Health system recovery from Covid-19: What policies are health systems using to tackle backlogs and bring down waiting times in the wake of the pandemic?

The pandemic has left even the most well-equipped health systems vulnerable and required difficult trade-offs to balance both Covid-19 and non-Covid-19 health services. Across the globe, planned and routine health services have been scaled down during peaks of the crisis to meet the needs of acute and Covid-19-related care, resulting in growing care backlogs and increase in the number of patients waiting for treatment. To identify potential policy solutions, we have consulted the Covid-19 Health System Response Monitor, interviewed experts and analysed recovery strategies in 16 OECD and EU countries. Many country responses display striking similarities despite very real differences in the organisation of health and care services. These include:

1) increasing the supply of workforce by widening the scope of authority for different roles, investing heavily in recruitment and training for key roles, and improving the terms and conditions of work;

2) boosting productivity by introducing financial incentives and targets, reconfiguring facilities to better separate planned and emergency work”, optimising referrals and waiting list management, and outsourcing more care to the private sector; and

3) investing in out-of-hospital alternatives to care, including expanding primary and community care models and developing digital, home care and rehabilitative capacity

Policymakers will need to balance the immediate pressures of clearing backlogs with long-term measures that place services on a more sustainable footing. International experience shows how these can be at odds, especially if actions taken in the short term exhaust an already depleted workforce, or resolve Covid-19-specific problems but leave services less prepared for tomorrow's challenges.

Meeting the governance challenges of integrated health and social care

Background

Many countries are experimenting with novel ways of organising and delivering more integrated health and social care. Governance is relatively neglected as a focus of attention in this context but addressing governance challenges is key for successful collaboration.

Methods

Cross-country case analysis involving document review and semi-structured interviews with 27 local, regional and national level stakeholders in Italy, the Netherlands and Scotland. We used the Transparency, Accountability, Participation, Integrity and Capability (TAPIC) framework to structure our analytical enquiry to explore factors that influence the governance arrangements in each system.

Results

Governance arrangements ranged from informal agreements in the Netherlands to mandated integration in Scotland. Novel service models were generally participative involving a wide range of stakeholders, including the public, although integration was seen to be driven, largely, from a health perspective. In Italy and Scotland some reversion to ‘command & control’ was reported in response to the imperatives of the Covid-19 pandemic. Policies, budgets, auditing and reporting systems that are clearly aligned at all levels were seen to help with implementing innovations in service organisation. Where alignment was lacking, cooperation and integration was suboptimal, regardless of whether governance arrangements were statutory or not. There was wide recognition of the importance of buy-in. Enablers of greater engagement included visible leadership, time and long-standing working relationships. Lack of suitable indicators and openness to data sharing to measure integration hindered working relationships and thus the successful delivery of integrated services.

Conclusions

Our study provides important insights into how to more effectively and efficiently govern service delivery structures within care systems. We will discuss approaches to governance that help support more resilient integrated care systems.

Key messages

• Different governance arrangements face common challenges to greater integration of care. Enablers include strong leadership, inclusivity and openness to work across traditional boundaries.

• Meeting the governance challenges of integrated health and social care requires clear lines of accountability, aligned policies, budgets and reporting systems.

The Second Case of Non-Mosaic Trisomy of Chromosome 26 with Homologous Fusion 26q;26q in the Horse

Simple Summary

We present chromosome and DNA analysis of a normal Thoroughbred mare and her abnormal foal born with neurologic defects. We show that the foal has an abnormal karyotype with three copies of chromosome 26 (trisomy chr26), instead of the normal two. However, two of the three chr26 have fused, forming an unusual derivative chromosome. Chromosomes of the dam are normal, suggesting that the chromosome abnormality found in the foal happened during egg or sperm formation or after fertilization. Analysis of the foal and the dam with chr26 DNA markers indicates that the extra chr26 in the foal is likely of maternal origin and that the unusual derivative chromosome resulted from the fusion of two parental chr26. We demonstrate that although conventional karyotype analysis can accurately identify chromosome abnormalities, determining the mechanism and parental origin of these abnormalities requires DNA analysis. Most curiously, this is the second case of trisomy chr26 with unusual derivative chromosome in the horse, whereas all other equine trisomies have three separate copies of the chromosome involved. Because horse chr26 shares genetic similarity with human chr21, which trisomy causes Down syndrome, common features between trisomies of horse chr26 and human chr21 are discussed.

