[Alcohol-related mortality in the assessments of hospital unit physicians and pathologists: analysis of accounting medical documents]

AIM

To make a comparative analysis of the data available in the accounting medical documents drawn up at a multidisciplinary hospital on the level and structure of alcohol-related mortality (ARM) and to evaluate the efficiency of its accounting.

MATERIALS AND METHODS

Accounting medical documents, such as 453 inpatient cards (Form 003/y), 453 postmortem protocols (cards) (Form 013/H-80), and 453 death certificates (Form 106/y-08), were chosen as the basis for the study. The data of the final clinical and postmortem diagnoses in the patients who had died at hospital and their primary cause of death were comparatively analyzed.

RESULTS

According to Form 003/y, ARM was 5.5%; the detection rate of alcohol-related disease (ARD) was 11% (95% confidence interval (CI), 8.3 to 14.3%); according to Form 013/H-80, ARM was 7.1% (95% CI, 4.9 to 9.8%) and the detection rate of ARD was 12.6% (95% CI, 9.7 to 16%). The consistency of the diagnoses of ARD as a main cause of death, made by hospital unit physicians and pathologists, is estimated as the mean--the Cohen's kappa coefficient (kappa) is 0.570) (p < 0.001).

CONCLUSION

The results of the investigation suggest that there are 3 types of ARM, which differ in its level and structure: ARM in the assessments of hospital unit physicians; that in the assessments of pathologists, and that according to the death certificates drawn up. The consistency index for the diagnosis of ARD as a main cause of death indicates that the hospital unit physicians only determine the etiology of alcohol-related cause of death, without identifying it specifically.

The objective and subjective outcome of orthodontic care in one municipal health center

OBJECTIVE

The aim of this study was to assess the outcome of orthodontic care in one municipal health center.

MATERIALS AND METHODS

The material consisted of one age-cohort of 15-16 year-old adolescents (n = 67). Of them, 97% participated in a clinical examination. The final group included in the study consisted of 61 adolescents (91% of the whole age cohort). The occlusions were evaluated applying the Occlusal Morphology and Function Index (OMFI), the Dental Health Component (DHC) and the Aesthetic Component (AC) of the Index of Orthodontic Treatment Need (IOTN). Moreover, all adolescents filled in a semi-structured questionnaire enquiring about their satisfaction with the function and appearance of their own dentition and self-perceived orthodontic treatment need. They also scored their own dental appearance on a Visual Analog Scale (VAS).

RESULTS

Of the adolescents, 42% had received orthodontic treatment, while 58% were untreated. All morphological criteria of the OMFI were met by 58% of orthodontically treated and 49% of untreated adolescents and all functional criteria by 67% and 57%, respectively. Treatment need was registered in two of the treated adolescents (7%) and five of the untreated adolescents (14%). Treated adolescents were more often satisfied with their dental appearance than untreated adolescents (p = 0.034). In both groups, satisfaction with the function was high (93%).

CONCLUSIONS

Orthodontic treatment seems to improve both occlusal morphology and function. The high satisfaction with one's own dental appearance among the treated adolescents is worth noting.

[An assessment of hospital services from the perspective of health professionals]

This study had the objective of determining the way in which health professionals assess hospital services offered by their institutions, as well as identifying the core of social representations elaborated by those professionals regarding such institutions. A hundred and fifty-three questionnaires, applied in two hospitals (a state hospital and a charity hospital) in the metropolitan area of Natal, Rio Grande do Norte, Brazil, were analyzed. In the service assessment the Charity Hospital got the highest average score as for Service Quality. The state hospital presented the lowest average in the item "Respect for patient's privacy". The central categories were "Overpopulation" and "Humanized care" in both State and Charity hospitals, respectively. The peripheral categories were "Low wages" and "Overpopulation". Conducting an assessment is a very complex and important task. The assessment should become part of the organizational culture and guide improvements hospital care quality.

Mass General makes its survey findings public

Hospital takes two-pronged approach, dealing with transparency while pursuing performance improvement. In addition to a copy of The Joint Commission survey, facility answers key questions and provides regular updates on web site. Policy of openness helps generate staff buy-in for PI initiatives.

