DNVF-Memorandum III „Methoden für die Versorgungsforschung“, Teil 3: Methoden der Qualitäts- und Patientensicherheitsforschung

Das Deutsche Netzwerk Versorgungsforschung e.V. (DNVF) fördert seit Jahren die methodische Qualität von Versorgungsforschungsstudien auf der Basis von Memoranden und anderen Initiativen. Die Qualitäts- und Patientensicherheitsforschung (QPSF) gilt als Kerngebiet der Gesundheitsversorgungsforschung. Das vorliegende Memorandum erläutert wesentliche etablierte Fragestellungen und Methoden der QPSF. Vor dem Hintergrund der besonderen gesundheitspolitischen Bedeutung des Themas werden Methoden der Messgrößenentwicklung und -prüfung, die Risikoadjustierung, Methoden zur Erhebung von Patientensicherheitsdaten, Instrumente zur Analyse sicherheitsrelevanter Ereignisse und Methoden zur Evaluation der meist multiplen und komplexen QPSF-Interventionen behandelt. Zudem werden vordringliche Forschungsthemen benannt.

[Quality analyses of the development of preterm infants: results of the Lower-Saxonian preterm infant follow-up project and a comparison group of term infants]

Based on perinatal and neonatal quality assurance programmes, a follow-up project for the high-risk group of extremely preterm infants, unparalleled in Germany, was initiated in the federal state of Lower Saxony in 2004. Here we describe the new approach of examining a comparison group of term infants, which, for the first time, allows a valid interpretation of the collection of area-wide long-term outcome data on preterm children. The prospective long-term outcome project investigates the medical care situation for children born at less than 28 weeks of gestation up to school age. Based on the information obtained about the children's development the quality of health care will be optimised. A standardised examining concept with established development tests at defined follow-up intervals (at the age of 6 months, 2, 5 and 10 years) is used. At the age of five years 75 % of the examined premature children exhibited impairments. In order to better assess remarkable results, a comparison group of term infants (n=305) selected by a matched-pairs method was examined at the age of five using an analogous concept in kindergartens in Lower Saxony. The results were compared with the first two age cohorts of the follow-up-project (n=226) and quality analyses performed. As expected, significant differences have been found in the children's motor, cognitive and linguistic development between the preterm and term infants examined. This fact draws attention to the importance of early support for the majority of extremely premature infants. Feedback on the results given to the medical staff involved allows for the implementation of best practices and quality improvements. Identifying potential for improvement in everyday health care will help to develop specific optimisation measures.

[Quality management in implementing specialist pediatric palliative home care in Lower Saxony, Germany]

BACKGROUND

To provide comprehensive high-quality health care is a great challenge in the context of high specialisation and intensive costs. This problem becomes further aggravated in service areas with low patient numbers and low numbers of specialists. Therefore, a multidimensional approach to quality development was chosen in order to optimise the care of children and adolescents with life-limiting conditions in Lower Saxony, a German federal state with a predominantly rural infrastructure.

METHODS

Different service structures were implemented and a classification of service provider's specialisation was defined on the basis of existing references of professional associations. Measures to optimise care were implemented in a process-oriented manner.

RESULTS

High-quality health care can be facilitated by carefully worded requirements concerning the quality of structures combined with optimally designed processes. Parts of the newly implemented paediatric palliative care structures are funded by the statutory health insurance.

[Process orientation as a tool of strategic approaches to corporate governance and integrated management systems]

The concept of general process orientation as an instrument of organisation development is the core principle of quality management philosophy, i.e. the learning organisation. Accordingly, prestigious quality awards and certification systems focus on process configuration and continual improvement. In German health care organisations, particularly in hospitals, this general process orientation has not been widely implemented yet - despite enormous change dynamics and the requirements of both quality and economic efficiency of health care processes. But based on a consistent process architecture that considers key processes as well as management and support processes, the strategy of excellent health service provision including quality, safety and transparency can be realised in daily operative work. The core elements of quality (e.g., evidence-based medicine), patient safety and risk management, environmental management, health and safety at work can be embedded in daily health care processes as an integrated management system (the "all in one system" principle). Sustainable advantages and benefits for patients, staff, and the organisation will result: stable, high-quality, efficient, and indicator-based health care processes. Hospitals with their broad variety of complex health care procedures should now exploit the full potential of total process orientation.

