Hospital-specific Template Matching for Benchmarking Performance in a Diverse Multihospital System

BACKGROUND

Hospital-specific template matching is a newer method of hospital performance measurement that may be fairer than regression-based benchmarking. However, it has been tested in only limited research settings.

OBJECTIVE

The objective of this study was to test the feasibility of hospital-specific template matching assessments in the Veterans Affairs (VA) health care system and determine power to detect greater-than-expected 30-day mortality.

RESEARCH DESIGN

Observational cohort study with hospital-specific template matching assessment. For each VA hospital, the 30-day mortality of a representative subset of hospitalizations was compared with the pooled mortality from matched hospitalizations at a set of comparison VA hospitals treating sufficiently similar patients. The simulation was used to determine power to detect greater-than-expected mortality.

SUBJECTS

A total of 556,266 hospitalizations at 122 VA hospitals in 2017.

MEASURES

A number of comparison hospitals identified per hospital; 30-day mortality.

RESULTS

Each hospital had a median of 38 comparison hospitals (interquartile range: 33, 44) identified, and 116 (95.1%) had at least 20 comparison hospitals. In total, 8 hospitals (6.6%) had a significantly lower 30-day mortality than their benchmark, 5 hospitals (4.1%) had a significantly higher 30-day mortality, and the remaining 109 hospitals (89.3%) were similar to their benchmark. Power to detect a standardized mortality ratio of 2.0 ranged from 72.5% to 79.4% for a hospital with the fewest (6) versus most (64) comparison hospitals.

CONCLUSIONS

Hospital-specific template matching may be feasible for assessing hospital performance in the diverse VA health care system, but further refinements are needed to optimize the approach before operational use. Our findings are likely applicable to other large and diverse multihospital systems.

The Path Forward: Using Metrics to Promote Equitable Work Environments

Women continue to be underrepresented in medicine, especially in senior leadership positions, and they experience challenges related to gender bias and sexual harassment. Women who are members of multiple groups that experience marginalization, including, for example, women who are American Indian, Alaskan native, indigenous, Black, or Hispanic, face a compounded challenge. In this article, we explore how institutions and professional organizations in medicine can use metrics to better understand the structural disparities that create and promote gender inequity in the work environment and how to employ these metrics to track progress in narrowing these gaps. Examples in health care (clinical medicine, scientific organizations, scientific publishing), business, and law are used to illustrate how impactful metrics can promote accountability when coupled with transparent reporting.

Cluster-Randomized Trial of Thrombolysis Implementation Support in Metropolitan and Regional Australian Stroke Centers: Lessons for Individual and Systems Behavior Change

Background Intravenous thrombolytic therapy (IVT) with tissue plasminogen activator for acute ischemic stroke is underutilized in many parts of the world. Randomized trials to test the effectiveness of thrombolysis implementation strategies are limited. Methods and Results This study aimed to test the effectiveness of a multicomponent, multidisciplinary tissue plasminogen activator implementation package in increasing the proportion of thrombolyzed cases while maintaining accepted benchmarks for low rates of intracranial hemorrhage and high rates of functional outcomes at 3 months. A cluster randomized controlled trial of 20 hospitals in the early stages of thrombolysis implementation across 3 Australian states was undertaken. Monitoring of IVT rates during the baseline period allowed hospitals (the unit of randomization) to be grouped into 3 baseline IVT strata-very low rates (0% to ≤4.0%); low rates (>4.0% to ≤10.0%); and moderate rates (>10.0%). Hospitals were randomized to an implementation package (experimental group) or usual care (control group) using a 1:1 ratio. The 16-month intervention was based on behavioral theory and analysis of the steps, roles, and barriers to rapid assessment for thrombolysis eligibility and involved comprehensive strategies addressing individual and system-level change. The primary outcome was the difference in tissue plasminogen activator proportions between the 2 groups postintervention. The absolute difference in postintervention IVT rates between intervention and control hospitals adjusted for baseline IVT rate and stratum was not significant (primary outcome rate difference=1.1% (95% CI -1.5% to 3.7%; P=0.38). Rates of intracranial hemorrhage remained below international benchmarks. Conclusions The implementation package resulted in no significant change in tissue plasminogen activator implementation, suggesting that ongoing support is needed to sustain initial modifications in behavior. Clinical Trial Registration URL: www.anzctr.org.au Unique identifiers: ACTRN12613000939796 and U1111-1145-6762.