Abstract

We present cytogenetic and genotyping analysis of a Thoroughbred foal with congenital neurologic disorders and its phenotypically normal dam. We show that the foal has non-mosaic trisomy for chromosome 26 (ECA26) but normal 2n = 64 diploid number because two copies of ECA26 form a metacentric derivative chromosome der(26q;26q). The dam has normal 64,XX karyotype indicating that der(26q;26q) in the foal originates from errors in parental meiosis or post-fertilization events. Genotyping ECA26 microsatellites in the foal and its dam suggests that trisomy ECA26 is likely of maternal origin and that der(26q;26q) resulted from Robertsonian fusion. We demonstrate that conventional and molecular cytogenetic approaches can accurately identify aneuploidy with a derivative chromosome but determining the mechanism and parental origin of the rearrangement requires genotyping with chromosome-specific polymorphic markers. Most curiously, this is the second case of trisomy ECA26 with der(26q;26q) in the horse, whereas all other equine autosomal trisomies are ‘traditional’ with three separate chromosomes. We discuss possible ECA26 instability as a contributing factor for the aberration and likely ECA26-specific genetic effects on the clinical phenotype. Finally, because ECA26 shares evolutionary homology with human chromosome 21, which trisomy causes Down syndrome, cytogenetic, molecular, and phenotypic similarities between trisomies ECA26 and HSA21 are discussed.

A cross-country comparison on providing health services effectively during the first wave of COVID-19

At the onset of the COVID-19 pandemic, health care providers had to abruptly change their way of providing care in order to simultaneously plan for and manage a rise of COVID-19 cases while maintaining essential health services. Even the most well-resourced health systems faced pressures from new challenges brought on by COVID-19, and every country had to make difficult choices about how to maintain access to essential care while treating a novel communicable disease. Using the information available on the HSRM platform from the early phases of the pandemic, we analyze how countries planned services for potential surge capacity, designed patient flows ensuring separation between COVID-19 and non-COVID-19 patients, and maintained routine services in both hospital and outpatient settings. Many country responses displayed striking similarities despite very real differences in the organization of health and care services. These include transitioning the management of COVID-19 mild cases from hospitals to outpatient settings, increasing the use of remote consultations, and cancelling or postponing non-urgent services during the height of the first wave. In the immediate future, countries will have to continue balancing care for COVID-19 and non-COVID-19 patients to minimize adverse health outcomes, ideally with supporting guidelines and COVID-19-specific care zones. Many countries expect to operate at lower capacity for routinely provided care, which will impact patient access and waiting times. Looking forward, policymakers will have to consider whether strategies adopted during the COVID-19 pandemic will become permanent features of care provision.

Benign adenoidal hypertrophy caused by adenovirus presenting as a nasopharyngeal mass concerning for malignancy

Benign adenoidal hypertrophy is the most common cause of nasopharyngeal obstruction. However, depending on size and location, masses may cause nasopharyngeal obstruction. We present our experiences with a ten-year-old female who presented with what appeared to be a large nasopharyngeal mass that was initially favored to be malignant and was ultimately found to be adenoid hypertrophy related to acute infection with adenovirus.

Acute and chronic effects of multivitamin/mineral supplementation on objective and subjective energy measures

Background

Vitamins and minerals play an essential role within many cellular processes including energy production and metabolism. Previously, supplementation with a multivitamin/mineral (MVM) for ≥28 days resulted in improvements to cognition and subjective state. We have also demonstrated shifts in metabolism during cognitively demanding tasks following MVM in females, both acutely and following 8-week supplementation. The current study aimed to assess these effects further in males and females using metabolically challenging exercise and cognitive tasks.

Methods

The current randomised, placebo-controlled, parallel groups study investigated the effects of a MVM complex in 82 healthy young (18-35y) exercisers. Subjective ratings and substrate metabolism were assessed during 30 min each of increasingly effortful incremental exercise and demanding cognitive tasks. Assessments took place on acute study days following a single dose (Day 1) of MVM, containing 3 times recommended daily allowance of water-soluble vitamins plus CoQ10, and following 4-week supplementation (Day 28).

