Prospective evaluation of the quality of oral anticoagulation management in an outpatient clinic and in general practices

OBJECTIVE

To compare the quality of oral anticoagulant therapy (QOAT), before and after referral of patients on oral anticoagulant therapy (OAT) from a hospital outpatient clinic (HOC) to general practitioners (GPs).

DESIGN

Prospective observational study. Patients were identified by using the Laboratory Information System (LIS), containing all prescribed International Normalised Ratio of Prothrombin Time (INR) tests, from the HOC and GPs in the hospital submission area.

SETTING

The HOC in a rural hospital, Aarhus County, Denmark (55,000 inhabitants), and GPs in the submission area.

SUBJECTS

124 OAT patients (59.7% males. Median age 70.0: 25-75 percentile: 62.0-76.0).

MAIN OUTCOME MEASURE

The QOAT in terms of time spent within therapeutic INR interval (TI). The QOAT was compared 8 months before with 8 months after altering the monitoring organization. For patients monitored less than 8 months before the alteration, the QOAT was compared to a corresponding time period after the alteration.

RESULTS

We identified 124 OAT patients, and found a significant increase in the QOAT from 65.0% before to 69.1% after referral of the patients to the GPs (P<.0001). In 75 patients with full follow-up, the QOAT increased from 67.5% before to 69.7% after the alteration (P<.0001).

CONCLUSION

The results indicate that the QOAT in this geographical area is adequate, and that the quality performed by the GPs was at least as good as in the HOC. In order to document and increase the QOAT, continuous quality surveillance using the LIS has been initiated.

Managing waiting patients' perceptions: the role of process control

In a study of 195 patients visiting the urgent care department of a hospital in the UK, we examined the effects of three elements of process control on patients' fairness and satisfaction perceptions. Patients who believed they had a voice in the triage process had higher fairness perceptions and waited a shorter period of time than those who believed they did not have a voice in the triage process. In addition, patients who were told the expected waiting time and were kept busy while waiting had higher satisfaction perceptions. We identify implications for hospital employees in managing the patient waiting process.

Etiology of child mortality in Goroka, Papua New Guinea: a prospective two-year study

OBJECTIVE

To collect accurate data on disease- and microbial-specific causes and avoidable factors in child deaths in a developing country.

METHODS

A systematic prospective audit of deaths of children seen at Goroka Hospital in the highlands of Papua New Guinea was carried out. Over a 24-month period, we studied 353 consecutive deaths of children: 126 neonates, 186 children aged 1-59 months, and 41 children aged 5-12 years.

FINDINGS

The most frequent age-specific clinical diagnoses were as follows: for neonates--very low birth weight, septicaemia, birth asphyxia and congenital syphilis; for children aged 1-59 months--pneumonia, septicaemia, marasmus and meningitis; and for children aged 5-12 years--malignancies and septicaemia. At least one microbial cause of death was identified for 179 (50.7%) children and two or more were identified for 37 (10.5%). Nine microbial pathogens accounted for 41% of all childhood deaths and 76% of all deaths that had any infective component. Potentially avoidable factors were identified for 177 (50%) of deaths. The most frequently occurring factors were as follows: no antenatal care in high-risk pregnancies (8.8% of all deaths), very delayed presentation (7.9%), vaccine-preventable diseases (7.9%), informal adoption or child abandonment leading to severe malnutrition (5.7%), and lack of screening for maternal syphilis (5.4%). Sepsis due to enteric Gram-negative bacilli occurred in 87 (24.6%). The strongest associations with death from Gram- negative sepsis were adoption/abandonment leading to severe malnutrition, village births, and prolonged hospital stay.

CONCLUSIONS

Reductions in child mortality will depend on addressing the commonest causes of death, which include disease states, microbial pathogens, adverse social circumstances and health service failures. Systematic mortality audits in selected regions where child mortality is high may be useful for setting priorities, estimating the potential benefit of specific and non-specific interventions, and providing continuous feedback on the quality of care provided and the outcome of health reforms.

Detecting and reducing adverse events in an Australian rural base hospital emergency department using medical record screening and review

OBJECTIVE

To determine if retrospective medical record screening and clinical review followed by appropriate action can effectively and efficiently detect and reduce adverse events in an emergency department.

METHOD AND PARTICIPANTS

The medical records of 20 050 patients who attended the emergency department over a two year period were screened for adverse events using five general patient outcome criteria. Records that screened positive were reviewed by the hospital's clinical risk manager. If an adverse event was detected, the record was also reviewed by the director of emergency. For the first three months details of adverse events were recorded to determine a baseline adverse event rate, but no further action was taken. When an adverse event was found in the remaining 21 months, further analysis and recommendations for action to prevent a recurrence were made to relevant hospital staff.