[Global and national strategies against antibiotic resistance]

Antimicrobial resistance (AMR) is increasingly perceived as a global health problem. To tackle AMR effectively, a multisectoral one health approach is needed. We present some of the initiatives and activities at the national and global level that target the AMR challenge. The Global Action Plan on AMR, which has been developed by the World Health Organization (WHO), in close collaboration with the Food and Agriculture Organization of the United Nations (FAO) and the World Organisation for Animal Health (OIE) is considered a blueprint to combat AMR. Member states endorsed the action plan during the World Health Assembly 2015 and committed themselves to develop national action plans on AMR. The German Antibiotic Resistance Strategy (DART 2020) is based on the main objectives of the global action plan and was revised and published in 2015. Several examples of the implementation of DART 2020 are outlined here.

Regional variation in patient selection and treatment for lower extremity vascular disease in the Vascular Quality Initiative

OBJECTIVE

Prior studies on the cause and effect of surgical variation have been limited by utilization of administrative data. The Vascular Quality Initiative (VQI), a robust national clinical registry, provides anatomic and perioperative details allowing a more robust analysis of variation in surgical practice.

METHODS

The VQI was used to identify all patients undergoing infrainguinal open bypass or endovascular intervention from 2009 to 2014. Asymptomatic patients were excluded. The 16 regional groups of the VQI were used to compare variation in patient selection, operative indication, technical approach, and process measures. χ² analysis was used to assess for differences across regions where appropriate.

RESULTS

A total of 52,373 interventions were included (31%). Of the 16,145 bypasses, 5% were performed for asymptomatic disease, 26% for claudication, 56% for chronic limb-threatening ischemia (CLI) (61% of these for tissue loss), and 13% for acute limb-threatening ischemia. Of the 35,338 endovascular procedures, 4% were for asymptomatic disease, 40% for claudication, 46% for CLI (73% tissue loss), and 12% for acute limb-threatening ischemia. Potentially unwarranted variation included proportion of prosthetic conduit for infrapopliteal bypass in claudication (13%-41%, median, 29%; P < .001), isolated tibial endovascular intervention for claudication (0.0%-5.0%, median, 3.0%; P < .001), discharge on antiplatelet and statin (bypass: 62%-84%; P < .001; endovascular: 63%-89%; P < .001), and ultrasound guidance for percutaneous access (claudication: range, 7%-60%; P < .001; CLI: 5%-65%; P < .001). Notable areas needing further research with significant variation include proportion of CLI vs claudication treated by bypass (38%-71%; P < .001) and endovascular intervention (28%-63%; P < .001), and use of closure devices in percutaneous access (claudication; 26%-76%; P < .001; CLI: 30%-78%; P < .001).

CONCLUSIONS

Significant variation exists both in areas where evidence exists for best practice and, therefore, potentially unwarranted variation, and in areas of clinical ambiguity. Quality improvement efforts should be focused on reducing unwarranted variation. Further research should be directed at identifying best practice where no established guidelines and high variation exists.

Pap Test Reporting Rates for Conventional Smear and Liquid-Based Cervical Cytology from the Largest Academic Women's Hospital in China: Analysis of 1,248,785 Pap Test Reports

OBJECTIVE

The Obstetrics and Gynecology Hospital of Fudan University (OGHFU) in Shanghai is the largest academic women's hospital in China. Between 2009 and 2014, the use of liquid-based cytology (LBC) significantly increased while gradually adopting the Bethesda System (TBS), and in 2012 local regulations mandated that pathologists replace technicians to sign out Pap tests.

