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MRI is the most recent of diagnostic imaging possibilities. It completes the information provided by panoramic X-rays and scanner. The technique is based on proton excitation within an intense magnetic field and does not release any ionizing radiation, as opposed to conventional images (panoramic and CT scanner). This technique is harmless, provided that known and continuously updated contraindications be complied with. Its major advantages include imaging within different spatial planes without moving the patient and its excellent tissular discrimination capacities. The latter quality accounts for spontaneous visibility of the TMA disc. Currently, it is the golden standard in exploring painful TMAs (internal derangements).
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BACKGROUND: Quality indicators are measurement tools for assessing the structure, processes and outcomes of care. Although quality indicators have been developed in other countries, Canadian cardiovascular disease indicators do not exist. OBJECTIVE: To develop quality indicators for measuring and improving congestive heart failure (CHF) care in Canada. METHODS: An 11-member multidisciplinary national expert panel was selected from nominees from national medical organizations. Potential quality indicators were identified by a detailed search of published guidelines, randomized trials and outcomes studies. A two-step modified Delphi process was employed with an initial screening round of indicator ratings, followed by a national quality indicator panel meeting, where definitions of the indicators were developed using consensus methods. Indicators were designed to be measurable, using retrospective chart review and linking existing administrative databases. RESULTS: The case definition criterion was developed based on a discharge diagnosis of CHF (International Classification of Diseases, 9th revision [ICD-9] code 428.x), with diagnostic confirmation using clinical criteria. In total, 29 indicators and five test indicators were recommended. Process indicators included prescription for angiotensin-converting enzyme inhibitors, beta-blockers or warfarin (for atrial fibrillation) at hospital discharge. Nonpharmacological in hospital process indicators included evaluation of left ventricular function, weight measurement and selected patient education counselling instructions. Process indicators in the ambulatory setting included prescription and adherence to drug therapies and physician follow-up. Outcome indicators included mortality, readmissions and emergency visits. CONCLUSIONS: A set of Canadian quality indicators for CHF care encompassing organizational attributes, pharmacotherapy, investigations, counselling, continuity of care and disease outcomes has been developed. These quality indicators will serve as a foundation for future studies evaluating the quality of CHF care in Canada.
INTRODUCTION: There is concern that many national non-fatal injury indicators currently in use are misleading. OBJECTIVE: To make the case for the validation of existing unvalidated indicators, as well as the validation of new indicators before they are promulgated. METHOD: The International Collaborative Effort on Injury Statistics (ICE) Criteria were used for investigating the validity of indicators. Examples of indicators that have been found to be valid using these criteria are presented. In contrast, examples of national road safety indicators are also presented, whose validity is questionable. Trends in road safety indicators with and without threats to validity are contrasted. RESULTS: The New Zealand Injury Prevention Strategy (NZIPS) serious injury indicators are presented as indicators with no identifiable threats to validity. National road safety indicators from Canada, New Zealand and the United Kingdom, with identifiable threats to validity, are also presented. When trends for the valid NZIPS motor vehicle traffic crash indicators are compared with the New Zealand national road safety indicators, which have identifiable threats to validity, they show contrasting trends. This raises concerns that the current national indicators are potentially misleading. CONCLUSION: Validation does matter. For any indicator, it is important that it is clearly defined and specified. The specification should make it clear what parameter the indicator aims to reflect. Before use, the indicator should be validated against this target parameter. That parameter, and the indicators aimed to estimate it, should focus attention on important injuries, ie. injuries that are associated with significant mortality, threat-to-life, threat-of-disablement, loss of quality of life, or increased cost.
