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PubMed2005

Incremental cost effectiveness evaluation in clinical research.

OBJECTIVE: The health economic evaluation of therapeutic and diagnostic strategies is of increasing importance in clinical research. Therefore also clinical trialists have to involve health economic aspects more frequently. However, whereas they are quite familiar with classical effect measures in clinical trials, the corresponding parameters in health economic evaluation of therapeutic and diagnostic procedures are still not this common. METHODS: The concepts of incremental cost effectiveness ratios (ICERs) and incremental net health benefit (INHB) will be illustrated and contrasted along the cost effectiveness evaluation of cataract surgery with monofocal and multifocal intraocular lenses. ICERs relate the costs of a treatment to its clinical benefit in terms of a ratio expression (indexed as Euro per clinical benefit unit). Therefore ICERs can be directly compared to a pre-specified willingness to pay (WTP) benchmark, which represents the maximum costs, health insurers would invest to achieve one clinical benefit unit. INHBs estimate a treatment's net clinical benefit after accounting for its cost increase versus an established therapeutic standard. Resource allocation rules can be formulated by means of both effect measures. RESULTS: Both the ICER and the INHB approach enable the definition of directional resource allocation rules. The allocation decisions arising from these rules are identical, as long as the willingness to pay benchmark is fixed in advance. Therefore both strategies crucially call for a priori determination of both the underlying clinical benefit endpoint (such as gain in vision lines after cataract surgery or gain in quality-adjusted life years) and the corresponding willingness to pay benchmark. CONCLUSION: The use of incremental cost effectiveness and net health benefit estimates provides a rationale for health economic allocation discussions and founding decisions. It implies the same requirements on trial protocols as yet established for clinical trials, that is the a priori definition of primary hypotheses (formulated as an allocation rule involving a pre-specified willingness to pay benchmark) and the primary clinical benefit endpoint (as a rationale for effectiveness evaluation).

Biomedical Research↗
PubMed2006

Standardization of Anaesthesia Ready Time and reasons of delay in induction of anaesthesia.

OBJECTIVE: Anaesthesia-Ready Time (ART) is the time taken by the anaesthetist to provide sufficient anaesthetic depth for start of surgery. Our aim was to set benchmark timings for ART and compare it with our current practice. METHODS: Benchmark ART time of 15 minutes was set for American Society of Anesthesiologists (ASA) class I and II patients, 30 minutes for ASA III and IV patients, 20 minutes for spinal and 30 minutes for epidural anaesthesia. An additional 15 minutes was added for each invasive procedure. RESULTS: Three hundred elective cases were audited. Seventy eight percent of the cases were within benchmark timings. The main causes of delay included undergraduate students performing procedures (24.6%), teaching invasive lines to postgraduates (21.3%) and paediatric patients (16.4%). CONCLUSION: The introduction of benchmark timings and its regular auditing can help standardize operating room booking time and reducing patient cost.

Anesthesia Recovery Period↗
PubMed1998

How many physicians does Canada need to care for our aging population?

BACKGROUND: There is concern that the aging of Canada's population will strain our health care system. The authors address this concern by examining changes in the physician supply between 1986 and 1994 and by assessing the availability of physicians in 1994 relative to population growth and aging, and relative to supply levels in the benchmark province of Alberta. METHODS: Physician numbers were obtained from the Canadian Institute for Health Information. The amount of services provided by each specialty to each patient age group was analysed using Manitoba physician claims data. Population growth statistics were obtained from Statistics Canada. Age- and specialty-specific utilization data and age-specific population growth patterns were used to estimate the number and type of physicians that would have been required in each province to keep up with population growth between 1986 and 1994, in comparison with actual changes in the physician numbers. Physician supply in Alberta was used as a benchmark against which other provinces were measured. RESULTS: Overall, Canada's physician supply between 1986 and 1994 kept pace with population growth and aging. Some specialties grew much faster than population changes warranted, whereas others grew more slowly. By province, the supply of general practitioners (GPs) grew much faster than the population served in New Brunswick (16.6%), Alberta (6.5%) and Quebec (5.3%); the GP supply lagged behind in Prince Edward Island (-5.4%). Specialist supply outpaced population growth substantially in Nova Scotia (10.4%), Newfoundland (8.5%), New Brunswick (7.3%) and Saskatchewan (6.8%); it lagged behind in British Columbia (-9.2%). Using Alberta as the benchmark resulted in a different assessment: Newfoundland (15.5%) and BC (11.7%) had large surpluses of GPs by 1994, whereas PEI (-21.1%), New Brunswick (-14.8%) and Manitoba (-11.1%) had substantial deficits; Quebec (37.3%), Ontario (24.0%), Nova Scotia (11.6%), Manitoba (8.2%) and BC (7.6%) had large surpluses of specialists by 1994, whereas PEI (-28.6%), New Brunswick (-25.9%) and Newfoundland (-23.8%) had large deficits. INTERPRETATION: The aging of Canada's population poses no threat of shortage to the Canadian physician supply in general, nor to most specialist groups. The marked deviations in provincial physician supply from that of the benchmark province challenge us to understand the costs and benefits of variations in physician resources across Canada and to achieve a more equitable needs-based availability of physicians within provinces and across the country.