Disparities in obstructive sleep apnea and its management between a minority-serving institution and a voluntary hospital

We assessed disparities in severity of obstructive sleep apnea (OSA) and associated comorbidities, as well as in provision of sleep medicine health care, between patients evaluated for OSA in a voluntary hospital (VH) primarily serving a middle-class population with health-care insurance and a city hospital-based minority-serving institution (MSI) largely treating lower income, uninsured, and indigent patients. A retrospective chart review of patients evaluated for OSA at the VH (n=200) and at the MSI (n=103) was performed. Despite similar age and apnea hypopnea index, MSI patients had a greater body mass index, higher daytime systemic blood pressure, more comorbid medical conditions, and a lower minimum sleep SaO2 than VH patients. Systemic hypertension, diabetes mellitus, asthma, and congestive heart failure were more prevalent in the MSI group. Forty-two percent of the MSI patients diagnosed with OSA failed to follow up for treatment compared with 7% in the VH group, p<0.001. Disparities in OSA-associated comorbid conditions, as well as in delivery of sleep medicine-related health care, were evident between the VH and MSI groups. These findings suggest that OSA may be an important factor contributing to socioeconomic-based differences in morbidity and mortality.

[National health policies and local decisions in Mexico: the case of an intercultural hospital in Cuetzalan, Puebla]

OBJECTIVE

To identify the changes brought about by various national and international factors in an intercultural hospital of the municipality of Cuetzalán, Puebla.

MATERIAL AND METHODS

A case study was conducted during 2000 and 2001 in two Intercultural Hospitals of Mexico; the Cuetzalán Hospital in Puebla and the Jesús María Hospital in Nayarit State. Data were collected by means of 72 semi-structured interviews with allopathic therapists, indigenous therapists, and authorities of the different health care levels. Moreover, documental research was carried out on national policies for indigenous peoples as well as on indigenist policies. These policies were related with the five organizational stages of the hospital. State authorities gave their permission and interviewees signed informed consent.

RESULTS

The hospital was created in 1958 by the Ministry of Health as a biomedical institution, in agreement with the integrationist indigenist policies going on at the time. It remained so during the beginning of the administration by the National Indigenist Institute. In 1990, the new participative indigenist policy trends and the creativity and sensitivity of some authorities, under the influence of international strategies, helped to transform the hospital into an Intercultural Hospital (offering both types of medicine, indigenous and allopathic) with regional coverage. In 2000, the devolution of the hospital to the State Ministry of Health, based on financial rather than socio-cultural considerations, caused the temporary loss of its intercultural character. The last stage as an Integral Hospital with Traditional Medicine (from 2003 onwards) was due to a combination of state official initiatives and the new political stance acquired by the Mexican indigenous movement. The hospital is now part of a regional project of five such hospitals officially denominated Integral Hospitals with Traditional Medicine, to be financed by the Puebla-Panama Plan of regional development.

CONCLUSIONS

Our results confirmed that health organizations follow a historical process in which selected national and international forces open opportunities to promote intercultural health models that respond to the needs of indigenous populations. Despite the formerly held belief that traditional and scientific medicines were incompatible, this study demonstrates the viability of intercultural health care models that may become a real possibility in the country, based on new conventions to establish alternative and intercultural health services, thereby setting an example for other regions and countries. The English version of this paper is available at: http://www.insp.mx/salud/index.html.

Impact of a cardiac risk reduction program in vulnerable patients hospitalized with coronary artery disease

STUDY OBJECTIVE

To increase the use of guideline-based pharmacotherapy in vulnerable patients (ethnic minorities and the poor) with coronary artery disease (CAD) through a nurse-based quality-improvement program.

DESIGN

Retrospective program evaluation.

SETTING

Inner-city hospital in Denver, Colorado.

PATIENTS

One hundred fifty-one consecutive patients hospitalized with a CAD-related diagnosis.

INTERVENTION

A nurse-management program was initiated for patients with angiographically documented CAD, and rates of guideline-based care were compared with rates for historic controls. The intervention consisted of two key elements: patient counseling with language-appropriate education materials and direct physician education regarding the importance of cardioprotective drugs. The 151 patients in the intervention group were compared with 125 historic control patients hospitalized before the program was begun. Multivariable logistic regression analysis was used to assess differences in care with regard to ethnicity, education level, and insurance status, and to adjust for different baseline characteristics.

MEASUREMENTS AND MAIN RESULTS

At hospital discharge, patients in the intervention group were more likely to receive statins (71% vs 52%, p=0.001) and angiotensin-converting enzyme inhibitors (79% vs 51%, p<0.001) compared with controls. These differences remained after adjusting for ethnicity, education level, insurance status, and baseline clinical characteristics. Also, a trend was noted toward greater use of aspirin (92% vs 86%, p=0.13) and beta-blockers (79% vs 73%, p=0.24) in the intervention group compared with controls. Patients in the intervention group were more likely to receive counseling for smoking cessation.

CONCLUSION

An inpatient nurse-management program improved the quality of care for patients with CAD regardless of sociodemographic status. Properly designed disease-management initiatives can be effective for disadvantaged patients, who often obtain health care through emergency and inpatient services.