[In-house team seminars: working together as a team--from data and statistics to quality development]

The concept of the "ZQ In-house Seminars" provided by external trainers/experts pursues the specific aim to enable all healthcare staff members of hospital departments to analyse statistical data--especially from external quality measurements--and to initiate in-hospital measures of quality improvement based on structured team work. The results of an evaluation in Lower Saxony for the period between 2004 and 2008 demonstrate a sustainable increase in outcome quality of care and a strengthening of team and process orientation in clinical care.

Generation and characterization of test atmospheres with nanomaterials

To ensure the product safety of nanomaterials, BASF has initiated an extensive program to study the potential inhalation toxicity of nanosize particles. As preparation work for upcoming inhalation studies, the following manufactured nanomaterials have been evaluated for their behavior in an exposure system designed for inhalation toxicity studies: titanium dioxide, carbon black, Aerosil R104, Aerosil R106, aluminum oxide, copper(II) oxide, amorphous silicon dioxide, zinc oxide, and zirconium(IV) oxide. As the physicochemical properties and the complex nature of ultrafine aerosols may substantially influence the toxic potential, the particle size, specific surface area, zeta potential, and morphology of each of the materials were determined. Aerosols of each material were generated using a dry powder aerosol generator and by nebulization of particle suspensions. The mass concentration of the particles in the inhalation atmosphere was determined gravimetrically and the particle size was determined using a cascade impactor, an optical particle counter, and a scanning mobility particle sizer. The dispersion techniques used generated fine aerosols with particle size distributions in the respiratory range. However, as a result of the significant agglomeration of nanoparticles in the test materials evaluated, no more than a few mass percent of the materials were present as single nanoparticles (i.e., < 100 nm). Considering the number, a greater percentage of nanoparticles was present. Based on the obtained results and experience with the equipment, a technical setup for inhalation studies with nanomaterials is proposed. Furthermore, a stepwise testing approach is recommended that also could reduce the number of animals used in testing.

The German cystic fibrosis quality assurance project: clinical features in children and adults

Cystic fibrosis (CF) is a complex disease which requires interdisciplinary care in specialized CF centres. In Germany, 97 paediatric and adult outpatient clinics agreed to report clinical data of their patients to a newly established registry, the Cystic Fibrosis Quality Assurance (CFQA) project. This article characterizes the design of the CFQA and the health status of the patients enrolled by the end of 1997. Data from 4,306 patients reported to the CFQA project were analysed. Nutritional status and lung function of the patients were examined as well as the use of specific therapeutic interventions. Mean age of all 4,182 patients alive by the end of 1997 was 15.7 yrs (maximum, 58 yrs), and 35.8% of patients were > 18.0 yrs of age. One-third of the CF population were treated in the nine largest centres (each caring for > 100 patients). Abnormal nutritional status (weight-for-height >90% of predicted or body mass index < 19.0 kg m2, respectively) was observed in 26.8% of children and adolescents and in 38.3% of adults. Lung function was abnormal (forced expiratory volume in one second < 80% predicted) in the majority of adults (83.9%) and in 42.5% of the younger patients. The mortality rate was 1.4 of 100 patients in 1997. No clear association of clinical status with centre size was observed. The clinical features of patients treated in German cystic fibrosis centres were generally comparable to those reported from other countries, although improvements are certainly warranted. The Cystic Fibrosis Quality Assurance project represents an important tool for future progress in the quality of cystic fibrosis care.

[The BAK/KBV/AWMF curriculum "Quality management for physicians": summary of three years of putting a practical program in a goal-oriented qualification]

Since 1996 a curriculum "Quality management for physicians" exists with a three-level training concept. Based on this, a purposeful course program has been developed by the Centre for Quality management in Public Health (ZQ), qualifying physicians for new professional roles as hospital quality managers. Up to December 1999 eight level I-, seven level II- and ten level III-courses have been performed in Hannover. After these three years of experience, the training concept has been evaluated by three approaches: 1. The evaluation of a standardized questionnaire shows a 90% achievement of course objectives, and that the concept is highly accepted--meanwhile by other professionals in health care as well; 2. The projects performed by participants as part of the course show the successful transfer into practice and a wide variety of applications and methodological aspects; 3. Standardized interviews of participants after several months (pilot project) concerning the practical experience, which were first performed as a pilot project, support continuous quality improvement of the training course. The revision of the curriculum in March 2000 will update the contents of the training program for actual needs--an important aspect due to the fact that quality management will play a central role in health care, and an up-coming model of quality assessment for German hospitals.

