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PubMed1993

Effects on response rates and costs of stamps vs business reply in a mail survey of physicians.

In the general population, the use of stamps rather than business reply postage significantly improves response rates in mail surveys. Among physicians, however, a smaller effect might be anticipated due to their greater sophistication. An experiment was conducted to test the hypothesis that stamps would improve response rates and lower costs in a physician survey that included intensive follow up. In 1989, 380 physicians who reported providing primary care were surveyed. The protocol included two mailings, a postcard reminder, and two telephone reminders. Physicians were randomly assigned to receive a return envelope with a first-class stamp or an envelope that had been preprinted "business reply mail" in the first and second mailings. Response rates, calculated as completed surveys divided by eligible physicians, were 83.8 and 72.1% for stamps and business reply respectively, a difference of 11.7 percentage points (p < 0.01). Moreover, the total cost per completed survey was $11.18 for the physicians receiving stamps and $14.25 for the physicians receiving business reply. As in mail surveys of the general public, the use of first-class stamps on return envelopes both improves response rates and reduces cost in surveys of physicians.

Data Collection↗
PubMed2004

Overshoot and oscillation in surface tension of gelatin solutions.

The experimental data of the surface tension of aqueous gelatin solution reported by Sato and Ueberreiter [H. Sato, K. Ueberreiter, Macromol. Chem. 180 (1979) 829; H. Sato, K. Ueberreiter, Macromol. Chem. 180 (1979) 1107; H. Sato, K. Ueberreiter, ACS Polym. Preprints 20 (1979) 907] were analyzed with a theory of adsorption kinetics with time delay. It is found that the observed overshoot and oscillation of the surface tension are well explained by the present theory. The delay time and the rate constants of adsorption and desorption of gelatin molecules onto the air/gelatin solution interface have been evaluated.

Adsorption↗
PubMed2005

Mathematical approaches to differentiation and gene regulation.

We consider some mathematical issues raised by the modelling of gene networks. The expression of genes is governed by a complex set of regulations, which is often described symbolically by interaction graphs. These are finite oriented graphs where vertices are the genes involved in the biological system of interest and arrows describe their interactions: a positive (resp. negative) arrow from a gene to another represents an activation (resp. inhibition) of the expression of the latter gene by some product of the former. Once such an interaction graph has been established, there remains the difficult task to decide which dynamical properties of the gene network can be inferred from it, in the absence of precise quantitative data about their regulation. There mathematical tools, among others, can be of some help. In this paper we discuss a rule proposed by Thomas according to which the possibility for the network to have several stationary states implies the existence of a positive circuit in the corresponding interaction graph. We prove that, when properly formulated in rigorous terms, this rule becomes a theorem valid for several different types of formal models of gene networks. This result is already known for models of differential [C. Soulé, Graphic requirements for multistationarity, ComPlexUs 1 (2003) 123-133] or Boolean [E. Rémy, P. Ruet, D. Thieffry, Graphic requirements for multistability and attractive cycles in a boolean dynamical framework, 2005, Preprint] type. We show here that a stronger version of it holds in the differential setup when the decay of protein concentrations is taken into account. This allows us to verify also the validity of Thomas' rule in the context of piecewise-linear models. We then discuss open problems.

Cell Differentiation↗
PubMed2005

An analysis of systematic reviews indicated low incorpororation of results from clinical trial quality assessment.

OBJECTIVE: We investigated the frequency of quality assessment of randomized controlled trials within systematic reviews and the incorporation of the quality assessment in the analysis. STUDY DESIGN AND SETTING: We included new systematic reviews of at least five trials of therapeutic or preventive interventions that appeared in issue 2, 2003, of the Cochrane Database of Systematic Reviews. All systematic reviews in the 2002 issues of the Annals of Internal Medicine, BMJ, JAMA, and Lancet were identified in Pubmed. All reviews were assessed under unblinded conditions using preprinted extraction forms. RESULTS: Trial quality was assessed in all Cochrane reviews and most (74%) of the paper reviews. When we excluded 11 paper reviews that were also published as Cochrane review, the percentage remained similar (67%). Fifty percent of all Cochrane reviews and 61% of all paper reviews incorporated the results of the quality assessment in the analysis. CONCLUSION: Half of the reviews did not incorporate the results of the quality assessment in the analysis. Authors, peer-reviewers, and editors should no longer focus exclusively on whether quality assessment has been performed but should also concentrate on incorporation of quality assessments in the analysis of the systematic review.

