The analysis of emergency surgical care in medical institution of Moscow for the last 20 years is presented in the article. There were 912 156 patients with acute appendicitis, strangulated hernia, perforated gastro-duodenal ulcer, gastro-duodenal bleeding, acute cholecystitis, acute pancreatitis, acute intestinal obstruction on treatment during this period. It was observed reduction overall and postoperative mortality. It was concluded that positive results are caused by development of material and technical base, transition on clock mode of diagnostic units, increase of patients? number hospitalized in department of intensive care for operation training and after it, using of modern diagnostic and therapeutic methods, edit documents regulating of health facilities activity according to medicine development.
The objective of this study was to evaluate the diagnosis and treatment of acute sinusitis at three health care centers in northern and eastern Iceland.
Information on all those diagnosed with acute sinusitis (ICD 10 J01.0, J01.9) in the year 2004 at the communal health care centers in Akureyri, Husavik and Egilsstadir was obtained retrospectively from computerized clinical records. Key factors used for diagnosis and treatment were recorded. In order to obtain an equal distribution in population size only about one-third of the diagnoses made in Akureyri were included in the search (the first ten days of every month).
The search yielded a total of 468 individuals. The average incidence of acute sinusitis was found to be 3.4 per 100 inhabitants per year. Adherence to clinical guidelines (albeit from other countries) regarding diagnosis of bacterial sinusitis was nearly nonexistent. There were considerable differences found between health care centers as to whether x-rays were used for diagnostic purposes. Blood tests were hardly used at all. The disease was diagnosed over the telephone in 28% of the cases (Husavik 38%, Akureyri 32%, Egilsstadir 10%). Over 90% of all individuals diagnosed with acute sinusitis received antibiotics, regardless of symptom duration. The antibiotics most often prescribed were Doxycyclin and Amoxicillin.
The incidence of acute sinusitis in these three communities seems to be similar to other western countries. Acute bacterial sinusitis seems to be overdiagnosed and the use of antibiotics is in no context with clinical guidelines. Our results support the hypothesis that physicians tend to regard acute sinusitis as a bacterial disease, and treat it accordingly.
A major advantage of using a rating scale in health-utility measurement is its practical applicability: the method is relatively easy to understand, and various health states can be assessed simultaneously. However, a theoretical foundation for rating-scale valuations has not been established. The primary aim of this paper is to present a theoretical foundation for rating-scale valuations based on the theory of measurable value functions and to provide a consistency test to see whether rating-scale valuations do indeed elicit a measurable value function. If rating-scale valuations elicit a measurable value function, then Dyer and Sarin have shown how they are related to von Neumann-Morgensterm (vNM) utilities. The appropriate technique to measure vNM utilities is the standard gamble. Torrance has suggested that rating-scale valuations and standard-gamble valuations are related by a power function. A secondary aim of this paper is to examine the relationship between rating-scale valuations and standard-gamble valuations hypothesized by Torrance. An experiment was designed to test consistency of rating-scale valuations and the relationship between rating-scale valuations and standard-gamble valuations. The experiment tested whether rating-scale valuations are independent of the context in which they are elicited, as they should be if they elicit points on a measurable value function. 80 Swedish and 92 Dutch respondents participated in the experiment. The results showed that rating-scale valuations depend on the number of preferred alternatives in the task and thus violate a basic property of measurable value functions. The estimation of the power function did not result in stable results: parameter estimates varied, in some cases there was indication of misspecification, and in most cases there was indication of heteroskedastic errors. The implications of these findings for the common use of rating-scale valuations in cost-utility analysis are serious: the dependency of the rating-scale valuations on the other health states included in the task casts serious doubts on the validity of the rating-scale method.
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Comment In: Med Decis Making. 1998 Apr-Jun;18(2):2369566457
To compare the appropriateness of case selection for primary hip and knee replacements between two regions in Ontario: one with a high population-based utilization rate and one with a low rate.
Random audit of medical records sampled from hospital discharge abstracts, with subsequent implicit and explicit criteria-based assessments of the appropriateness of surgery.
People aged 60 years or over who underwent elective, single-joint, non-fracture-related, primary hip or knee replacement between Apr. 1, 1992, and Mar. 31, 1993, at one of seven hospitals in a high-rate region (comprising Brant, Huron and Oxford countries) or one of eight hospitals in a low-rate region (comprising the cities of Scarborough and Toronto).