Q-switch laser and tattoo pigments: first results of the chemical and photophysical analysis of 41 compounds

BACKGROUND AND OBJECTIVE

In the Western world, there are at least 20-30 million people with tattoos. Improved self-image and social stigmatization are the main reasons for removing tattoos from skin. Q-switched lasers are applied to destroy the tattoo compounds in the skin. The treatment of tattoos containing ink often gives excellent results, whereas the results of treatments for coloured tattoos are not predictable and usually are worse. The chemical structure and the absorption spectra of the tattoo pigments are usually unknown. However, the efficacy of the treatment by using light of different Q-switched lasers (wavelengths 510, 532, 694, 755, 1064 nm) is correlated to both the chemical structure of the tattooed compounds yielding specific absorption spectra and the laser wavelength used.

STUDY DESIGN/MATERIALS AND METHODS

A structural and spectroscopic analysis of 41 coloured pigments was performed.

RESULTS

The 41 substances were identified, and they consist of 16 individual chemicals of different structured well-known industrial organic pigments. The absorption spectra of the 16 pigments were measured quantitatively.

CONCLUSION

The results of the present analysis explain to some extent the outcome of clinical studies regarding laser therapy of coloured tattoos. Because the laser energy used produces a high temperature in the azo or polycyclic pigments, it is necessary to investigate whether that change causes possibly toxic or cancerogenic compounds.

[BAK/KBV/AWMF curriculum "Quality assurance--medical quality management": concept of goal-oriented conversion to general practice applications]

Since 1996, the curriculum "Quality management for physicians" exists with a three-level training concept. Based on these contents, a purposeful course program has been developed by the ZQ, and through May 1998 four level I-, four level II- and four level III-courses have been performed in Hannover. Thus, 50 physicians are qualified for new professional roles as hospital quality managers. The evaluation of a standardized questionnaire shows that the concept is highly accepted--meanwhile also by other professionals in health care. As a new model of quality assurance/quality evaluation is now developed for German hospitals, the contents of the training program will be updated for actual needs.

[Mucoviscidosis quality assurance. Problems, success and prospects 1995-1998]

The German project "quality assurance in cystic fibrosis" collects data from 97 CF centres with 4,306 patients. Project goals are improvement of quality of life and life expectancy catching up with international standards. Collection of data and evaluation are done anonymously. In Germany, most patients including adults are under care of paediatric institutions. Nutrition and lung function data with decisive prognostic significance (weight for height, one-second-capacity) exhibited less favourable results for patients treated by very small institutions (less than 20 patients). Between 1995 and 1997 some parameters could be improved particularly in pupils children and young adults. In Germany, mean cumulative survival was 29.3 years for 1997. This figure is comparable to other European countries. However, further improvement with respect to quality of structure has to be made.

Smoking during pregnancy and poor antenatal care: two major preventable risk factors for sudden infant death syndrome

BACKGROUND

In this case-control study on sudden infant death syndrome (SIDS), the magnitude of the risk factors 'maternal smoking during pregnancy' and 'poor antenatal care' was assessed and the attributable proportions of SIDS incidence estimated.

METHODS

Perinatal data from 190 SIDS cases, who died between 1986 and 1990 at age > 7 days and had a diagnosis of SIDS confirmed by autopsy, were compared to 5920 controls. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were computed by unconditional logistic regression. The attributable risk per cent among the exposed (AR%) and the population attributable risk per cent (PAR%) were calculated.

