In countries where the National Health Service provides universal health coverage, socioeconomic position should not influence the quality of health care. We examined whether socioeconomic position plays a role in short-term mortality and waiting time for surgery after hip fracture.
Retrospective cohort study.
From the Hospital Information System database, we selected all patients, aged at least 65 years and admitted to acute care hospitals in Rome for a hip fracture between 1 January 2006 and 30 November 2007. The socioeconomic position of each individual was obtained using a city-specific index of socioeconomic variables based on the individual's census tract of residence.
Three different outcomes were defined: waiting times for surgery, mortality within 30 days and intervention within 48 h of hospital arrival for hip fracture. We used a logistic regression to estimate 30-day mortality and a Cox proportional hazard model to calculate hazard ratios of intervention within 48 h. Median waiting times were estimated by adjusted Kaplan–Meyer curves. Analyses were adjusted for age, gender and coexisting medical conditions.
Low socioeconomic level was significantly associated with higher risk of mortality [adjusted relative risk (RR) = 1.51; P < 0.05] and lower risk of early intervention (adjusted RR = 0.32; P < 0.001). Socioeconomic level had also an effect on waiting times within 30 days.
Individuals living in disadvantaged census tracts had poorer prognoses and were less likely than more affluent people to be treated according to clinical guidelines despite universal healthcare coverage.
Although specialized centers are generally accepted for treatment of relatively uncommon diseases, such as cystic fibrosis, statements regarding the amount of expertise or minimum number of patients treated are increasingly included in guidelines for the treatment of other chronic diseases such as rheumatoid arthritis and diabetes mellitus.
Medline and Embase from 1987 through March 2008 were searched.
Studies reporting the effect of treatment in a specialized or high-volume center or by subspecialists on a clinically relevant outcome.
Two reviewers extracted the data independently and assessed the methodological quality.
We included 22 articles. Two randomized-controlled trials and a quasi-experimental study compared the effect of outpatient team care with traditional outpatient care for patients with rheumatoid arthritis. These studies showed no difference or were inconsistent. Studies on the outcomes of care for diabetic patients (5 prospective or historical cohort studies and 10 retrospective cohort studies) were generally of poor quality. Studies comparing the subspecialist care with the care provided by general internists or primary care providers produced inconsistent results. Similar inconsistency and poor quality were found for three observational studies on cystic fibrosis.
The available literature suggests that among patients with rheumatoid arthritis, diabetes mellitus or cystic fibrosis, outcomes are not superior in specialized centers or with subspecialists compared with other forms of chronic illness care.
To assess the effectiveness of acute medical units (AMUs) in hospitals.
(i) Controlled and observational studies in peer-reviewed journals retrieved from PubMed, EPOC, CINAHL and ERIC databases published between January 1990 and July 2008; and (ii) reports from non-peer-reviewed websites combined with Google search.
Articles reporting effects of the introduction of an AMU on mortality, length of stay, discharge disposition, readmissions, resource use and patient and/or staff satisfaction.
Data on unit operations and outcome measures were extracted by a single author and confirmed by a second author, with disagreement settled by consensus.
Nine peer-reviewed reports of before–after analyses of seven units introduced into the UK and Ireland were analysed. Two studies, one prospective, reported significant reductions in in-patient mortality between 0.6 and 5.6% points following commencement of AMU. Four studies reported significant reductions in the length of stay between 1.5 and 2.5 days. Waiting times for patient transfer from emergency departments to medical beds decreased by 30% in one study. In three studies, the proportion of medical patients discharged directly home from the AMU increased by 8–25% points. Three studies noted no increase in 30-day readmission rates following unit commencement. Two studies described significant improvements in patient and staff satisfaction with care. Eight non-peer-reviewed reports relating to 48 units confirmed reductions in the length of stay.
Limited observational data suggest AMUs reduce in-patient mortality, length of stay and emergency department access block without increasing readmission rates, and improve patient and staff satisfaction.
To determine the impact and preventability of adverse events (AEs) associated with health care in Spanish hospitals.
Retrospective cohort study.
Twenty-four Spanish hospitals.
Patients of any age with a clinical record indicating an inpatient stay of >24 h and a discharge between 4 and 10 June 2005 (n = 5908).
None.
Percentage of AEs considered preventable.
We were able to identify 525 patients suffering AEs associated directly with medical care, who accumulated 655 AEs with 43% of these AEs considered preventable. Overall, 45% (295 AEs) were considered minor, 39% (255 AEs) moderate and 16% (105 AEs) severe. There were no significant differences in AE severity by hospital size, but AEs associated with surgical services were more likely to be severe than those associated with medical services. Some 31.4% of AEs resulted in a longer stay and 23.4% led to hospital admission. AEs associated with medical care caused 6.1 additional days per patient. Of the patients, 66.3% required additional procedures and 69.9% required additional treatments. Incidence of death in patients with AEs was 4.4% (CI 95%: 2.8–6.5). Age over 65 was associated with a higher incidence of preventable AEs. The highest percentages of preventable AEs were related to diagnosis (84.2%), to nosocomial infections (56.6%) and to care (56%).