Databases, Bibliographic↗
PubMed2004

A content analysis of forms, guidelines, and other materials documenting end-of-life care in intensive care units.

OBJECTIVE: The purpose of this study was to determine the extent to which data entry forms, guidelines, and other materials used for documentation in intensive care units (ICUs) attend to 6 key end-of-life care (EOLC) domains: 1) patient and family-centered decision making, 2) communication, 3) continuity of care, 4) emotional and practical support, 5) symptom management and comfort care, and 6) spiritual support. A second purpose was to determine how these materials might be modified to include more EOLC content and used to trigger clinical behaviors that might improve the quality of EOLC. PARTICIPANTS: Fifteen adult ICUs-8 medical, 2 surgical, and 4 mixed ICUs from the United States, and 1 mixed ICU in Canada, all affiliated with the Critical Care End-of-Life Peer Workgroup METHODS: Physician-nurse teams in each ICU received detailed checklists to facilitate and standardize collection of requested documentation materials. Content analysis was performed on the collected documents, aimed at characterizing the types of materials in use and the extent to which EOLC content was incorporated. MEASUREMENTS AND MAIN RESULTS: The domain of symptom management and comfort care was integrated most consistently on forms and other materials across the 15 ICUs, particularly pain assessment and management. The 5 other EOLC domains of patient and family centered decision-making, communication, emotional and practical support, continuity of care, and spiritual support were not well-represented on documentation. None of the 15 ICUs supplied a comprehensive EOLC policy or EOLC critical pathway that outlined an overall, interdisciplinary, sequenced approach for the care of dying patients and their families. Nursing materials included more cues for attending to EOLC domains and were more consistently preprinted and computerized than materials used by physicians. Computerized forms concerning EOLC were uncommon. Across the 15 ICUs, there were opportunities to make EOLC- related materials more capable of triggering and documenting specific EOLC clinical behaviors. CONCLUSIONS: Inclusion of EOLC items on ICU formatted data entry forms and other materials capable of triggering and documenting clinician behaviors is limited, particularly for physicians. Standardized scales, protocols, and guidelines exist for many of the EOLC domains and should be evaluated for possible use in ICUs. Whether such materials can improve EOLC has yet to be determined.

Attitude of Health Personnel↗
PubMed2006

Medication errors in children.

Medication error is a major source of iatrogenic injuries in children. Dosing errors are the most common type of medication errors in pediatrics. Sicker patients in intensive care units and emergency departments are more often harmed by such errors. Strategies that have been found to be effective in reducing medication errors include the use of computerized physician order entry systems, preprinted order forms, and color-coded systems. Adopting the "systems approach" to medication errors is crucial to every health system where practitioners seek to enhance patient safety.

Child↗
PubMed1998

Ten-year durability and success of an organized program to increase influenza and pneumococcal vaccination rates among high-risk adults.

