The age-specific incidence of GBS increased with age from 1.5/100,000 in persons <15 years old to 8.6/100,000 in persons 70-79 years old. The total estimated number of GBS-related deaths from 1985 through 1990 was 3770 (95% confidence interval, 3506-4034), for an average of 628 GBS deaths per year. These rates suggest that the proposed national surveillance system for acute flaccid paralysis should capture at a minimum the 796 GBS cases in persons <15 years old. GBS remains a significant health burden among older adults in the United States, with a marked increase in risk after age 40.

Utilization of hospital services by the elderly: geriatric crisis in one Canadian single payer system

As the number and proportion of elderly persons in the Canadian population increase, utilization of health services by the elderly becomes a growing concern for health service insurers, financial managers and policy makers, as well as for care providers. The purpose of this paper is to present the results of a study to analyse the use of hospital services by the elderly in Alberta since the introduction of a universal single payer health care insurance system in 1970. The study period coincides with the implementation of publicly-financed comprehensive medical and hospital insurance programmes for all Alberta residents, making it possible to perform historical and population-based utilization analyses. Thus the data used for the study included all hospital discharge abstracts generated by all Alberta hospitals from 1971 to 1991. Trends in hospital service utilization by the elderly in terms of total number of separations, patient-days, and per case measures such as average length of stay as well as per capita utilization rates were reviewed to identify utilization patterns over the study period. Further, relative per capita utilization measures, in comparison with the base year (1971), age group 15-44, male, metropolitan residents, were derived and historical trends identified. A series of regression analyses were carried out to estimate the effects of age, sex and origin on utilization rates. In addition, for the period of 1984-1991, Diagnosis Related Groups (DRG) case weights were used to measure per capita and per case rates and to analyse historical relative utilization rates over the 8-year period. In general, there has been a significant decline in hospital utilization by Albertans under the publicly-financed single payer system, but utilization rates for elderly have remained high, resulting in high relative utilization rates in comparison with other age groups. It was also noted that per capita utilization rates for rural residents were substantially higher than urban residents. It appears that these higher utilization rates by the elderly and rural residents in combination with tight bed and financial control by the government have been causing significant bed shortage problems for non-elderly elective patients in urban areas.