BACKGROUND: Acute viral bronchiolitis is one of the most common causes of hospitalisation during infancy in our region with respiratory syncytial virus (RSV) historically being the major causative agent. Many infants with early-life RSV bronchiolitis have sustained bronchial hyperreactivity for many years after hospitalisation and the reasons for this are probably multifactorial. The principal aim of the present study was to investigate if children hospitalised for any acute viral bronchiolitis during infancy in our region, and not only those due to RSV, had more episodes of subsequent wheezing up to age seven years and reduced lung function at that age compared to children not hospitalised for acute bronchiolitis during infancy. A secondary aim was to compare the hospitalised infants with proven RSV bronchiolitis (RS+) to the hospitalised infants with non-RSV bronchiolitis (RS-) according to the same endpoints. METHODS: 57 infants hospitalised at least once with acute viral bronchiolitis during two consecutive winter seasons in 1993-1994 were examined at age seven years. An age-matched control group of 64 children, who had not been hospitalised for acute viral bronchiolitis during infancy, were recruited from a local primary school. Epidemiological and clinical data were collected retrospectively from hospital discharge records and through structured clinical interviews and physical examinations at the follow-up visit. RESULTS: The children hospitalised for bronchiolitis during infancy had decreased lung function, more often wheezing episodes, current medication and follow-up for asthma at age seven years than did the age matched controls. They also had lower average birth weight and more often first order family members with asthma. We did not find significant differences between the RSV+ and RSV- groups. CONCLUSION: Children hospitalised for early-life bronchiolitis are susceptible to recurrent wheezing and reduced pulmonary function by seven years compared to age-matched children not hospitalised for early-life bronchiolitis. We propose that prolonged bronchial hyperreactivity could follow early-life RSV negative as well as RSV positive bronchiolitis.
BACKGROUND: Doctors' ability to predict the duration of their patients' certified sickness absence is important for follow-up efforts aimed at patients with increased probability of long-term absence. OBJECTIVES: The aim of this study was to examine the accuracy of doctors' predictions of their patients' sickness absence status 4 weeks ahead, and which factors were associated with it. METHODS: A questionnaire survey was carried out in primary health care concerning 796 patients certified sick within 140 days after the start of absence. The episodes of absence were labelled short-standing (up to 2 weeks) and long-standing (from 3 to 20 weeks), at the time of consultation. The doctors' prediction of the patients' absence status 4 weeks ahead, diagnoses, work ability, clinical information sources used and the presence of non-medical factors that could have influenced the doctors' work ability assessments were collected. The predictions were compared with the patients' absence status 4 weeks later by positive predictive values (PPVs) for the statements 'returned to work' and 'still certified sick'. Factors associated with the accuracy of the predictions were analysed by multiple logistic regression analyses. RESULTS: The doctors accurately predicted return to work in 84% [95% confidence interval (CI) 79-87] of the cases in short-standing episodes, and in 53% (43-62) in long-standing episodes. The corresponding PPVs for still certified sick were 72% (62-80) and 91% (85-94). In short-standing episodes, the doctors' probability of making accurate predictions was higher for respiratory disorders [odds ratio (OR) 2.84; 95% CI 1.36-5.90], than for the reference category 'all other disorders', and lower for mental disorders (0.46; 0.24-0.89). In long-standing episodes, the probability was lower for musculoskeletal disorders (0.33; 0.12-0.86) and injuries (0.12; 0.03-0.48). Neither the age nor gender of patients or doctors, nor the degree of work ability reduction, nor other factors were associated with the accuracy of the predictions. CONCLUSIONS: The doctors' predictions were highly accurate for return to work in short-standing episodes, and for still certified sick in long-standing episodes. Diagnoses were associated with the accuracy; other factors, including the doctors' work ability assessments, were not.
One year after the introduction of Information and Communication Technology (ICT) to support diagnostic imaging at our hospital, clinicians had faster and better access to radiology reports and images; direct access to Computed Tomography (CT) reports in the Electronic Medical Record (EMR) was particularly popular. The objective of this study was to determine whether improvements in radiology reporting and clinical access to diagnostic imaging information one year after the ICT introduction were associated with a reduction in the length of patients' hospital stays (LOS).