Fatores associados à assistência pré-natal precária em uma amostra de puérperas adolescentes em maternidades do Município do Rio de Janeiro, 1999-2000

Caracterizou-se o perfil das gestantes com pré-natal precário, segundo variáveis sócio-demográficas, história reprodutiva da mãe, apoio familiar, satisfação com a gestação e comportamentos de risco durante a gravidez. Foram entrevistadas 1.967 adolescentes no pós-parto imediato de maternidades públicas, conveniadas com o SUS e particulares no Município do Rio de Janeiro. A variável dependente foi o número de consultas de pré-natal (0-3; 4-6; 7 e mais). A análise estatística testou a hipótese de homogeneidade de proporções mediante análises bi e multivariada, com o uso de regressão logística multinomial, cuja categoria de referência da variável-resposta foi a realização de > 7 consultas. Foram encontradas maiores proporções de 0-3 consultas nos grupos de mães com grau de escolaridade < 4ª série do ensino fundamental; que não têm água encanada; não vivem com o pai do bebê; tiveram nascidos vivos anteriores; não ficaram satisfeitas com a gestação; não tiveram apoio do pai do bebê; tentaram interromper a gestação e as que fumaram, beberam e/ou usaram drogas durante a gestação. Pode-se concluir que as mães com piores condições de vida e comportamentos de risco na gravidez foram as que mais ficaram à margem da assistência pré-natal.

[Model project on coding accuracy]

First experiences with the external evaluation of coding accuracy in view of the German DRG-System are reported. 387 randomised inpatient cases of three departments of a municipal hospital were evaluated. 1.648 diagnosis codes and 946 procedure codes were evaluated with complete clinical data. Before and after correction by the reviewers the cases were grouped (AR-DRG 4.1) and the casemix index of the sample was calculated. 45.9% to 56.7% of primary diagnosis in the department samples were rated as correct. 25.2% to 37.5% of secondary diagnosis were rated as correct, 8.3% to 14.2% were corrected and 49.2% to 60.5% were rated as not relevant with regard to the German coding standards. 7.2% to 22.7% of secondary diagnosis had to be completed in the data. Evaluation of procedure codes resulted in 54.2% to 65.7% accepted codes, 5.9% to 12.1% corrected codes and 23.1% to 39.9% not accepted with regard to the German coding standards. 30.8% to 37.0% of procedure codes had to be completed in the data. After review, remarkable shift in DRGs was seen and casemix index increased 6.9% in average (0.25-12.1%). General and department-specific implications for improvement of coding accuracy could be evaluated. Consequences of potential coding errors in a prospective payment system on DRG basis were seen under conditions of daily hospital practice. External evaluation of coding accuracy used in this study could be the methodological basis for further investigations on this topic.

[Quality of health care of the urban population]

A study was carried out in 3 outpatient clinics in the city of Makhachkala (Daghestan Republic), aimed at working out recommendations to enhance the quality of medical aid. The latter was studied through expert inspection of clinical records of 568 outpatients. The expert inspection showed an inadequate level of therapeutic aid in municipal outpatient clinics. There was an irregular and insufficient examination, on the average, in 2/3 of patients, deficient treatment in every fourth patient, discrepant diagnoses in 8.3% of cases, groundless sick leaves in every 8th case. There was a succession in examinations and patients' treatment between outpatient clinics and hospitals. The results of the study provided the basis for working out a system of measures to assure and manage the quality of therapeutic aid in municipal clinics.

Case management: an evaluation at Childrens Hospital Los Angeles

This prospective, quantitative, and qualitative evaluation of the case management program at CHLA clearly demonstrated the value of professional service coordination of care for children with complex, special health needs. Most specifically, the program documented improvement in three discrete areas of evaluation: 1. Financial, with decreased unnecessary expenditures and increased revenue. 2. Patient satisfaction, documented with validated questionnaires. 3. Clinical process improvement, using quantifiable clinical outcomes. At the very least, case management is an extremely valuable service in the present managed health care environment, and may in fact be indispensable.

Implementation of guidelines in primary health care. A challenge for the municipal health centres in Finland

OBJECTIVE

To assess the implementation of guidelines in Finnish primary health care units.

DESIGN

A semi-quantitative analysis of a cross-sectional interview survey.

SETTING

All municipal health centres in a selected region in Finland.

SUBJECTS

Head physicians and head nurses of the 31 participating units.

MAIN OUTCOME MEASURES

Number of guidelines adopted; methods used in the implementation; and the unit's estimated purposefulness in the implementation of guidelines.