SETTING

A rural base hospital in the Wimmera region of Victoria, Australia between October 1997 and September 1999.

RESULTS

Of all the patient attendances 573 (2.85%) were screened positive for one or more criteria. An adverse event was confirmed in 250 patient attendances (1.24% of all attendances). Of the adverse occurrences, 81 (32.4%) were determined to be of major severity and 169 (67.6%) of minor severity. Quality improvement activities, mostly changes to hospital policies and work processes, were implemented with the aim of preventing the recurrence of specific adverse patient events. Over two years the number of adverse events fell from 84 (3.26% of all patient attendances) in the pre-intervention quarter to 12 (0.48% of all patient attendances) in the final quarter (relative risk reduction 85.3% (95% CI, 62.7% to 100%)).

CONCLUSIONS

Adverse events in emergency departments can be efficiently detected and their rate reduced using retrospective medical record screening together with clinical review, analysis and action to prevent recurrences.

Utility of provider volume as an indicator of medical care quality and for policy decisions

Associations between hospital volume or physician caseload and patient outcome have been used to assess the performance of health care providers. Although most studies have focused on major surgical procedures, in-hospital or 30-day mortality from many nonsurgical conditions and procedures has also been examined. Although high volume may be a surrogate for the provider's skill and experience, and better outcomes may attract greater volumes, aggregate data on provider volume show many outliers indicating that the outcome for some low-volume providers is better than that for high-volume providers. Mortality is only one measure of medical care quality. Although high volume may not always be indicative of favorable outcome, referral of patients from low-volume to high-volume providers has been recommended. It has also been suggested that patients choose health care providers on the basis of physician caseload. It is unclear how such recommendations could be implemented in practice; furthermore, they would deprive many patients from access to, as well as disrupt the provision of, adequate health care in many areas. An alternative to requiring patients to receive care from high-volume providers is to adopt other measures for improving outcomes, such as improving the quality of care provided by low-volume providers and attracting better providers to low-volume areas.

Outcomes in rural obstetrics, Atherton Hospital 1991-2000

Analysis of annual obstetric audit data collected over the decade 1991-2000 from the Atherton Hospital in Far North Queensland provides ongoing evidence of safe obstetric practice provided by a group of non-specialist doctors in a rural community. During that period, there were 2997 deliveries; of these, 2400 (80.1%) were public patients and 596 (19.9%) were private patients. There were 16 perinatal deaths (perinatal mortality rate 5.3/1000). This is remarkably consistent with the outcome of the previous decade, 1981-90, when the total deliveries was 2883 with 15 perinatal deaths (perinatal mortality rate 5.2/1000). However, compared with 1981-90, the number of Caesarean sections rose from an overall rate of 13.0% (public 10.6%; private 18.3%) to an overall rate of 17.4% (public 16.7%; private 20.4%). In 1981-90, there were 909 private confinements (31.5% of total) and in 1991-2000 there were 597 (19.9% of total). This decline in the number of private obstetric cases may have significant implications for future models of care. There were no maternal deaths in the 20 years 1981-2000.

Clinical profile and management of heart failure: rural community hospital vs. metropolitan heart center

BACKGROUND

Knowledge on clinical characteristics and prognosis of patients with heart failure originates from studies of selected populations in clinical trials or from epidemiological observations. Reports on the large numbers of patients with heart failure treated in community hospitals are sparse.

OBJECTIVE

Are there differences in patient characteristics and heart failure management between a metropolitan heart center (HC) and a rural community hospital (RCH)?

PATIENTS AND METHODS

Retrospective analysis of medical charts from all patients admitted for heart failure (ICD 428.x, NYHA II-IV, EF<45%) between May 1997 and April 1998 and discharged alive from a rural community hospital. A similar, but prospective registry was available at the HC. Follow-up information was obtained by request at registration authorities.

RESULTS

Patient groups comprised 120 in RCH and 146 in HC. Mean age was 75+/-11 and 66+/-11 years, respectively (P<0.001); 48% (RCH) vs. 74% (HC) of patients were male (P<0.001). On admission the proportion of functional class IV was 69% (RCH) vs. 17% (HC) (P<0.001). At discharge, the rate of ACE-inhibitors was 74% (RCH) vs. 98% (HC); 11% (RCH) vs. 43% (HC) of patients received beta-blocker therapy. Ninety-six percent of patients in HC underwent and 22% in RCH had undergone invasive diagnostics. One-year mortality rate of patients discharged alive was 26% in RCH and 19% in HC (P=n.s. after adjustment for age and gender).