OBJECTIVES: (1) To propose definitions for the discretionary screening indicators described by the National Cholesterol Education Program for Children and Adolescents (NCEP-Peds); (2) to examine the relative prevalence of major screening indicators (family history of premature heart disease and parental plasma cholesterol concentration > or = 6.21 mmol/L (240 mg/dl)) and discretionary screening indicators (excessive consumption of fat or cholesterol or both, smoking, diabetes, hypertension, and steroid use) in a family population; and (3) to evaluate the relative value of the major and the discretionary indicators in detecting high serum levels of low-density lipoprotein-cholesterol (LDL-C) (> or = 3.36 mmol/L (> or = 130 mg/dl)). DESIGN: Control cohort from a case-control study. SETTING: Lipid research clinic. PARTICIPANTS: White children and adolescents < 20 years of age from 232 nuclear families who participated in the Cincinnati Myocardial Infarction Hormone Study. MAIN OUTCOME MEASURES: (1) Number of children who have major and discretionary screening indicators; (2) sensitivity and specificity of the major and the discretionary screening indicators in identifying children with LDL-C concentrations > 3.36 mmol/L (130 mg/dl) (high LDL-C). RESULTS: With cutoff points of the 90th percentile for blood pressure, the 85th percentile for obesity, and the 80th percentile for dietary fat and cholesterol, and self-report for diabetes, smoking, and corticosteroid use, 54% of the 232 children in the cohort had one or more discretionary indicators. Additionally, applying the major screening indicators raised the percentage of children identified to 74%. Twenty-eight percent had both major and discretionary indicators. Having a discretionary screening indicator did not increase the probability of having a major indicator. Applying both discretionary and major screening indicators to the cohort identified 96% of the children who had a high concentration of LDL-C; 30% of the children with high LDL-C levels were discovered solely by the discretionary indicators. Similar sensitivity and specificity were noted between the major and the discretionary indicators. Children with high LDL-C concentrations were more likely to have multiple screening indicators. CONCLUSION: Discretionary and major screening indicators suggested by the National Cholesterol Education Program for Children and Adolescents identify different subsets of children at risk of having premature cardiovascular disease. Both major and discretionary indicators contribute to the identification of children with high LDL-C concentrations.
OBJECTIVES: (i) to describe the variation in a number of potential prescribing indicators across a large number of general practices, (ii) to determine whether particular indicators are associated with higher or lower overall prescribing costs, (iii) to determine how particular indicators are correlated with each other, (iv) to determine whether the indicators are stable over time. DESIGN: Observational study based on the analysis of PACT (Prescribing Analysis and Cost) data for general practices. SETTING: The Trent region of England. SUBJECTS: 809 general practices. MAIN OUTCOME MEASURES: Variations in a range of potential prescribing performance indicators; correlations between these indicators and NIC (net ingredient costs) per ASTRO-PU (Age, sex and temporary resident originated prescribing unit); change in indicators between the financial year 1994-5 and 1995-6. RESULTS: Wide variations were found between practices in a range of potential prescribing performance indicators. There were positive correlation (P < 0.001) between NIC per ASTRO-PU and indicators of relatively high cost prescribing within different therapeutic areas. There were negative correlations (P < 0.001) with indicators of relatively low cost prescribing. There were positive intercorrelations (P < 0.001) between indicators of relatively high cost prescribing. For most indicators there were significant changes (P < 0.001) in values between the two years. CONCLUSION: There are considerable variations between general practices in prescribing performance indicators and the indicators show changes over time. We have demonstrated correlations between different indicators that lend support to the idea that such indicators might act as proxies for more general prescribing patterns. However, most of the correlations we observed were not strong. Further research is needed into the development and use of indicators based on PACT data.
OBJECTIVES: To determine the role of population based indicators of health outcome in local health outcome assessments; the constraints of using such indicators; how they could be made more useful; and whether health authorities had developed their own indicators of health outcome. DESIGN: A structured telephone interview with representatives of 91 of the 100 English health authorities. RESULTS: Interviewees, asked to give details on two clinical areas in which population health outcome assessments had been of most value, nominated 147 examples in over 30 clinical areas. They chose 50 (34%) of the examples because of an outlying national indicator, and 20 (14%) because of local variations in a national indicator. The main perceived constraints in the use of population based indicators of health outcome were: data validity and timeliness; the attributability of these health outcomes to the quality of health care; the difficulties of changing clinical behavior; and organisational change within health authorities. To make these indicators more useful interviewees wanted an increased use of process indicators as proxies for health outcome, indicator trend data, and indicator comparisons of districts with similar population structures. Some recent publications have started to consider some of these issues. 27 (30%) health authorities had developed their own indicators, mostly provider based process indicators. 10 of these used their own indicators to manage the performance of local provider units. CONCLUSIONS: Population based indicators of health outcome had an important role in prompting districts to undertake population health outcome assessments. Health authorities also used these indicators to examine local variations in health outcome. They helped to highlight areas for further investigation, initiated data validation, and enabled the monitoring of changes to services. Comparative population based indicators of health outcome may have an increasing part to play in assessing the performance of health authorities.