RESULTS

All health centres had adopted at least one guideline in the defined task areas, but only one-third of the units had implemented several guidelines. The implementation methods utilised were usually directive and passive rather than co-operative and problem-solving. Half of the units used training and methods involving active participation of the personnel, and in one-third a multiprofessional approach was applied. Clients' representatives were hardly ever involved in the adaptation of guidelines. A quarter of the health centres were assessed as purposeful in their policy to implement guidelines, the large units being more goal-oriented than the smaller ones.

CONCLUSIONS

A minority of health centres are goal-oriented in the adoption of guidelines and use versatile methods to support the implementation; this presents an important managerial challenge for national health care development in Finland.

Determinants of patient satisfaction in a large, municipal ED: the role of demographic variables, visit characteristics, and patient perceptions

We investigated predictors of patient satisfaction in a large, municipal emergency department (ED). Patients were telephoned 10 days postvisit, and satisfaction was assessed using a structured survey with 22 items measuring several domains, as well as the estimated length of stay. The dependent variables consisted of ratings of overall satisfaction and likelihood of recommending the ED to others. Data were obtained from 437 (38.7%) patients. Univariate statistics revealed strong relations between indicators of perceived care and both dependent variables, with weaker and mixed findings pertaining to demographics and visit characteristics. The final logistic regression predicting overall satisfaction included the following items (P < .05): degree to which staff cared for the patient as a person, perceptions of safety, understandability of discharge instructions, nurse's technical skills, and satisfaction with wait for physician. Likelihood to recommend was associated with (P < .05): degree to which staff cared for the patient as a person, understandability of discharge instructions, perceptions of safety, age, and insurance status. Patients' perceptions of care, rather than demographics and visit characteristics, most consistently predicted satisfaction. However, differences were observed between the specific predictors for overall satisfaction and likelihood to recommend, providing a possible explanation for inconsistencies observed in the literature.

Reengineering the Lithuanian healthcare system: a hospital quality improvement initiative

A tertiary-level academic hospital in Kaunas, Lithuania, adopted a continuous quality improvement (CQI) management paradigm from June 1996 through July 1997 in response to new political, economic, and social environments. This article presents an overview of the hospital's strategy, initial steps, and main accomplishments, as well as mitigating factors that arose in its quest to manage its own resources. Because historical influences are key to understanding the Lithuanian healthcare system, this discussion includes pre- and post-independence dynamics that caused a multidisciplinary hospital management team to choose a CQI approach that targets organizational and professional structures for change. In addition, it identifies environmental factors, internal and external to the hospital organization, that influence the continued development and sustainability of these healthcare management reform efforts.

Impact of surgeon's technique on outcome after treatment of rectal carcinoma

PURPOSE

The aim of this study was to analyze the impact of institutions and individual surgeons on long-term prognosis after curative resection of rectal carcinoma.

METHODS

We used univariate and multivariate analysis of data from a German prospective, multicenter, patient-care evaluation study.

RESULTS

The locoregional recurrence rates and the observed and cancer-related survival rates showed a considerable interinstitutional and intersurgeon variability. Multivariate analysis confirmed the institution and the individual surgeon as significant independent factors influencing locoregional recurrence and survival. There was a statistically highly significant correlation between the rate of locoregional recurrence and survival rate.

CONCLUSIONS

The surgeon's technique and skill has to focus on prevention of locoregional recurrence to achieve good long-term outcome after curative resection for rectal carcinoma. New clinical trials on adjuvant treatment have to include quality assurance for surgery and pathology and documentation of the surgeon (as local code).

Towards safer blood transfusion practice

The objective of this study was to determine the current state of transfusion practice at a large metropolitan hospital in South Australia, with a view to making recommendations to improve safety. Transfusion practice was monitored using a questionnaire and a concurrent audit design. Patients identified as having received a packed red blood cell transfusion in the previous 24 h, were selected by a random number generator. Questions included those about blood pack identification, documentation of the transfusion process, and patient observation. The results of this audit indicated that areas of documentation, primarily patient consent, blood pack administration times and patient monitoring required re-evaluation. Recommendations to improve practice were made based on these results. This is an ongoing service provided by the hospital, which has proven invaluable in identifying deficiencies in transfusion practice in order to improve patient care.

