The Consortium of E-Learning in Geriatrics Instruction

This paper describes the activities of the Consortium of E-Learning in Geriatrics Instruction (CELGI), a group dedicated to creating, using, and evaluating e-learning to enhance geriatrics education. E-learning provides a relatively new approach to addressing geriatrics educators' concerns, such as the shortage of professionals trained to care for older people, overcrowded medical curricula, the move to transfer teaching venues to community settings, and the switch to competency-based education models. However, this innovative education technology is facing a number of challenges as its use and influence grow, including proof of effectiveness and efficiency. CELGI was created in response to these challenges, with the goal of facilitating the development and portability of e-learning materials for geriatrics educators. Members represent medical and nursing schools, the Department of Veterans Affairs healthcare system, long-term care facilities, and other institutions that rely on continuing streams of quality health education. CELGI concentrates on providing a coordinated approach to formulating and adapting specifications, standards, and guidelines; developing education and training in e-learning competencies; developing e-learning products; evaluating the effect of e-learning materials; and disseminating these materials. The vision of consortium members is that e-learning for geriatric education will become the benchmark for valid and successful e-learning throughout medical education.

Pharmacy management approach: how do we align all the incentives?

BACKGROUND

While health care costs continue to rise and shift toward employers, a parallel improvement in health care quality has not been evident. As a means to repair this apparent disconnect, pay for performance (P4P) initiatives are being implemented across the country.

OBJECTIVE

To explore the need for P4P in the current state of health care delivery and review the design, components, and results of P4P programs.

SUMMARY

In P4P, clinical evidence is used by managed care organizations (MCOs) to drive financial incentives and align physicians and MCO goals, thereby improving delivery of care. At the center of all P4P programs are specific metrics, employed to measure the quality of care by which incentives are provided. These metrics fall into 4 main categories: clinical, patient satisfaction, efficiency, and technology. After metrics are employed and a provider is determined to be deserving of an incentive according to the P4P program in place, several different options exist and vary by plan in terms of incentive type. Primarily, these types of incentives include bonuses, adjustable fee schedules, and withholds. SelectHealth, a nonprofit health insurance company serving members in Utah and Idaho, implemented a primary care incentive program in 2002 for several different conditions and for pharmacy utilization that has been successful to date.

CONCLUSIONS

While P4P programs are becoming increasingly common in managed care, challenges still remain, and data on whether these initiatives improve outcomes and manage costs is still limited.

Clinical case study: achieving long-term control of insulin resistance

BACKGROUND

A total of 20.8 million people in the United States have diabetes, including 10.3 million adults over the age of 60 years, and more than 6 million people remain undiagnosed. Although diabetes is widely recognized as a prevalent and serious disease in managed care, current care is suboptimal, with less than 2% of American adults with diabetes receiving optimal quality of care.

OBJECTIVE

To review the various treatment interventions available in diabetes care, including the use of pay for performance (P4P) initiatives.

SUMMARY

In an effort to improve the current state of diabetes care, the NCQA's Health Plan Employer Data and Information Set (HEDIS) diabetes measure was developed as a means to better promote monitoring of various clinical markers in patients with this disease. This measure has been employed in P4P initiatives across the country by granting incentives to providers who have a prespecified proportion of their patients with diabetes meeting the measure. Likewise, to improve outcomes, many experimental and recently approved treatment options for diabetes target different processes in the course of the disease.

CONCLUSIONS

An effective program for the management of a diabetes patient population must be multidisciplinary, coordinating the efforts of many different levels of health care providers. Furthermore, components commonly incorporated in P4P initiatives, such as patient self-management education, provider contact, and the use of the American Diabetes Association standards of care measures for screening and lab levels, are imperative to the success of a diabetes management program.

Evaluating the management of septic shock using patient simulation

OBJECTIVE

Develop a scoring system that can assess the management of septic shock by individuals and teams.

DESIGN

Retrospective review of videotapes of critical care house staff managing a standardized simulation of septic shock.

SETTING

Academic medical center; videotapes were made in a recreated intensive care unit environment using a high-fidelity patient simulator.

SUBJECTS

Residents in medicine, surgery, and anesthesiology who had participated in the intensive care unit rotation.

INTERVENTIONS

The septic patient was managed by the intensive care unit team in a graded manner with interns present for the first 10 mins and more senior-level help arriving after 10 mins. The intern was graded separately for the first 10 mins, and the team was graded for the entire 35-min performance.

