Improving the utilization of clinical laboratory testsWu, Alan H. B.
doi: 10.1046/j.1365-2753.1998.00001.xpmid: 9744706
Reimbursement policies for health care services are greatly diminishing in the U.S. and Western Europe. Hence, there is an increasing need for doctors and other care givers to reduce costs without compromising the quality of the care being delivered. The clinical laboratory is viewed as an area of high costs where significant reductions have been targeted. Efficient utilization of laboratory services can be achieved by elimination of the general health panel, removal of old tests or those that provide redundant information, a reduction in the use of standing orders, more judicious use of drug assays, acceptance of clinical practice guidelines, and use of reflex testing algorithms. New technologies such as DNA probes can substantially improve diagnostic efficiency. Point‐of‐care testing devices which have higher costs than incremental central laboratory expenses should only be used if they reduce overall operating expenses. Implementation of expert systems can make remaining tests more effective. Doctors and laboratorians must collaborate to achieve more efficient utilization practices.
Challenges in evaluating primary health care for teenagersJacobson, Lionel D.; Matthews, Sarah J.; Robling, Michael R.; Donovan, Chris; Mellanby, A.; Donovan, C.; Parry‐Langdon, N.; Kramer, T.
doi: 10.1046/j.1365-2753.1998.00002.xpmid: 9744707
This paper concerns the evaluation of health care for teenagers and examines the role of primary care and its interaction with the teenage users of this service. It recognizes that the majority of health care for teenagers takes place within general practice. The challenge posed is to identify and put in place suitable evaluation tools. There are government targets to improve the health of teenagers by reducing teenage pregnancy, drug use, smoking rates and suicides. It is an assumption of this paper that improvements in experiences of primary care will lead to improvements in more population‐based outcomes of care, although this link needs investigation. The paper shows that there are few measures of generic outcome which are available for use in experiments to assess teenage health care as a baseline now. This has implications for conducting future research projects. Such measures are important and it is a necessary feature of research into teenage health that these measures are devised, tested and validated as a priority.
Improving clinical outcome in bacteremiaHerchline, Thomas; Gros, Sheila
doi: 10.1046/j.1365-2753.1998.00003.xpmid: 9744708
Bacteremia is associated with significant morbidity and mortality. There is wide variation in morbidity and mortality rates according to organism and predisposing conditions. Additionally, prompt administration of appropriate antimicrobial agents is associated with a decrease in mortality. Unfortunately, many bacteremic patients receive inappropriate or no antibiotics. Infectious disease consultation can decrease the number of patients receiving inappropriate initial therapy. ‘Quality standard for the treatment of bacteremia’ (Gross et al., 1994, Infection Control and Hospital Epidemiology15, 189–192) is a consensus paper; its purpose is to ‘improve the treatment of hospitalized patients with documented bacteremia by ensuring that they receive an antibiotic appropriate in light of the blood‐culture susceptibility of the pathogen isolated.’ A programme to assess the treatment of bacteremia can improve the quality of care with a modest commitment of additional resources. Many of the activities could be performed by a pharmacist, infection control practitioner, or pathologist. However, physician‐to‐physician communications are most likely to be successful. This programme should be considered a component of a hospital's quality‐improvement programme; either the hospital quality assurance or infection control committee could be responsible for the programme. We encourage adoption of the standard, and recommend prospective monitoring to include the choice of empiric antimicrobial agents.
Methodological challenges to prospective study of an innovation: interregional nursing care management of cardiovascular patientsAadalen, Sharon Price
doi: 10.1046/j.1365-2753.1998.00004.xpmid: 9744709
This paper discusses the methodological challenges of conducting a interregional intersystem study in a highly competitive health care environment. Nurses from a three‐hospital rural health consortium and an urban tertiary medical centre collaborated in a two‐phase study (a) to describe current interregional cardiovascular health care process (phase I) and (b) to test an interregional nurse‐coordinated cardiovascular health care model (phase II). Phase I was a 1‐year exploratory descriptive retrospective study involving patient interviews and chart reviews. Findings from the phase I study suggested a pattern of patient health problems occurring weeks and months following successful tertiary centre interventions. Phase II was quasi‐experimental prospective study with 90 intervention subjects and 64 comparison group subjects who completed pencil and paper survey tools over a 12‐month period following discharge from the tertiary centre. Nurse and doctor providers completed a satisfaction survey twice, at an interval, 1 year. Concurrent data collection via telephone calls (comparison group) and a retrospective record review (intervention group) provided data on cost, resource use and system efficiency. Initial results of phase II are presented, together with tests of significance for hypotheses related to interregional nurse care management and patient outcomes, patient satisfaction, cost/system efficiency, and provider satisfaction. Methodological considerations and recommendations related to phases I and II of this interregional collaborative cardiovascular project are presented and discussed.
Riposte to Guest Commentaries on ‘Problems associated with randomized controlled clinical trials in breast cancer’Johnson, Ann E.
doi: 10.1046/j.1365-2753.1998.00006.xpmid: 9744711
This paper addresses the objections of Professor M. Baum and Mr W. J. Cunliffe to my thesis that the randomized controlled clinical trial is a poor tool for the investigation of the treatment of breast cancer, argued in a discussion paper entitled ‘Problems associated with randomized controlled clinical trials in breast cancer’ (A.E. Johnson, 1998, Journal of Evaluation in Clinical Practice4, 119–126). The objections range from those that have a philosophical basis, through those founded on differing concepts of the classification of primary tumours and the nature of the metastatic tumour, to those that question the reliability and usefulness of the clinical evaluation of response to treatment in terms of histological grade and rate of tumour shrinkage. An alternative approach to research through primary systemic therapy with selection of treatment according to predicted tumour behaviour was severely criticized, both on the preceding grounds and because it was assumed that the alternative to randomization is management by anecdote. These objections are examined and evidence in support of reliable and useful clinical measurement of response is presented in some detail. The problems associated with randomization as a technique for the evaluation of treatments, when the intrinsic variability of tumours is very large without the intervention of treatment, remain unsolved.