Quality improvement in an integrated urban healthcare system: a necessary journey

Public hospitals and clinics in the United States provide health care for the needs of large numbers of people who are medically indigent, homeless, chronically mentally ill, and suffer medical and social disorders associated with poverty. These "safety-net" healthcare providers traditionally struggle with barriers to providing high-quality, patient-sensitive care, including decaying physical facilities, burdensome bureaucracies, underfunded capital equipment and construction programs, and complex, politically driven budgets and governance. However, these same institutions now must compete for their own Medicaid and Medicare clientele because the private sector is marketing to those patients. They also must continue to provide increasing services to growing numbers of uninsured patients. To accomplish this, these institutions must reinvent themselves as patient-focused, high-quality, cost-effective healthcare providers. The Denver Health system is the public safety-net provider for the city and county of Denver. This large public institution has instituted a multifaceted performance-improvement program. The program includes training employees for patient-focused service, implementing continuous quality-improvement practices, instituting clinical pathways, revising the preexisting ambulatory quality-management program, reengineering key aspects of ambulatory clinic services, and redesigning the hospital-based patient-care services. Major successes have been achieved in some initiatives, but not in all. Many key "lessons learned" may guide others.

[What do people expect from their hospital? Results of a visitor survey at open house in a general hospital]

Both increasing competition between hospitals and growing demands for quality by patients and health insurances require a good knowledge of patients' needs and expectations. For this reason the hospital management organized a survey during Open Day in the hospital. The visitors were asked to find facts about their expectations concerning a potential stay in a hospital. The results of this survey show the importance of hospital staff's communication skills. Moreover, the results indicate that structural changes in a hospital must be aimed at patient's needs and requirements. Only in this manner can the expectations of potential patients be met to ensure high patient satisfaction.

Diagnostic delay in breast disease: a system analysis of a public urban hospital

OBJECTIVE

To analyze the diagnostic process in 146 women referred to a breast clinic in an urban setting between January 1, 1994, and December 31, 1996.

DESIGN

We devised the "diagnostic delay index (DDI)," defined as the time between the medical system's awareness of a diagnostic need and the completion of the diagnostic process. The time awaiting breast clinic consultation and the diagnostic events experienced--including clinic visits, imaging studies, and biopsies--were recorded. We stratified patients in 2 pathways (palpable masses and mammogram-identified lesions) and by benign or malignant outcome.

RESULTS

Patients in pathways 1 (n = 85) and 2 (n=61) had a mean (+/-SD) DDI of 68.4 (+/-46.9) days and 71.9 (+/-35.2) days, respectively. Patients in both pathways who had a malignant outcome had a significantly lower DDI than those who had a benign outcome (47.5+/-30.9 days vs 78.6+/-42.6) (P<.001); this advantage was most pronounced in patients with palpable lumps. The average patient waited more than 3 weeks for both an initial clinic consultation and operating room access. Quartile analysis of the DDI revealed statistically significant differences in clinic access time, number of visits, diagnostic events per visit, and operating room access time. Regression analysis demonstrates the relationship between DDI and measured process variables: DDI= -21.11+0.09 age+1.86 pathway-12.18 outcome+1.08 clinic access+11.91 visits+0.94 operating room access (R2=61.5%).

CONCLUSIONS

In a public hospital, diagnostic delay is related to inadequate access to surgical consultation and a delay in operating room access. Regression analysis demonstrates the relationships between these components of system diagnostic delay and suggests strategies for reducing the DDI.

Continuous quality improvement decreases length of stay and adverse events: a case study in an interventional cardiology program

A study was performed to assess the effectiveness of continuous quality improvement in achieving a better quality of care for patients undergoing coronary interventions. Increasing utilization of new coronary interventional devices has incurred a higher incidence of complications, prolonged hospital stay, and related costs. Using a clinical information system, we adopted continuous quality improvement to control the incidence of complications and postprocedural length of stay. Multiple regression analysis and a matched case-control study were performed to detect complications related to postprocedural length of stay and their causes among 342 patients. The results led to the modification of the postprocedural heparin anticoagulation protocol, which was followed by the introduction of a ticlopidine-based poststent anticoagulation regimen. Two sequential groups of patients (n = 261, n = 266) were selected to compare postprocedural length of stay and frequency of complications with those for the first group. Adjustments were made for patients and procedural characteristics through stratification and multiple regression methods. Blood transfusion was the most important predictor of prolonged hospital stay (partial R2 = 0.26, P < 0.01). A high level of postprocedural anticoagulation and intracoronary stent use were significantly associated with blood transfusion (P = 0.01, P = 0.02, respectively). The comparison among the three groups showed that heparin protocol change reduced only postprocedural length of stay (P < 0.001) for patients without stents, whereas the stent change in anticoagulation protocol significantly reduced both transfusion and hospital stay for patients with stents (P < 0.001, P < 0.05, respectively). Continuous quality improvement based on clinical information is promising to control both complications and hospital costs. Physician involvement is necessary throughout the process.