MEASUREMENTS AND MAIN RESULTS

Both technical and nontechnical scoring systems were developed to rate the management of septic shock. Technical scores are based on guidelines and principles of managing septic shock. Team leadership, communication, contingency planning, and resource utilization were addressed by the nontechnical rating. Technical scores were calculated for both interns and teams; nontechnical scores applied only to the team. Of 16 technical checklist items, interns completed a mean of 7 with a range of 1.5-11. Team technical ratings had a mean of 9.3 with a range of 3.3-13. Nontechnical scores showed similar intergroup variability with a mean of 26 and a range of 10-35. Technical and nontechnical scores showed a modest correlation (r = .40, p = .05). Interrater reliabilities for intern and team technical scores were both r = .96 and for nontechnical scores r = .88.

CONCLUSIONS

Objective measures of both knowledge-based and behavioral skills pertinent to the management of septic shock were made. Scores identified both adequate and poor levels of performance. Such assessments can be used to benchmark clinical skills of individuals and groups over time and may allow the identification of interventions that improve clinical effectiveness in sepsis management.

[Comment about the policy statement of the MDS. A position statement of the assessment group of the University Witten/Herdecke with regard to nursing documentation]

In 2005 the Medical Advisory Service of Social Health Insurance (MDS) in Germany published a policy statement with regard to the nursing process and documentation. According to the intention of the association, this statement should be considered as recommendations which are able to improve nursing practice and to contribute to streamlining of bureaucracy in nursing care. Recognising the broad impact of this publication on nursing institutions, a working group on nursing assessment of the University Witten/Herdecke conducted a critical review of the statement. Significant criteria for evaluation were the primary role of nursing documentation, quality requirements for the documentation as well as recent scientific results concerning the implementation of nursing process and assessment-based nursing diagnoses. The review revealed that the statement lacks of a clear rationale and its content appears to be merely research-based. Therefore it has to be questioned if the publication will accomplish the claimed effects. In fact, future quality criteria for health care are to be developed independently on the basis of scientific results and in consideration of the experiences of all concerned social groups.

[Certificate: "Occupational Dermatology (ABD)". New curriculum 2006 of the CME-seminars of the Task Force of Occupational and Environmental Dermatology]

The certification of experts is an important component in the overall concept of quality management in occupational dermatology. With the certificate "Occupational Dermatology (ABD)" the Task Force on Occupational and Environmental Dermatology (ABD) has developed a comprehensive CME concept in the field of medico-legal evaluations. The ABD seminars meet the current requirements of the statutory accident insurances and social welfare courts. The new CME seminar curriculum 2006 of the ABD takes into account the recent pioneering achievements in occupational dermatology, e.g. the Bamberg leaflet, the optimized dermatologic report and other prevention/early intervention measures. The ABD seminars (total of 21 hrs) are subdivided into 3 consecutive modules: basic, advanced and special seminar (7 hrs each). The seminars are interactive, based on practice-oriented discussions with experts from different disciplines (occupational dermatology, social law). The seminars should be attended in chronological order; there are no time limits during which they must be completed. Prerequisite for the certification is a specialist's degree in dermatology. To maintain the certificate it is expected to attend one of the newly-created ABD "quality management workshops" (7 hrs) within 5-year-intervals; these focus on interdisciplinary case discussions of the current legal regulations and recent social welfare court decisions. More than 400 dermatologists have already been certified by the ABD.

[Quality assurance in sociomedical evaluation]

Presented is the work of the Quality Assurance in Sociomedical Evaluation Project Group and its findings so far. The Project Group has developed a quality assurance concept for the outcome quality of sociomedical evaluations with personal examination and for evaluations on the basis of medical records. The quality criteria proposed by the Project Group are divided into primary as well as particular criteria. The primary criteria are: plausibility and conclusiveness, reproducibility, neutrality; the particular criteria are: formal and content programming, medical-scientific foundations, understandability, completeness, transparency, and efficiency. Both, the primary and the particular criteria are operationalized through examination questions. To fulfill a primary quality criterion, all related examination questions have to be answered in the affirmative. The particular criteria are related using a scoring system. The quality assurance programme also provides for a peer-review procedure; however, the manual for this procedure has yet to be developed. Research projects will be needed to determine the methodological requirements that have to be fulfilled for the proposed peer review procedure. Prior to implementation of the programme with the financially responsible pension insurance agencies it will be necessary to estimate the amount of time and manpower involved.

