The Norwegian Knowledge Centre for the Health Services (NOKC) reports 30-day survival as a quality indicator for Norwegian hospitals. The indicators have been published annually since 2011 on the website of the Norwegian Directorate of Health (www.helsenorge.no), as part of the Norwegian Quality Indicator System authorized by the Ministry of Health. Openness regarding calculation of quality indicators is important, as it provides the opportunity to critically review and discuss the method. The purpose of this article is to describe the data collection, data pre-processing, and data analyses, as carried out by NOKC, for the calculation of 30-day risk-adjusted survival probability as a quality indicator.
Three diagnosis-specific 30-day survival indicators (first time acute myocardial infarction (AMI), stroke and hip fracture) are estimated based on all-cause deaths, occurring in-hospital or out-of-hospital, within 30 days counting from the first day of hospitalization. Furthermore, a hospital-wide (i.e. overall) 30-day survival indicator is calculated. Patient administrative data from all Norwegian hospitals and information from the Norwegian Population Register are retrieved annually, and linked to datasets for previous years. The outcome (alive/death within 30 days) is attributed to every hospital by the fraction of time spent in each hospital. A logistic regression followed by a hierarchical Bayesian analysis is used for the estimation of risk-adjusted survival probabilities. A multiple testing procedure with a false discovery rate of 5% is used to identify hospitals, hospital trusts and regional health authorities with significantly higher/lower survival than the reference. In addition, estimated risk-adjusted survival probabilities are published per hospital, hospital trust and regional health authority. The variation in risk-adjusted survival probabilities across hospitals for AMI shows a decreasing trend over time: estimated survival probabilities for AMI in 2011 varied from 80.6% (in the hospital with lowest estimated survival) to 91.7% (in the hospital with highest estimated survival), whereas it ranged from 83.8% to 91.2% in 2013.
Since 2011, several hospitals and hospital trusts have initiated quality improvement projects, and some of the hospitals have improved the survival over these years. Public reporting of survival/mortality indicators are increasingly being used as quality measures of health care systems. Openness regarding the methods used to calculate the indicators are important, as it provides the opportunity of critically reviewing and discussing the methods in the literature. In this way, the methods employed for establishing the indicators may be improved.
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The adherence of patients with stable angina to antianginal therapy is the key factor of controlling the disease. The purpose of the study was to evaluate the relationship of adherence of patients with stable angina to treatment with trimetazidine modified release (MR) with frequency (risk) of emergency medical care. We consistently included in the study patients with stable angina in primary health care. The results of treatment for 16 weeks were monitored at patients with angina attacks three times per week or more, use of short nitrate and treatment with generic trimetazidine. To strengthen the antianginal therapy generic was replaced with original trimetazidine MR. Adherence is considered relatively high while taking 80-120% of the recommended dose of the drug (70 mg/day). The effectiveness of treatment evaluated by the frequency of emergency hospitalizations and/or ambulance calls because of the pain, discomfort, tightness in the chest or ischemic changes on the electrocardiogram. 870 patients were included in the study, the results of treatment in 185 were assessed. Patients with a relatively high adherence to trimetazidine MR (n=151) were used (median) 99% (98, 104), with low (<80%, n=34) adherence - 67% (49, 76) of the recommended dose of the drug. During the study period, the primary end point is fixed in 7 (21%) patients with low and in 18 (12%) - with relatively high adherence (p=0.182). The number of angina attacks, having necessitated taking short-nitrate, decreased in the groups, respectively, with 5 (3; 10) and 6 (4; 10) to 2 (1; 3) per week (p=0.791). Thus, replacing generic trimetazidine with original trimetazidine MR in patients with a high frequency of angina attacks can achieve significant antianginal effect. Adherence of patients to the reception of the drug by an average 1/3 below the recommended amount does not affect the risk of emergency hospitalizations and/or ambulance calls for 16 weeks.
Etherizations were developed in USA and was applied for the first time of the dentist Thomas Greene Morton (1819-1868) in 1846. Professor Dr. Ole Secher (1918-1996) studied the first Danish anaesthesias and discovered that the first etherization was carried out in February 1847 at the surgical department, Almindelig Hospital in Copenhagen. The patient was a young girl, with an albus tumore in the knee. She was etherized during an appliqué of ferrum candens. Dr. Secher was not able to find the case record, but she was identified in the hospital records dated 1846 and 1847. The hospital was separated in an alms department and a hospital. Patients were not allowed to stay at the hospital for more than 6 months, then they were placed in the alms department. The etherization was carried out in the alms department, to which the girl was transferred from the hospital. Reviewing the hospital records for the previous 6 months the girl was identified at the surgical department. Her name was Amalie, and she was 14 years old. She died two months after the etherization in April 1847.