Assessing inner-city patients' hospital experiences. A controlled trial of telephone interviews versus mailed surveys

OBJECTIVES

Obtaining accurate and representative patient-centered data may be difficult among poor, inner-city patients because of changing addresses, variable access to telephones, and a higher prevalence of illiteracy than in the populations in which many survey instruments were developed and tested. Assumptions about the usefulness of mailed surveys versus telephone interviews may not hold for the urban poor. Therefore, identifying the most efficient mode of survey administration in this population becomes an important methodological question.

METHODS

We conducted a randomized trial of patients discharged from the inpatient medicine service of an urban teaching hospital to compare telephone interview with mailed self-administration of a detailed instrument for measuring patients' experiences with hospital care. Our primary outcomes were response rate, missing data, and data collection costs. Patients were excluded if they were not discharged to home or were mentally or physically unable to complete mailed or telephone interviews. The research assistant contacted eligible patients while hospitalized, informed them of the postdischarge survey, and obtained current phone numbers and addresses. Patients then were randomized to receive a 116-item satisfaction survey via one of two survey methods: mail-first (mailed surveys with follow-up on nonrespondents by telephone) or telephone-first (telephone interviews with follow-up of nonrespondents by mail).

RESULTS

Of the 252 patients enrolled, 130 were randomized to the mail-first and 122 to the telephone-first method. Response rates were higher with the telephone-first (73%) compared with the mail-first method (50%; P < 0.0001). Surveys obtained by the telephone-first method had fewer missing data (0.7 +/- 2.39) for those items not involved in skip patterns compared with the mail-first method (7.1 +/- 12.3; P < 0.001) and were 42% less expensive per completed survey ($26.32 versus $37.35; P < 0.0001).

CONCLUSIONS

In this survey of patients served by an urban teaching hospital, a strategy of telephone interviews with mail follow-up proved less expensive and yielded a higher response rate with more complete data than using a method where mailed surveys were followed by back-up telephone interviews. In addition, we believe that the improved response rate for telephone interviews compared with those reported in the literature for similar populations is the result of informing inpatients of the survey and obtaining telephone numbers and addresses in the hospital.

Quality improvement, housestaff, and the role of chief residents

PURPOSE

Little is known about the role of chief residents in utilizing and promoting continuous quality improvement (CQI) and quality assurance (QA) methods with housestaff. The purpose of this study was to ascertain how chief residents could be involved more formally in improving the quality of care in a major public teaching hospital.

METHOD

Fourteen chief residents on the major services at Boston City Hospital participated in early 1994 in either a focus group or an individual interview. Data were analyzed qualitatively using a grounded-theory methodology.

RESULTS

The chief residents saw themselves as central to service delivery, teaching, and administration of the hospital. While they identified many role conflicts and system obstacles to providing quality patient care, they were uniformly positive about the contributions they made to Boston City Hospital and its patient population. They distinguished between formal QA and the major improvements they made on their services. Very few knew much about CQI methodology.

CONCLUSIONS

Given increasing competition as a result of the rapid growth in managed care, hospitals with residency programs, especially public hospitals, must integrate their teaching programs into patient care models. Chief residents and the housestaff they supervise receive little training in CQI methods. As housestaff will be training and practicing in an environment where costs and quality will be intertwined, chief residents, with their credibility, contacts, and concern, can help incorporate CQI into the environment of graduate medical education.

Quality of care activities in Danish hospitals

This article describes how hospitals in Denmark have tried to meet the quality challenge. How to improve health care has been a topic of debate in Denmark in the last decade, and various authorities and professional organizations have implemented quality improvement initiatives. A 1991 survey of Danish hospitals showed that methods of quality improvement and the responsibility for quality management were still issues in need of further clarification. This article illustrates the process of quality improvement using hospitals in the city of Copenhagen as examples.

Inequity in the distribution of urban health care infrastructure in Kenya: the Kisumu Municipality as an example

This paper discusses the phenomenon of the intra-urban inequities in the provision of health care. Using the example of Kisumu municipality in Kenya, the author demonstrates that the current gross differentials in the state of health and access to health care are neither inevitable nor unavoidable. The author however contends that the crisis is not insurmountable. What it requires is the willingness and readiness by the political superstructure to stimulate, institute and enforce appropriate changes in the legislative policies affecting the very basis upon which appropriate and innovative application of various policy alternatives to urban health planning and the overall domain of physical planning and urban renewal should take place.