RESULTS

Maternal smoking during pregnancy was associated with a more than twofold risk of SIDS (OR = 2.4; 95% CI: 1.7-3.4) and showed a significant dose-response. Low numbers of antenatal care visits were also associated with an increased risk of SIDS: OR = 1.6 (95% CI: 1.1-2.3) for 4.8 consultations and 2.9 (95% CI: 1.4-5.8) for 0-3 consultations; reference: > 8 consultations. Maternal smoking during pregnancy yielded an AR% of 58% (95% CI: 42-70) and a PAR% of 28% (95% CI: 16-40). The AR% for < or = 8 antenatal care visits versus > 8 consultations was 41% (95% CI: 16-59); the PAR% 10% (95% CI: 3-17).

CONCLUSIONS

Assuming causality, our data suggest that a reduction of the prevalence of either risk factor by population-based interventions may yield a worthwhile public health impact in terms of a substantially lower SIDS incidence.

Changes in intubation rates and outcome of very low birth weight infants: a population-based study

OBJECTIVE

There have been indications of a recent decrease in intubation rates of very low birth weight (VLBW) infants in Germany. We wanted to quantify this decrease and analyze its effect on clinical outcome.

METHODS

Population-based data on the treatment and outcome at hospital discharge from a statewide quality assurance program were analyzed for 2001 VLBW infants (500 to 1499 g) born from 1992 to 1994 in Lower Saxony, North Germany.

RESULTS

The proportion of patients not intubated and mechanically ventilated increased from 7% to 14% in infants less than 1000 g and from 28% to 44% in those greater than or equal to 1000 g (P < .02 and < .01, respectively). This increase was not associated with any significant increase in adverse outcome such as death, intraventricular hemorrhage, periventricular leucomalacia, or bronchopulmonary dysplasia (BPD). Instead, there was an increase in the proportion of infants less than 1000 g who survived without BPD (from 38% in 1992 to 48% in 1994; P < .05) and a decrease in the proportion of infants greater than or equal to 1000 g in whom BPD developed (from 14% to 9%; P < .05).

CONCLUSIONS

The data from a statewide quality assurance program show a significant reduction in the aggressiveness of the treatment of VLBW infants, which was not associated with an increased mortality or morbidity. This observational study, however, cannot define whether a more selective approach to the intubation of VLBW infants will ultimately result in a better outcome. A randomized, controlled trial would be required to answer this clinically important question.

Sudden infant death and maternal cigarette smoking: results from the Lower Saxony Perinatal Working Group

Maternal smoking has long been identified as a risk factor for sudden infant death (SID). However, only few studies analysed the biological plausibility of the relationship between maternal smoking and SID. In Lower Saxony (North Germany), detailed information concerning the perinatal period is routinely obtained for almost all infants born in this region. The perinatal data sets from 190 SID cases who had died between 1986 and 1990 and in whom a full autopsy had been performed were identified and compared to data sets from 5920 random controls, frequency matched to cases on year of birth. After adjusting for potential confounders (socio-economic status, birth weight, maternal age and nationality), smoking during pregnancy was still associated with a significantly increased risk of SID (odds ratio (OR) 2.7, 95% confidence interval (CI) 1.7-4.5). There was a clear dose-effect relationship between the number of cigarettes smoked and the risk of SID: adjusted ORs were 2.6 (1.5-4.4) for 1-10 cigarettes/day, 2.8 (1.8-6.0) for 11-20 cigarettes/day, and 6.9 (1.9-25.5) for > 20 cigarettes/day. There also appeared to be an interaction between smoking during pregnancy and maternal anaemia: the risk of SID almost doubled if mothers not only smoked, but were also anaemic (haemoglobin < 100 g/l). These results support the concept that smoking during pregnancy has direct biological effects on the fetus which are associated with an increased risk of SID later in life. The exact mechanism(s) whereby smoking increases the risk of SID, however, remains to be determined.(ABSTRACT TRUNCATED AT 250 WORDS)

Tunable picosecond pulses around 1.3 microm generated by a synchronously pumped infrared dye laser

An infrared dye laser is synchronously pumped by a cw mode-locked Nd:YAG system at 1.06 microm. The tuning range extends from 1.20 to 1.32 microm. A pulse duration of 3 psec was measured at 1.25 microm. The high photostability of the laser dye makes the laser system a practical device.