Results

Energy expenditure (EE) was increased during cognitive tasks following MVM across Day 1 and Day 28, with greater effects in males. In males, MVM also increased carbohydrate oxidation and energy expenditure during exercise across Day 1 and Day 28. In females, mental tiredness was lower during exercise; increases in physical tiredness following 30 min of exercise were attenuated; and stress ratings following cognitive tasks were reduced following MVM. In males, MVM only lowered mental tiredness following 10 min of exercise. These effects were apparent irrespective of day, but effects on mental tiredness were greater on Day 28. Ferritin levels were also higher on Day 28 in those receiving MVM.

Conclusion

These findings extend on existing knowledge, demonstrating increased carbohydrate oxidation and increased energy expenditure in males following MVM supplementation for the first time. Importantly, they show modulation of energy expenditure and subjective tiredness following a single dose, providing further evidence for acute effects of MVM. Differential effects in men and women suggest that sex may play an important role in the effects of MVM on energy metabolism and should be considered in future research.

Trial registration

ClinicalTrials.gov, NCT03003442. Registered 22nd November 2016 – retrospectively registered

Crossbreeding with a tropically adapted Bos taurus breed (Senepol) to improve meat quality and production from Brahman herds in Northern Australia. 1. Steer performance

The performance of four year groups of Brahman and F1 Senepol × Brahman steers was compared grazing buffel pasture at the Douglas-Daly Research Farm, Douglas-Daly, NT, Australia. F1 Senepol × Brahman steers were on average 32 kg heavier at turnoff at ~18 months of age (P < 0.001) as a result of higher average weaning weights (+19 kg, P < 0.001) and higher growth during the post-weaning year (+12 kg, P < 0.001). These results, combined with previous studies that found that F1 Senepol × Brahman steers had more tender meat and performed better than Brahman in an Indonesian feedlot, indicate that crossbreeding with a tropically adapted Bos taurus breed, such as Senepol, could be an effective way for north Australian cattle producers with Brahman herds to produce cattle that perform well under northern conditions, and are suited to both the live export and domestic markets.

Building Bridges Between AI and Cognitive Psychology

My goal in this article is to encourage greater integration of the fields of AI and cognitive psychology by reviewing work on shared interests. I begin with examples that link my early research related to AI with my current efforts to organize knowledge in the cognitive sciences. I then describe how cognitive psychologists have contributed to the methods explained in the book The Master Algorithm: How the Ultimate Learning Machine Will Remake Our World (Domingos, 2015), including how these methods can be combined. The final section discusses three benefits of building bridges: using computational models in AI as theoretical models in cognitive psychology, solving joint computational problems, and facilitating the interactions between people and machines.

Abstract GS3-07: Genome-wide copy number analysis of chemotherapy-resistant metastatic triple-negative breast cancer from cell-free DNA

Introduction:

Triple-negative breast cancer (TNBC) is a poor prognosis breast cancer subset characterized by relatively few mutations but extensive copy number alterations (CNAs). Cell-free DNA (cfDNA) offers the potential to overcome infrequent tumor biopsies in metastatic TNBC (mTNBC) and interrogate the genomics of chemotherapy resistance.

Methods:

506 archival or fresh plasma samples were identified from 164 patients with mTNBC who had previously received chemotherapy. We performed low coverage whole genome sequencing to determine genome-wide copy number and estimate 'tumor fraction' of cfDNA (TFx) using our recently-developed approach, ichorCNA. In patient samples with TFx >10%, we identified regions that were significantly gained or lost using GISTIC2.0. We compared CNAs of 20 paired primary-metastatic samples and also mTNBCs from cfDNA versus primary TNBCs from TCGA and METABRIC.

Results:

We successfully obtained high quality, low coverage whole genome sequencing data for 478 (94.5%) plasma samples from 158 patients, with 1 to 14 samples per patient. TFx and copy number profiles were highly concordant with paired metastatic biopsy (n=10, range 0-7 days from biopsy to blood draw) with sensitivity of 0.86 and specificity of 0.90 and reproducible in independently-processed blood draws (TFx intraclass correlation coefficient 0.984). Median overall survival from time of first blood draw was 8 months, and TFx was highly correlated independent of primary stage, primary receptor status, age at primary diagnosis, BRCA status, and metastatic line of therapy: adjusted hazard ratio between 4th and 1st quartiles = 2.14 (95% CI 1.40-3.28; p=0.00049). 101/158 patients (63.9%) had at least one sample with TFx >10%, our threshold for high confidence CNA calls. Copy number profiles and percent genome altered were remarkably similar between mTNBCs and primary TNBCs in TCGA and METABRIC (n=433), suggesting that large-scale chromosomal events are infrequent in TNBC metastatic progression. We identified chromosomal gains that demonstrated significant enrichment in mTNBCs relative to paired primary TNBCs (n=20) and also TCGA/METABRIC, including driver genes (NOTCH2, AKT2, AKT3) and putative antibody-drug conjugate targets. Finally, we identify a novel association of gains of 18q11 and/or 19p13 with poor metastatic prognosis, independent of clinicopathologic factors and TFx.