DESIGN

A retrospective OGHFU database search documented all Pap test reports between 2009 and 2014 by specimen type, either LBC or conventional Pap smears (CPS), and final reporting category. A total of 1,224,785 Pap reports were analyzed to document variations in Pap test reporting during a period of major change in cervical screening in China.

RESULTS

LBC gradually replaced CPS, which declined from over 65% of Pap tests in 2010 to 6.4% in 2014. Of 514,811 Pap reports using the traditional class system, class I (negative) reports accounted for 98.3% of results. With the introduction of TBS reporting, pathologist reviews and substantial replacement of CPS by LBC, the laboratory abnormal Pap test rate increased significantly to almost 5%.

CONCLUSIONS

Changes in cervical cytology reporting between 2009 and 2014 in China's largest academic women's hospital reflected both increased use of LBC and the introduction of pathologist TBS reporting. Abnormality rates increased significantly and fell within CAP benchmark ranges.

[Potentials of cooperative quality management initiatives: BQS Institute projects, January 2010 - July 2013]

Alongside the projects of internal quality management and mandatory quality assurance there is a variety of quality driven projects across institutions initiated and run by various partners to continuously improve the quality of care. The multiplicity and characteristics of these projects are discussed on the basis of projects run by the BQS Institute between 2010 and 2013. In addition, useful interactions and linking with mandatory quality benchmarking and with internal quality management are discussed. (As supplied by publisher).

Surgical report cards: the myth and the reality

There seems no good reason for doctors to work in secret. Individual users of healthcare and the community in general, which ultimately bears the cost, are perfectly entitled to know how their health services and health providers are performing. The promulgation of surgical report cards has been hailed by some as a liberating step in the right direction. This paper seeks to analyse, from a clinician's perspective, the evolution and limitations of report cards. Ultimately, the importance of report cards will not be their immediate utility, which is minimal, but as a first step in a much wider and far more important debate about how we meaningfully measure the quality of health services and providers (including managers and bureaucrats), the likely cost of such an enterprise, how much we are willing and able to pay and how we reconcile the competing needs of information versus clinical and preventive care when all are competing for the same and inadequate pool of resources.

A review of post-modern management techniques as currently applied to Turkish forestry

This paper reviews the effects of six post-modern management concepts as applied to Turkish forestry. Up to now, Turkish forestry has been constrained, both in terms of its operations and internal organization, by a highly bureaucratic system. The application of new thinking in forestry management, however, has recently resulted in new organizational and production concepts that promise to address problems specific to this Turkish industry and bring about positive changes. This paper will elucidate these specific issues and demonstrate how post-modern management thinking is influencing the administration and operational capacity of Turkish forestry within its current structure.

Revving up the quality campaign

Throughout the election season, H&HN will analyze some of the most critical health care issues facing voters and candidates. Our aim is to provide a deeper understanding of the political and business environment that surrounds these areas. This, the fourth of a five-part series, explores quality. The final story will look at access and coverage.

An approach to risk assessment for TiO2

Titanium dioxide (TiO2) is a poorly soluble, low-toxicity (PSLT) particle. Fine TiO2 (<2.5 microm) has been shown to produce lung tumors in rats exposed to 250 mg/m3, and ultrafine TiO2 (< 0.1 microm diameter) has been shown to produce lung tumors in rats at 10 mg/m3. We have evaluated the rat dose-response data and conducted a quantitative risk assessment for TiO2. Preliminary conclusions are: (1) Fine and ultrafine TiO2 and other PSLT particles show a consistent dose-response relationship when dose is expressed as particle surface area; (2) the mechanism of TiO2 tumor induction in rats appears to be a secondary genotoxic mechanism associated with persistent inflammation; and (3) the inflammatory response shows evidence of a nonzero threshold. Risk estimates for TiO2 depend on both the dosimetric approach and the statistical model that is used. Using 7 different dose-response models in the U.S. Environmental Protection Agency (EPA) benchmark dose software, the maximum likelihood estimate (MLE) rat lung dose associated with a 1 per 1000 excess risk ranges from 0.0076 to 0.28 m2/g-lung of particle surface area, with 95% lower confidence limits (LCL) of 0.0059 and 0.042, respectively. Using the ICRP particle deposition and clearance model, estimated human occupational exposures yielding equivalent lung burdens range from approximately 1 to 40 mg/m3 (MLE) for fine TiO2, with 95% LCL approximately 0.7-6 mg/m3. Estimates using an interstitial sequestration lung model are about one-half as large. Bayesian model averaging techniques are now being explored as a method for combining the various estimates into a single estimate, with a confidence interval expressing model uncertainty.