As good as anyone: antenatal shared care at an inner Sydney hospital

An exploratory survey design was used to assess satisfaction with antenatal care over a two-month period of women giving birth in an inner Sydney teaching hospital. Patients received obstetric services from private obstetricians, midwives, the hospital outpatient clinic, or 'shared care' between general practitioners and the outpatient clinic or birth centre. Insurance status and demographic information were collected across all groups. Shared care patients gave reasons why they chose that model of antenatal service. Ten per cent of women in the sample received shared care. Shared care patients were equally as satisfied as those in other modes of care in all but one factor--promptness of service (in which private obstetricians received higher ratings). They also judged shared care to have the advantages of being convenient, personal, and culturally appropriate. Significantly more patients in the shared care group were born overseas and they were less likely to hold private insurance. This paper discusses the results of the current study in the context of the Australian literature, explores some issues surrounding satisfaction research, and suggests further research arising from this work.

Guidelines for the selective ordering of admission chest radiography in adult obstructive airway disease

STUDY OBJECTIVE

To validate previously developed guidelines for the selective use of chest radiography in adults admitted for exacerbation of obstructive airway disease.

DESIGN

Prospective, observational cohort study using criteria developed in a previous retrospective study.

PARTICIPANTS

Unselected convenience sample of 128 adults with obstructive airway disease who did not respond to standard emergency department treatment and required admission.

SETTING

Municipal hospital ED and inpatient medical service.

INTERVENTIONS

Patients were categorized as "complicated" or "uncomplicated" according to previously developed criteria. Management was recorded as altered if the patient's physician answered the question, "Did the chest radiography alter your management of this patient?" affirmatively.

RESULTS

Of 27 patients whose management was altered by the chest radiography, 26 were classified as complicated, for a sensitivity of 96% (95% confidence interval [CI], 81, 100). One of 44 admissions classified as uncomplicated had management altered by the chest radiography (negative predictive value, 98%, 95% CI, 88, 100). This chest radiography was later reread as normal. Classification as an uncomplicated patient with obstructive airway disease was strongly associated with either a normal chest radiography or a radiographic finding that was clinically unimportant (P = .0002).

CONCLUSION

Patients with acute exacerbation of obstructive airway disease who are otherwise uncomplicated do not benefit from routine admission chest radiography. The use of this simple clinical strategy would safely reduce the number of chest radiographs by about one-third in this and similar patient populations, decreasing both health care costs and exposure to ionizing radiation.

The impact of clinical trial protocols on patient care systems in a large city hospital. Access for the socially disadvantaged

Some Americans suffer a higher cancer incidence and mortality than those in mainstream American society, and, in general, do not enjoy the same health status. Black Americans, for example, have higher cancer incidence and lower survival rates than do white Americans. To date, there is no known genetic basis to account for the disparities in cancer incidence and outcome between these races. Controlling for socioeconomic status greatly reduces, and sometimes nearly eliminates, the apparent contrast in cancer mortality and incidence between ethnic groups. Poverty clearly is associated with diminished access to health care, an increased incidence of cancer, and 10-15% lower 5-year survival rates. Diminished access often is manifested by low quality and inadequate continuity of health care, as well as insufficient access to methods of disease detection, diagnosis, treatment, and rehabilitation. Poor people tend to concentrate on day-to-day survival, often feel hopeless and powerless, and may become socially isolated. It is more difficult to conduct cancer treatment trials in a population characterized by such dramatic socioeconomic and cultural differences. Lack of insurance and lack of compliance become trial-limiting issues. This paper examines what must be done to tear down the economic and cultural barriers to prevention, early detection, and treatment of cancer.

Breaking down barriers. Cambridge Hospital ensures access to care for diverse community groups

The American Hospital Association and the Baxter Foundation present the Foster G. McGaw Prize annually to a hospital that distinguishes itself in meeting the diverse health and social needs of its community. The winner receives $75,000; the three finalists each receive $10,000. This year's winner and finalists were chosen from more than 100 entries. Applicants were judged by a panel of 77 hospital executives and a nine-member prize committee of health care experts.

[The health survey in Finnmark--satisfaction with hospital services]

Global satisfaction with hospital services was examined in a comprehensive population study (age group 20-62) in the county of Finnmark, Norway. Indicators of availability of and access to the health care services in general appeared to have considerable impact on the evaluation of hospital services. People were least satisfied in municipalities with a high rate of turn-over of general practitioners, and among respondents who had difficulty in getting in touch with a general practitioner. Further, geographical proximity to hospitals and shutting down of local hospitals significantly influenced satisfaction. Various measures of health status, chronic disease and use of health care services were found to have marginal or no impact. On the other hand, low satisfaction with life in general, length of education and high preoccupation with health appeared to increase dissatisfaction.

Sociodemographic determinants in the hospitalization decision: evaluation of an emergency department interhospital transfer policy

STUDY OBJECTIVES

To evaluate an emergency department's "treat and transfer" policy during a two-month period of reduced inpatient capacity by determining the number and characteristics of transferred patients not admitted as planned to the receiving hospital.