Conclusions:

Here, we present the first large-scale genomic characterization of metastatic TNBC to our knowledge, derived exclusively from cfDNA. 'Tumor fraction' of cfDNA is an independent prognostic marker in mTNBC. Primary and metastatic TNBC have remarkably similar copy number profiles yet we identify alterations enriched and prognostic in mTNBC. Collectively, these data have potential implications in the understanding of metastasis, therapeutic resistance, and novel therapeutic targets.

Citation Format: Stover DG, Parsons HA, Ha G, Freeman S, Barry B, Guo H, Choudhury A, Gydush G, Reed S, Rhoades J, Rotem D, Hughes ME, Dillon DA, Partridge AH, Wagle N, Krop IE, Getz G, Golub TA, Love JC, Winer EP, Tolaney SM, Lin NU, Adalsteinsson VA. Genome-wide copy number analysis of chemotherapy-resistant metastatic triple-negative breast cancer from cell-free DNA [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr GS3-07.

Characterization of exosomes from body fluids of dairy cows

Exosomes are a specific subpopulation of extracellular vesicles that are widely released by cells of different origins with divergent functions that make their way into body fluids that can be conveniently sampled. In the current study, we isolated and evaluated exosomes from concurrently collected samples of milk, plasma, saliva, and urine from a group of 6 pregnant Holstein-Friesian dairy cows (aged 7 mo, 174 to 203 d of gestation). The cows had BCS of 3.5 to 5.25 (on a scale of 1 to 10), and the milk production for the season to the time of sampling ranged between 5,118 and 6,959 kg. The low levels of extracellular vesicles in saliva and urine (more than 86% fewer compared to the extracellular vesicles in milk and plasma) precluded further detailed evaluation since utility for diagnostics was deemed unlikely. In exosomes isolated from milk and plasma, size distribution, morphology, and the presence of exosome markers was confirmed by nanoparticle tracking analysis, electron microscopy, and Western blot. In addition, a targeted proteomic approach using the quadrupole ion trap mass spectrometer was also used in the study to screen for the exosome marker (e.g., Tumor susceptibility gene 101). Following confirmation of the presence of exosomes, the proteomic profiles of milk and plasma exosomes were evaluated using information-dependent acquisition-mediated liquid chromatography-tandem mass spectrometry (LC-MS/MS). The milk exosomes contain proteins that differed greatly from the plasma exosomes, with only 8 similar proteins harbored in both the milk and plasma exosomes. The milk and plasma exosomes were found to contain proteins (e.g., immunoglobulin J chain and α2 macroglobulin) associated with specific biological processes and molecular functions. Hence, the fluid of origin required for exosome analysis will be dependent on the specific information needed. In conclusion, isolated exosomes from milk and plasma samples collected at the same time point from the same dairy cows encapsulated different profiles of proteins associated with different biological processes and molecular functions.

Effect of circulating exosomes from transition cows on Madin-Darby bovine kidney cell function