Adolescent↗
PubMed2005

Estimating the optimal external-beam radiotherapy utilization rate for genitourinary malignancies.

BACKGROUND: Benchmark radiotherapy utilization rates for genitourinary malignancies are largely unknown, despite the finding that genitourinary cancers comprise approximately 19% of all registered malignancies in Australia. METHODS: To develop an evidence-based benchmark of the optimal proportion of patients with genitourinary malignancies who should receive at least one course of radiotherapy at some time during their illness, the authors studied treatment guidelines and treatment reviews regarding genitourinary malignancies. Optimal radiotherapy utilization trees were constructed to show the clinical attributes that indicated possible benefit from radiotherapy based on evidence. Epidemiologic incidence data for each of these clinical attributes were obtained to calculate the optimal proportion of all patients with genitourinary cancer for whom radiotherapy was considered appropriate. RESULTS: The proportion of patients with genitourinary malignancies for whom radiotherapy was indicated at some point in their illness, according to the best available evidence, was estimated to be 27% of patients with renal cancer, 58% of patients with bladder cancer, 60% of patients with prostate cancer, and 49% of patients with testicular cancer. The occurrence of ureteric and penile cancers among patients was too rare, and, therefore, these patients were not included in the current study. CONCLUSIONS: There was a large discrepancy between actual radiotherapy utilization and the evidence-based optimal rate. The authors recommended strategies to implement the evidence-based guidelines. Evidence-based benchmarks for radiotherapy utilization rates such as the ones described in the current study were important in the evaluation of the appropriate use of radiotherapy.

Australia↗
PubMed2002

A procedure for developing risk-based reference doses.

Reference doses (RfDs) for toxic substances based on a no observed adverse effect level (NOAEL) or lowest observed adverse effect level (LOAEL) are established to restrict human exposures to only nontoxic or minimally toxic levels. In order to calculate a risk-based RfD, for the point of departure it is necessary to replace a NOAEL or LOAEL by a benchmark dose (BMD) estimated to be associated with a specified level of estimable risk in or near the low end of an experimental dose range. Then the RfD is calculated by dividing the BMD by a series of uncertainty factors. Among these uncertainty factors is one for interindividual sensitivity, typically assigned a value of 10. If information is available on interindividual sensitivity, this default factor can be replaced with a factor expected to provide protection for a specified proportion of a population. Examination of published databases suggests interindividual effects often to be approximately log-normal. For example, in order to illustrate the procedure for establishing a risk-based RfD, a standard deviation of the logarithm (base e) of individual sensitivity of 1.7 was selected, i.e., a factor of 5.5. This value is near the upper range of values reported in the literature (D. Hattis et al., 1999, in "Characterizing Human Variability in the Risk Assessment Process," ILSI Press, Washington, DC). Using this information in combination with an RfD based on a benchmark dose associated with a specified level of risk, the risk at the RfD can be estimated. For example, a benchmark dose associated with a risk of 10% divided by 60, to account for interindividual variation, is expected to limit risk at the RfD to about 1 in 10,000. If the standard deviation of the logarithm (base e) of individual sensitivity is 1.2, a more typical value, the divisor is approximately 20. These would replace an RfD having an unknown risk based on the LOAEL divided by 100. Or, an RfD with a specified level of risk could be estimated. The estimate of risk can be improved for a specific case by replacing an overall estimate of the standard deviation for interindividual variability by an estimate of the standard deviation for a particular class of chemicals and/or biological endpoint, if available. Risks can be substantially lower for smaller values of interindividual variability. Determination of an RfD still would require an additional uncertainty factor for animal to human extrapolation.