PURPOSE: Influenza and pneumococcal vaccines are underused. Systems approaches that incorporate administrative and organizational strategies are more successful than education of providers for improving vaccination rates. Little has been published on the long-term success and durability of such efforts. METHODS: We performed a 10-year time-series study to examine the durability and success of an ongoing, multifaceted, institution-wide influenza and pneumococcal vaccination program. The program was first implemented at the Minneapolis Department of Veterans Affairs (VA) Medical Center in 1987-88 following the demonstration that a clinic-based standing order policy was much more successful than provider education for improving vaccine delivery. The program ensures that vaccine is offered to all high-risk patients followed up at the medical center, promotes convenient access for patients, and facilitates efficient administration of vaccine. Specific elements include an annual mailing to patients, standing orders for nurses, walk-in clinics, and the use of standardized, preprinted documentation forms. Initially the program targeted high-risk outpatients for influenza vaccination. It was extended to include inpatients in 1989-90. Pneumococcal vaccinations were added to the program in 1994-95. Vaccination rates are estimated each year from surveys mailed to randomly selected patients, and vaccine utilization is monitored through pharmacy logs. RESULTS: The survey response rates have exceeded 75% each year. Influenza vaccination rates for all high-risk patients followed up at the medical center have increased from 58% following the 1987-88 vaccination season to 84% in 1996-97 (P < 0.001). Pneumococcal vaccination rates have also increased from 34% in 1994-95 to 63% in 1996-97 (P < 0.001). Vaccination rates are similar for inpatients and outpatients, but rates for high-risk patients < 65 years of age remain lower than for the elderly: 69% versus 89% for influenza, 1996-97 (P < 0.001); 52% versus 66% for pneumococcal, 1996-97 (P = 0.05). For elderly patients followed up at the medical center, influenza (89% versus 67%, P < 0.0001) and pneumococcal (66% versus 43%, P < 0.0001) vaccination rates significantly exceeded those for the state of Minnesota in 1996-97. The annual number of influenza vaccine doses dispensed has increased from 10,000 in 1987-88 to more than 22,000 in 1996-97; and more than 13,000 doses of pneumococcal vaccine have been administered from 1994-95 through 1996-97. CONCLUSION: This simple, multifaceted program that incorporates administrative and organizational strategies to enhance influenza and pneumococcal vaccination rates has been highly durable and successful over a 10-year peroid. Similar strategies if implemented in other settings may enhance vaccination rates for the millions of high-risk patients who have yet to be immunized.

Adult↗
PubMed1979

A grid for calculating vectorcardiographic loop areas.

A graph consisting of small squares of equal size preprinted on a transparent plastic chart can be used for a quick and accurate calculation of the VCG loop area in each quadrant of the three conventional planes.

Humans↗
PubMed2003

Mathematical analysis of a model describing evolution of an asexual population in a changing environment.

We investigate a mathematical model for an asexual population with non-overlapping (discrete) generations, that exists in a changing environment. Sexual populations are also briefly discussed at the end of the paper. It is assumed that selection occurs on the value of a single polygenic trait, which is controlled by a finite number of loci with discrete-effect alleles. The environmental change results in a moving fitness optimum, causing the trait to be subject to a combination of stabilising and directional selection. This model is different from that investigated by Waxman and Peck [Genetics 153 (1999) 1041] where overlapping generations and continuous effect alleles were considered. In this paper, we consider non-overlapping generations and discrete effect alleles. However in [Genetics 153 (1999) 1041] and the present work, there is the same pattern of environmental change, namely a constant rate of change of the optimum. From [Genetics 153 (1999) 1041], no rigorous theoretical conclusion can be drawn about the form of the solutions as t grows large. Numerical work carried out in [Genetics 153 (1999) 1041] suggests that the solution is a lagged travelling wave solution, but no mathematical proof exists for the continuous model. Only partial results, regarding existence of travelling wave solutions and perturbed solutions, have been established (see [Nonlin. Anal. 53 (2003) 683; An integral equation describing an asexual population in a changing environment, Preprint]). For the discrete case of this paper, under the assumption that the ratio between the unit of genotypic value and the speed of environment change is a rational number, we are able to give rigorous proof of the following conclusion: the population follows the environmental change with a small lag behind, moreover, the lag is represented using a calculable quantity.

Biological Evolution↗
PubMed1992

The impact of status asthmaticus practice guidelines on patient outcome and physician behavior.

This study assesses the effects of a status asthmaticus guideline on patient outcome and pediatrician behavior in a staff model health maintenance organization (HMO). The guidelines were drafted by an asthma specialist in the HMO and then discussed with key clinical personnel. A preprinted protocol order form was developed to help implement the guideline into clinical practice. The medical records of pediatric patients admitted to the hospital with status asthmaticus before (N = 67) and after (N = 59) guideline development and implementation were reviewed. This study demonstrates that locally developed, treatment-specific guidelines based on scientific evidence and combined with a staff consensus process and a user-friendly protocol form can influence physician behavior and patient outcome positively.