A Benchmark for Evaluating Innovative Treatment of Left Main Coronary Disease

BACKGROUND

Left main trunk stenosis (> or = 50%) has traditionally been treated with coronary artery bypass grafting. Improvements in coronary stents have led some to advocate percutaneous coronary intervention. To provide a benchmark of outcomes against which percutaneous coronary intervention may be compared, we (1) assessed survival and freedom from coronary reintervention after coronary artery bypass grafting in these patients and (2) identified their risk factors.

METHODS AND RESULTS

From 1971 to 1998, the first 1000 primary coronary artery bypass grafting patients (n=26,927) were followed every 5 years. Of these, 3803 had left main trunk stenosis > or = 50%. A multivariable, nonproportional hazards, time-related analysis was performed to model survival and freedom from coronary reintervention (percutaneous coronary intervention or reoperation) and to identify their risk factors. Survival at 30 days, 1, 5, 10, 15, and 20 years was 97.6%, 93.6%, 83%, 64%, 44%, and 28%, respectively, and freedom from coronary reintervention was 99.7%, 98.9%, 96.6%, 89%, 76%, and 61%, respectively. Worse left ventricular function (P<0.0001), diabetes (P<0.0001), hypertension (P<0.001), peripheral arterial disease (P=0.0002), smoking (P<0.0001), and elevated triglycerides (P=0.01) decreased survival, and younger age (P<0.0001), elevated triglycerides (P=0.005), and incomplete revascularization (P=0.003) increased coronary reintervention. Internal thoracic artery grafting of the left anterior descending improved survival and decreased coronary reintervention.

CONCLUSIONS

This study provides a 20-year outcome benchmark for surgical treatment of left main trunk disease. It indicates that simple comparisons of new treatments are inadequate without risk adjustment. Risk factor adjustment should be used when comparing coronary artery bypass grafting with current and future treatment innovations and when selecting the best treatment strategy for individual patients.

The United States approach to strategies in the battle against healthcare-associated infections, 2006: transitioning from benchmarking to zero tolerance and clinician accountability

Approximately 2,000,000 healthcare-associated infections (HAIs) annually occur in US healthcare facilities and lead to approximately 60,000 90,000 deaths and cost $17 29 billion dollars. Such HAIs are an equal, if not more common problem, worldwide. Many evidence-based HAI prevention guidelines exist. However, despite knowing what to do, the challenge remains of getting clinicians to comply with these recommendations. In the USA, a variety of forces, including the public and legislators, are demanding HAI prevention. This is illustrated by the Consumers Union's effort to get legislation in every state for public HAI rate reporting. In addition, a number of profit-making and non-profit-making organizations have initiated major HAI prevention interventions. At least three common themes for these interventions exist. First, no single intervention prevents any HAI; rather a "bundle" approach, using a package of multiple interventions based on evidence provided by the infection control community and implemented by a multidisciplinary team is the model for successful HAI prevention. Second, benchmarking is inadequate and a culture of zero tolerance is required. Third, a culture of accountability and administrative support is required. Such interventions have illustrated that much greater levels of HAI prevention can be accomplished than ever estimated in the past. Implementation of evidence-based HAI prevention interventions should be a high priority for all healthcare facilities to reduce preventable HAIs to the greatest extent possible.