Adult↗
PubMed2000

Analysis of anesthesia physician resources: projected Ontario deficit in 2005.

PURPOSE: To clarify the recent perception of shortfalls in anesthesia physician resources, two models were used to assess these resources in Ontario, Canada. METHODS: Two models, demand-based and benchmarking, were used. In the demand-based model estimated future supply and attrition were obtained from information on Ontario Ministry of Health funded trainees. Data from the Canadian Residents Matching Service and the Association of Canadian University Departments of Anesthesia were also used. Current demand was identified from a telephone survey of Departments of Anesthesia in ten Ontario cities. The number of anesthesia practitioners in Ontario was estimated from the 1996 Canadian Anesthesiologists' Society Physician Resource Database (CASPRD) in the demand-based model. In the benchmarking model, using Alberta as the closest published analogue to Ontario, the annual specialist growth rate in Ontario since 1986 was calculated in the literature as 2.8%/yr for 1986-1994. The number of anesthesiologists in Ontario from the 1986 CASPRD was used to calculate need based on that growth rate. Results are compared with population to anesthesiologist (P/A) ratios calculated from Statistics Canada population data and physician numbers from CASPRD. RESULTS: A shortfall in the number of anesthesiologists has been identified. The P/A ratio worsened by 17.6% from 1986 to 1996. The demand-based model indicated that the shortfall is increased from a current deficit of 40 to 68 by 2005, using CASPRD. Benchmarking showed that the estimated shortfall in 1994 was 131. CONCLUSION: This conservative approach indicates that the shortfall in anesthesiologist physician resources will worsen by 2005.

Adult↗
PubMed2006

Multihospital surveillance of nosocomial methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus, and Clostridium difficile: analysis of a 4-year data-sharing project, 1999-2002.

BACKGROUND: This study sought to establish a benchmark of resistant organism rates among a cohort of regional hospitals. METHODS: The Centers for Disease Control and Prevention (CDC) definitions were used to standardize the methodology for obtaining rates per 1000 patient days of nosocomial infection and colonization with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE), and nosocomial infection with Clostridium difficile (CDIF). Only newly acquired nosocomial cases were counted. Data were reported as individual hospital control charts and as cohorted aggregate data. VHA East Coast Infection Control Professionals from 32 hospitals in New Jersey and Pennsylvania were involved. RESULTS: Benchmarks were established with pooled mean rates for each cohort. During the observational period, a statistically significant downward trend was observed for VRE and MRSA (P = .02 and .0007, respectively), and an upward trend was observed for CDIF (P = .0256). CONCLUSION: Benchmarks were established to compare nosocomial MRSA, VRE, and CDIF rates. Although significant changes in rates were observed, no attempt was made to establish a causal relationship between infection control practices and observed rates. However, a secondary gain was achieved through sharing best practices.

Benchmarking↗
PubMed2005

Issues in neurological risk assessment for occupational exposures: the Bay Bridge welders.

The goal of occupational risk assessment is often to estimate excess lifetime risk for some disabling or fatal health outcome in relation to a fixed workplace exposure lasting a working lifetime. For sub-chronic or sub-clinical health effects measured as continuous variables, the benchmark dose method can be applied, but poses issues in defining impairment and in specifying acceptable levels of excess risk. Such risks may also exhibit a dose-rate effect and partial reversibility such that effects depend on how the dose is distributed over time. Neurological deficits as measured by a variety of increasingly sensitive neurobehavioral tests represent one such outcome, and the development of a parkinsonian syndrome among welders exposed to manganese fume presents a specific instance. Welders employed in the construction of piers for a new San Francisco-Oakland Bay Bridge in San Francisco were previously evaluated using a broad spectrum of tests. Results for four of those tests (Rey-Osterrieth Complex Figure Test, Working Memory Index, Stroop Color Word Test and Auditory Consonant Trigrams Test) were used in the benchmark dose procedure. Across the four outcomes analyzed, benchmark dose estimates were generally within a factor of 2.0, and decreased as the percentile of normal performance defining impairment increased. Estimated excess prevalence of impairment, defined as performance below the 5th percentile of normal, after 2 years of exposure at the current California standard (0.2 mg/m3, 8 h TWA), ranged 15-32% for the outcomes studied. Because these exposures occurred over a 1-2-year period, generalization to lifetime excess risk requires further consideration of the form of the exposure response and whether short-term responses can be generalized to equivalent 45-year period. These results indicate unacceptable risks at the current OSHA PEL for manganese (5.0 mg/m3, 15 min) and likely at the Cal OSHA PEL as well.

