Ten-year review of hysterectomy morbidity and mortality: can we change direction?

The medical records of all women who underwent hysterectomy for benign disease performed between 1986 and 1995 were reviewed to ascertain the incidence of morbidity and mortality of abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy at a university teaching hospital. A total of 1940 hysterectomies were performed during this period; 74% of hysterectomies were performed abdominally, 24% vaginally and 2% were laparoscopically assisted. In 80% of the patients uterine leiomyomas, adenomyosis, dysfunctional uterine bleeding or uterine prolapse were the indications for hysterectomy The overall complication rate was 44% for abdominal hysterectomy (AH) and 27.3% for vaginal hysterectomy (VH). An unintended major surgical procedure was required in 3% and 1% of women undergoing AH and VH respectively The rate of return to the operating room for haemostasis was 0.6% for AH and 0.2% for VH. The AH group was four times more likely than the VH group to require surgical intervention (36% versus 9%) at readmission. Vaginal hysterectomy was associated with a lower febrile morbidity and minor complication rate. Prophylactic antibiotics reduced the febrile morbidity for VH and AH by 50% (Student's t-test, p = 0.02) and 40% (Student's t-test, p < 0.001) respectively The overall mortality rate was 1.5 per 1000.

Privately funded quality health care in India: a sustainable and equitable model

OBJECTIVE

As the cost and degree of training necessary to provide state of the art health care has increased throughout the world, the present challenge in health care is to establish institutions that are financially sound and responsive to the dynamic needs of the communities in which they exist. As public funds have diminished, the role of the private sector in estabhshing innovative health care institutions has increased.

SETTING AND STUDY PARTICIPANTS

This paper reviews the case of the LV Prasad Eye Institute (LVPEI), an ophthalmologic institute in Hyderabad, India, that is financially sound and medically vital. With an annual budget of US$3 million, 180 000 patients are seen and 23 000 surgeries are performed at the Institute and its satellites each year.

MAIN MEASURES

The Institute provides patient care at a ratio of 1:1 non-paying to paying patients through fee cross-subsidization. The Institute uses a combination of financial modalities, including donations, grants and fees to administer its non-patient care programs. Non-clinical programs of the Institute include a paramedical training program and a fellowship in ophthalmology, an internationally accredited eye bank for the preservation of corneal tissues, a rural out-reach and education program, a basic science and epidemiology program that directs health policy activities of the Institute and a rehabilitation program for patients with incurable visual deficits. To evaluate its effectiveness, LVPEI uses quality improvement measures, including patient surveys, post-operative outcomes studies and service utlization reviews.

CONCLUSION

This case report of a privately-funded medical institution describes a successful model through which high-quality, equitable health care can be provided in a developing country. The LVPEI's active program of quality management, its academic commitment and programmatic relevance to the needs of its community should be modularized and replicated to establish equitable, efficient and effective health care institutions in the developing world.

CM can play critical role in reducing medical errors

These days, virtually every hospital in the country is actively engaged in finding ways to reduce medical errors. And now, many are catching on to the fact that case management can play a pivotal role in this pursuit. Indeed, the role of case managers in reducing medical errors is critical, says Michelle Gofney, director of case management at Deborah Heart and Lung Center, a 161-bed hospital with a full-service ambulatory care center in Mills, NJ. 'Case managers are the primary specialty voice to reduce medication errors,' explains Gofney. She says that is because case managers alone look at the patient's medical care through the physician's eyes and the nurse's eyes as well as every ancillary department in the hospital.

'One-stop' cataract surgery: the Bristol Eye Hospital experience 1997-1999

PURPOSE

To evaluate patient satisfaction with and effectiveness of the 'one-stop' cataract service at the Bristol Eye Hospital.

METHODS

One hundred and ninety patients referred with a view to cataract surgery were selected to attend 24 'one-stop' clinics between February 1997 and August 1999. Patients had initial assessment in the morning with suitable cases undergoing surgery during the afternoon. Forty 'one-stop' patients and 40 patients undergoing traditional surgery (three separate visits: initial clinic, pre-assessment and surgery) were surveyed by a questionnaire to determine their satisfaction with the service.

RESULTS

One hundred and fifty-six of 190 (82.1%) patients invited to one-stop clinics underwent surgery the same day. Questionnaires were returned by 72 patients (35 'one-stop' and 37 control patients). Twenty-eight (80%) 'one stop' patients were 'very satisfied' and 7 (20%) were 'satisfied' with the time allowed to decide upon undergoing surgery, compared with 21 (57%) and 16 (43%) respectively in the control group (p = 0.06, chi-square, not significant). Overall satisfaction with the service was similar between the groups, with 33 (94%) of 'one-stop' and 35 (95%) of control patients considering the service 'very good'.

CONCLUSIONS

There is a high level of patient satisfaction with a 'one-stop' cataract service which reduces hospital attendance from three visits to one. Potential problems include wasted theatre space when there is a shortfall of suitable cases on the day.