[Cancer research at the transition from bench to bedside]

BACKGROUND

Despite great advances in basic oncology research, the situation in clinical oncology continues to be dissatisfying. Reasons for this include a lack of highly effective and specific types of treatment, late diagnosis of cancers (i. e., in advanced stages) and poor translation of new research results into clinical practice. BASIC SITUATION: Knowledge in cancer research has grown exponentially over the past 2 decades. While our understanding of cancer development at the molecular level continues to improve, the actual transfer of these findings into practice is lagging behind today's possibilities. Examples from the German Cancer Research Center ("Deutsches Krebsforschungszentrum" [DKFZ]) and numerous other research institutes show that novel approaches in diagnostics and therapy do exist.

SOLUTION

To close the gap between basic research and clinical practice, completely new organizational forms in oncology are needed. Intelligent models of integrated care of tumor patients shaped after US Comprehensive Cancer Centers may lead to fundamental improvements in clinical oncology, opening up a way to closely interlock research and clinical practice in order to create synergies for both sides. Such models are currently being established in different places in Germany, with the National Center for Tumor Diseases (NCT) Heidelberg occupying a special place due to its affiliation with the German Cancer Research Center. Moreover, collaboration with industry engaged in research needs to be intensified in order to advance new approaches in research to market readiness.

OUTLOOK

Cancer medicine of the future will be more specific, more individual and more interdisciplinary than it is today. Cancer research, clinical oncology and industry engaged in research need to join forces in a strong alliance for the transfer of scientific findings into clinical application.

Essential steps and practical applications for database studies

As the information that is collected from health care encounters becomes more available, managed care pharmacy will have greater insights on the impact of pharmaceutical policy on patient outcomes. Database studies provide valuable information that depicts actual health care consumption and provides a tool to help manage the health care benefit. As compared with clinical trials, one of the strengths of database studies is that they are nonintrusive to patients and providers. However, the integrity of the data and any subsequent analysis are dependent on accurate and consistent coding practices at the time of data entry into the system. This article describes the 6 main steps required to complete a database study.

Usefulness of database studies as applied to managed care

Benchmarking, an industry comparison tool and a well-known business technology, offers health care a method of establishing standards for health care use with clinical governance. Benchmarking can lead to practice innovations necessary for survival in a managed care environment that has a need for decreasing cost and increasing quality. Information gleaned from the benchmarking dataset can be used to determine where limited resources for disease management programs should be directed. It can also be used to help decision makers manage a drug formulary by providing a basic knowledge about the environment in which a drug will be used and prescribed. This article describes the relationship of database studies and benchmarking and the usefulness as applied to managed care.

Applications of disease benchmarks and case presentations

A large dataset of integrated pharmacy and medical claims, extracted from independent third-party databases, is being combined with disease benchmarking technology to facilitate analysis of inpatient, outpatient, ancillary services, and pharmaceutical utilization and costs. The Disease Benchmarks Program was developed to create opportunities for health care decision makers to evaluate the entire health care continuum in a disease-specific fashion. The Benchmarks program is valuable because of its flexibility and because it depicts what is occurring in clinical practice. It can be customized and also show regional variations in treatment. The possible applications of benchmarking applications are discussed in the case presentations of otitis externa, acute otitis media with tympanostomy tubes, and Sjorgren's syndrome.

Current issues for DNA microarrays: platform comparison, double linear amplification, and universal RNA reference

DNA microarray technology has been widely used to simultaneously determine the expression levels of thousands of genes. A variety of approaches have been used, both in the implementation of this technology and in the analysis of the large amount of expression data. However, several practical issues still have not been resolved in a satisfactory manner, and among the most critical is the lack of agreement in the results obtained in different array platforms. In this study, we present a comparison of several microarray platforms [Affymetrix oligonucleotide arrays, custom complementary DNA (cDNA) arrays, and custom oligo arrays printed with oligonucleotides from three different sources] as well as analysis of various methods used for microarray target preparation and the reference design. The results indicate that the pairwise correlations of expression levels between platforms are relative low overall but that the log ratios of the highly expressed genes are strongly correlated, especially between Affymetrix and cDNA arrays. The microarray measurements were compared with quantitative real-time-polymerase chain reaction (QRT-PCR) results for 23 genes, and the varying degrees of agreement for each platform were characterized. We have also developed and tested a double amplification method which allows the use of smaller amounts of starting material. The added round of amplification produced reproducible results as compared to the arrays hybridized with single round amplified targets. Finally, the reliability of using a universal RNA reference for two-channel microarrays was tested and the results suggest that comparisons of multiple experimental conditions using the same control can be accurate.