Adolescent↗
PubMed1993

The use of structured, complaint-specific patient encounter forms in the emergency department.

STUDY OBJECTIVE: To assess the effect of preprinted, structured, complaint-specific patient encounter forms on documentation, use of testing, and treatment compared with free-text record keeping. DESIGN: Nonrandomized case-control trial. SETTING: University-affiliated, tertiary referral hospital emergency department. METHODS: The records of all patients with lacerations, pharyngitis, asthma, or isolated closed-head injury during an eight-month period were reviewed. INTERVENTION: Use of structured complaint-specific patient encounter forms versus traditional free-text record keeping. MAIN OUTCOME MEASURE: The null hypothesis was that there would be no differences in documentation, test use, or practice when the structured forms were used compared with free-text record keeping. RESULTS: Differences in documentation that favored the use of the structured forms for all four problems studied were seen consistently. Not only was documentation improved, but test use also was affected in a way that decreased use. In addition, in certain areas (eg, treatment of pharyngitis), clinical practice also was changed. CONCLUSION: Structured, problem-specific ED records improve documentation and affect both resource use and clinical practice. These forms may be useful for improving communication and reimbursement as well as for medicolegal documentation. They provide a method for standardized quality assurance review and clinical data abstraction. Finally, they provide a method for active dissemination of clinical standards.

Adolescent↗
PubMed1980

A systems approach to the management of radiation accidents.

Management of radiation accident patients should have a multidisciplinary approach that includes all health professionals as well as members of public safety agencies. Emergency plans for radiation accidents include detection of the ionizing radiation, patient evacuation, resuscitation, and decontamination. The resuscitated patient should be transported to a radiation control area located outside but adjacent to the emergency department. Ideally this area is accessed through an entrance separate from that used for the main flow of daily emergency department patients. The hospital staff, provided with protective clothing, dosimeters, and preprinted guidelines, continues the resuscitation and definitive care of the patient. This system approach to the management of radiation accidents may be tailored to meet the specific needs of other emergency medical systems.

Accidents↗
PubMed2003

Early use of glycoprotein IIb/IIIa inhibitors in the ED treatment of non-ST-segment elevation acute coronary syndromes: a local quality improvement initiative.

A prospective observational study was conducted in 2,007 patients experiencing chest pain to determine impact of local quality improvement (QI) measures on the use of glycoprotein (GP) IIb/IIIa inhibitors in the ED treatment of high-risk patients with non-ST-segment elevation acute coronary syndromes (ACS). Patients with injury on the initial ECG or new sustained injury on continuous ECG were excluded. QI interventions were as follows: control (0-4 mo): no interventions (standardized protocols and prewritten orders in place 4 months prior); phase I (5-8 mo): simple education/awareness program with posted drug information pamphlets and eligibility criteria; phase II (9-12 mo): mandated QI form with real-time feedback and focused one-on-one physician education championed by an ED physician QI advocate. A total of 179 (8.9%) of the study patients met predefined high-risk criteria. Of these, a total of 41 (23.0%) patients had GP IIb/IIIa inhibitor therapy initiated in the ED. Percent of high-risk patients receiving therapy increased from 6.0% during the control phase to 16.1% during phase I and 50.9% during phase II. After controlling for patient demographics, patients treated during phase I had a 2.8 times increased odds (95% confidence interval CI: 0.8-10.3; P =.11 [not significant]) of receiving GP IIb/IIIa inhibitor relative to the control phase, and patients treated during phase II had a 20.2 times increased odds (95% CI: 6.1-66.9; P <.0001) of treatment. In conclusion, local QI measures incorporating standardized protocols, preprinted orders, physician education, and interactive feedback championed by an ED QI physician advocate can increase early use of GP IIb/IIIa inhibitors in the ED treatment of high-risk patients presenting with chest pain.

Anticoagulants↗
PubMed2002

A systematic approach for increasing pneumococcal vaccination rates at an inner-city public hospital.

