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

Although many reliability studies on cervical cytology have been carried out, measurements of sensitivity and specificity have rarely been made since biopsies are not often performed on patients with a negative smear result. This screening assessment was performed over 3 years, using a database of 230,167 smears from 177,051 women. It would seem that cervical cytology has a high specificity (over 99%) but a relatively low sensitivity (61%). Values for sensitivity (exceeding 95%) and specificity (exceeding 99%) for invasive carcinoma should be regarded as reasonably accurate as all incident cases of symptomatic cervical carcinoma are recorded in the Burgundy register. The sensitivity (57%) for pre-invasive lesions is underestimated while their prevalence is overestimated: the lack of organized screening leads to the loss of prevalent cases. The predictive value of a positive smear is 76% for moderate-severe dysplasia, 85% for in situ carcinoma and over 95% for invasive carcinoma.

Three different forms of feedback designed to improve the sampling quality of cervical smears were tested in a randomized controlled trial among 179 physicians. The reactions of the doctors to the various interventions are reported as they appeared from their answers in a questionnaire. The influence of the interventions on the employed sampling technique is described on the basis of their answers to a telephone inquiry. The inclusion in laboratory protocols of an evaluation of the sampling quality of the submitted smears was largely appreciated, as was specific advice offered on indication. Monthly overviews comparing the performance of the individual doctor to that of his peers were esteemed by three out of four. Further information, help or training was requested more frequently than average by physicians obtaining inadequately sampled smears relatively often. The number of doctors using the combined spatula and Cytobrush method as sampling technique doubled during the study period.

The Flemish Centre for the Study of Perinatal Epidemiology was formally established in 1986. Its objectives are the promotion of perinatal epidemiology and the study of maternal and perinatal mortality and morbidity. One of the means to accomplish these objectives was the creation of a databank of perinatal medicine. The registry at present covers almost 80% of all deliveries in Flanders. The registry indicates a maternal death rate of 5.8/100,000 living births whereas the Belgian official national statistics indicate a maternal death rate of 2.8/100,000. This means that either the matter is under reported at the national level or there is a real problem in the Flemish part of the country. The perinatal death rate varies among the participating services form 3.9 to 22.4%.

In 1989 the Government in the UK announced a fundamental review of the financing of the National Health Service (NHS). Before the review, health authorities were responsible for both establishing need and providing services. Health Authorities are now allocated resources with which they commission services from managerially independent provider units. In the discussion that preceded the review concern was expressed about standards of clinical care given by doctors. It was recognised that these were professional issues which could not be directly addressed through the commissioning process, therefore within its NHS review proposals, the Government made clear its expectation that all doctors working in the NHS should participate in medical audit. This was defined as a systematic peer review of their work, including procedures used for diagnosis and treatment, the use of resources and the resulting outcome for patients. Managers should be provided with regular general reports of audit activity. These proposals for medical audit have been well received by the medical profession, who are now working closely with the Government to put them into practice.

An assessment was made on emergency laboratory test ordering at Udine General Hospital (Italy) to investigate the reasons for the excessive number of requested tests. All the orders for emergency laboratory tests during one week in June 1990 were studied. For each test the time of the order was recorded for every day of the week. The most important aspect of our investigation is the distribution of the orders during the day: in fact, test orders reached two peaks, the upper between 7 and 11 a.m., and the lower between 3 and 6 p.m. The analysis of the record cards showed that 42% of the orders were inappropriate. These preliminary findings were very useful in making the consensus on a Quality Assurance program easier, to improve the use of the Emergency Laboratory by doctors and nurses. Some preliminary results in the Emergency Medicine Department confirmed the validity of this program.

This article reports on a 3-year quality assurance (QA) support activity in the Assistance Publique-Hôpitaux de Paris, a large university hospital system covering the Greater Paris area. This activity stressed the interprofessional and voluntary character of QA. As well as showing the traditional reservations that usually prevent physicians from embracing QA. French physicians have specific problems with the word "evaluation" that has for them greater monetary than scientific connotations. In addition, the above-mentioned reservations are aggravated by the background culture and career structure of university physicians in France. In spite of these initial difficulties the support programme succeeded in getting QA off the ground in 60 departments in 25 hospitals. The need for a well developed medical information system as an incentive for QA activities in AP is discussed.

An integrated informatic system may have an important role in identifying and reducing those errors which affect the reliability of laboratory results. The present work reports on the development of a system that, by means of a computer connected with laboratory instrumentation, allows monitoring of global error (bias, random, gross) using classical statistical quality control systems, integrated by auxiliary methods built on a database stored in the computer. These methods succeeded in greatly reducing bias and random error in the most frequent laboratory tests. Further methods to find, quantify, and reduce the gross and extra-analytical errors are under development.

A formal variability study has been carried out in a geriatric hospital in Genoa, Italy, in order to estimate the degree of agreement between geriatricians in disability and functional assessment, recommendation for rehabilitation treatments, need for mobility and daily activities aids, and decisions about optimal place of treatment (own home, sheltered housing, old peoples' home, nursing home). Sixteen long-stay geriatric patients, average age 83 years, were visited by eight geriatricians, a patient receiving from two to five visits. The participating physicians could visit the patients at their leisure, had access to clinical records and could interview a nurse well acquainted with the patient. A marked variability was observed for most items, e.g. the agreement concerning the recommendation for individual physiotherapy was only 52%. The results of this study may not be generalized to other situations and to actual practice; however, variability studies of this kind, that assess diagnosis habits, treatment and managerial decisions at the same time, may be useful to pinpoint the most important problems and to stimulate professionals' participation in proper Quality Assurance projects.

Since a radiotherapy department is a clinical and technical entity, quality assurance (QA) is a team effort. This is necessary for the treatment of a patients with the required high degree of accuracy and precision. The physical and technical aspects of QA programmes performed in radiotherapy institutions have been reviewed in this paper. Firstly, the accuracy required in radiotherapy has been discussed. An increasing amount of clinical evidence indicates that an accuracy of 3.5% in the dose value at the specification points and an accuracy of less than 5 mm in the position of the field with respect to the target volume in the patient is required. Secondly, various aspects of QA programmes related to beam characteristics of treatment machines, treatment planning and treatment verification have been elucidated. It is recommended that international organizations formulate minimum and ideal QA programmes for this purpose. Finally, some recent developments in the field of treatment verification concerning portal imaging and in vivo dosimetry, partly sponsored by the CEC/AIM programme, have been illustrated in more detail. The latter project concerns the further development of an on-line electronic portal imaging device for checking the correct position of the target volume with respect to the radiation beam.

Appropriate access to health care is one of the components of Primary Health Care (PHC) and it can be a good quality indicator. We present in this paper the results of 1 year of follow-up of an appointment system applied in 29 PHC centers in the Balearic Islands, Spain; the program was set up by the National Institute of Health. Telephonic appointment proportion increased from the first weeks, stabilizing at about 70%. The number of calls that it is necessary to make in order to get an appointment at peak time is now 1.5 and only 1 throughout the rest of the day. To determine changes in the waiting time and visit time, and the user opinion of the system, an enquiry was made to a sample of patients 1 month before, and 1 month, 6 months and 1 year after the program started. The waiting time is now less than 15 min for most of the people interviewed, in contrast with the previous situation when the waiting time was more than 30 min. The visit time is longer now and more than two thirds of the people think that care is better or much better than prior to the start of the program. These results have been verified in the waiting room (11.2 min mean waiting time and 7.2 min mean visit time). We conclude that we have achieved the goals of the appointment system program in all the centers covered by our department.