INTRODUCTION: Measuring the quality of care in emergency departments requires tools to quantify the most important aspects in the care process. The quality indicator is the quantitative measure used in quality assurance. OBJECTIVES: To review the document created by the Catalan Society of Emergency Medicine (SCME) and the Avedis Donabedian Foundation (FAD) in which the quality indicators for the emergency departments were established and to incorporate their methodology and select the indicators that could be adapted to pediatric emergencies. To add new indicators that, in the opinion of experts in pediatric emergencies, could be useful in daily pediatric care. To agree on the definitive list of indicators for use in pediatric emergencies and to define those that will be considered the main indicators. To develop a document on behalf of the Spanish Society of Pediatric Emergencies (SEUP), which will serve as a reference in quality of care. MATERIAL AND METHODS: In the first stage, a Working Group of the SEUP was formed. The SCME/FAD paper was distributed after exclusion of the indicators that were not applicable to children. Each member adapted the indicators and proposed others. The Working Group then chose a set of indicators considered essential in any pediatric emergency department. RESULTS: The final document has 89 indicators, each with the following parameters: dimension, justification, ratio, explanation of terms, population, type, sources of information, standard and comments. Depending on the content, they are classified in one of the following sections: diseases, activities and work areas. Eighteen indicators were adapted to the pediatric age group. Twenty new indicators were added and 12 were proposed as basic or essential. CONCLUSIONS: The quality indicators are useful in measuring concrete and specific aspects of clinical care and in providing information on quality. The indicators provide valid, reliable and objective information. The indicator is an early warning sign to identify areas requiring improvement and allows appropriate measures to be taken to correct the detected deficiencies. The use of indicators allows comparisons with uniform criteria to be made.
Biological indicators are used in the efficacy test of microbicidal procedures. The indicators consist of an object carrying or holding micro-organisms which exhibit resistance to microbicidal agents. The biological indicators are exposed to the procedure to be tested and afterwards examined for viable germs. If test germs are still found to grow in the cultures, the microbicidal effect of the procedure is considered as insufficient. Biological indicators are suitable for such tests only if it is known how intensive the action of the microbicide has to be to destroy the test germs. The individuals of a germ population do not die at the same time under the action of a microbicide. This phenomenon can also be observed with germs simultaneously grown as a pure culture under identical conditions. Therefore, the biological indicators do not become sterile after one and the same period of action or dose of the microbicide but within a certain period or dose range. At the beginning of this transition range, sterile biological indicators will be found very rarely. With increasing period of action or dose, the frequency of indicators carrying viable germs decreases until, eventually, hardly any biological indicators with viable germs are detectable. When samples of identical biological indicators equal in size are exposed to one and the same period of action or dose of a microbicide, the number of indicators carrying viable germs will vary from one sample to another in the transition range. The number of biological indicators that has to be exposed to the resistance test per period of action and dose, respectively, in order to obtain reliable results, can be estimated only if the regularities are known by which the findings vary from one sample to another. Twelve different batches of biological indicators were employed to determine the variation of the resistance values obtained. Spores of Bacillus subtilis served as test germs. The batches differed in the number of spores per biological indicator. The microbicide used was saturated steam of 100 degrees C with a 9 min period of action. Forty-eight samples of five indicators each were taken per batch. The number of indicators carrying viable germs (n+) varied more or less and characteristic frequency distributions were observed (Table 2, columns 3 and 4). Afterwards, the mean relative frequency of indicators with viable germs was calculated for the different batches (Q; Table 2, column 2).(ABSTRACT TRUNCATED AT 400 WORDS)
The information contained in pathology reports of radical prostatectomy specimens is critically important to treating physicians for selecting adjuvant therapy, evaluating therapy, estimating prognosis, and analyzing outcomes. This information is also of importance to patients and their families. In recent years, the Cancer Committee of the College of American Pathologists and the Association of Directors of Anatomic and Surgical Pathology developed suggested protocols for reporting the findings on radical prostatectomy specimens. The objectives of this study were to assess radical prostatectomy-specimen reports by using quality indicators derived from existing suggested protocols and to thereby assist pathologists in improving the quality of their reports on such specimens. A retrospective chart review of 554 cases for the second 6-month period of 1996 focused on 10 quality indicators: submission of a frozen section; location of the adenocarcinoma; proportion of the specimen involved by adenocarcinoma; perineural involvement; vascular involvement; seminal vesicle involvement; periprostatic fat status; number of nodes submitted; status of nodes; and prostate intraepithelial neoplasia (PIN). The findings of this study were shared with the pathology departments in all hospitals in New York State. In addition, the 113 hospitals from which the 554 cases were drawn were given their institution-specific data. Teleconferences were held with the 37 hospitals that accounted for 72.4% of all cases. These conferences included directors of pathology and laboratories and focused on the aggregate statewide findings. The presence of quality indicators in reports varied from a mean of 14.8% (periprostatic fat) to a mean of 85.9% (seminal vesicle involvement). For all hospitals, 4 indicators (proportion of the specimen involved by adenocarcinoma, vascular involvement, periprostatic fat status, and PIN) were included in fewer than 50% of cases. These 4 quality indicators and an additional 3 others (submission of a frozen section, perineural involvement, and the number of nodes submitted) were included in fewer than 70% of cases. Only 3 indicators (location of the adenocarcinoma, seminal vesicle involvement, and the status of nodes) were found in more than 70% of cases. Although the mean level of quality indicator inclusion ranged from 14.8% to 85.9% for all cases examined, the absolute range for any individual indicator was 0% to 100%. Thus, some hospitals included a given indicator 100% of the time; others never included it. This pattern held true for all 10 indicators. High-volume hospitals (10 or more cases) performed significantly better than low-volume hospitals (1-4 cases) on 5 indicators (P < .05), and better, but not significantly so, for an additional 2 indicators. Overall, the mean inclusion levels for all 10 indicators were 10% higher for high-volume hospitals compared with low-volume and medium-volume hospitals (5-9 cases). This study demonstrated wide variations in the inclusion of quality indicators by pathologists in their radical prostatectomy-pathology reports. Whereas some hospitals always include given indicators, others never mentioned them. These marked disparities point to the need for standardized reporting for radical prostatectomy specimens.
