Topotecan in the treatment of gynecologic cancer

Topotecan (Hycamtin; SmithKline Beecham Pharmaceuticals, Philadelphia, PA), a derivative of the topoisomerase I inhibitor camptothecin, was approved by the Food and Drug Administration in May 1996 for the salvage treatment of ovarian cancer. It has shown promising clinical activity in a variety of solid tumors, including cervical cancer. Phase II and III trials in patients with cisplatin-resistant ovarian cancer have been conducted using a regimen of a single 30-minute intravenous topotecan infusion (1.5 mg/m2/d) for 5 days, repeated every 21 days. Significant responses, both partial and complete, have been observed in 14% to 21% of patients, with stable disease achieved in as many as 61%. In advanced or recurrent cervical cancer, partial response or stable disease was achieved in 59% of phase II trial patients. Myelosuppression is the major dose-limiting toxicity associated with topotecan. In general, the severity of myelosuppression shows a positive correlation to the magnitude of exposure to topotecan. Support with granulocyte colony-stimulating factor may partially ameliorate myelosuppressive effects.

Increasing HIV prevalence in a rural district of South Africa from 1992 through 1995

OBJECTIVES

To describe the increasing prevalence of HIV infection in a rural district in South Africa, to compare this with a nearby urban setting, and to estimate the prevalence of infection in the general population of the rural district.

DESIGN

Serial anonymous cross-sectional HIV seroprevalence surveys among consecutive women attending antenatal clinics in the rural Hlabisa health district, and the urban King Edward VIII Hospital, Durban, South Africa.

RESULTS

Crude antenatal HIV seroprevalence in Hlabisa increased from 4.2% (95% confidence interval [95%CI], 3.0-5.7) in 1992, to 14% (95%CI, 10.4-18.4) in 1995 (p < 0.0001). Age-specific prevalence was highest in women aged 20 to 24 years (21.1% in 1995) and in the more urbanized areas of the district (29.5% in 1995). Prevalence in Durban, at 19% (95%CI, 16.5-21.7), was higher than in Hlabisa in 1995 (p = 0.046), in large part as a result of the higher prevalence in the 15 to 19 year age group in Durban (22.4% vs. 7.4%, p = 0.004). An estimated 5.6% (95%CI, 3.0-9.6) of the general population of the Hlabisa district was HIV infected in 1995.

CONCLUSIONS

The HIV epidemic, fueled by a high incidence in young people, has escalated rapidly in this part of rural South Africa. Lower crude rural than urban prevalence is largely a result of a lower prevalence in young rural women; the underlying social reasons for this need to be fully explored. South Africa urgently needs to implement effective prevention programs, to plan for the impact of HIV-related disease on the health service, and to develop community-based care strategies.

Variance of plasma human immunodeficiency virus type 1 RNA levels measured by branched DNA within and between days

Previous studies have shown that CD4-positive T cells vary in a predictable manner over 24 h. This diurnal variance has significant clinical implications. Recently, viral RNA measurements have been increasingly used as a standard marker in the management of human immunodeficiency virus (HIV)-infected patients. Little detailed analysis of the variability of this marker has been conducted. To define the variance of plasma HIV-1 RNA levels within days, 11 clinically stable patients with established HIV infection and a baseline viral RNA level >40,000 copies/mL were studied. Following the patients' admission to an inpatient research unit, plasma samples were obtained frequently over 48 h and analyzed for HIV-1 RNA levels by use of a quantitative branched chain DNA assay (bDNA). No diurnal pattern was detected. In these clinically stable patients, viral RNA levels exhibited a variance of approximately 0.4 log.

Carboplatin and short-infusion paclitaxel in high-risk and advanced-stage ovarian carcinoma

PURPOSE

To present tolerance and toxicity information on previously untreated high-risk early-stage and advanced-stage primary epithelial ovarian cancer patients treated with adjuvant 3-hour paclitaxel and carboplatin.

PATIENTS AND METHODS

Consecutive patients with high-risk early-stage and advanced-stage epithelial ovarian cancer underwent maximal surgical debulking and/or staging. Paclitaxel (175 mg/m2) was infused over 3 hours followed by a 30-minute carboplatin infusion (area under the plasma concentration time curve = 7.0-7.5 mg/mL/min) for a planned six (q 21 day) courses.