In Spanish hospitals, AEs associated with health care cause distress, disability, death, lengthen hospital stay and cause increased consumption of health-care resources. A relatively high percentage of AEs in Spain may be preventable with improvements in medical care.
To develop international guidance for improving the quality of mental health care in low- and middle-income countries.
A panel developed recommendations based on a comprehensive literature review, consultation with over 100 experts from 46 countries and an analysis of international best practices.
A 5-pronged approach to improving the quality of mental health care is recommended. Quality improvement requires the alignment of policy and legislation with the attainment of good quality mental health outcomes. Key partners must be brought into the quality improvement process. Funding can be an important tool for promoting good quality but needs to be correctly aligned to meet policy objectives and to promote evidence-based interventions. Accreditation procedures and quality standards need to be carefully developed and resources allocated for their implementation. Finally, quality improvement must be brought into routine service management and delivery.
Through a systematic approach to quality improvement, it is possible to ensure that the best possible interventions are provided within the constraints of each country and that the rights and well-being of people with mental disorders is optimally promoted. Quality improvement is not a luxury but an integral part of ensuring that the best possible services are provided to all who need them.
The objective of this study was to elicit hospital staff's knowledge, attitudes, and current practices regarding hospital standards and to assess the level of motivation for staff and hospitals to meet new standards.
This was a qualitative study using in-depth interviews and focus group discussions with staff in four hospitals. There was no intervention.
Four rural public and private not-for-profit hospitals in central Uganda.
Medical superintendents and other staff of four hospitals in Uganda who were familiar with the use of standards and had participated in a previous Uganda national accreditation program (Yellow Star).
All staff expressed strong support for the development and implementation of hospital standards, but also said they would need more recognition and ongoing motivation. They cited the need for technical assistance, funding, and training as the main obstacles. Key areas requiring standards were: infection control, cleanliness and hygiene, infrastructure and medical records.
There was strong support for the development and implementation of hospital standards. The main perceived obstacles to the implementation of hospital standards are resource limitations and technical capability. There is a need to develop and implement preliminary standards for hospitals in Uganda.
To explore how hospital management could gain a better picture of risks to support them in setting priorities for patient safety.
This study deals with the combined application of prospective and retrospective methods for risk analysis on two units of a Dutch general hospital. In the prospective analyses, employees identified and assessed possible risks in selected processes. In the retrospective analyses, incidents were reported by employees and subsequently investigated. The methods were integrated by using information from retrospective incident reports for prospective risk identification and assessment, and by matching their categorization schemes. Two evaluation forms provided insight into the perceived usefulness of the methods and their integration.
For both units, the prospective and retrospective analyses resulted in divergent overviews of risks in terms of nature and magnitude, which suggests that one or both methods were subject to biases. Findings from the evaluation forms showed that both methods were perceived as useful and that triangulation provided additional insight into risks. Due to the convergent evidence, triangulation of prospective and retrospective methods can provide hospital management and frontline staff with a more complete and less biased picture of risks. An integrative approach might be advantageous in terms of efficiency of analysis, setting priorities for patient safety and improving the methods themselves.
The purpose of this study was to determine the optimum content of a 1-day classroom-based crew resource management (CRM) course for health-care personnel working in ad hoc teams in complex, time-critical hospital departments such as surgery, intensive care or emergency.
A two-round modified Delphi panel. Participants selected teamwork competency components suitable for inclusion in 1 day of training from a list developed via literature review.
Fifteen experts in health care, CRM and training.
Knowledge, skill and attitude competency components for a 1-day CRM course.
Of the 110 knowledge, skill and attitude CRM competency components, 40 components were selected by greater than 70% of respondents, whereas the remaining 62 components were selected by fewer than 55% of respondents. These 40 competency components ranged across five competency domains: communication, task management, situational awareness, decision-making and leadership, and provided a consensus on the most critical areas for inclusion in training for health-care personnel.
This new competency model is now available for use. Although the sample size was limited, a high degree of consensus was reached after only two rounds. A modified Delphi technique within the context of competencies first refined from the literature was a useful and cost-effective method for determining the content of a 1-day CRM training course for health-care workers.
The aim of this study was to develop a grading scale for predicting the 30-day mortality of spontaneous intracerebral hemorrhage (ICH) using initial evaluation data.
Univariate and multivariate logistic regression models were used to identify independent risk factors and to construct a grading scale for predicting the outcome of ICH.
The Taichung Veterans General Hospital in Taichung, Taiwan.
Two hundred and ninety-three patients were diagnosed with spontaneous ICH between 1 January 2006 and 31 December 2007.
Development of the simplified ICH score (sICH score) for predicting the 30-day mortality of ICH.
The discrimination of the prediction model was determined by measuring the accuracy, sensitivity, specificity and the area under the receiver operating characteristic curves (AUC).
The accuracy of the sICH score was 80.5%, the sensitivity was 82.5% and the specificity was 80.2%. The AUCs are as follows: sICH score, 0.89 (0.84–0.94); ICH score, 0.74 (0.65–0.83) and ICH-GS, 0.74 (0.65–0.83).
The sICH score showed best discrimination among tested models. Also, it was easier for physicians without special training in neurology or radiology to use this scale. With statistical power and ease of use, the sICH score is a very suitable model for risk stratification of spontaneous ICH.