Adult↗
PubMedDate not supplied

Evaluation of the quality of care in the clinical care centers of the National Centers of Excellence in Women's Health.

This study evaluated the quality of primary care services provided in 15 National Centers of Excellence in Women's Health (CoE) clinical sites in operation in 2001 using self-reported clinical preventive services and patient satisfaction as indicators of quality of care. A sample of 3,111 women served by the CoE program was surveyed and compared with quality of care benchmarks from national and local community surveys. The benchmark surveys were: a nationally representative sample of 2,075 women from the 1998 Commonwealth Fund Survey of Women's Health; a community sample of women who lived within a geographical catchment area for three CoEs; and a sample of 71,438 women in the 1999 Consumer Assessment of Health Plans Study (CAHPS) of commercial managed care plans. Adjusting for region, age, education, perceived health status, and managed care enrollment, women in the CoEs were more satisfied with their care and had received significantly more screening tests and counseling services than women in the benchmark samples. The largest effects among primary care services were for physical breast examination, mammogram (ages 50+), and counseling for smoking, domestic violence, and sexually transmitted diseases.

Benchmarking↗
PubMed1999

The five-year evolution of a malnutrition treatment program in a community hospital.

BACKGROUND: Studies suggest that 30%-55% of hospitalized patients are at risk for malnutrition, an avoidable comorbidity contributing to increases in hospitalization and readmission, length of stay, complications, and mortality. Yet a variety of issues have impeded many hospitals' implementation of effective nutrition intervention programs. BENCHMARKING STUDY: St Francis Hospital (SFH), a 395-bed community acute care facility in Wilmington, Delaware, participated in a nationwide benchmark study in fall 1993. In comparison with the 12-hospital means, data for SFH showed both delays in initiating a nutrition care plan for acutely ill patients and a significantly higher risk for malnutrition. NUTRITION SCREENING PILOT: A pilot study was implemented in 1994 to identify nutrition needs within 48 hours of admission as a first step in the improvement process. Although interventions occurred earlier for a greater number of high-risk patients, nutrition intervention was not being provided in a uniform and timely manner. THE MALNUTRITION CLINICAL PATHWAY: A free-standing hospital committee, the Nutrition Care Committee (NCC), with guidance from the care management department, began developing a malnutrition pathway that would serve as an integrated plan for providing nutrition care to high-risk patients. The original pathway was organized into four stages that outlined the progression and timing of care--identification of the patient at high risk for malnutrition, nutrition care decisions, treatment in progress (the remainder of the patient's hospitalization), and discharge planning. OUTCOME STUDIES: Outcome studies were conducted in 1996 and again in 1998 to assess the malnutrition treatment pathway's impact on patient health outcomes and the cost of care. The 1996 outcome study indicated significant improvements in the identification of high-risk patients (from 25.9% to 86%) and the timeliness of nutrition intervention (from 6.9 days to 2.4 days). A second outcome study was conducted in 1998, following revision of the pathway. Comparison of the 1996 after-pathway patient population with a matched study group in 1998 indicated reductions in average length of stay from 10.8 to 8.1 days; the incidence of major complications from 75.3% to 17.5%; and 30-day readmission rates from 16.5% to 7.1%. DISCUSSION: The performance improvement project described in this article began with SHF's voluntary participation in an interdisciplinary benchmarking study and continued when it was apparent that SFH had an opportunity for performance improvement. Forming an NCC at SFH was the first step in a process that gained the administrative support necessary to fully develop the program. SUMMARY AND CONCLUSIONS: SFH has developed and implemented a malnutrition treatment program that is integrated into the care plan of all acute care patients and is included in the discharge planning process. Outcome studies have demonstrated the effect of the malnutrition treatment program on patient recovery and cost of care.

