Patients' expectations of information provided at cancer hospitals in Japan

In order to survey patients' views on disease and treatment information that should be provided at hospitals, an anonymous self-administered questionnaire was distributed to patients at Aichi Cancer Center Hospital in 1995. All eligible first-visit outpatients (97 persons), randomly selected revisit outpatients (99 persons; about one in ten refused), and all except six eligible inpatients in good condition at discharge (97 persons) responded. Out of 293 patients (115 males, 174 females and 4 unspecified), 74% answered that they wanted to be informed of their diagnosis irrespective of circumstances, 20% answered that they would want to be informed only in certain circumstances, and 2% did not want to be informed at all. There were no significant differences in response among the three sources of patients. Inpatients wanted more (81%) to be explained about recommended therapy than either first-visit outpatients (67%) or revisit outpatients (67%). The majority considered that about a 30-minute explanation was needed using pamphlet-like written materials or video. When asked what information was needed when choosing a cancer hospital, 71% specified information on the specialty of the hospital, 57% the content of the care provided, 23% the name and specialty of the doctors, 20% the waiting period before scheduled admission, 13% the average admission period, 11% the number of patients with the same disease, 10% the waiting time at the outpatient clinic, 6% the meal menu, and 4% the number of private wards. Forty-three percent wanted an information service covering all hospitals in the region through an information center. The results revealed that patients at this cancer hospital required information on their disease, treatment, and hospital specialty.

[Quality assurance in coloscopy in private practice and the hospital. The Gastroenterology Quality Circle (GEQC) Munich]

OBJECTIVE

As quality control in medicine is part of a doctor's professional duty, the "Munich Quality Circle" conducted a prospective feasibility study in which ten, previously defined, quality indicators were to be assessed.

PATIENTS AND METHODS

Six specialised private practice groups and three specialised hospitals centers took part. Data on 2928 consecutive patients were collected by questionnaire and ten quality indicators assessed: concordance with the indication list; intestinal cleansing; premedication; duration and completeness of the study; sensation of pain; use of radiology; complications; diagnosis; and therapeutic intervention.

RESULTS

Concordance with the indication list was present in 97.8% (range 93-100), premedication was given to 94.6% (77-100), midazolam to 77%. The proportion of patients who recorded no or only moderate pain correlated with the dose but not with the duration of advancing the coloscope. Mean time of advancing the instrument to the caecum was 8.0 min, the duration directly depending on the experience of the examiner. A mean time of less than 10 minutes was achieved only after more than 1200 examinations. The more a centre used fluoroscopic control the shorter the time of coloscopy. The examination was completed in 97.6% (92-99). There was no correlation between experience (assuming supervision) and dose of midazolam or frequency of fluoroscopy.

CONCLUSIONS

Nowadays total coloscopy is a primary diagnostic method, but it needs an intensive learning phase. In clinical centers consequent supervision of less experienced examiners achieved comparable results to those with experience. Informative quality indicators for coloscopy can be documented with little cost.

An audit of meal provision in an elderly care hospital

OBJECTIVES

To estimate the nutritional provision to elderly patients, to compare with United Kingdom (UK) Government dietary reference values (DRV), to modify food provision to correct any major deficiencies, and to evaluate these modifications for their acceptability and consumption.

METHODS

Energy, principal macro nutrients, vitamins, minerals and non-starch polysaccharide (NSP) and dietary fibre provision were measured prospectively throughout the menu cycle in a 72-bedded hospital for patients over 65 years before and after dietary supplementation with both energy-rich foods and high-fibre cakes.

RESULTS

At baseline, mean energy provision was 1472(320) kcal, 6153(1340) kJ, representing less than the estimated average requirement (EAR) for elderly males and females. Fat provided 49% of total energy, daily protein provision exceeded the EAR for males and females (16% energy) and provision of the micro nutrients thiamine, riboflavin, vitamins B12, C, A, calcium and iron met or exceeded these recommendations. Vitamin B6 provision was only adequate for females. Provision of niacin, folate, vitamin D, NSP and dietary fibre was also below recommendations. Supplementation allowed energy provision to reach the target EAR and fibre provision the reference nutrient intake.

CONCLUSIONS

Nutritional provision in hospital is meeting some, but not all, available Government standards for nutritional guidelines in elderly people. Increased fibre provision was poorly tolerated, but dietary supplementation with energy-rich foods was well tolerated.