Appropriateness of admission and hospitalization days in a specialist hospital

The assessment of hospital utilization is an important tool in the management of Hospital Health Care. The Authors examined the extent and the reasons of inappropriate hospital admission and stay in patients admitted to the Monaldi Hospital, Naples, Italy. Five hundred and thirty three medical records, were analysed. The survey was carried out in the period May-October 1999, using the italian version of the Appropriateness Evaluation Protocol (AEP) method. Of the admissions days, 15.8% were considered inappropriate; the most frequent cause of inappropriateness was waiting period for diagnostic test. The highest percentage of inappropriateness was found for females, for less serious pathologies and in the summer months. Compared to the admissions, the proportion of inappropriateness of the index days was higher (35.5%); the most frequent cause of an inappropriate day of stay was the persistence of mild symptoms which according to the attending physician justified prolonging the stay, while the same variables found for inappropriate admission (female sex, less serious pathologies and summer months) were related to inappropriateness of stay. This survey has allowed us to offer some useful suggestions with a view to making some of the activities of the "Monaldi Hospital" more efficient.

[Quality management according to DIN EN ISO 9001 at a university eye hospital]

BACKGROUND

Quality assurance is an integral part of modern microsurgical ophthalmology. Health care laws also mandate overall quality management.

MATERIALS AND METHODS

In recent years we have standardized the preexisting features of quality management according DIN EN ISO 9001 and have integrated previously missing features.

RESULTS

Establishing quality management according to ISO 9001 is possible even at a university eye hospital and department of ophthalmology. Certification according to ISO 9001 specifications was granted in April 1999. The major difficulty was in translating industrial norms to the context of an eye hospital. It was also difficult to overcome skepticism towards quality-assurance measures that lie beyond ophthalmological quality control.

CONCLUSION

It is useful and feasible to establish a quality management system at German university eye hospitals and departments of ophthalmology. Certification according to ISO 9001 is one possibility to make a quality management system transparent and evaluable both inside and outside the hospital.

Audit of a multidisciplinary vulvar clinic in a gynecologic hospital

OBJECTIVE

To perform a five-year retrospective audit of all new patients referred to a tertiary vulvar referral service.

STUDY DESIGN

A review was made of the records of all new clients who attended the vulvar clinic between 1993 and 1997. Information was entered into a database and analyzed.

RESULTS

Four hundred seventeen women were seen in the study period. Their ages ranged from 8 to 94 years (mean, 48.5). The most common symptoms were pruritus (44.8%), soreness (28.6%) and irritation (24.2%). Striking features were the poorly defined and lengthy histories and multiple symptomatology. Biopsies were performed in 61% of cases. Histologic diagnoses included vulvar intraepithelial neoplasia (VIN), 18.5%; nonneoplastic epithelial disorders, 16.8%; and carcinoma, 8.1%. Clinical diagnoses included dermatitis in 10% and normal vulva in 7.7%. The remaining cases represented a wide variety of dermatologic, pain and gynecologic conditions. There was a 95% correlation between the clinical and histologic diagnosis of VIN and 87% in lichen sclerosus. In 64.7% of women, treatment resulted in an improved outcome, 13.7% reported no improvement, and 1.6% cases deteriorated during treatment; 19.9% were lost to follow-up.

CONCLUSION

Provision of a multidisciplinary vulvar clinic in a tertiary setting provides an invaluable service for both primary and secondary clinical practitioners. The increasing demand for our services has created lengthy waiting times. The chronic nature of many vulvar diseases results in long-term follow-up of many women. Patient selection bias has developed as a consequence of the interests of the clinicians involved.

Inpatient care of mentally ill people in prison: results of a year's programme of semistructured inspections

OBJECTIVE

To investigate the facilities for inpatient care of mentally disordered people in prison.

DESIGN

Semistructured inspections conducted by doctor and nurse. Expected standards were based on healthcare quality standards published by the Prison Service or the NHS.

SETTING

13 prisons with inpatient beds in England and Wales subject to the prison inspectorate's routine inspection programme during 1997-8.

MAIN OUTCOMES MEASURES

Appraisals of quality of care against published standards.

RESULTS

The 13 prisons had 348 beds, 20% of all beds in prisons. Inpatient units had between 3 and 75 beds. No doctor in charge of inpatients had completed specialist psychiatric training. 24% of nursing staff had mental health training; 32% were non-nursing trained healthcare officers. Only one prison had occupational therapy input; two had input from a clinical psychologist. Most patients were unlocked for about 3.5 hours a day and none for more than nine hours a day. Four prisons provided statistics on the use of seclusion. The average length of an episode of seclusion was 50 hours.

CONCLUSION

The quality of services for mentally ill prisoners fell far below the standards in the NHS. Patients' lives were unacceptably restricted and therapy limited. The present policy dividing inpatient care of mentally disordered prisoners between the prison service and the NHS needs reconsideration.

[The situation of physician in the state prison--constitutional state guarantees of individual rights]

In Germany, 220,000 persons are imprisoned yearly. Their health care is provided by physicians supported by medical teams in 9 prison hospitals. There is a total of 395 physicians mainly practicing in general medicine, internal medicine, surgery, and psychiatry. Other medical disciplines are represented by external physicians that are paid by fees. It is common to consult external physicians which can be explained by the legislation ruling the penal system. The prison administration has to provide a health care of equal quality as outside of prison. A pathology typical in prison, the unproportional representation of certain social groups (poor people, foreigners) and diseases (mental diseases, drug abuse, tbc, hepatitis, HIV) request an expanded profile of expertise from the physician. Except the task of health care, the physician is included in executive functions. Thus, the physician is exposed to control by non-medical institutions.