RESULTS

Twenty-two patients underwent 132 cycles and were evaluable for toxicity. Myelosuppression was dose-limiting. Grade 4 granulocytopenia occurred in 31% of the cycles. Grade 3 and 4 thrombocytopenia was uncommon (5%, 1%) and predictable. Delay in administration was necessary in 10 of 132 (7.6%) cycles (5 of 22 patients). Eight of these 10 delays were 7 days. Seventeen of 22 (77%) patients completed therapy without a delay. Non-hematologic toxicity was mild. A significant individual weight gain of 2.5 kg was noted. Among 19 patients with advanced disease, 16 had a complete clinical remission after six cycles of therapy. Nine patients with stage IIB-IV disease have undergone reassessment procedures (four pathologic complete responses, three microscopic positive, two macroscopic positive). Sixteen of 22 (77%) have no evidence of disease, four have no evidence of disease following a secondary therapy, one is under therapy with salvage chemotherapy, and one is dead of disease. Median follow-up is 14 months (range: 6-30 months). Comparatively, the mean carboplatin dose administered was 440 mg/m2 (95% CI, 428-486 mg/m2).

CONCLUSION

Paclitaxel and carboplatin administered in this design are well tolerated, with predictable and acceptable hematologic and nonhematologic toxicity. Dose-limiting toxicity is granulocytopenia with relative platelet sparing. Outpatient administration is safe.

The successful implementation of pharmaceutical practice guidelines. Analysis of associated outcomes and cost savings. SWiPE Group. Systematic Withdrawal of Perioperative Expenses

BACKGROUND

Although approximately 2,000 medical practice guidelines have been proposed, few have been successfully implemented and sustained. We hypothesized that we could develop and institute practice guidelines to promote more appropriate use of costly anesthetics, to generate and sustain widespread compliance from a large physician group, and to decrease costs without adversely affecting clinical outcomes.

METHODS

A prospective before and after comparison study was performed at a tertiary care medical center. Clinical outcomes data and times indicative of perioperative patient flow were collected on the first of two sets of patients 1 month before discussion of practice guidelines. Practice guidelines were developed by the physicians and their associated care team for the intraoperative use of anesthetic drugs. A drug distribution process was developed to aid compliance. Clinical outcomes data and times indicative of perioperative patient flow were collected on the second set of patients 1 month after institution of practice guidelines. Hospital drug costs and adherence to guidelines were noted throughout the study period and for each of the following 9 months by querying the database of an automated anesthesia record keeper.

RESULTS

A total of 1,744 patients were studied. Drug costs decreased from 56 dollars per case to 32 dollars per case as a result of adherence to practice guidelines. Perioperative patient flow was minimally affected. Time (mean +/- SD) from end of surgery to arrival in the post-anesthesia care unit (PACU) increased from 11 +/- 7 min before the authors instituted practice guidelines to 14 +/- 8 min after practice guidelines (P < 0.0001). Admission of inpatients to the PACU receiving monitored anesthesia care increased from 6.5 to 12.9% (P < 0.02). Perioperative patient flow and clinical outcomes were not otherwise adversely affected. Compliance and cost savings have been sustained.

CONCLUSIONS

This study is an example of a successful physician-directed program to promote more appropriate utilization of health care resources. Cost savings were obtained without any substantial changes in clinical outcomes. Institution of similar practice guidelines should result in pharmaceutical savings in the range of 50% at tertiary care centers around the country, with a slightly smaller degree of savings expected at institutions with more ambulatory surgery.

Using an anesthesia information management system as a cost containment tool. Description and validation

BACKGROUND

Medical informatics provide a new way to evaluate the practice of medicine. Anesthesia automated record keepers have introduced anesthesiologists to computerized medical records. To derive useful information from the stored data requires programming that is not currently commercially available. The authors describe how they custom-programmed an automated record keeper's database to perform cost calculations, how they validated the programming, and how they used the data in a successful pharmaceutical cost-containment program.

METHODS

The Arkive (San Diego, CA) automated record keeper database was programmed at Duke University Medical Center as an independent noncommercial project to calculate costs according to standard formulae and to follow adherence to Duke University Department of Anesthesiology's prescribing guidelines for anesthetic drugs. Validation of that programming (including analysis of discarded drugs) was accomplished by comparing database calculated costs with actual pharmacy distribution of drugs during a 1-month period.

RESULTS

Validation data demonstrated a 99% accuracy rate for total costs of the drugs studied (atracurium, vecuronium, rocuronium, propofol, midazolam, fentanyl, and isoflurane). The study drugs represented approximately 67% of all drug costs for the period studied.