Perceptions of quality in long-term care: a satisfaction survey

At a 387-bed geriatric hospital in Montreal, Canada, a cross-sectional satisfaction survey was conducted on random samples of patients, families, families of deceased patients, and nursing staff. Using the same pretested structured questionnaire, the subjects were asked to rank (assign importance to) and rate (assign a rate of success to) 15 indicators of quality care. Significant differences both between and within the four groups were found on the perceived importance and rate of success of many of the indicators, supporting the primary hypotheses. Ethnicity and several sociodemographic covariates influenced the importance and rate of success assigned to the key indicators. The article discusses survey methodology issues as well as the integration of a satisfaction survey into an overall quality improvement program.

Comparison of measures to assess outcomes in total hip replacement surgery

OBJECTIVES

To compare the performance of a disease specific and a general health questionnaire in assessing changes resulting from total hip replacement.

DESIGN

Two stage prospective study of patients undergoing total hip replacement surgery involving an assessment at a clinic before and six months after surgery. 60(32%) patients were followed up by post.

SETTING

Outpatient departments at a specialist orthopaedic hospital and peripheral clinics within Oxfordshire.

PATIENTS

188 patients admitted for unilateral total hip replacement between February and mid-August 1994.

MAIN MEASURES

Patients' self assessed scores with the 12 item Oxford hip score and SF-36 general health questionnaire together with surgeons' assessment with Charnley hip score obtained before and again at six months after surgery.

RESULTS

186 patients were followed up six months after total hip replacement; a subsample (n=60) by post. Of the 60 postal patients, 59(98.3%) fully completed the Oxford hip score compared with 44(73.3%) who fully completed the SF-36. For the followup sample as a whole, post operative changes in scores produced a large effect size of 2.75 on the Oxford hip score, compared with -1.89 physical function (SF-36), -2.13 pain (SF-36). With the exception of physical function and role (physical), postoperative SF-36 scores were shown to be similar to or better than those found by two population surveys on patients of comparable age. The responsiveness of a disease specific questionnaire, the Oxford hip score, and relevant sections of a general questionnaire, SF-36, were found to be similar as assessed by three different criteria.

CONCLUSIONS

A disease specific questionnaire, the Oxford hip score, and a general state of health questionnaire, SF-36, performed similarly in assessing outcomes of total hip replacement except that the disease specific questionnaire resulted in a higher completion rate and greater responsiveness in some sections. On the other hand the general health questionnaire drew attention to broader problems of physical function not considered by the Oxford hip score. The health questionnaires examined here offer a valid and practical means of monitoring outcomes of hip replacement surgery.

Who should see eye casualties?: a comparison of eye care in an accident and emergency department with a dedicated eye casualty

Emergency care for eye complaints is provided both by accident and emergency (A&E) departments as well as by dedicated eye casualty departments. This study examines the role of each type of department and the quality of eye care provided. Significant differences were found between the accident and emergency department and the eye casualty department in the history, examination and management of eye patients. Most notably, there were significant differences in the quality of the assessment in the two institutions. Overall 19% (19/100) of A&E records had an inadequate history, compared with 2% (1/50) for eye casualty records. Fifty-nine per cent (59/100) of A&E records contained a significant examination omission, compared with only 8% (4/50) of eye casualty records. Most of the omissions related to a failure to perform an adequate, yet simple, ocular examination including failure to record visual acuity. In 44% (44-100) of A&E cases visual acuity was not recorded or recorded incorrectly. In comparison acuity omissions in eye casualty were present in only 4% (2/50) of cases.

Auditing the health care enterprise. Evaluation research can improve strategic planning and implementation in hospitals

Financial audits that focus on the recent past have been criticized for not answering questions concerning whether or not the enterprise will survive and thrive during the next few years. Strategic management/marketing audits (SMMAs) are designed to respond to these concerns. In conducting an SMMA for a long-term care hospital, the authors found critical differences in the beliefs held by key executives and staff members regarding the strategic goals, planning, and actions of the hospital.

Comprehensive geriatric assessment in a day hospital

OBJECTIVE

To assess the effectiveness of comprehensive geriatric assessment conducted in day hospitals.