The effect of continuous quality improvement on compliance with clinical practice guidelines in an optometric clinic: a retrospective review

BACKGROUND

Quantitative documentation of quality is becoming increasingly more important. The SUNY State College of Optometry established clinical protocols outlining clinical standards for patient care. We compared documentation of actual clinical performance to these standards.

METHODS

The Primary Care Service's Quality Management Team retrospectively reviews a random 10% sample of charts of patients seen in the teaching clinic of the SUNY State College of Optometry on an ongoing basis. They compare the care documented in the medical record to internally distributed clinical protocols. We reviewed the resultant data from January 1995 through June 1997 by analyzing the number of indicators that were out of compliance for each month. Then we graphed these data to ascertain trends and variability to determine what effect this continuous quality improvement process had on clinical care as measured by compliance with clinical protocols.

RESULTS

A least-squares regression analysis demonstrated a correlation (0.717) between the decreasing number of items out of compliance and the time during which feedback was provided (r2 = 0.5143, p = 0.0001). These data show a distinct downward trend, indicating better compliance with the clinical protocols over time. We also found that the variability of the data decreased during the time period studied.

CONCLUSIONS

A properly designed continuous quality improvement program that gives appropriate feedback to faculty optometrists and student interns measurably increased their compliance with--and decreased their variability from--this clinic's internally distributed clinical protocols over a 30-month time period.

Hospital vs community care: a Romanian perspective

In the Summer of 1997, two Romanian charities which provide financial support to care for children with human immunodeficiency virus (HIV) living in Romania invited a team of healthcare professionals to conduct an independent audit of care for children nursed in hospital and community settings. The primary objective of the mission was to: witness hospital and community care of HIV positive children; work with Romanian healthcare professionals in the development of a simple user friendly audit tool for use in a variety of child care settings; and utilize the tool to audit and produce a written report related to care provision in the hospital and community home setting. The results of the audit exercise demonstrate that the provision of care for HIV positive children in the community homes exceeds that of similar children cared for in a tertiary hospital setting.

Management of cerebral aneurysms. How can current management be improved?

In the present article, we have reviewed potential avenues for improvement in the care of and present management of patients with cerebral aneurysms. Opportunities exist in areas of prevention, systems approach and organization of centers, physician and patient education, screening, and advances in surgical and endovascular therapy. All such advances, however, depend on rigorous academic evaluation. This issue represents a review of the current management of cerebral aneurysms, hopefully providing a basis for future improvements in the treatment of these lesions.

Clinical outcome in relation to care in centres specialising in cystic fibrosis: cross sectional study

OBJECTIVES

To assess the effect on clinical outcome of managing paediatric and adult patients with cystic fibrosis at specialised cystic fibrosis centres.

DESIGN

Cross sectional study.

SETTING

Two adult cystic fibrosis centres in the United Kingdom.

SUBJECTS

Patients from an adult cystic fibrosis centre in Manchester were subdivided into those who had received continuous care from paediatric and adult cystic fibrosis centres (group A), and those who had received paediatric care in a centre not specialising in cystic fibrosis followed by adult care in a cystic fibrosis centre (group B). Group C were referrals to the new adult cystic fibrosis centre in Cambridge who had received neither paediatric nor adult centre care for their cystic fibrosis.

MAIN OUTCOME MEASURES

Body mass index (weight (kg)/height (m2)), lung function (forced expiratory volume in one second (FEV1 percentage of predicted)), the Northern chest x ray film score, and age at colonisation with Pseudomonas aeruginosa.

RESULTS

A prominent stepwise increase in body mass index was associated with increasing amounts of care at a cystic fibrosis centre; 18.3, 20.2, and 21.3 for groups C, B, and A respectively (P<0.001). Improved nutritional status was correlated with a higher FEV1 and better (lower) chest x ray film scores; r=0. 52 and -0.45 respectively (P<0.001 for both).

CONCLUSION

These findings provide the first direct evidence that management of cystic fibrosis in paediatric and adult cystic fibrosis centres results in a better clinical outcome, and strongly supports the provision of these specialist services.

The influence of the San Lazaro Hospital of Seville in the creation and management techniques of the "lazaretto" hospitals in the Americas

The San Lazaro Hospital of Seville that was established in the middle of the 13th century was one of the most important in Spain and Europe throughout nearly eight centuries in terms of caring for leprosy patients. In the 1930s the exclusive treatment of leprosy patients ceased and San Lazaro became a general hospital. The Spanish Crown (Alfonso X) accorded certain privileges and rules to the hospital which also were conferred by subsequent monarchs. These rules and ordinances contributed to the establishment and functioning of many lazarettos throughout the Americas of which we have documentation, notably those of Santo Domingo, Tlaxplana (Mexico City), Lima, Cartagena de Incias, La Habana, and Yucatan.