The greatest risk of metabolic and infectious disease in dairy cows is during the transition from pregnancy to lactating (i.e., the transition period). The objective of this experiment was to determine the effects of extracellular vesicles (microvesicles involved in cell-to-cell signaling) isolated from transition cows on target cell function. We previously identified differences in the protein profiles of exosomes isolated from cows divergent in metabolic health status. Therefore, we hypothesized that these exosomes would affect target tissues differently. To investigate this, 2 groups of cows (n = 5/group) were selected based on the concentration of β-hydroxybutyrate and fatty acids in plasma and triacylglycerol concentration in liver at wk 1 and 2 postcalving. Cows with high concentrations of β-hydroxybutyrate, fatty acids, and triacylglycerol were considered at increased risk of clinical disease during the transition period (high-risk group; n = 5) and were compared with cows that had low concentrations of the selected health indicators (low-risk group; n = 5). At 2 time points during the transition period (postcalving at wk 1 and 4), blood was sampled and plasma exosomes were isolated from the high-risk and low-risk cows. The exosomes were applied at concentrations of 10 and 1 µg/mL to 5 × 10³ Madin-Darby bovine kidney cells grown to 50% confluence in 96-well plates. Results indicate a numerical increase in cell proliferation when exosomes from high-risk cows were applied compared with those from low-risk cows. Consistent with an effect on cell proliferation, quantitative reverse transcriptase PCR indicated a trend for upregulation of 3 proinflammatory genes (granulocyte colony-stimulating factor, ciliary neurotrophic factor, and CD27 ligand) with the application of high-risk exosomes, which are involved in cellular growth and survival. Proteomic analysis indicated 2 proteins in the low-risk group that were not identified in the high-risk group (endoplasmin and catalase), which may also be indicative of the metabolic state of origin. It is likely that the metabolic state of the transition cow affects cellular function through exosomal messaging; however, more in-depth research into cross-talk between exosomes and target cells is required to determine whether exosomes influence Madin-Darby bovine kidney cells in this manner.

Plasma exosome profiles from dairy cows with divergent fertility phenotypes

Cell-to-cell communication in physiological and pathological conditions may be influenced by neighboring cells, distant tissues, or local environmental factors. Exosomes are specific subsets of extracellular vesicles that internalize and deliver their content to near and distant sites. Exosomes may play a role in the maternal-embryo crosstalk vital for the recognition and maintenance of a pregnancy; however, their role in dairy cow reproduction has not been established. This study aimed to characterize the exosome profile in the plasma of 2 strains of dairy cow with divergent fertility phenotypes. Plasma was obtained and characterized on the basis of genetic ancestry as fertile (FERT; <23% North American genetics, New Zealand Holstein-Friesian strain, n=8) or subfertile (SUBFERT; >92% North American genetics, North American Holstein-Friesian strain, n=8). Exosomes were isolated by differential and buoyant density centrifugation and characterized by size distribution (nanoparticle tracking analysis, NanoSight NS500, NanoSight Ltd., Amesbury, UK), the presence of CD63 (Western blot), and their morphology (electron microscopy). The total number of exosomes was determined by quantifying the immunoreactive CD63 (ExoELISA kit, System Biosciences), and the protein content established by mass spectrometry. Enriched exosome fractions were identified as cup-shape vesicles with diameters around 100 nm and positive for the CD63 marker. The concentration of exosomes was 50% greater in FERT cows. Mass spectrometry identified 104 and 117 proteins in FERT and SUBFERT cows, of which 23 and 36 were unique, respectively. Gene ontology analysis revealed enrichment for proteins involved in immunomodulatory processes and cell-to-cell communication. Although the role of exosomes in dairy cow reproduction remains to be elucidated, their quantification and content in models with divergent fertility phenotypes could provide novel information to support both physiological and genetic approaches to improving dairy cow fertility.

Radiation doses from fluoroscopically guided cardiac catheterization procedures in children and young adults in the United Kingdom: a multicentre study

OBJECTIVE

To gather data on radiation doses from fluoroscopically guided cardiac catheterization procedures in patients aged under 22 years at multiple centres and over a prolonged period in the UK. To evaluate and explain variation in doses. To estimate patient-specific organ doses and allow for possible future epidemiological analysis of associated cancer risks.

METHODS

Patient-specific data including kerma area product and screening times from 10,257 procedures carried out on 7726 patients at 3 UK hospitals from 1994 until 2013 were collected. Organ doses were estimated from these data using a dedicated dosimetry system based on Monte Carlo computer simulations.

RESULTS

Radiation doses from these procedures have fallen significantly over the past two decades. The organs receiving the highest doses per procedure were the lungs (median across whole cohort, 20.5 mSv), heart (19.7 mSv) and breasts (13.1 mSv). Median cumulative doses, taking into account multiple procedures, were 23.2, 22.2 and 16.7 mSv for these organs, respectively. Bone marrow doses were relatively low (median per procedure, 3.2 mSv; cumulative, 3.6 mSv).

CONCLUSION

Most modern cardiac catheterizations in children are moderately low-dose procedures. Technological advances appear to be the single most important factor in the fall in doses. Patients undergoing heart transplants undergo the most procedures. An epidemiological assessment of cancer risks following these procedures may be possible, especially using older data when doses were higher.