Increasing patient safety and efficiency in transfusion therapy using formal process definitions

The administration of blood products is a common, resource-intensive, and potentially problem-prone area that may place patients at elevated risk in the clinical setting. Much of the emphasis in transfusion safety has been targeted toward quality control measures in laboratory settings where blood products are prepared for administration as well as in automation of certain laboratory processes. In contrast, the process of transfusing blood in the clinical setting (ie, at the point of care) has essentially remained unchanged over the past several decades. Many of the currently available methods for improving the quality and safety of blood transfusions in the clinical setting rely on informal process descriptions, such as flow charts and medical algorithms, to describe medical processes. These informal descriptions, although useful in presenting an overview of standard processes, can be ambiguous or incomplete. For example, they often describe only the standard process and leave out how to handle possible failures or exceptions. One alternative to these informal descriptions is to use formal process definitions, which can serve as the basis for a variety of analyses because these formal definitions offer precision in the representation of all possible ways that a process can be carried out in both standard and exceptional situations. Formal process definitions have not previously been used to describe and improve medical processes. The use of such formal definitions to prospectively identify potential error and improve the transfusion process has not previously been reported. The purpose of this article is to introduce the concept of formally defining processes and to describe how formal definitions of blood transfusion processes can be used to detect and correct transfusion process errors in ways not currently possible using existing quality improvement methods.

[Quality assurance in student training. Prerequisites for DIN EN ISO 9001:2000 in teaching]

Standards of quality assurance according to DIN EN ISO 9001:2000 have been implemented in many university hospital departments, but often teaching activities are not included. This work presents a method that allows, after having defined the various teaching activities as sub-processes of one single core process, to include the manifold teaching activities of university hospital departments into the certification process. The stepwise description of the prerequisites for including teaching activities into ISO 9001 certification is illustrated by a concrete implementation example.

The role of telemedicine in fostering health-care innovations to address problems of access, specialty shortages and changing patient care needs

The integration of advanced technologies into health-care services promises to aid society in its transition to a coordinated, systems approach which is focused on disease prevention, enhanced wellness, chronic disease management, decision support, quality and patient safety. By incorporating such technologies, clinicians will be able to manage the growing volumes of medical information, research and decision support analytical tools. The deployment of advanced technologies will minimize the barriers of distance and geography to enhance access and facilitate the delivery of integrated health care. This will support and enhance the goals of the US federal Healthy People 2010 initiative.

Directly observed therapy and tuberculosis: how can a systematic review of qualitative research contribute to improving services? A qualitative meta-synthesis

AIM

This paper reports the findings from a qualitative meta-synthesis concerning people with, or at risk of, tuberculosis, service providers and policymakers and their experiences and perceptions of tuberculosis and treatment.

BACKGROUND

Directly observed therapy is part of a package of interventions to improve tuberculosis treatment and adherence. A Cochrane systematic review of trials showed an absence of evidence for or against directly observed therapy compared with people treating themselves.

METHOD

Qualitative systematic review methods were used to search, screen, appraise and extract data thematic analysis was used to synthesize data from 1990 to 2002, and an update of literature to December 2005. Two questions were addressed: 'What does qualitative research tell us about the facilitators and barriers to accessing and complying with tuberculosis treatment?' and 'What does qualitative research tell us about the diverse results and effect sizes of the randomized controlled trials included in the Cochrane review?' Findings help explain the diverse trial results in a Cochrane systematic review of directly observed therapy and tuberculosis and consider implications for research, policy and practice.

FINDINGS

Five themes emerged from the 1990 to 2002 synthesis: socio-economic circumstances, material resources and individual agency; explanatory models and knowledge systems in relation to tuberculosis and its treatment; the experience of stigma and public discourses around tuberculosis; sanctions, incentives and support, and the social organization and social relationships of care. Two additional themes emerged from the 2005 update.

CONCLUSION

The qualitative meta-synthesis improved the relevance and scope of the Cochrane review of trials. The findings make a major contribution to the development of theory concerning global WHO-branded disease control and the practicality of local delivery to people.

Avaliação da qualidade ou avaliação qualitativa do cuidado em saúde?