Business Ethics 101 for the biotech industry

Biotechnology companies face ethical challenges of two distinct types: bioethical challenges faced on account of the nature of work in the life sciences, and corporate ethical challenges on account of their nature as commercial entities. The latter set of challenges has received almost no attention at all in the academic literature or media. This paper begins to remedy that lacuna, examining ethical issues that arise specifically on account of the status of biotech companies as commercial entities. The focus here is on three representative issues: product safety, corporate social responsibility, and corporate governance. It is argued that each of these issues poses particular ethical challenges for companies in the biotech sector. In the area of product safety, it is noted that biotech companies face particular challenges in determining what counts as a "safe" product, given the contentious nature of what might count as a "harm" in the biotech field. In the area of corporate social responsibility, the adoption of a "stakeholder approach" and an attempt to manage the social consequences of products pose special challenges for biotech companies. This is due to the enormous range of groups and individuals claiming to have a stake in the doings of such companies, and the trenchant controversies over just what the social consequences of various biotechnologies might be. In the area of corporate governance, biotech companies need to seek out and follow best practices regarding the ways in which information, authority, and influence flow between a company's shareholders, managers, and Board of Directors, if they are to avoid duplicating the ethical and financial scandal that brought down ImClone. An important meta-issue, here--one that renders each of these corporate ethical challenges more vexing--is the difficulty of finding the appropriate benchmarks for ethical corporate behavior in a field as controversial, and as rapidly evolving, as biotechnology. Three programmatic suggestions can be made: Firstly, scholars and others interested in the ethical performance of the biotech sector must seek out and build opportunities for richer interdisciplinary collaboration. Secondly, companies within the biotech sector must seek out expertise and build capacity and competency in dealing with the corporate ethical issues that arise in their sector. Finally, companies in the biotech sector should explore the opportunities for collective problem solving afforded by the existence of local, national, and international industry associations such as the Biotechnology Industry Organization, BIOTECanada, and EuropaBio.

[Best practices in Community Nutrition: challenges and commitments]

Community Nutrition is a science in continuous evolution that needs to be adapted to changing nutritional problems and to geographical, cultural and socieconomical diversity. Best practices in community nutrition is a concept that facilitates enhanced diffusion and application of knowledge through the analysis of properly designed, executed and evaluated experiences. The conclusions of the five presentations in the session organized by the Spanish Society of Community Nutrition at the XIII Latin American Conference on Nutrition are analyzed. Also, the major challenges and commitments are described: planning and forecasting, intersectorial collaboration, international cooperation, evaluation and monitoring, empowerment, training, fostering institutional support, community participation, leadership, sustainability, continuity, transparency and dissemination. The needs to further develop cooperation and sharing of experiences in the area of community nutrition between Latin America and Spain is highlighted.

Searching for cancer information on the internet: analyzing natural language search queries

Background

Searching for health information is one of the most-common tasks performed by Internet users. Many users begin searching on popular search engines rather than on prominent health information sites. We know that many visitors to our (National Cancer Institute) Web site, cancer.gov, arrive via links in search engine result.

Objective

To learn more about the specific needs of our general-public users, we wanted to understand what lay users really wanted to know about cancer, how they phrased their questions, and how much detail they used.

