Clinical indicators: development and applications

Clinical indicators give an indication of the quality of the patient care delivered. They must comply with highquality standards and should be constructed in a careful and transparent manner. Indicators must be relevant to the important aspects of quality of care. There should be adequate research evidence that the recommendations from which they are derived are related to clinical effectiveness, safety and efficiency. They should measure the quality in a valid and reliable manner with little inter- and intra-observer variability so that they are suitable for comparisons between professionals, practices, and institutions. Indicators are selected from research data with consideration for optimal patient care (preferably an evidence-based guideline), supplemented by expert opinion. In the selection procedure, the feasibility, such as their measurability and improvability, is important beside validity and reliability. A clinical indicator should be defined exactly and expressed as a quotient. After a try-out, the measurements and reporting should follow. The report contains an in-depth analysis of causal and contributing factors associated with the measured results. A description of the clinical circumstances and a correction for case mix should be included to allow for a justified interpretation. The indicators must be part of an improvement strategy, for which comparison feedback is often used. We give examples of indicator development and applications in oncology, diabetes care, and the use of antibiotics for treating pneumonia. We explain how comparison with reference data can be used to construct improvement programmes.

Effectiveness and efficiency of guideline dissemination and implementation strategies

OBJECTIVES

To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines.

DATA SOURCES

MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE and the specialised register of the Cochrane Effective Practice and Organisation of Care (EPOC) group.

REVIEW METHODS

Single estimates of dichotomous process variables were derived for each study comparison based upon the primary end-point or the median measure across several reported end-points. Separate analyses were undertaken for comparisons of different types of intervention. The study also explored whether the effects of multifaceted interventions increased with the number of intervention components. Studies reporting economic data were also critically appraised. A survey to estimate the feasibility and likely resource requirements of guideline dissemination and implementation strategies in UK settings was carried out with key informants from primary and secondary care.

RESULTS

In total, 235 studies reporting 309 comparisons met the inclusion criteria; of these 73% of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was 11 comparisons. Overall, the majority of comparisons reporting dichotomous process data observed improvements in care; however, there was considerable variation in the observed effects both within and across interventions. Commonly evaluated single interventions were reminders, dissemination of educational materials, and audit and feedback. There were 23 comparisons of multifaceted interventions involving educational outreach. The majority of interventions observed modest to moderate improvements in care. No relationship was found between the number of component interventions and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. The majority of studies only reported costs of treatment; only 25 studies reported data on the costs of guideline development or guideline dissemination and implementation. The majority of studies used process measures for their primary end-point, despite the fact that only three guidelines were explicitly evidence based (and may not have been efficient). Respondents to the key informant survey rarely identified existing budgets to support guideline dissemination and implementation strategies. In general, the respondents thought that only dissemination of educational materials and short (lunchtime) educational meetings were generally feasible within current resources.

CONCLUSIONS

There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.

Lifetime health effects and costs of diabetes treatment

BACKGROUND

This article presents cost-effectiveness analyses of the major diabetes interventions as formulated in the revised Dutch guidelines for diabetes type 2 patients in primary and secondary care. The analyses consider two types of care: diabetes control and the treatment of complications, each at current care level and according to the guidelines.

METHODS

A validated probabilistic diabetes model describes diabetes and its complications over a lifetime in the Dutch population, computing quality-adjusted life years and medical costs. Effectiveness data and costs of diabetes interventions are from observational current care studies and intensive care experiments. Lifetime consequences of in total sixteen intervention mixes are compared with a baseline glycaemic control of 10% HBA1C.

RESULTS

The interventions may reduce the cumulative incidence of blindness, lower-extremity amputation, and end-stage renal disease by >70% in primary care and >60% in secondary care. All primary care guidelines together add 0.8 quality-adjusted life years per lifetime.

CONCLUSION

In case of few resources, treating complications according to guidelines yields the most health benefits. Current care of diabetes complications is inefficient. If there are sufficient resources, countries may implement all guidelines, also on diabetes control, and improve efficiency in diabetes care.

The distally based sural artery flap

The sural artery flap is a distally based fasciocutaneous flap. It is based on a reverse flow through anastomoses between the peroneal artery and the communicating vascular network of the medial sural nerve. In the difficult area of defects in the lower leg and the ankle and heel region, it has a wide variety of indications, even in vascularly compromised patients. It has the largest arc of rotation of all flaps that have been described in this region. The most important advantage is that it does not compromise a major artery. Furthermore, it is simple to dissect and has a low donor morbidity. A series of 15 patients is described in which we covered defects in the lower leg, malleolar, and heel regions. Seven patients were vascularly compromised seriously. Twelve flaps survived completely, two survived partially, and one flap failed.