BACKGROUND: While the Advisory Committee on Immunization Practices recommends a standing order as the most effective mechanism to increase pneumococcal and influenza vaccination rates, Georgia's Medical Practice Act does not authorize nurses to screen, order, and administer adult vaccines in inpatient settings. METHODS: The setting was a 1000-bed public teaching hospital in metropolitan Atlanta. A 1-month intervention (INT1) included four wards randomized to intervention or control. A 5-month hospital-wide intervention (INT2) followed INT1. The intervention used was provider reminder with in-service training. Chart review was the measure used. The main outcome was pneumococcal vaccination prior to discharge. RESULTS: During INT1, 534 patients (296 intervention and 238 control) were discharged. Of the 534 patients, 475 (89.0%) were African American, 188 (35.2%) were uninsured, and the median age was 48 (range 19 to 96). Of the 205 intervention patients with vaccine indications and no contraindications, 78 of 205 (38%) were vaccinated compared to 7 of 143 (4.9%) of the control patients (p<0.001). During INT2, 879 patient charts were reviewed. Patient demographics were similar to INT1. However, of 554 eligible patients, 16% were vaccinated, significantly higher than control floors during INT1 (p<0.001). Although nurses initiated the form almost 70% of the time, physicians assessed fewer than 35% of patients with indications. CONCLUSIONS: Significantly higher proportions of high-risk patients were vaccinated through the use of a preprinted nurse screening and physician order form. However, a significant percentage of patients did not receive the vaccine owing to the physician's failure to order it. In these cases, use of standing orders would have further increased vaccination rates while also promoting a more sustainable program.

Adolescent↗
PubMed2002

[Evaluation of the demand for access to peridural obstetrical anesthesia in maternity units].

OBJECTIVES: This prospective study was initiated by a multicentric work. Each participating hospital, was asked to give data about 20 patients. Because of the importance of these informations for our practice, we decided to continue the evaluation, using the same inquiry, until 200 patients were enrolled. PATIENTS AND METHODS: An independent student (resident pharmacist), using a preprinted inquiry from interviewed two hundred consecutive in the, 48 hours after delivery in order to evaluate the following aspects: reasons to wish an epidural analgesia (EA) or not, modalities of achievement of EA. Statistical study: Chi-square and logistic regression. RESULTS: Among 199 analyzable files, 137 women wished for an EA (68.5%) but in only 90 the procedure was performed. Reasons for non-achievement of EA were the following: labour too advanced (43/47), obstetrical contraindication (2/47), anaesthesiologist non available (2/47). Delay between arrival at hospital and EA performance was 5 h 30 during daytime and 4 h 40 during nighttime. Delay and rate of EA achievement were not different between day and night time. Logistic regression analysis found following criteria related to: Wish for an EA analgesia: anaesthesiology consultation (OR = 193, p < 0.001), nulliparity (OR = 4, p < 0.002) and satisfactory information about EA (OR 35, p = 0.051). Achievement of EA: nulliparity (OR 38, p < 0.002), length of labour (OR = 1.01/min, p < 0.001). CONCLUSION: This study underlined the fact that one third of parturients do not wish for an epidural analgesia, mainly out of fear for neurological complications. When the obstetrician indicated an EA, our organisation allowed its achievement in 98% of cases. The latency between arrival and EA should be shortened.

Adult↗
PubMed1998

A model for collaboration in quality improvement projects: implementing a weight-based heparin dosing nomogram across an integrated health care delivery system.

BACKGROUND: At Aurora Health Care, an integrated delivery system based in Milwaukee, a system-level clinical quality improvement department was established in 1995 to facilitate collaboration on clinical quality improvement (QI) initiatives. THE COLLABORATIVE MODEL: A model was developed to use expertise within the system and avoid unnecessary duplication of efforts, while maintaining buy-in for the project's interventions at the point of service delivery. It was believed that a single team could design the improvement efforts or guidelines, and then work at a more local level with a different group of people to implement the processes. APPLYING THE MODEL TO THE HEPARIN QI PROJECT: Anticoagulation with heparin is considered the mainstay of treatment for pulmonary embolism and deep venous thrombosis. However, a large gap was found between present anticoagulation practices and published best practice in regards to achieving a key process measure. To reduce the overall time to achieving effective anticoagulation, a system-level team created an intervention primarily consisting of a preprinted order sheet, including the weight-based heparin dosing nomogram, and an education plan for physicians and other health care professionals. Significant improvement was observed at all pilot sites with overall rates of adequate anticoagulation within the first 24 hours improving from 73% to 95%. DISCUSSION: The system was able to standardize care at four of its five major hospitals and provide for better patient outcomes to a larger segment of the community, and then to replicate the heparin project to four additional sites during a six-month period. This model has been successfully applied to other quality improvement projects.