Analysing duration of treatment episodes has become a standard task in many pharmacoepidemiological studies. However, such analyses are often carried out in a rather simplistic manner and more subtle issues are often ignored. In this paper, methods of analysing duration treatment episodes beyond simple analyses allowing investigation of the risk for certain events over time are demonstrated. In particular, the use of cumulative incidence functions, cause-specific hazard functions, hazard rate models and expected mortality in analysing duration of episodes is presented. We used these statistical techniques in analysing the early treatment history of patients who started a regular treatment with antidepressant drugs in the primary health care sector in Denmark. We have extracted some important features: The risk of discontinuing and switching treatment was very high around 10 weeks after starting treatment. After discontinuing the first treatment period, many patients soon started a second treatment period depending on the duration of the first treatment period with highest risk around 10 weeks. The mortality rate among the patients in treatment was about three times higher than the expected mortality. The risk of dying immediately after stopping treatment was about twice the expected mortality. The analysis suggests that: (1) there is a critical period for a first discontinuing, switching and restarting treatment around 10 weeks, (2) the GPs prescribing habits have more influence on the patterns than patient or drug characteristics, (3) over time Danish GPs tend to prolong the duration of first treatment period and avoid longer treatment breaks.
Effective utilisation of limited resources is a challenge for health care providers. Accurate and relevant information extracted from the length of stay distributions is useful for management purposes. Patient care episodes can be reconstructed from the comprehensive health registers, and in this paper we develop a Bayesian approach to analyse the length of care episode after a fractured hip. We model the large scale data with a flexible nonparametric multilayer perceptron network and with a parametric Weibull mixture model. To assess the performances of the models, we estimate expected utilities using predictive density as a utility measure. Since the model parameters cannot be directly compared, we focus on observables, and estimate the relevances of patient explanatory variables in predicting the length of stay. To demonstrate how the use of the nonparametric flexible model is advantageous for this complex health care data, we also study joint effects of variables in predictions, and visualise nonlinearities and interactions found in the data.
Structured diagnostic inter- views include items that evaluate physical etiologies for mood and anxiety disorders. The objective of this article was to assess the impact of such items.
A mental health survey in Canada collected data from n = 36,984 household residents. The lifetime prevalence of mood and anxiety disorders was calculated with and without exclusions due to physical causes.
Approximately 10% of subjects with a lifetime depressive disorder reported that all of their episodes were due to one or more physical cause. Many of the reported etiologies were implausible given the DSM-IV requirement that the disturbance be a "direct physiological consequence" of the physical cause. The results were similar for manic episodes and anxiety disorders.
Structured diagnostic interviews assess physical etiologies in ways that are subject to inconsistency and inaccuracy. Physical etiology items may bias estimates by introducing etiological opinions into the assessment of disorder frequency.
Between 1989 and 1992 the number of 'bed-blocking' patients in Sweden decreased from 15 to 7% according to national registers containing approx. 4000 patients. Part of this reduction can be explained by the 1992 Elderly Reform, which placed economic responsibility for bed-blockers on municipalities. However, the decrease began before the economic reform, implying that other factors are also involved, such as access to alternative institutional beds and other forms of care. An in-depth study of one district has provided a description of these often elderly patients, their heavy hospital utilization both before and after the bed-blocking period and their mortality. Nearly half the patients were dead within a year. Bed-blocking is a poorly defined concept requiring urgent discussion. Other related topics to which attention should be drawn are the administrative costs of economic control systems and efficient utilization of public resources as a whole.
To introduce health care production functions into human resources planning and to apply the approach to analysing the need for registered nurses in Ontario during a period of major reduction in inpatient capacity.
Measurement of changes in services delivered by acute care hospitals in Ontario between 1994/95 and 1998/99, and comparison with changes in the mix of human resources, non-human resources and patient needs.
Inpatient episodes per nurse fell by almost 2%. At the same time the number of beds was cut by over 20%. As a result, the number of patients per bed increased by 12%. Allowing for severity, there was a 20% reduction in beds per episode and a 3.7% reduction in nurses per episode.
The demands on nurses in acute care hospitals have increased as an increasing number of severity-adjusted episodes are served using fewer beds by a reduced number of nurses. Human resources planning traditionally only considers the effects of demographic change on the need for and supply of health care. Failure to recognize the variable and endogenous nature of other health care inputs leads to false impressions about the adequacy of existing supplies of human resources. Consideration of human resources in the context of the production function for health services provides a meaningful way of improving the effectiveness and efficiency of human resources planning.
To estimate the burden of acute otitis media (AOM) on Canadian families.
Telephone survey using random-digit dialing.
All Canadian provinces between May and June 2008.
Caregivers of 1 or more children aged 6 months to 5 years.
Caregivers' reports on the number of AOM episodes experienced by the child in the past 12 months, as well as disease characteristics, health services and medication use, time spent on medical consultations (including travel), and time taken off from work to care for the sick children.
A total of 502 eligible caregivers were recruited, 161 (32%) of whom reported at least 1 AOM episode for their children and 42 (8%) of whom reported 3 or more episodes during the past 12 months. Most children (94%, 151 of 161) visited with health professionals during their most recent AOM episodes. The average time required for medical examination was 3.1 hours in an emergency department and 1.8 hours in an outpatient clinic. Overall, 93% of episodes resulted in antibiotics use. A substantial proportion of caregivers (38%) missed work during this time; the average time taken off work was 15.9 hours.
In Canada, episodes of AOM are still associated with substantial use of health services and indirect costs to the caregivers.
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