Alcohol consumption in the rural population of Misungwi subdistrict in Mwanza Region, Tanzania

OBJECTIVE

This study was undertaken to investigate the frequency and quantity of alcohol consumption in four villages on the southern shores of Lake Victoria, Tanzania.

METHOD

Study participants were 148 men and 162 women selected by cluster sampling from the population (N = 9,243) of four villages in Misungwi subdistrict, Mwanza Region, Tanzania. Interviews on self-reported alcohol consumption were conducted at the participants' home in Kiswahili using a standardized questionnaire.

RESULTS

Fifty-five percent of the men and 33% of the women had consumed alcohol at least once during the year prior to the interview; 24% of the men and 6% of the women had consumed alcohol on six or more occasions during the past month. The quantity of alcohol consumed at the last sitting and in the month prior to the interview was twice as high among male compared to female respondents. The frequency and quantity of alcohol consumption per month increased with age for men but not for women. The large majority of respondents consumed locally produced alcoholic beverages.

CONCLUSIONS

Alcohol consumption in this area was low compared to estimates from other parts of Tanzania and national data. Drinking patterns suggested that traditional rules and regulations concerning alcohol were still adhered to.

Fowler's tenotomy for mallet deformity

35 patients with established mallet finger deformities were treated with Fowler's tenotomy of the central extensor tendon. The mean lack of extension before operation was 45 degrees. 26 patients regained full extension, eight patients had a residual deformity of 10-20 degrees and one patient of 30 degrees.

Thumb reconstruction in the severely damaged hand using finger remnants

In severely injured hands with loss of the thumb and irreparable damage to one or more fingers, the thumb can often be reconstructed by transfer of a comparatively useless finger remnant. Sometimes this reconstruction can be performed at the time of primary treatment, but generally this is done as a secondary procedure. Seven patients were treated and considerable functional improvement was obtained in all instances.

The result of breast reconstruction after mastectomy for breast cancer in 109 patients

One hundred and eleven breast reconstructions after a mastectomy for carcinoma in 109 patients are reported. Depending on the quality of muscle and skin coverage, reconstructions were performed either with a latissimus dorsi musculocutaneous flap or a subpectoral prosthesis (including expander prosthesis). The follow-up involved 90 patients. The purely aesthetic results as well as the very positive result of reconstruction with regard to appearance in clothing, participation in sports, and self-esteem were of great importance to the patients. The difference in ptosis, the most obvious shortcoming in our reconstructions, is discussed. Attention is given to the importance of flap planning and the restoration of the anterior axillary fold in the latissimus dorsi flap reconstructions. The disappointing results of tissue expansion and the shortcomings of the nipple-areola reconstructions are discussed.

Tissue expansion in reconstructive surgery

A surplus of skin for closure of a defect can be obtained by gradual filling of a subcutaneous balloon. In this way reconstruction of extensive skin defects with neighbouring skin is possible. Two patients with skin defects of the head are illustrative for this expansion technique. The technique, indications and histology are discussed.

Results of microsurgical treatment of nerve injuries of the wrist

A retrospective study was made of 62 patients with sharp, total transection of the ulnar and/or median nerves, operated on with use of microsurgical techniques. The results were evaluated in 44 patients. Following primary repair of the median nerve, eight patients achieved a reasonable result (8/25, 32%) and 13 a good result (13/25, 52%). In contrast, after secondary nerve grafting in six patients, only one patient achieved a reasonable result (1/6, 17%) and three a good result (3/6, 50%). After primary repair of the ulnar nerve, four patients (4/10, 40%) achieved a reasonable result, and five a good result (5/10, 50%). In contrast, after secondary nerve grafting in five patients, four achieved a reasonable result (4/5, 80%) and none a good result. The age of the patients appeared to determine the quality of recovery; in all patients younger than 20 years reasonable or good function of the nerve returned.

Functional results of thumb reconstruction

Twenty three cases of thumb reconstruction were analysed. Functional results of different methods of reconstruction are compared and discussed. Different injuries and different patients call for different types of reconstruction.

Survival of the thumb by a vein graft in a case of a severe hand lesion

A case of severe lesion of the hand is reported in which the circulation of the thumb was restored by using a vein graft. The operative procedure and postoperative management are described. The periods of arterial insufficiency in the thumb, likely due to spasms, are discussed.