The ambiguity of the quantitative description of the resistance of microbiological indicators by means of the terms common thus far, namely "resistance" (maximal period of action after which all indicators still exhibit organisms capable of reproduction) and "death time" (minimal period of action after which organisms capable of reproduction cannot be demonstrated any more in any of the indicators) is shown. Among other factors, the probability that all indicators will yield identical findings (sterility or growth of surviving organisms) at a defined time, is dependent upon the number of indicators in each case. The more indicators are tested, the lower "resistance" and the later the "death time" will be. Instead of times when all indicators present an identical reaction, times (or values related to these times in a defined way) should be taken at which indicators show the absence of organisms or the presence of surviving ones with a defined frequency. There is a defined relationship between the frequency of indicators found free from (resp. containing) surviving organisms and the number of surviving organisms per indicator (cf. Figs. 1 and 2). If the regularity of the decrease of organisms with the period of action of the destroying agent is known, 2 values are sufficient for a clear description of the resistance of a preparation of microbiological indicators. As characteristic values those values of action are proposed after which 99% and 1% of indicators will exhibit surviving organisms (t99% and t1%, respectively). The period during which the dependence of the frequency of presence of sterile indicators (po) upon the period of action of the destroying agent may be determined with sufficient precision and at justifiable experimental expenditure, is corresponding to a decrease of surviving organisms to appr. 1/30. From practical experience, it will be justified in the preponderant majority of cases to assume a logarithmic orderof death as given. Under such conditions, there will be a clear relationship between lg(-ln po) and the period of action of the destroying agent, so that test results may be easily evaluated by means of a simple graphical method or regression calculation. Graphical (FIG. 3) and mathematical determination of characteristic values from the frequency of indicators exhibitoring surviving organisms in the destruction test, after different periods of action, is explained by means of an example (Fig. 3; Tables 2 and 3) and a calculation (Table 1). To keep variation of experimental results sufficiently low, at least 30 (if possible 50) indicators per period of action should be studied for surviving organisms (cf. Fig 4). When evaluating results, different weights of the individual values and their asymmetric distribution around a maximum at t80% (Fig 5) should be taken into consideration.
This report describes a new set of molecular descriptors of relevance to QSAR/QSPR studies and drug design, atom linear indices fk(xi). These atomic level chemical descriptors are based on the calculation of linear maps on Rn[fk(xi): Rn--> Rn] in canonical basis. In this context, the kth power of the molecular pseudograph's atom adjacency matrix [Mk(G)] denotes the matrix of fk(xi) with respect to the canonical basis. In addition, a local-fragment (atom-type) formalism was developed. The kth atom-type linear indices are calculated by summing the kth atom linear indices of all atoms of the same atom type in the molecules. Moreover, total (whole-molecule) linear indices are also proposed. This descriptor is a linear functional (linear form) on Rn. That is, the kth total linear indices is a linear map from Rn to the scalar R[ fk(x): Rn --> R]. Thus, the kth total linear indices are calculated by summing the atom linear indices of all atoms in the molecule. The features of the kth total and local linear indices are illustrated by examples of various types of molecular structures, including chain-lengthening, branching, heteroatoms-content, and multiple bonds. Additionally, the linear independence of the local linear indices to other 0D, 1D, 2D, and 3D molecular descriptors is demonstrated by using principal component analysis for 42 very heterogeneous molecules. Much redundancy and overlapping was found among total linear indices and most of the other structural indices presently in use in the QSPR/QSAR practice. On the contrary, the information carried by atom-type linear indices was strikingly different from that codified in most of the 229 0D-3D molecular descriptors used in this study. It is concluded that the local linear indices are an independent indices containing important structural information to be used in QSPR/QSAR and drug design studies. In this sense, atom, atom-type, and total linear indices were used for the prediction of pIC50 values for the cleavage process of a set of flavone derivatives inhibitors of HIV-1 integrase. Quantitative models found are significant from a statistical point of view (R of 0.965, 0.902, and 0.927, respectively) and permit a clear interpretation of the studied properties in terms of the structural features of molecules. A LOO cross-validation procedure revealed that the regression models had a fairly good predictability (q2 of 0.679, 0.543, and 0.721, respectively). The comparison with other approaches reveals good behavior of the method proposed. The approach described in this paper appears to be an excellent alternative or guides for discovery and optimization of new lead compounds.