Algorithms↗
PubMed2003

Estimating the effects of 17alpha-ethinylestradiol on populations of the fathead minnow Pimephales promelas: are conventional toxicological endpoints adequate?

Environmental benchmarks have recently been proposed for several steroids including the synthetic steroid, 17alpha-ethinylestradiol (EE2). These benchmarks are based on extrapolation from studies involving long-term exposure of various fish species to EE2. One of the critical studies was a complete life-cycle experiment performed with the fathead minnow Pimephales promelas over a 289 day exposure period. The lowest observed effect concentration (LOEC) and the no observed effect concentration (NOEC) for gonad histology were 4 and 1 ng L(-1) respectively. This was because no testicular tissue could be found in any fish exposed to 4 ng L(-1). In the present paper, the survival and reproduction data from that study are reanalyzed to determine the effects of EE2 on the intrinsic rate of population growth (r = In (lambda)), a parameter of demographic importance. We estimate critical threshold concentrations with respect to r and compare these with those previously derived from conventional toxicity test summaries. Further, we assess the influence of individual variability on threshold estimates using a combination of bootstrap and regression approaches, together with a suite of perturbation analyses. These yield ErC100 values (the concentration estimated to reduce intrinsic growth rate to zero) of 3.11 ng L(-1) (linear model) and 3.41 ng L(-1) (quadratic model), comparable with a maximum acceptable toxicant concentration (MATC) of 2 ng L(-1) for feminization of exposed fish calculated by Laenge et al. Our results indicate that reduction in population growth rate with increasing concentration occurred more through EE2 acting to reduce fertility than survival rates. The significance of these summary statistics when deriving environmental benchmarks for steroid estrogens is discussed in the context of affording protection to populations following long-term exposure.

Animals↗
PubMed2000

Effect of diagnostic threshold on the validity and reliability of epidemiological caries diagnosis using the Dundee Selectable Threshold Method for caries diagnosis (DSTM).

OBJECTIVES: To develop a method for recording dental caries at the D1 (enamel and dentine) diagnostic threshold (without loss of D3 information) and assess its reliability, 'benchmark' validity and potential effects on reported caries prevalence and needs assessment. METHODS: Multi-examiner training, calibration and validation trial. Two groups of 10 dental examiners were trained to diagnose dental caries at the D1 (enamel and dentine) diagnostic threshold under the conditions of a caries prevalence survey, prior to a calibration trial being undertaken. RESULTS: Where 'experienced examiners' were trained to examine at the D1 (enamel and dentine) diagnostic threshold, under the conditions of a cross-sectional epidemiological survey, there was no significant deterioration in inter-examiner agreement on the assessment of teeth and a significant difference in one of two comparisons on the assessment of surfaces using the kappa statistic. Assessed against a benchmark examiner, there was no significant loss of sensitivity at the D1 diagnostic threshold compared with the D3 threshold and, although there was a significant loss of specificity at the D1 threshold, all specificity values could be considered to be high. CONCLUSIONS: Modifying the diagnostic criteria typically used in surveys of caries prevalence (to allow assessment of the levels of enamel caries which could benefit from preventive care as well as dentinal caries requiring restorative care) in adolescents does not adversely affect the reliability or benchmark validity of experienced examiners to a significant degree.

Adolescent↗
PubMed2000

Risk-adjusted infection rates in surgery: a model for outcome measurement in hospitals developing new quality improvement programmes.

