Quality assurance in health care : the official journal of the International Society for Quality Assurance in Health Care最新文献

Autopsy findings from a representative sample of deaths in a clinic provide an opportunity for regular and systematic revision of medical diagnostics and treatment. A standardized analysis of the collected results can furnish useful figures for comparisons and follow-up. On this basis, new strategies for future improvement of medical care should be outlined. Autopsy results can also be used for medical audit concerning more limited items like the certification of death.

In many treatment trials the aim is to prevent deaths from one type of disease. The cause of death evaluation is therefore of the utmost importance. A high autopsy rate is required, even as regards sudden deaths that cannot routinely be referred to as ischemic heart disease. Autopsies are also necessary for studying non-lethal and lethal side effects of the involved drug. Even in the best of cases the post-mortem rate is far from 100% and correctness of the cause of death evaluation is not ensured. If the treatment has prevented deaths from the cause studied, this gain must not be outweighed by increases of other causes of death, for the result to be considered reliably positive.

The aim of the study was to analyse the agreement between pathologists regarding macroscopic autopsy diagnostics. Four pathologists examined 35 autopsies and determined the principal disease and its complications, the immediate cause of death, other major diseases and their complications, and minor diseases. The participants were paired and their diagnoses were analysed by using kappa statistics for interobserver variation. The agreement on the principal disease was almost perfect between the participants (kappa values between 0.83 and 0.97), whereas that on the immediate cause of death was moderate/substantial (kappa values between 0.43-0.75). The list of all other major diseases and their complications was almost complete for each observer, but that of the minor diseases showed a more considerable variation. In spite of the high level of agreement it is recommended that the autopsy findings be discussed among pathologists if the clinical picture cannot be explained satisfactorily, and that the cause of death be determined by the clinicians after the demonstration of the autopsy.

The role of a high autopsy frequency in the registration of cancer cases in a population was studied in the region of southern Sweden, in particular in Malmö. Due to a declining autopsy frequency the number of incidentally found cancer cases at autopsy has diminished greatly during the past 10 years. The value of the reports from cancer registries regarding the total number of tumours in a population is thus doubtful. In order to follow the real frequency of tumours, centres ought to be established where a high autopsy frequency can be achieved.

Four randomized Swedish studies on the usefulness of mammography in screening for breast cancer have been published. The results have shown a variable but positive effect of screening in women more than 50 years of age but the effect is questionable before this age. The protocol and end points however differ between the studies and in order to summarize the results of the present studies, an unbiased, blinded end-point committee was created. The results of this study have been published recently. The present communication only concerns the role of autopsy in this study. The deaths of 1367 patients with a diagnosis of breast cancer have been studied. The percentage of autopsy varied from 21 to 74% between the four studies. When autopsy was performed, 58% were found to have died from breast cancer, 13% from other malignancies and the rest from other diseases. In cases with no autopsy, 73% were considered to have died of breast cancer and 9% of other malignancies. Deaths due to other cancers included a surprising number of cancers of the stomach, gallbladder and pancreas, two to three times higher than expected.

The nursing staff of the Nijmegen University Hospital has implemented a project to formulate and evaluate objectives of quality of care. A quality profile, formulated on a national level, has been used as a guide in quality projects at nursing units for four years. The results of these quality projects show a lot of definite quality improvements and also a large number of quality requirements. In 1991 an inventory was made of these requirements. A specific method was used to select these requirements. Finally, a new framework of quality requirements was formulated. This framework offers the Nijmegen University Hospital possibilities such as: (i) being a source from which targets may be selected for quality improvement projects; (ii) requirements being made operational and used to measure the quality of nursing care.

This paper aims to describe and evaluate the results of the Nursing Quality Assurance (QA) Program in the Hospital de la Santa Creu i Sant Pau. The program was designed in 1987 as part of a global QA program involving all aspects of patients' care. The QA Program was organized at three levels: hospital, ward and joint medical-nursing. During the first 3 years of the study the following activities were carried out: (A) nursing process and results; (B) risk management; (C) patients' opinion; (D) utilization review; (E) ward nursing QA programs. Among other significant results, the program has detected that only 55.6% patients manifest that they sleep well at hospital, hygiene of dependent males (51%) is significantly worse than dependent females (81%) and patients' falls are more prevalent among oriented patients (73%) than disoriented patients (27%). Also a significative improvement has been demonstrated after implementing corrective measures in patients' information (7.5/10-8.1/10) and patients without supervision in emergency areas became from 35% to 0.02%. New nursing records were designed as a result of the QA assessment. The most important conclusion is that the Nursing QA Program is a valid instrument to evaluate general problems in the hospital and concrete problems in each ward.

During the last decade, treatment of myocardial infarction has changed and the prognosis dramatically improved. A sex bias in considering revascularization in men and women with coronary heart disease has been reported. The influence of gender on treatment given to patients with an acute myocardial infarction has not been investigated. From 1989 to 1991 there were 1515 patients with acute myocardial infarction admitted to the coronary care unit at Ostra Hospital; 67% were men. Pharmacological treatment limiting infarct size was given to 60% of all women and to 67% of all men; p < 0.05. In addition, coronary angiography during the hospital stay was performed in 0.2% of all women vs 1.9% of all men; p < 0.05. The prevalence of diabetes, age, symptoms or prehospital delay cannot explain these findings. While a sex bias in referring patients for revascularization has been reported, this report also describes a possible sex bias in the pharmacological treatment of acute myocardial infarction.

A cross-sectional study was performed upon a group of patients (N = 222) with rheumatoid arthritis (RA), from a Swedish health care district. The aim was to elucidate expectations and satisfaction with health care workers. The participants indicated that a good reception is more important than professional knowledge followed by the ability to inform about RA and the ability to show empathy. There was a trend towards increasing satisfaction with information about medical problems with severity of RA. This stands in contrast to the lack of such a systematic relation with regard to increasing functional disability as measured by the Stanford Health Assessment Questionnaire. Reasons for this could be that the physicians tend to respond more to clinical signs than to daily living restrictions. A relatively high percentage (around 80%) of the patients were satisfied with the surgical procedures offered to them. Only one third of the individuals felt that they had been involved in planning of treatment and discharge although a majority expressed this as very important. The importance of a continuous dialogue between patient and physician with regard to fulfillment of patient expectations is emphasized.

The Swedish systems for complaints and supervision with many possibilities of claiming on different levels may lead to prevention of future problems in medical and dental care. The systems are corrective, preventive and compensatory, and are important in the process of quality assurance. However, some elements need improvement. The present paper gives as a background an overview of the Swedish systems and discusses a few cases. Comparisons with systems in other countries, especially the USA, are made, and new measures are discussed. There is a need for smooth, preventive measures as well as strong, punitive and corrective measures. Recidivist doctors/dentists must be stopped.