BACKGROUND: For several years now, the French national recommendations have been trying to set up a surveillance system in hospitals to link data on antibiotic resistance and data on the use of antibiotics, particularly for certain 'micro-organism/antibiotic' pairs. The indicators recommended in the lastest newsletter of the Direction Générale de la Santé (French Public Health Department) for monitoring the consumption of antibiotics were the number of days of treatment or the number of defined daily doses (DDD), both (in)directly related to the number of days of hospitalisation and/or the number of patients hospitalised. OBJECTIVE: The aim of this study was to compare the actual number of days of treatment, which is an observed indicator, with two indicators calculated on the basis of the DDD and the DPD (daily prescribed dose), both in terms of feasibility of collection and the relevance of the information generated. MATERIALS AND METHODS: For several hospital care units, the 'length of exposure' to a given antibiotic was determined by four different indicators: two actual observed indicators [the patient's medical file (reference) and the named-patient based, computerised dispensing system from the central pharmacy] and two derived calculated indicators [obtained by dividing the number of grams prescribed by the DDD or by the DPD]. RESULTS: The average incidence density of antibiotic treatment (length of exposure per 1000 days of hospitalisation) obtained by the calculated indicators was higher than that obtained with the observed reference (+52% for the DDD and +33% for the DPD) but lower than that obtained with the second observed indicator (computerised system) (-10%). The differences were large and random (high variability depending on the hospital department, the antibiotic and the administration route; variations in both directions: actual length of treatment longer or shorter than the calculated length of treatment). CONCLUSION: The question which indicator should be chosen is inconclusive for the evaluation of the selection pressure exerted by an antibiotic. The two indicators proposed in the newsletter (observed indicator and calculated indicator) seem to be complementary for use in a regional or national network to monitor resistance and consumption of antibiotics. Each hospital should validate the indicators and define for itself which indicator is most appropriate for estimating the actual length of antibiotic exposure. This may imply different indicators for different units, antibiotics or even administration routes within one particular hospital setting. Once validated the hospital has a powerful tool generating data that can be linked to resistance data.
AIMS: This study describes development and field testing of a set of indicators for drug and therapeutics committees (DTCs) in hospitals. It was intended that these indicators should be accessible, useful and relevant in the Australian setting. METHODS: Candidate indicators were written following consultation and data collection. A framework of outcome, impact and process indicators was based on DTC goals, objectives and strategies. The candidate indicators were field tested over a 2 month period in teaching, city non-teaching, rural and private hospitals. The field tests provided response data for each indicator and evaluation of the indicators against criteria for accessibility, relevance, usefulness, clarity and resource utilisation. Consensus on which indicators to accept, modify or reject was reached at a workshop of stakeholders and experts, taking account of the field test results. RESULTS: Thirty-five candidate indicators were tested in 16 hospitals. Twenty-two had a response from >80% of sites, 23 had a mean relevance rating >3.5, 19 had a mean usefulness rating >3.5, 27 were correctly interpreted by > 90% of sites and 25 could be collected in an acceptable time. The most acceptable indicators required least data collection or provided data deemed useful for purposes other than the field test. At the consensus workshop 13 indicators were accepted with no or minor change, nine were accepted after major modification and eight were discarded. It was recommended that a further five indicators should be merged or subsumed into one indicator. CONCLUSIONS: This study has developed and field tested a set of indicators for DTCs in Australia. The indicators have been taken up enthusiastically as a first attempt to monitor DTC performance but require ongoing validation and development to ensure continuing relevance and usefulness.