CONCLUSIONS

Programming of an anesthesia automated record keeper's database yields essential information for management of an anesthetic practice. Accurate economic evaluation of anesthetic drug use is now possible. In the future, as definitive identification of best anesthetic practices that yield optimal patient outcomes and higher measures of patient satisfaction is pursued, large numbers of patients should be studied. This is only possible through database analysis and complete computerization of the perioperative medical record.

A 5-year retrospective review of adverse drug reactions and their risk factors in human immunodeficiency virus-infected patients who were receiving intravenous pentamidine therapy for Pneumocystis carinii pneumonia

The incidence and severity of adverse drug reactions (ADRs) in human immunodeficiency virus-infected persons receiving intravenous pentamidine for Pneumocystis carinii pneumonia during a 5-year period were reviewed retrospectively. Predisposing risk factors for ADRs were identified. ADRs were included if they occurred during or within 1 week following the discontinuation of pentamidine treatment. Nephrotoxicity, dysglycemia, hepatotoxicity, hyperkalemia, and hyperamylasemia accounted for 80% of ADRs (n = 174) that occurred in 76 (71.7%) of 106 patients during 84 treatment courses of pentamidine. A significant relationship between hypoglycemia and nephrotoxicity was observed (P = .002). Four factors were significantly associated with occurrence of an ADR: number of concomitant medications (odds ratio [OR] = 1.36, P = .005), nonwhite ethnicity (OR = 5.00, P = .017), cumulative dosage of pentamidine (OR = 1.03, P = .030), and concurrent use of other nephrotoxic drugs (OR = 2.34, P = .047). Two factors, daily dosage and history of intravenous drug use, approached significance. Knowledge of and avoidance of potential risk factors might allow safer use of pentamidine and reduce the prevalence of ADRs.

Anesthesia information management systems as a cost containment tool

Anesthesia information management systems (AIMS) have uses that extend far beyond automatic anesthesia record-keeping. After initial experience with the development of monitoring technology, the Department of Anesthesiology at Duke University Medical Center, Durham, North Carolina, began the installation of the Arkive anesthesia information management system in 1987. The system was installed hospital-wide in 1992. AIMS played an integral role in determining the cost of pharmaceutical agents used during an anesthetic procedure. Clinicians targeted areas of high cost in which anesthetic practice could be modified. Establishment of an educational program followed by the institution of practice guidelines allowed for an annualized savings of more than $900,000 on drug costs with no effect on the quality of care provided. Future generations of AIMS need to be more fully integrated into hospital information management systems.

Quality management in mental health. II. Managing risk of dangerousness

In 1995 R. L. Coleman and D. E. K. Hunter described a quality management approach that produced measurable improvements in quality of care in a state-operated psychiatric hospital. Continued evolution of this approach has subsequently enabled the development and implementation of effective processes for managing risk of dangerousness among patients throughout the hospital. Supported by management principles that promote hospital-wide quality improvement, clinicians and managers produced an environment that was conducive to promoting quality. The hospital-wide quality improvement context involved integrating multiple activities designed to promote quality of care, including significant collaborations with other health care organizations. The hospital's mission as an acute care psychiatric facility has required that it focus on assessing and managing risk of dangerousness in a systematic manner. This was done through developing and utilizing a predictive risk assessment instrument and indicators for managerial oversight. This was accomplished in these steps. First, clinical leaders rated potential criteria according to estimates of their ability to predict dangerousness behavior and reviewed their estimates in relation to clinical findings. Second (and concurrently), clinicians and managers implemented procedures to monitor clinical risk and performance. Finally, outcome data were reviewed. They suggested that this approach was effective in reducing risk of dangerous behavior among patients on all psychiatric wards.

Statistical approaches to outcomes assessment

BACKGROUND

Statistical methods and software can be useful for evaluating clinical outcomes data.

METHOD

The use of control charts and regression analysis can be particularly helpful in outcomes assessment. Control charts can reveal outlier events and patterns that require additional review leading to changes that improve outcomes. Regression analysis can show factors that affect process characteristics. This article uses examples derived from hospital outcomes assessment activities relating to length of stay, treatment planning, insurance coverage, patient characteristics, and clinical decision making.

RESULTS

Minitab statistical software is used to create control charts and perform regression analysis, and essential Minitab commands are explained.