Structured review of hospital medical records, with additional review of information from surgeons and family physicians' office charts if necessary. Three physicians reviewed patient data and rated the preoperative pain level and functional status of patients, with agreement among at least two reviewers. The proportion of inappropriate cases was then assessed according to explicit criteria defined by a multidisciplinary panel using the delphi process. Profiles of each case were also subjected to independent implicit review by two rheumatologists and two orthopedic surgeons.
Proportion of joint replacements deemed inappropriate in the high- and low-rate regions according to either the explicit criteria or the implicit review, as well as preoperative pain levels and functional status of patients in the high- and low-rate regions.
Hip replacements were more common among patients sampled in the low-rate region than among those in the high-rate region (57.3% v. 39.3%; p
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The volume-outcome hypothesis suggests that if increased provider procedure volume is associated with improved patient outcomes, then greater regionalization to high-volume providers should improve region-level outcomes. Quality improvement interventions for pancreas cancer surgery implemented in year 1999 in Ontario, Canada were designed to regionalize surgery to high-volume hospitals and decrease operative mortality. Similar interventions were not used in Quebec, Canada. We assessed the volume-outcome hypothesis and the impact of the Ontario quality improvement interventions.
Administrative databases helped identify pancreatic resections from years 1994 to 2004 and relevant patient and hospital characteristics. Hospitals were high-volume if they provided =10 procedures in a given calendar year. Outcomes were regionalization of surgery to high-volume providers and rates of operative mortality.
From 1994 to 2004 the percentage of cases in high-volume hospitals increased from 33 to 71% in Ontario and from 36 to 76% in Quebec. Annual rates of operative mortality dropped in Ontario (10.4-2.2% or less) and changed little in Quebec (7.2-9.8%). Changes in measures over time in both provinces were similar before and after year 1999.
Regionalization was associated with improved operative mortality in Ontario but not in Quebec, undermining the volume-outcome hypothesis. The Ontario quality improvement interventions likely were of little influence since patterns in regionalization and operative mortality were similar before and after year 1999.
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Comment In: Ann Surg Oncol. 2010 Oct;17(10):2535-620499281
The purpose of this project was to develop, implement and evaluate a community-based education/support programme for families of head-injured survivors. Three measures were used in evaluating the programme: (a) a written evaluation by the participants, (b) the clinical impressions of the programme facilitators and the principal investigator, and (c) the three outcome measures: coping, self-esteem, and well-being. A pretest-posttest quasi-experimental design was used to test the effect of the intervention (the programme) on the outcome measures. Data yield mixed results and suggest that the programme had considerable practical but not statistical significance.
To describe the patient characteristics, circumstances and community response in cases of out-of-hospital cardiac arrest; to evaluate the effect on survival of the introduction of prehospital defibrillation; and to identify factors that predict survival.
Population-based before-and-after clinical trial.
Five Ontario communities: London, Sudbury, the Greater Niagara region, Kingston and Ottawa.
A consecutive sample of 1510 primary cardiac arrest patients who were transported to hospital by ambulance over 2 years.
The use of defibrillators by ambulance attendants.
Patient characteristics (sex and age), circumstances of arrest (place, whether arrest was witnessed and cardiac rhythm), citizen response (whether cardiopulmonary resuscitation [CPR] was started by a bystander, time to access to emergency medical services and time to initiation of CPR), emergency medical services response (ambulance response time, time to initiation of CPR and time to rhythm analysis with defibrillator) and survival rates.
A total of 92.1% of the patients were 50 years of age or older, and 68.3% were men. Overall, 79.6% of the arrests occurred in the home. The average ambulance response time for witnessed cases was 7.8 minutes. The overall survival rate was 2.5%. The survival rates before and after defibrillators were introduced were similar, and the general functional outcome of the survivors did not differ significantly between the two phases. Factors predicting survival included patient's age, ambulance response time and whether CPR was started before the ambulance arrived.
The survival rate was lower than expected. The availability of prehospital defibrillation did not affect survival. To improve survival rates after cardiac arrest ambulance response times must be reduced and the frequency of bystander-initiated CPR increased. Once these changes are in place a beneficial effect from advanced manoeuvres such as prehospital defibrillation may be seen.