ADVANCES IN KNOWLEDGE

This is the first large-scale, patient-specific assessment of organ doses from these procedures in a young population.

Analysis of pathogenic bacteria using exogenous volatile organic compound metabolites and optical sensor detection

A novel, low-cost and simple method for the detection of pathogenic bacteria is proposed.

NEOCENT: a randomised feasibility and translational study comparing neoadjuvant endocrine therapy with chemotherapy in ER-rich postmenopausal primary breast cancer

Neoadjuvant endocrine therapy is an alternative to chemotherapy for women with oestrogen receptor (ER)-positive early breast cancer (BC). We aimed to assess feasibility of recruiting patients to a study comparing chemotherapy versus endocrine therapy in postmenopausal women with ER-rich primary BC, and response as well as translational endpoints were assessed. Patients requiring neoadjuvant therapy were randomised to chemotherapy: 6 × 3-weekly cycles FE₁₀₀C or endocrine therapy: letrozole 2.5 mg, daily for 18-23 weeks. Primary endpoints were recruitment feasibility and tissue collection. Secondary endpoints included clinical, radiological and pathological response rates, quality of life and translational endpoints. 63/80 patients approached were eligible, of those 44 (70, 95% CI 57-81) were randomised. 12 (54.5, 95% CI 32.2-75.6) chemotherapy patients showed radiological objective response compared with 13 (59.1, 95% CI 36.4-79.3) letrozole patients. Compared with baseline, mean Ki-67 levels fell in both groups at days 2-4 and at surgery [fold change: 0.24 (95% CI 0.12-0.51) and 0.24; (95% CI 0.15-0.37), respectively]. Plasma total cfDNA levels rose from baseline to week 8 [fold change: chemotherapy 2.10 (95% CI 1.47-3.00), letrozole 1.47(95% CI 0.98-2.20)], and were maintained at surgery in the chemotherapy group [chemotherapy 2.63; 95% CI 1.56-4.41), letrozole 0.95 (95% CI 0.71-1.26)]. An increase in plasma let-7a miRNA was seen at surgery for patients with objective radiological response to chemotherapy. Recruitment and tissue collection endpoints were met; however, a larger trial was deemed unfeasible due to slow accrual. Both regimens were equally efficacious. Dynamic changes were seen in Ki-67 and circulating biomarkers in both groups with increases in cfDNA and let-7a miRNA persisting until surgery for chemotherapy patients.

Effect of rider experience and evaluator expertise on subjective grading of lameness in sound and unsound sports horses under saddle

The primary objective of this study was to investigate whether rider experience influences the assessment and grading of lameness in horses based on under-saddle gait analysis. Thirteen adult sports horses in active training were included in the study. After a baseline lameness and neurologic examination by the principal investigators, horses were videotaped while being ridden by an experienced and a less experienced rider. A 3-minute video was made for each horse and rider and 26 videos were randomly ordered and compiled on a DVD. Veterinarians with different levels of experience in evaluating lameness and veterinary students viewed the DVD and assigned a lameness score to each horse/rider combination. In a model accounting for the expertise of the evaluator, there was no difference in overall lameness scores between experienced and less experienced riders. This result was consistent for both sound and unsound horses. The overall lameness scores reported by specialists and students, however, differed significantly. The lameness score reported by the study participants while the horse was ridden was significantly associated with the subjective baseline lameness assessment reported by the principal investigators for the same limb when the horse was not under saddle. Additional work is necessary to determine whether riders with even lower skill levels would further alter the balance and motion pattern of the horse and have more influence on subjective grading of lameness.

National critical incident reporting systems relevant to anaesthesia: a European survey

BACKGROUND

Critical incident reporting is a key tool in the promotion of patient safety in anaesthesia.

METHODS

We surveyed representatives of national incident reporting systems in six European countries, inviting information on scope and organization, and intelligence on factors determining success and failure.

RESULTS

Some systems are government-run and nationally conceived; others started out as small, specialty-focused initiatives, which have since acquired a national reach. However, both national co-ordination and specialty enthusiasts seem to be necessary for an optimally functioning system. The role of reporting culture, definitional issues, and dissemination is discussed.

CONCLUSIONS

We make recommendations for others intending to start new systems and speculate on the prospects for sharing patient safety lessons relevant to anaesthesia at European level.