CONCLUSION

Heart failure management according to current guidelines, using beta-blockers and ACE inhibitors, and invasive cardiac examination was significantly less performed in the rural community hospital than in the metropolitan heart center. Therefore, strategies to improve heart failure management according to guidelines are urgently needed.

Insights obtained from an evaluation of a falls prevention program set in a rural hospital

An evaluation of a Falls Prevention Program that took place in a 29-bed rural hospital in New South Wales is described. The aim of the project was to ascertain the overall effectiveness of the Program and to explore the usefulness of the assessment criteria in predicting falls. The sample consisted of 111 participants, representing all patients 65 years and over who were admitted to the general ward of the hospital between January and December 1997. The Falls Prevention Program had reduced the incidence of falls and was found to be effective for those patients requiring minimal assistance with walking. However, it was less effective for those using pick-up frames or forearm support frames. The patients who fell were more likely to be in the high risk category and it was concluded that while the assessment criteria was useful in predicting falls, the Falls Prevention Program could only limit the number of falls but not prevent them altogether. Age, mental status and mobility of patients in combination with time and location of falls suggested a pattern that was possibly peculiar to this rural hospital, which has implications for funding and staffing.

Influence of trauma system implementation on process of care delivered to seriously injured patients in rural trauma centers

BACKGROUND

Statewide trauma systems are implemented by health care policy makers whose intent is to improve the process of care delivered to seriously injured patients. In Oregon, Advanced Trauma Life Support (ATLS) training was mandated for all physicians employed in the emergency department of trauma centers. The purpose of this study was to test the hypothesis that mandatory ATLS training favorably influenced processes of care.

METHODS

Seriously injured patients treated at 9 rural Level 3 and Level 4 hospitals were studied before (PRE) and after (POST) implementation of Oregon's trauma system. The processes of care evaluated on the basis of chart review were 20 diagnostic and therapeutic interventions advocated in the ATLS course. A cumulative process score (CPS) between 0 and 1 was assigned on the basis of the processes of care delivered. A CPS of 1 indicated optimal process of care.

RESULTS

Mean CPS for 506 PRE period patients (0.44 +/- 0.27) was significantly lower than the mean CPS for 512 POST period patients (0.57 +/- 0.27) with an unpaired t test (P <.001). For the subgroup with injury severity score of 16 to 34, the mean CPS of survivors (0.67 +/- 0.19) was significantly higher than the mean CPS of decedents (0.57 +/- 0.25).

CONCLUSIONS

Process of care for seriously injured patients improved after categorization of rural trauma centers in Oregon. Evidence shows improved process of care may have benefitted patients with serious but survivable injuries. Measurement of process of care is an alternative to mortality analysis as an indication of the quality of care.

Rural training and the state of rural health services: effect of rural background on the perception and attitude of first-year medical students at the university of melbourne

The aim of this project is to investigate the relationship between medical students' background and their perception of the state of rural health services; willingness to undertake internship training or work as a doctor in a rural hospital; expected benefits and disadvantages of training or working as a doctor in a rural hospital; and factors interfering with acceptance of a job as a doctor in rural areas. A questionnaire-based survey was distributed to 100 first-year medical students attending the Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne at the end of semester 1. The response rate was 97%, including 44 males and 53 females. A strong relationship was found between rural background and an intention to undertake internship training in a rural hospital (86% of students from a rural background expressed this desire vs 30% of students from an urban background). Furthermore, all students from a rural background expressed a desire to work as a doctor in a rural hospital after completing postgraduate training. Compared to urban students, students from a rural background showed a more positive attitude towards health services in rural areas including public hospitals ( P = 0.02), private general practice ( P = 0.004), ambulance service ( P = 0.0002) and baby health centres ( P = 0.005). Citizenship or gender was not significantly related to the perception of any of these services. The ranking of factors interfering with acceptance of a job as a doctor in rural areas were different for rural and urban students. Students from rural backgrounds reported spouse/partner needs (76% vs 49%, P = 0.038) and school availability for children (59% vs 30%, P = 0.023) as barriers more frequently than urban students, respectively). On the other hand, urban students rated the following factors higher: personal factors (76% vs 53%, respectively), education opportunities (56% vs 24%), social/cultural facilities (50% vs 41%) and the need for frequent travel (29% vs 12%). None of these interfering factors were significantly different. Urban students were more likely than rural students to report that their views were a result of adverse media reports. In conclusion, students from a rural background were more willing to be trained or to work as doctors in rural areas. This was associated with a greater adverse influence by the media upon students.

Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program

OBJECTIVES

To determine if an integrated clinical risk management program that detects adverse patient events in a hospital, analyses their risk and takes action can alter the rate of adverse events.

DESIGN

Longitudinal survey of adverse patient events over eight years of progressive implementation of the risk management program.

PARTICIPANTS AND SETTING

49,834 inpatients (July 1991 to September 1999) and 20,050 emergency department patients (October 1997 to September 1999) at a rural base hospital in the Wimmera region of Victoria.

MAIN OUTCOME MEASURES

Rates of adverse events detected by medical record review and clinical incident and general practitioner reporting.

RESULTS

The annual rate of inpatient adverse events decreased between the first and eighth years of the study from 1.35% of all patient discharges (69 events) to 0.74% (49 events) (P<0.001). Absolute risk reduction was 0.61% (95% CI, 0.23%-0.99%), and relative risk reduction was 44.9% (95% CI, 16.9%-72.9%). The quarterly rate of emergency department adverse events decreased between the first and eighth quarters of monitoring from 3.26% of all attendances (84 events) to 0.48% (12 events) (P< 0.001). Absolute risk reduction was 2.78% (95% CI, 2.04%-3.52%), and relative risk reduction was 85.3% (95% CI, 62.7%-100%).

CONCLUSIONS

Adverse patient events can be detected, and their frequency reduced, using multiple detection methods and clinical improvement strategies as part of an integrated clinical risk management program.

Quality oversight: why are rural hospitals less likely to be JCAHO accredited?

There is a large rural-urban disparity in the proportion of hospitals that are accredited by the Joint Commission on the Accreditation of Health Care Organizations (JCAHO). Several factors can influence whether a hospital participates in the accreditation process. A few of those factors include the hospital's size, case mix and ownership. However, even after controlling for many of these factors, hospitals in the most rural locations are less likely to be accredited by the JCAHO than urban hospitals. A survey was conducted to explore why rural hospitals are not participating in the accreditation process. Survey results show that the largest factor contributing to rural hospital deterrence to seeking accreditation is cost. Without accreditation by the JCAHO and compliance with their movement into performance measurement, quality monitoring of rural hospitals will fall further behind that of urban hospitals. Policy initiatives that make accreditation more financially feasible should be considered.

Anaesthesia in rural Tanzania

A survey of the anaesthetic services in rural Tanzania was carried out in an area of 67500 km2 and population of 4 million in order to assess the quality of anaesthesia and the major obstacles to good practice. Lack of draw-over vaporizers, Ayre's T-pieces, and a supply of oxygen were found to be the major obstacles to safe practice in this area of Africa.

Lapses in measures recommended for preventing hospital-acquired infection

This study was carried out in a rural tertiary care referral hospital in central India, to ascertain lapses made by people caring for neonates in measures recommended for preventing hospital-acquired infections. Unobtrusive observation of the healthcare personnel (doctors, nurses, mothers and hospital attendants) during care of the newborn was undertaken. Lapse in handwashing by healthcare personnel was observed around 41% of the time, although mothers practiced their instructions meticulously. Lapses in methods of hand drying were seen around 7-8% of the time, in those who did wash their hands. Gloves were not used around 21% of the time, when they should have been; and of those using gloves, they were unsterile in around 22% cases. At delivery babies were received unhygienically on approximately 67% of occasions observed. Lapses during cord care ranged from 14.2% to 28.6% and during resuscitation from 16.6% to 60% of occasions. An uncleaned stethoscope was used 75% of the time. The practice of putting a finger in the baby's mouth was observed on 18 occasions. Considerable lapses by all, in every measure recommended for the prevention of hospital-acquired infections were observed. It is concluded that nothing other than an individual's commitment is likely to be successful in preventing hospital-acquired infections.

Critical access hospitals: how many rural hospitals will meet the requirements?