CONCLUSION

Through the use of the techniques described the clinical and manager can more effectively evaluate clinical outcomes data to improve healthcare quality.

Contemporary quality management in mental health

Contemporary approaches to quality management in mental health utilize methods derived from traditional quality assurance and industrial quality improvement. Quality assurance involves the use of measurable indicators to monitor and evaluate care. Sentinel event indicators refer to high risk events that require review each time they occur. Rate indicators refer to events that are reviewed in the context of trends and patterns. The process of choosing and developing indicators should involve identification of the indicator topic, the monitoring objectives, data collection mechanisms, and responsible staff. As well, indicator data must be evaluated, actions taken, and communication of results must occur. Positive results, like positive diagnostic findings, point to a probability of the presence of a quality related issue. Quality improvement methods have led to a further evolution of efforts to promote quality care. A major goal of quality management is to utilize data to improve clinical decisions. Reaching this important goal is difficult in mental health due to the uncertain relationship between interventions and outcomes of care. In the effort described,, interventions were initiated to improve decisions relating to clinical risk management and resource utilization. Administrative restructuring enabled real-time review procedures and retrospective data analysis focused on decisions related to clinical instability and on permissive and restrictive clinical decisions. Permissive decisions were defined as decisions to allow off-ward privileges for patients whose level of functioning scores suggested the need for greater restriction. Restrictive decisions involved extending hospitalization of low risk patients. Inappropriate permissive or restrictive decisions are undesirable from both risk management and quality-of-care perspectives.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical therapy of T1 and T2 vulvar carcinoma: further experience with radical wide excision and selective inguinal lymphadenectomy

Radical wide excision and selective inguinal node dissection provide a more conservative and less morbid surgical option for women with vulvar carcinoma than en bloc radical vulvectomy with bilateral inguinofemoral lymphadenectomy. We have expanded our initial experience with this approach to 76 patients with T1 (n = 33) and T2 (n = 43) squamous carcinomas with invasion > 1 mm and clinically negative groin nodes treated between 1978 and 1994. Lateral tumors (n = 53) were more frequent than midline lesions (n = 23). Tumors were excised with a measured gross margin of 2 cm, and dissection was carried to the deep perineal fascia. The mean largest tumor dimension was 26 mm; the mean depth of invasion was 4.4 mm. Superficial inguinal lymphadenectomy, unilateral or bilateral depending on lesion location, was performed. Perioperative complications occurred on the vulva in 8% of cases and in the groin in 11%. Delayed complications, all related to groin treatment, were seen in 29%. The median follow-up interval was 38 months. Seven patients (9%) had inguinal lymph node metastases identified at their primary operation. Most received additional therapy; one has died of disease. Nine women (12%) developed recurrent disease in the vulva: all were controlled by additional resection. Four (5%) developed recurrence in a previously negative groin: three of these are dead of disease. Actuarial 4-year survival is 81%. Radical wide excision and selective inguinal lymphadenectomy can be safely offered to women with T1 and T2 vulvar cancers. Patients with known positive nodes or vulvar failure can be salvaged by further therapy. Women with unanticipated groin failure usually die of disease. These experiences are similar to those observed in more radically resected patients.

Clinical and immunologic responses to human immunodeficiency virus (HIV) type 1SF2 gp120 subunit vaccine combined with MF59 adjuvant with or without muramyl tripeptide dipalmitoyl phosphatidylethanolamine in non-HIV-infected human volunteers

A phase 1 study of 42 non-human immunodeficiency virus type 1 (HIV)-infected volunteers was initiated to determine the safety and immunogenicity of an HIV subunit vaccine consisting of recombinant envelope gp120 derived from HIVSF2 (rgp120SF2) combined with a novel adjuvant, MF59, with or without the immunomodulator muramyl tripeptide dipalmitoyl phosphatidylethanolamine (MTP-PE). All injections contained adjuvant MF59, and subjects were grouped according to MTP-PE dose. Injections were given on days 0, 30, 180, and 365. The vaccine was well tolerated with limited local and systemic reactions. These immunizations induced rgp120SF2-specific binding antibodies that persisted > or = 24 weeks. After three immunizations, all subjects receiving the antigen developed neutralizing antibodies to HIVSF2, and serum from 67% of these subjects also cross-neutralized HIVMN. ELISA-reactive antibodies to the HIVSF2 V3 region and strong lymphoproliferative responses to HIVSF2 envelope proteins were detected in all rgp120SF2-immunized subjects.