DESIGN

Retrospective cohort comparison study with restricted inclusionary criteria and adjustment for baseline characteristics.

SETTING

A hospital-based geriatric day hospital and geriatric clinic sites (both in the university and in the community).

PATIENTS

Four hundred sixty-eight patients referred for comprehensive geriatric assessment during a 12-month period.

INTERVENTION

Comprehensive geriatric assessment in a geriatric day hospital compared with assessment received in clinic sites without a day hospital.

MAIN OUTCOME MEASURES

Services received in the first 2 weeks; hospitalization, emergency room visits, placement, death, and change in selected health status measures. Follow-up data was obtained from medical records, a telephone survey, and death certificates.

RESULTS

Except in the case of rehabilitative services, day hospital patients were more likely to receive interdisciplinary services. The population seen in the day hospital was more functionally impaired and had significantly more dementia and depression. After adjusting for subjects' baseline characteristics and limiting the analyses to subjects meeting specific inclusionary criteria, the day hospital had no significant effect on mortality, use of emergency or hospital services, placement, or change on selected measures of health status. For example, compared with the clinic patients, receiving care in the day hospital was associated with an adjusted odds ratio of 1.01 (95% confidence interval: 0.53, 1.91) of being at a higher level of care at 6 months. The results were not sensitive to the choice of inclusionary criteria.

CONCLUSION

Given their cost and uncertain effectiveness, day hospitals need additional evaluation before their further diffusion occurs.

The effect of transplant center volume on cardiac transplant outcome. A report of the United Network for Organ Sharing Scientific Registry

OBJECTIVE

The number of cardiac transplant programs continues to increase despite no increase in the number of hearts available for transplantation. As a result, the majority of heart transplant centers perform extremely small numbers of transplant operations annually. To determine the effect of small transplantation volume on transplant outcome, the following study was performed.

DESIGN

Using the Scientific Registry of the United Network for Organ Sharing, all cardiac transplant procedures from October 1987 through December 1991 were analyzed to determine whether center volumes affected cardiac transplant outcome. Patient survival rates for each center were determined, and the survival rates were modeled for the following patient variables: first transplantation or retransplantation, patient condition at the time of transplantation, patient underlying cardiac disease (congenital vs all others), and time.

SETTING

All cardiac transplant centers in the United States were included in the analysis.

PATIENTS

All patients undergoing cardiac transplantation in the United States from October 1987 through December 1991 were included in the analysis.

MAIN OUTCOME MEASURE

The primary end point in this analysis was mortality.

RESULTS

Throughout the entire study, of the 150 cardiac transplant centers, 35.3% of the centers were performing fewer than five cardiac transplantations per year, 53.3% were performing fewer than nine transplantations per year, and 61.3% were performing fewer than 12 transplantations per year, the minimum required for Medicare payment eligibility. Using the modeled survival rates, the risk of mortality decreased to a basal level in those centers performing between eight and 10 transplant operations per year. In centers performing fewer than nine transplantations, mortality increased sharply and exponentially. Dividing centers into those that performed nine or more transplantations per year (70 centers) and fewer than nine transplantations per year (80 centers), the increased risk of mortality at 1 month and 12 months was 40.3% and 33.1%, respectively, in centers performing fewer than nine cardiac transplantations per year (P < .001). Once the threshold of nine transplant procedures was met, those centers that were eligible for Medicare payment did not have significantly better survival than those centers not eligible for Medicare coverage.

CONCLUSIONS

These data demonstrate that the risk of mortality at early and intermediate time points is substantially higher in low-volume cardiac transplant centers, which make up more than half of the centers performing cardiac transplantation in the United States.

Asthma care map for decision making

In the second part of a three-part series on patient-centered asthma care, the authors describe the eight critical elements of multidisciplinary care management for patients with moderate to severe asthma.

Patient-centered asthma care: a community-based multidisciplinary model

In this first part of a three-part series, the authors discuss a treatment program for patients with chronic, severe asthma. Of all chronic diseases, asthma has proven to be one of the most expensive--financially, physically, and psychologically. Although the symptoms are usually reversible, they can be severe if left untreated. Physicians, nurses, and case managers across the country are recognizing the total value of treatment at "centers of excellence." In referring their toughest asthma cases to these centers, health care professionals and patients alike are experiencing the positive benefits received from a patient-centered, multidisciplinary approach.