DESIGN

Matched case-control analysis.

SETTING

Public hospital adult ED.

TYPE OF PARTICIPANTS

Patients transferred to other hospitals for admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Twelve percent of patients (16 of 135) were not admitted after transfer during the first month, and 8% during the two-month period. Only IV drug use was found to be significantly associated with an increased risk of discharge without admission (odds ratio = 9.5; 95% confidence interval, 1.9 to 47.8).

CONCLUSION

Patients transferred from the public hospital ED resulted in admission to the receiving hospital in 92% of transfers. A history of IV drug use was the only characteristic found to be associated with discharge without admission to the accepting hospital.

Evaluation of prophylaxis against hepatitis B in a large municipal hospital

BACKGROUND

Perinatal transmission of hepatitis B can be interrupted by the administration of hepatitis B vaccine and hepatitis B globulin to the infants of carrier mothers. Universal screening of pregnant women makes this strategy possible.

METHODS

To evaluate the implementation of universal hepatitis B surface antigen screening of women giving birth at Kings County Hospital Center during 1988, we reviewed laboratory records to find all women with a positive test result who might give birth. We also randomly reviewed records of women who gave birth to live infants to determine the percentage of screening in the population. Infants' charts were reviewed for documentation of maternal hepatitis B surface antigen status and administration of hepatitis B immune globulin and vaccine.

RESULTS

Sixty infants who lived long enough to receive antihepatitis B prophylaxis were distinguished out of a total of 5146 births. Screening was done for from 66.8% to 80.4% (95% confidence interval) of the mothers of these infants. Although 44 of 60 infants received hepatitis B immune globulin and 39 of 60 infants received vaccine, only 27 of 60 received vaccine within 12 hours in combination with immune globulin (Centers for Disease Control-recommended therapy).

CONCLUSIONS

Documentation of hepatitis B surface antigen in the infant's delivery room record was present in 23 of 60 infants. Those infants all received hepatitis B immune globulin and vaccine; 21 received hepatitis B immune globulin within 12 hours. Hepatitis B immune globulin was given within 12 hours to 8 of 37 infants who lacked documentation of hepatitis B surface antigen status on the delivery room record. These differences were highly significant (p less than 0.001) even when only the 40 patients who had documented prenatal screening at Kings County Hospital Center (21/23 vs 4/17). Prenatal care did not have any effect on outcome.

Management of admitted malaria cases in four major hospitals of Delhi: a case study

A hospital-based retrospective case study of admitted patients was undertaken in four major hospitals of Delhi during 1991, with a view to assessing (i) recording and reporting system of malaria cases, (ii) diagnostic criteria being followed, (iii) management of complicated and severe malaria cases, and (iv) availability of life-saving antimalarials. The study showed that none of the hospitals either followed the international coding system for recording or adopted the National Malaria Eradication Programme guidelines for diagnostic criteria malaria, i.e. by blood smear examination. Diagnosis of malaria in three out of four hospitals was not preceded by blood examination in all cases. Only 55% of the 283 clinically suspected malaria cases were screened for malaria parasite with overall positivity of 20.14 per cent and of 38.25 per cent in examined cases. Age and sex break-up indicated that males suffered more and 65 per cent of the patients belonged to 16-40 years' age groups as compared to 38.4 per cent population falling in this age group according to 1981 census. Out of 263 recovered study cases, 13 per cent came from adjoining states while this percentage went up to 35 per cent (7 out of 20 cases) in the case of malaria deaths. Over 80 per cent of the clinically suspected cases presented with signs and symptoms of fever or fever with rigour, chills or vomiting. In 38 per cent of the cases there was a definite time lag in reporting of the cases to hospitals but most of the cases (91 per cent) were administered antimalarials within 24 h of admission.(ABSTRACT TRUNCATED AT 250 WORDS)

The impact of social factors on the content of care. Treatment of ischemic heart disease at a public and a voluntary hospital

To assess the impact of social factors on the content of care, panels of patients with ischemic heart disease at a public and its affiliated voluntary hospital were followed up through their acute hospitalizations and 3 months after discharge. Data were collected from firsthand observation of rounds, chart review, and a 3-month patient follow-up survey. Among patients for whom cardiac catheterization was indicated, 100% from the voluntary hospital underwent this procedure compared with 41% from the public institution. For patients for whom exercise stress testing was indicated, 90% from the voluntary hospital compared with 50% from the public institution underwent the procedure. Factors observed to contribute to these patterns emanated from the hospital setting as well as from the patients' social environment, including difficulties in arranging transfers for procedures, obstacles to coordinating inpatient and ambulatory care, and patient problems in keeping outpatient appointments.