Methods

The National Cancer Institute partnered with AskJeeves, Inc to develop a methodology to capture, sample, and analyze 3 months of cancer-related queries on the Ask.com Web site, a prominent United States consumer search engine, which receives over 35 million queries per week. Using a benchmark set of 500 terms and word roots supplied by the National Cancer Institute, AskJeeves identified a test sample of cancer queries for 1 week in August 2001. From these 500 terms only 37 appeared ≥ 5 times/day over the trial test week in 17208 queries. Using these 37 terms, 204165 instances of cancer queries were found in the Ask.com query logs for the actual test period of June-August 2001. Of these, 7500 individual user questions were randomly selected for detailed analysis and assigned to appropriate categories. The exact language of sample queries is presented.

Results

Considering multiples of the same questions, the sample of 7500 individual user queries represented 76077 queries (37% of the total 3-month pool). Overall 78.37% of sampled Cancer queries asked about 14 specific cancer types. Within each cancer type, queries were sorted into appropriate subcategories including at least the following: General Information, Symptoms, Diagnosis and Testing, Treatment, Statistics, Definition, and Cause/Risk/Link. The most-common specific cancer types mentioned in queries were Digestive/Gastrointestinal/Bowel (15.0%), Breast (11.7%), Skin (11.3%), and Genitourinary (10.5%). Additional subcategories of queries about specific cancer types varied, depending on user input. Queries that were not specific to a cancer type were also tracked and categorized.

Conclusions

Natural-language searching affords users the opportunity to fully express their information needs and can aid users naïve to the content and vocabulary. The specific queries analyzed for this study reflect news and research studies reported during the study dates and would surely change with different study dates. Analyzing queries from search engines represents one way of knowing what kinds of content to provide to users of a given Web site. Users ask questions using whole sentences and keywords, often misspelling words. Providing the option for natural-language searching does not obviate the need for good information architecture, usability engineering, and user testing in order to optimize user experience.

Use of benchmarking in the development of biopharmaceutical products

As the pharmaceutical and biotechnology industry enters the 21st century, the pressure on companies to maintain the level of productivity required for consistent year-on-year growth is increasing. Benchmarking has become a tool for obtaining the information needed to support continuous improvement and gain a competitive advantage. During the process of benchmarking, best practices can be identified while giving management the ability to improve on existing performance in an objective, well-informed manner. When used appropriately, benchmarking provides a new perspective on traditional methods while enabling companies to monitor their performance.

Younger people in dementia care: a review of service needs, service provision and models of good practice

This paper reviews the literature on younger people (under 65 years of age) with dementia, in dementia care. Seventy-four relevant papers were identified by use of a search strategy derived from the methodology of systematic reviews, the majority of which originated in the UK (69, 93.2%). The need for specialist, flexible, age-appropriate, and dedicated services was a central theme in the literature. A person-centred approach was advocated within an individual or 'tailor made' model of care. However, the available evidence suggests that this model of good practice is not currently reflected in the majority of services provided in the United Kingdom. Overall, the literature argues that the needs of younger people with dementia are best served by inter-agency collaboration, early assessment, and an awareness of individual needs. Clearly, these proposals could usefully serve anybody with dementia, irrespective of age. However, aside from a few prevalence studies, and some exploratory work with small numbers of service users, little in the way of empirical work is available. The recommendations that have been made regarding dementia services for younger people are based largely on the practical experience of professionals and paid carers, rather than scientific evidence.

The New South Wales Medical Record Department Benchmarking Project: a work in progress

Benchmarking is having an increasing impact on the health information management (HIM) profession. With the current focus in healthcare on competition and outcomes, the challenge for managers of MRDs (predominantly HIMs) lies in proving that what they do, and the way they do it, achieves results which benefit the organisation and, ultimately, the patient or client. The Medical Record Department (MRD) Benchmarking Project is an initiative being undertaken on behalf of the HIM profession in New South Wales by the Health Information Management Association of Australia Limited (NSW Branch). The project has five phases and this article describes Phases 1 and 2, which comprised a survey of MRDs to identify any current performance indicator/benchmarking activities and to determine priorities for benchmarking. As the project progresses, further articles will appear in Health Information Management.

[External quality assurance in Germany. The current status]

BACKGROUND

The so-called "external quality assurance" allows the comparison of hospitals using selected quality indicators for process and outcome of care. The methods were developed in early projects of perinatologists and surgeons in the mid 70s. The comparative statistics inform hospitals about their strengths and deficiencies compared to other hospitals.