Radical hysterectomy for recurrent carcinoma of the uterine cervix after radiotherapy

Patients with small recurrent cervical carcinomas following radiation therapy may be salvaged with radical hysterectomy rather than exenteration. Between 1953 and 1993, 50 patients underwent radical hysterectomy for persistent (n = 18) or recurrent (n = 32) cervical cancer after primary radiotherapy. The mean age of the cohort was 44 years (range, 23-70). Histologic types were squamous in 46, adenocarcinoma in 3, and adenosquamous in 1. Of 37 patients with staged disease, 24 had stage IB/IIA, 7 had stage IIB, 2 had stage IIIA, and 2 had stage IIIB. Combination radiotherapy, consisting of 40-45 Gy external-beam radiation plus brachytherapy (mean 6980 mg/hr), was performed in 32 patients (64%). In the 32 patients with recurrent lesions, the median interval from definitive radiotherapy to radical hysterectomy was 16 months (4-301), with 19 of these patients (60%) presenting within the first 24 months. Patients with persistent carcinomas underwent radical hysterectomy after a median observation interval of 2 months (1-4). A class II or III radical hysterectomy was performed in 39 (78%) cases. Pelvic and para-aortic lymph node samplings were performed in 39 patients (78%), including 33 (66%) who underwent complete pelvic lymphadenectomy. Among those sampled, 5 (13%) had metastatic nodal disease. All 5 patients died of disease at a median 13 months after surgery. Severe postoperative complications occurred in 21 patients (42%). The most common site of injury was the urinary tract, with 14 patients (28%) developing vesicovaginal or rectovaginal fistulae, 11 (22%) developing ureteral injuries, and 10 (20%) developing severe long-term bladder dysfunction. There was one postoperative death from sepsis among the entire population. Patients with abnormal preoperative intravenous pyelograms (P < 0.05), patients with recurrent presurgical lesions (P < 0.05), and patients with postoperative pelvic cellulitis (P < 0.01) were more likely to develop fistulae. The 5- and 10-year actuarial survival rates for all cases was 72 and 60%, respectively. Tumor size at radical hysterectomy was significantly associated with survival. Five-year actuarial survival in 12 of 44 patients (27%) with identifiable lesion diameters less than 2 cm was 90% compared with 64% in patients with larger lesions (P < 0.01). Prolonged disease-free survival occurred in 26 of 50 patients (52%) who had known disease status at follow-up, whereas recurrence after radical hysterectomy was seen in 24 patients (48%).(ABSTRACT TRUNCATED AT 400 WORDS)

Familial aggregation of carcinoma of the endometrium

OBJECTIVE

Our purpose was to describe histologically verified endometrial carcinoma and other cancer types manifested through three generations in a pedigree, where these findings do not fit any classic hereditary cancer syndrome.

STUDY DESIGN

Our family study protocol used detailed patient interviews whenever possible and questionnaires with permission forms that, when signed, enabled retrieval of pertinent medical-genetic and pathologic study documents.

RESULTS

Endometrial carcinoma was histologically verified in five women through three consecutive generations. The triad of obesity, hypertension, and diabetes mellitus was not observed. Primary carcinomas of both the endometrium and ovary and endometrium and lymphoma were documented in two relatives in the direct genetic lineage of the pedigree.

CONCLUSION

An aggregation of endometrial carcinoma in families, even when classic hereditary cancer syndrome identification is lacking, nevertheless merits surveillance and management strategies targeted to putative high-risk family members.

Intraoperative radiographs to confirm the adequacy of lymph node resection in patients with suspicious lymphangiograms

Between June 1991 and October 1992, we used presurgery lymphangiograms and intraoperative radiographs to identify and remove suspicious nodes in the pelvic and para-aortic chains of 19 patients with bulky pelvic cancers. Surgery comprised extraperitoneal exploration using a midline vertical or paramedian "J" incision. After grossly enlarged nodes were removed, an intraoperative anterior-posterior (AP) abdominal radiograph was obtained. The exposure field approximated the 24-hr delay AP LAG radiograph. Both films were compared in the operating room to confirm removal of abnormal nodes. Initial resection removed all suspicious nodes in 16 of 19 cases. Additional dissection resulted in successful node excision in the other 3 patients. Most of these "missed" nodes were behind or between vessels. The median number of nodes sampled was 15 (range 2-47). Bilateral sampling was performed in 15 cases. Metastatic tumor was present in 14 patients (74%) who had from 1 to 8 positive nodes. Of the 5 negative specimens, all contained lipogranulomata; two had extensive fatty replacement, 2 contained Müllerian inclusions, and 1 had reactive follicular hyperplasia which could be accountable for the radiographic abnormalities. Extracapsular extension was noted in 12 of 14 metastatic samplings. Radiotherapeutic treatment planning was then tailored to lymph node status and the location of positive nodes. Combined use of preoperative LAG and intraoperative films is useful in ensuring that complete resection of abnormal nodes has been accomplished. Whether removal of gross lymph node metastases enhances survival requires further study.