Although the Medicare Rural Hospital Flexibility Program (MRHFP), which establishes a new designation for limited-service hospitals called critical access hospitals (CAH), intends to assist small rural hospitals having financial difficulty, it is unclear how many hospitals will qualify for the program. Potential CAHs are identified and the strategic issues that will impact actual participation in the program are discussed. Potential CAHs are identified by applying the legislative criteria for designation to a data set created from both the 1992-1995 Medicare Hospital Cost Report Information System and the 1993 and 1995 Prospective Payment System's Impact files. Descriptive analyses are used to identify potential CAHs by three parameters: distance to nearest hospital, average daily census and operating margin. Results indicate that the majority of potential CAHs have low volume and report poorer operating margins than other rural hospitals. Findings also show that the mileage requirements significantly impact the number of potential CAHs. There is more than a ninefold difference between the 93 hospitals that meet the mileage criterion and the 864 hospitals that might be eligible if certified by the state as "necessary providers," regardless of distance to the nearest hospital. The MRHFP is designed to prevent small, isolated hospitals from closing and thus to ensure continued access to care for rural residents. However, the number of potential CAHs that participate will clearly hinge on the flexibility of the program and the ability of states to determine "necessary providers."

Quality-of-care challenges for rural health

The purpose of this article is to examine the issue of quality of care in rural America and to help others examine this issue in a way that is consistent with the very real challenges faced by rural communities in ensuring the availability of adequate health services. Rural citizens have a right to expect that their local health care meets certain basic standards. Unless rural providers can document that the quality of local health care meets objective external standards, third-party payers might refuse to contract with rural providers, and increasingly sophisticated consumers might leave their communities for basic medical care services. To improve the measurement of health care quality in a rural setting, a number of issues specific to the rural environment must be addressed, including small sample sizes (volume and outcome issues), limited data availability, the ability to define rural health service areas, rural population preferences and the lower priority of formal quality-of-care assessment in shortage areas. Several current health policy initiatives have substantial implications for monitoring and measuring the quality of rural health services. For example, to receive community acceptance and achieve fiscal stability, critical access hospitals (CAHs) must be able to document that the care they provide is at least comparable to that of their predecessor institutions. The expectations for quality assurance activities in CAHs should consider their limited institutional resources and community preferences. As managed care extends from urban areas, there will be an inevitable collision between the ability to provide care and the ability to measure quality. As desirable as it might be to have a national standard for health care quality, this is not an attainable goal. The spectrum and content of rural health care are different from the spectrum and content of care provided in large cities. Accrediting agencies, third-party carriers and health insurance purchasers need to develop rural health care quality standards that are practical, useful and affordable.

Evaluating the clinical management of severely malnourished children--a study of two rural district hospitals

BACKGROUND

Severe malnutrition is an important cause of preventable mortality in most South African hospitals. Work recently done in two rural Eastern Cape hospitals supports the literature which shows that many deaths occur as a result of outdated clinical practices and that improving these practices reduces case fatality rates. Rapid assessment of clinical management in paediatric wards is necessary to highlight areas for improvement.

OBJECTIVE

To assess the management of severely malnourished children in two rural district hospitals and to recommend improvements for their care.

METHODS

Based on draft World Health Organisation (WHO) guidelines for inpatient care of children with severe malnutrition, data collection instruments were developed in conjunction with the district nutrition team to assess the quality of care given to malnourished children in two Mount Frere hospitals, Eastern Cape. Data were collected through retrospective review of case records, with detailed studies of selected cases, structured observations of the paediatric wards, and interviews with ward sisters and doctors.

RESULTS

The combined case fatality rate for severe malnutrition was 32%. Inadequate feeding, poor management of rehydration and infection, lack of resources, and a lack of knowledge and motivation among staff were identified as areas that need attention.

CONCLUSION

The clinical management of severely malnourished children can be rapidly assessed to highlight areas for improvement. Involving staff in the assessment process has led to their active involvement in improving the management of malnourished children in their hospitals.

Preventing medication errors in cancer chemotherapy referred to rural and remote hospitals

Patients from rural areas receiving simple chemotherapy regimens in regional or metropolitan centres are often sent back to their local hospital for treatment. As these centres commonly have health professionals with limited experience in the use of antineoplastic agents, it is particularly important to provide information that is accurate, thorough and has no potential for misinterpretation. The minimum information necessary has been identified in a previous study and includes patient details, diagnosis, chemotherapy protocol, dosages and method of confirmation, interval between cycles, supportive care and contact details for the prescriber. Staff at a number of small rural and remote hospitals were contacted to determine further useful information. Suggestions included: availability of premixed cytotoxics, methods of administration and possible adverse effects. A standardised computer format for providing oncological information was developed. Specific patient information is entered into the chosen protocol for each individual referred. This initiative has proven popular with participating hospitals and resulted in fewer inquiries and problems.