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How well can hospital discharge abstracts be used to estimate patient health status? This paper compares information on comorbidity obtained from hospital discharge abstracts for patients undergoing prostatectomy or cholecystectomy at a Winnipeg teaching hospital with clinical data on preoperative medical conditions prospectively collected during an Anesthesia Follow-up study. The diagnostic information on cardiovascular disease, respiratory disease, and metabolic disorders showed considerable agreement, ranging from 65 to over 90% correspondence across the two data sets. Certain conditions noted by the anesthesiologist were often absent from the claims data; cardiovascular disease was recorded in the clinical data but absent from the claims for 31% of prostatectomy and 17% of cholecystectomy cases. Such patients were less likely to have been assigned a high score on the ASA Physical Status measure or to have high-risk diagnoses on the hospital file. Similar findings resulted from comparing the two sources in their ability to predict such adverse outcomes as mortality and readmission to hospital: the anesthesia file generally included less serious comorbidity.
Since, at the health system level, there is little research into the possible interrelationships among the various indicators of health, healthcare performance, non-medical determinants of health, and community and health system characteristics, we conducted this study to explore such interrelationships using the Canadian Health Indicators Framework.
We conducted univariate correlational analyses with health and healthcare performance as outcomes using recent Canadian data and the ten Canadian provinces and three territories as units of the analyses. For health, 6 indicators were included. Sixteen healthcare performance indicators, 12 non-medical determinants of health and 16 indicators of community and health system characteristics were also included as independent variables for the analysis. A set of decision rules was applied to guide the choice of what was considered actual and preferred performance associations.
Health (28%) correlates more frequently with non-medical determinants than healthcare does (12%), in the preferred direction. Better health is only correlated with better healthcare performance in 13% of the cases in the preferred direction. Better health (24%) is also more frequently correlated with community and health system characteristics than healthcare is (13%), in the preferred direction.
Canadian health performance is a function of multiple factors, the most frequent of which may be the non-medical determinants of health and the community characteristics as against healthcare performance. The contribution of healthcare to health may be limited only to relatively small groups which stand to benefit from effective healthcare, but its overall effect may be diluted in summary measures of population health. Interpreting multidimensional, multi-indicator performance data in their proper context may be more complex than hitherto believed.
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Cost-effectiveness of lumbar fusion and nonsurgical treatment for chronic low back pain in the Swedish Lumbar Spine Study: a multicenter, randomized, controlled trial from the Swedish Lumbar Spine Study Group.
A cost-effectiveness study was performed from the societal and health care perspectives.
To evaluate the costs-effectiveness of lumbar fusion for chronic low back pain (CLBP) during a 2-year follow-up.
A full economic evaluation comparing costs related to treatment effects in patients with CLBP is lacking.
A total of 284 of 294 patients with CLBP for at least 2 years were randomized to either lumbar fusion or a nonsurgical control group. Costs for the health care sector (direct costs), and costs associated with production losses (indirect costs) were calculated. Societal total costs were identified as the sum of direct and indirect costs. Treatment effects were measured using patient global assessment of improvement, back pain (VAS), functional disability (Owestry), and return to work.
The societal total cost per patient (standard deviations) in the surgical group was significantly higher than in the nonsurgical group: Swedish kroner (SEK) 704,000 (254,000) vs. SEK 636,000 (208,000). The cost per patient for the health care sector was significantly higher for the surgical group, SEK 123,000 (60,100) vs. 65,200 (38,400) for the control group. All treatment effects were significantly better after surgery. The incremental cost-effectiveness ratio (ICER), illustrating the extra cost per extra effect unit gained by using fusion instead of nonsurgical treatment, were for improvement: SEK 2,600 (600-5,900), for back pain: SEK 5,200 (1,100-11,500), for Oswestry: SEK 11,300 (1,200-48,000), and for return to work: SEK 4,100 (100-21,400).
For both the society and the health care sectors, the 2-year costs for lumbar fusion was significantly higher compared with nonsurgical treatment but all treatment effects were significantly in favor of surgery. The probability of lumbar fusion being cost-effective increased with the value put on extra effect units gained by using surgery.