Ensaio teórico sobre avaliação da produção do cuidado em saúde, visando à demarcação de alguns conceitos. Inicialmente, assinalam-se a multidimensionalidade da qualidade em saúde, as diferenças entre avaliação da qualidade e avaliação qualitativa e as implicações decorrentes da não-distinção entre esses dois conceitos. Discute-se o cuidado em saúde como expressão material das relações interpessoais nesse campo de prática e como objeto de avaliação, explicitando sua intricada relação com a integralidade e com a humanização. Sustenta-se que avaliação de qualidade e avaliação qualitativa não são rótulos intercambiáveis, mas opções políticas atreladas a projetos sócio-sanitários que não se justapõem. A compreensão dessa distância é necessária para a construção de propostas avaliativas que superem perspectivas tradicionais e excludentes.

Quality indicators for type-2 diabetes care in practice guidelines: an example from six European countries

INTRODUCTION

Diabetes mellitus patients need a multidisciplinary management and rigorous follow up. Quality indicators are important to assess and improve the quality of the health-care delivery. Less straightforward, however, is choosing which indicators to use for the assessment of the disease management.

METHODS

Review of guidelines. Process and outcome indicators were extracted out of type-2 diabetes guidelines from Belgium and its neighbouring countries. The "most evidence based" indicators were derived after applying a "best evidence" ratio.

RESULTS

Thirty-four indicators were classified in five diabetes management topics: (1) control of glycaemia, (2) early detection of glycaemic complications, (3) treatment of glycaemic complications, (4) cardiovascular disease and, (5) quality of life. Target values to outcome indicators and appropriate specifications to process indicators were not assigned because direct transfer to different countries is not possible without considering contextual information such as typical preconditions of every society and health-care system.

CONCLUSION

Although not all aspects of care are described in guidelines, five 'mini' lists of highly valuable indicators for optimal treatment in the field of type-2 diabetes could be drawn up. The target sets for indicators' values and specifications are a matter of ongoing concern because evidence changes over time.

Antibiotic resistance in Neisseria gonorrhoeae

The incidence of gonorrhea is increasing in developed countries and remains high elsewhere. This untenable disease burden, the complication rate in women and newborns, and the amplification of human immunodeficiency virus transmission that accompanies gonorrhea makes control of gonococcal disease a priority. However, antibiotic resistance in Neisseria gonorrhoeae has severely compromised the successful treatment of gonorrhea. Older therapies are ineffective, whereas those that remain efficacious are unaffordable in many high-incidence settings. Penicillins, tetracyclines, and newer macrolides have limited utility, and spectinomycin (and in many parts of the world, quinolones) have been withdrawn because of resistance. Of the usually recommended treatments, only the third-generation cephalosporins, and most notably ceftriaxone, have retained their efficacy, but decreased susceptibility to these antibiotics has also appeared. A sustained decrease in gonococcal disease requires an integrated approach combining improved prevention, better diagnosis, and effective treatment. Without continued commitment and effort, gonorrhea may well become untreatable.

[Quality criteria for common surgical operations]

Personal contact with a hospital and patients who have received treatment there offer the best opportunity to assess its quality. A certification merely shows that a quality management system has been implemented, but says nothing about the quality of the actual outcomes achieved. Quality reports aid the family doctor to make an estimate of departments with which he has not so far cooperated. Objective information regarding the quality of outcomes are considerably more difficult to obtain. There appears to be a correlation between large numbers of operations and the quality of the surgery. In this area, the physician is dependent on voluntary publication of performance reports.

The World Health Organization/International Union Against Tuberculosis and Lung Disease Global Project on Surveillance for Anti-Tuberculosis Drug Resistance: a model for other infectious diseases

Tuberculosis remains a global epidemic, with one-third of the population infected and 9 million active cases. Mono- and multidrug resistance in 6 World Health Organization (WHO) regions have been assessed in 40% of the global cases diagnosed by positive results of sputum testing. The 2004 report of the WHO Global Project on Anti-Tuberculosis Drug Resistance Surveillance confirms earlier findings that drug-resistant tuberculosis is ubiquitous and that multidrug-resistant tuberculosis has increased alarmingly. Control of tuberculosis, which is undermined by the human immunodeficiency virus (HIV) epidemic, is seriously jeopardized by multidrug resistant strains, for which treatment is complex, more costly, and less successful. Challenges for high-burden countries include implementation of the DOTS strategy and management of identified multidrug resistance with DOTS-Plus. Strengthening of the laboratory network in conjunction with improvement of surveillance, elucidation of the impact of HIV on transmission of tuberculosis and on amplification of resistance at individual and population levels, and implementation of private sector policies on drug resistance are imperative. New diagnostic tools and drugs are needed to expedite early detection and cure of multiresistant strains.