STATE OF THE ART

Since 2001 the Federal Committee on Quality Assurance (Bundeskuratorium Qualitätssicherung) requests the realization of external quality assurance measures for 27 diseases and procedures in all German hospitals based on the 5th Social Law. If hospitals refuse participation or participate incompletely, they have to expect financial sanctions. The comparative statistics enable first assessments of the quality of hospital care. However, the methods have to be improved if they will be used to demonstrate quality of hospital care to people outside the hospitals.

Future of benchmarking: more data, more sharing, and better patient care

Automated systems that provide whatever regulatory information is needed when it is needed; sharing of data to improve quality; data mined for specific groups of patients: Those are just a few of the trends predicted by health care experts asked to comment on the future of benchmarking and data strategies. Such improvements are needed; many hospitals continually run into problems when it comes to finding the right data sets for targeted patient groups.

Basics of evidence-based practice. Part 2: Unscrambling the terms and processes

Rapid developments within the enterprise of evidence-based health care have resulted in a state of flux in the related concepts and terminology. Basic processes include original research, evidence summary, translation, implementation, and evaluation. Together with a glossary of basic terms in evidence-based practice (EBP), these provide a basis for nurses to adopt evidence-based practice into clinical decision making.

Follow-up of abnormal gynecologic cytology: a college of American pathologists Q-probes study of 16132 cases from 306 laboratories

OBJECTIVES

To measure the percentage of women with abnormal gynecologic cytology who have follow-up within 1 year and to identify patient and laboratory characteristics associated with higher percentages of follow-up.

DESIGN AND SETTING

Retrospective identification of patients with abnormal cervicovaginal cytology and identification of the initial clinical follow-up activity during the 12 months following the cytologic diagnosis.

MAIN OUTCOME MEASURE

Percentage of women receiving follow-up.

RESULTS

Three hundred six laboratories reported follow-up information on 16 132 patients with gynecologic cytology diagnoses of carcinoma, high-grade squamous intraepithelial lesion, low-grade squamous intraepithelial lesion, or glandular intraepithelial lesion. The following percentages of women received follow-up within 1 year: 85.6% of patients with cytologic diagnoses of carcinoma, 87.2% with diagnoses of high-grade squamous intraepithelial lesion, 82.7% with diagnoses of low-grade squamous intraepithelial lesion, and 84.9% with diagnoses of glandular intraepithelial lesion. Within 6 months, 82.2% of patients with cytologic diagnoses of carcinoma, 82.4% with diagnoses of high-grade squamous intraepithelial lesion, 71.9% with diagnoses of low-grade squamous intraepithelial lesion, and 74.7% with diagnoses of glandular intra-epithelial lesion received follow-up. Overall, 90. 8% of patients who received follow-up within the 1-year time frame of this study had their follow-up completed within 6 months. Specific follow-up activities and their frequencies are listed for each diagnostic category. Patients 30 years old or younger and pregnant patients had lower follow-up percentages.

CONCLUSIONS

With less than 83% of patients with high-grade squamous intraepithelial lesion or carcinoma cytology findings having available documentation of follow-up within 6 months, and less than 88% within 1 year, there is room for improvement in this area of health care. Monitoring and critical analysis of the follow-up process is a starting point for improvement.

[Health targets and health reporting--significance of a basis for health reporting to achieve health targets]

This report demonstrates the benefits for future health policy performance related to a close connection between health monitoring activities and the implementation of health objectives. Health reports are basically useful for setting up and quantifying health targets, for the construction of target-related measures and evaluation procedures. On the other hand health objectives can be regarded as landmarks for the allocation of health monitoring resources. Deriving appropriate results for health policy makers from data collecting activities, health statistics, and related health reports could be more effective if these activities were connected with an elaborate health target programme. An interactive unit or working group of health target workers and health monitoring professionals is to guarantee optimum interaction between future health practice, research and policy.