DNA flow cytometric analysis of clinical stage I endometrial carcinomas with lymph node metastases

Twenty-one (8%) of 264 consecutive evaluable patients with clinical stage 1 endometrial carcinoma had histologic evidence of pelvic and/or para-aortic lymph node metastases. DNA flow cytometry was performed on both the primary tumor and nodal metastasis. Seventeen of 21 sets could be analyzed. Overall, 11 (65%) of the primary carcinomas were aneuploid. Nine of 17 (53%) had consistent ploidy patterns when the primary tumor and lymphatic metastasis were compared. The remaining 8 (47%) had aneuploid primaries with diploid nodal metastases. Five (83%) of the 6 patients with diploid primary tumors were alive without evidence of disease compared to 3 of 11 (27%) patients with aneuploid tumors (P < 0.05). Other predictors of disease outcome included tumor histology, lymph vascular space invasion, and depth of myometrial invasion. Ploidy status of the lymphatic metastasis was not important in terms of overall survival. All 8 patients with para-aortic nodal metastases had aneuploid primary carcinomas compared to 4 (44%) of 9 patients with pelvic node involvement only (P < 0.01). Mean survival was 31 months for patients with para-aortic node metastases compared to 51 months for patients with only pelvic node metastases. Comparison of survival curves among these two groups demonstrated a significant survival advantage in patients with regional nodal metastases (P = 0.032). S-phase fraction of both the primary tumor and lymphatic metastasis did not correlate with survival or predict disease outcome. DNA index of the primary tumor, as a continuous variable, was inversely proportional to survival, demonstrating poorer survivorship with incremental increases of DI. Ploidy status of the lymph node metastasis was an inconsistent reflection of the primary tumor's expression and behavior and, therefore, little additional information was gained by knowledge of the lymphatic ploidy status.

Promoting quality through managed care

Managed care organizations will be able to promote quality care as well as control costs by utilizing quality management approaches and practice guidelines. By so doing, organized systems of care could promote adherence to standards of quality and appropriateness. Focusing on systems of care is a major component of the quality improvement process and fits well with the development and utilization of practice guidelines. Practice guidelines, as well as risk management, quality assurance, and quality improvement techniques, can help reduce undesirable variation in practice patterns and prevent problems from occurring. Guidelines may be based on different levels of explicitness ranging from subjective judgment to specific outcomes and patient preferences. The use of guidelines and quality improvement mechanisms will enhance the effectiveness of clinical decision making and enable managed care organizations to work productively with physicians to promote quality.

The staff psychiatrist and the Joint Commission survey

The psychiatrist on a hospital's medical staff has a major role in maintaining the quality standards established by the Joint Commission on Accreditation of Healthcare Organizations and in preparing for its accreditation survey. The authors review the medical staff's role in quality assurance activities, including development of clinical indicators, monitoring of clinical data, peer review of problems, and planning for improved care. Other areas of hospital operation requiring the attention of the medical staff are the functioning of the medical executive committee, hospital bylaws, and procedures for granting, denying, and amending clinical privileges.

The use of decision analysis in quality assessment

Now that major efforts are being made to develop clinical indicators, it is also imperative that participants in quality assurance programs have useful mechanisms to review data derived on the basis of these indicators. The decision tree is one means of conceptualizing clinical problems in a manner that can enhance both the development and review of clinical indicators. The decision tree can assist in presentation of clinical decisions and outcomes. When applied to specific clinical indicator data, such as a failure to order diagnostic tests, or to a trend of failure to follow a standard protocol for admissions, decision trees and decision analysis can assist in the review of quality and appropriateness of care. Both individual cases and trends lend themselves to decision analysis, which can help determine the decisions likely to be appropriate. When numerical data are available, decision analysis can provide quantitative evaluations of clinical and quality assurance data.