Data describing hospital stays and diagnostic imaging were collected retrospectively from the EMR during periods of equal duration before and one year after the introduction of ICT. The post-ICT period was chosen because of the documented improvement in clinical access to radiology results during that period. The data set was randomly split into an exploratory part used to establish the hypotheses, and a confirmatory part. The data was used to compare the pre-ICT and post-ICT status, but also to compare differences between groups.
There was no general reduction in LOS one year after ICT introduction. However, there was a 25% reduction for one group - patients with CT scans. This group was heterogeneous, covering 445 different primary discharge diagnoses. Analyses of subgroups were performed to reduce the impact of this divergence.
Our results did not indicate that improved access to radiology results reduced the patients' LOS. There was, however, a significant reduction in LOS for patients undergoing CT scans. Given the clinicians' interest in CT reports and the results of the subgroup analyses, it is likely that improved access to CT reports contributed to this reduction.
To assess the impact of a Picture Archiving and Communication System (PACS) on the diagnostic accuracy of the interpretation of chest radiology examinations in a "real life" radiology setting.
During a period before PACS was introduced to radiologists, when images were still interpreted on film and reported on paper, images and reports were also digitally stored in an image database. The same database was used after the PACS introduction. This provided a unique opportunity to conduct a blinded retrospective study, comparing sensitivity (the main outcome parameter) in the pre and post-PACS periods. We selected 56 digitally stored chest radiograph examinations that were originally read and reported on film, and 66 examinations that were read and reported on screen 2 years after the PACS introduction. Each examination was assigned a random number, and both reports and images were scored independently for pathological findings. The blinded retrospective score for the original reports were then compared with the score for the images (the gold standard).
Sensitivity was improved after the PACS introduction. When both certain and uncertain findings were included, this improvement was statistically significant. There were no other statistically significant changes.
The result is consistent with prospective studies concluding that diagnostic accuracy is at least not reduced after PACS introduction. The sensitivity may even be improved.
Misinterpretation of radiological examinations is an important contributing factor to diagnostic errors. Double reading reduces interpretation errors and increases sensitivity. Consultant radiologists in Norwegian hospitals submit 39% of computed tomography (CT) reports for quality assurance by double reading. Our objective was to estimate the proportion of radiology reports that were changed during double reading and to assess the potential clinical impact of these changes.
In this retrospective cross-sectional study we acquired preliminary and final reports from 1023 consecutive double read chest CT examinations conducted at five public hospitals. The preliminary and final reports were compared for changes in content. Three experienced pulmonologists independently rated the clinical importance of these changes. The severity of the radiological findings in clinically important changes was classified as increased, unchanged, or decreased.
Changes were classified as clinically important in 91 (9%) of 1023 reports. Of these: 3 were critical (demanding immediate action), 15 were major (implying a change in treatment) and 73 were intermediate (affecting subsequent investigations). More clinically important changes were made to urgent examinations and less to female first readers. Chest radiologist made more clinically important changes than other second readers. The severity of the radiological findings was increased in 73 (80%) of the clinically important changes.
A 9% rate of clinically important changes made during double reading may justify quality assurance of radiological interpretation. Using expert second readers and targeting a selection of urgent cases prospectively may increase the yield of discrepant cases and reduce harm to patients.
Double reading as a quality assurance (QA) tool is employed extensively in Norwegian hospital radiology departments. The practice is resource consuming and regularly debated.
To investigate the rates of double reading in Norwegian hospital radiology departments, to identify department characteristics associated with double reading rates, and to investigate associations between double reading and other quality improvement.
We issued two parallel national surveys to management and to consultant radiologists, respectively. Management was defined as the chief medical officer and/or the head of the radiology department. The management survey covered staffing, perceived resource situation, double reading, guidelines, and quality improvement. The radiologist survey served to validate management responses concerning double reading. Management survey items concerning practices of quality improvement were organized into three indices reflecting different quality approaches, namely: appropriateness of investigations; personal performance feedback; and system performance feedback.
The response rates of the surveys were 100% (45/45) for management and 55% (266/483) for radiologists. Of all exams read by consultants, 33% were double read. The double reading rate was highest in university hospital departments (59%), intermediate in other teaching departments (30%), and lowest in non-teaching departments (11%) (P?=?0.01). Among the quality indices, mean scores were highest on appropriateness index (68%), intermediate on the person index (56%), and lowest on system index (37%). There were no correlations between double reading rates and scores on any of the quality indices.
The rate of double reading in Norwegian hospital radiology is significantly correlated to department teaching status, but not to other practices of quality work.