Anticoagulants↗
PubMed2001

[Design, implementation, and results of the clinical pathway for herniated lumbar disk].

INTRODUCTION: Clinical or critical pathways are a useful tool in the continuous quality improvement. They develop the main characteristics of the quality programs: implementation of the evidence based medicine, increase staff and patient satisfaction and adequacy in hospital costs. This is the application of evidence-based medicine to a process management and it promotes integration of clinical guides, protocols and algorithms. OBJECTIVE: We present our experience in the design, and first nine month's implementation and development of a clinical pathway for lumbar hemilaminectomy. PATIENTS AND METHODS: This clinical pathway consists on four documents: main guide and check sheet, preprinted treatment orders and variation sheet, iconographic information for the patients and patient satisfaction questionnaire. After desing, development and a pilot study, the hemilaminectomy critical pathway was permanently adopted by our Service. A total of 106 patients underwent programmed lumbar disc hemilaminectomy in our Service between April and December-1999. Patients' average age was 44.7 years (SD = 11.2), 55.3% were men and 43.7% women. Twelve were hospitalized in a ward other than Neurosurgery unit and therefore were excluded from the study. This evaluation is based on the initial results obtained from both the pathway documents and the general data collected as usual during hospital care. The impact of the critical pathway on hospital stay has been assessed by comparing the average stay of critical pathway patients to the average of the 70 hemilaminectomies performed at our Service in the period April-December 1998. RESULTS: Clinical pathway coverage has been 68% (standard > 80%). The patients' average stay was 4 days (SD = 1.1), one day more than planned. The pathway establishes a 4 day hospital stay (3 bed-days), a time that was fulfilled by 49% of the patients. The average stay of the 1998 patients was 5.6 days (SD = 2.7), 1.6 days more than the clinical pathway patients (p < 0.0001). Additionally, undesirable variability in the length of hospital stays was also reduced. Analysis of variations identified those corresponding to patient's condition, increases in medication beyond that originally specified due to patient needs, and unjustified prolonged stays. There were no systematic variations. There was a 2.2% incidence of adverse effects. Although satisfaction questionnaire was only returned by 51% of the patients (instead of > 70%), satisfaction index were 93% (vs 90%). CONCLUSIONS: Critical pathways are still under development and changing continuously. Nevertheless their impact on improving patient care and satisfaction, and resource consumption is already evident, and it constitutes a major aim to work in its complete development.

Adolescent↗
PubMed2006

Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer.

BACKGROUND: The administration of chemotherapy to hospitalized children with cancer is a complex and high-risk process. A team divided the process into three areas--prescribing, dispensing, and administration--and used Failure Mode and Effects Analysis (FMEA) to identify the elements of risk and implement appropriate strategies. For each area, potential failures within subprocesses were assigned risk priority numbers (RPNs), reflecting their frequency, severity, and detectability. STRATEGIES FOR RISK REDUCTION: The team made prescribing and administration, the areas with the highest RPNs, the focus of most of its strategies, which were introduced and completed in 2002. POSTIMPLEMENTATION RESULTS: The potential prescribing error rate decreased from 23% to 14%; use of preprinted standard order sets increased from 22% to 45% in 2003 (one year after the FMEA was conducted) and 76% in 2005. Actual dispensing errors decreased from 3 to 1, and the actual administration errors from 4 to 3. FINAL REFLECTIONS: Computerized order entry systems would only affect prescribing, dispensing, and administering, which would still be done manually, resulting in potential for failure. The FMEA project will be an ongoing part of providing safe chemotherapy treatments.

Antineoplastic Agents↗