To test the hypothesis that a 20-h communication skills course based on the Four Habits model can improve doctor-patient communication among hospital employed doctors across specialties.
Crossover randomized controlled trial in a 500-bed hospital with interventions at different time points in the two arms. Assessments were video-based and blinded. Intervention consisted of 20 h of communication training, containing alternating plenary with theory/debriefs and practical group sessions with role-plays tailored to each doctor.
Of 103 doctors asked to participate, 72 were included, 62 received the intervention, 51 were included in the main analysis, and another six were included in the intention-to-treat analysis. We found an increase in the Four Habits Coding Scheme of 7.5 points (p = 0.01, 95% confidence interval 1.6-13.3), fairly evenly distributed on subgroups. Baseline score (SD) was 60.3 (9.9). Global patient satisfaction did not change, neither did average encounter duration.
Utilizing an outpatient-clinic training model developed in the US, we demonstrated that a 20-h course could be generalized across medical and national cultures, indicating improvement of communication skills among hospital doctors.
The Four Habits model is suitable for communication-training courses in hospital settings. Doctors across specialties can attend the same course.
To identify potential barriers in communication with non-Western immigrant patients by comparing the frequency and nature of emotional cues and concerns, as well as physician responses during consultations, between ethnically Norwegian patients and immigrant patients in a general hospital setting.
Consultations with 56 patients (30 non-Western immigrants and 26 ethnic Norwegians) were coded using the Verona Coding Definitions of Emotional Sequences (VR-CoDES) and the Verona Codes for Provider Responses (Verona Codes-P).
There were no significant differences in frequencies of cues and concerns between immigrant and Norwegian patients. However, the immigrant patients with high language proficiency expressed more concerns compared to immigrant patients with language problems and Norwegian patients. Moreover, more concerns were expressed during consultations with female physicians than with male physicians.
Expression of cues and concerns in immigrant patients is dependent on the patient's language proficiency and the physician's gender.
Providers should recognize that immigrant patients may have many emotional cues and concerns, but that language problems may represent a barrier for the expression of these concerns.
National Resource Centre for Rehabilitation in Rheumatology (NRRK), Diakonhjemmet Hospital, PO Box 23 Vinderen, 0319 Oslo, Norway; Norwegian Knowledge Centre for the Health Services, PO Box 7004, St Olavs plass, 0130 Oslo, Norway.
OBJECTIVE: To assess the data quality of two approaches to scaling items within the Patient Experiences Questionnaire (PEQ); a five-point scale with descriptors for all scale points and a 10-point scale with descriptors only at the end points. STUDY DESIGN AND SETTING: The two versions were pretested through cognitive interviews with 14 patients. The PEQ was then mailed to 1,000 patients after inpatient treatment at a large university hospital in Norway, randomized to receive the 5- or 10-point scale versions. Response rates, missing data, item means, floor, and ceiling effects were assessed. Regression analysis was used to examine the impact of response scale on missing data, floor, and ceiling effects after controlling for age, education level, and health status. RESULTS: The five-point scale produced data with unimodal and fairly symmetric distributions in contrast to the highly skewed J- and U-shaped distributions for the 10-point scale. The five-point scale data had significantly lower item means, floor, and ceiling effects. Regression analysis showed that the type of scale explained a significant component of the variation in both floor and ceiling effects. CONCLUSION: The five-point scale performed better than the 10-point scale and is more suitable for assessing patient experiences. The revised PEQ will be used in Norwegian national surveys.
"Four Habits" is the first larger generic clinical communication program to have a documented effect. It has not been evaluated outside USA. In a pilot study, Norwegian hospital physicians assessed its usefulness, and we developed a questionnaire where patients reported "Four Habits"-specific physician behaviour.
We ran a 3-day course with 16 participants and three US facilitators. The questionnaire mapping "Four Habits" with 23 items was distributed by participating physicians to 210 patients. Participating physicians met in evaluative focus groups 3 months after the course.
The questionnaire was condensed to 10 items after factorial analysis. The resulting scale performed well. A large amount of missing data on some items suggested that patients found it difficult to evaluate details of "Four Habits"-specific physician behaviour. Participants found that the "Four Habits" short course led to improvement of their encounters. Some elements of the method were not perceived as relevant for all types of encounters (habits II and III).
"Four Habits" is applicable outside US with some adjustments. A shortened version of the questionnaire will be used in a planned randomized controlled trial.