Assessment of healthcare quality is a major challenge in countries such as Hungary where there is limited experience with measurement of patient outcomes. We sought to develop the capacity for valid outcome measurement in Hungarian hospitals using surgical site infection (SSI) surveillance as a model and to identify areas for improvement by comparing SSI rates in Hungarian hospitals to benchmarks published by the United States Centers for Disease Control and Prevention's National Nosocomial Infection Surveillance (NNIS) System. We surveyed the incidence of SSI among 5126 patients undergoing 6006 procedures in 20 public hospitals in Hungary during 1996 using the Hospitals in Europe Link for Infection Control through Surveillance (HELICS) protocol, a protocol consistent with the methods used by the NNIS System. Cholecystectomy, herniorrhaphy, appendectomy, and open reduction of fracture--four of the five most commonly performed procedures in Hungary in 1996--comprised 85% of the procedures analysed. Cumulative SSI rates for herniorrhaphy and appendectomy were comparable to NNIS System benchmarks. Cumulative SSI rates for cholecystectomy were significantly higher in Hungarian hospitals among risk categories that included open procedures. Nearly half of the hospitals had SSI rates for cholecystectomy that were high outliers (>90% percentile) compared to NNIS System benchmarks. Cumulative SSI rates for open reduction of fracture and mastectomy were significantly higher in Hungarian hospitals due to high rates in a few hospitals. The duration of surgery for all procedure types was substantially shorter in Hungarian hospitals compared with NNIS System hospitals. Future work should focus on optimizing prevention strategies for patients undergoing cholecystectomy, open reduction of fracture, and mastectomy. The effect of the utilization of open vs. laparoscopic cholecystectomy, short procedure duration, and procedure volume on SSI rates should be evaluated further. This programme expanded the capacity of Hungarian hospitals to perform surgical site infection surveillance and can serve as a model for hospitals in other countries with limited experience with outcome measurement.

Benchmarking↗
PubMed2003

Environmental surface cleanliness and the potential for contamination during handwashing.

Effective handwashing (including drying) is important in infection control. The ability of the various stages of handwashing to decrease skin-surface microbial counts has been documented. However, an important element, environmental surface cleanliness, and the potential for contamination of hands during the process has not been well studied or quantified. An examination of the adenosine triphosphate (a measure of residual organic soil), bacterial, and staphylococcal load on ward handwash station surfaces, which could be touched during handwashing, is reported. Hand contact surfaces tested consisted of approximately 620 each of: faucet handles, soap dispenser activator mechanisms, and folded paper-towel dispenser exits. Failure rates in excess of benchmark clean values were higher with adenosine triphosphate assays than microbial counts. This could indicate the presence of a higher level of general organic debris (eg, skin cells) as opposed to microbial contamination or could reflect greater assay sensitivity. Faucet handles were more likely to be contaminated and be in excess of benchmark values than paper-towel dispenser exits. However, the latter are likely to be the final surface touched during the handwashing process and overall nearly 20% were above microbiologic benchmark values. Many of the organisms isolated were staphylococci and the results are discussed within the context of microbial cross-contamination and potential pathogen spread.

Adenosine Triphosphate↗
PubMed2001

Analysis of air toxics emission inventory: inhalation toxicity-based ranking.

Air toxics emission inventories play an important role in air quality regulatory activities. Recently, Minnesota Pollution Control Agency (MPCA) staff compiled a comprehensive air toxics emission inventory for 1996. While acquiring data on the mass of emissions is a necessary first step, equally important is developing information on the potential toxicity of the emitted pollutants. To account for the toxicity of the pollutants in the emission inventory, inhalation health benchmarks for acute effects, chronic effects, and cancer were used to weight the mass of emissions. The 1996 Minnesota emissions inventory results were ranked by mass of emissions and by an index comprised of emissions divided by health benchmarks. The results show that six of eight pollutants ranked highest by toxicity were also the pollutants of concern indicated in environmental monitoring data and modeling data. Monitoring data and modeling results did not show high impacts of the other two pollutants that were identified by the toxicity-based emission ranking method. The biggest limitation in this method is the lack of health benchmark values for many pollutants. Despite uncertainties and limited information, this analysis provides useful information for further targeting pollutants and source categories for control.

Air Pollutants↗
PubMed2005

Generation and validation of a shielding library based on ENDF/B-VI.8.

For various shielding and reactor pressure vessel dosimetry applications, a pseudo-problem-independent neutron-photon coupled MATXS-format library, based on the last release of ENDF/B-VI, has been generated as a part of the update program for KASHIL-E6, which was based on ENDF/B-VI.5. It has a VITAMIN-B6 neutron and photon energy group structures, i.e. 199 groups for the neutron and 42 groups for the photon. The neutron and photon weighting functions and the Legendre orders of scattering are the same as in KASHIL-E6. The library has been validated through some benchmarks: the PCA-REPLICA and NESDIP-2 experiments for the light-water reactor (LWR) pressure vessel facility benchmark, the Winfrith Iron 88 experiment for the validation of the iron data and the Winfrith Graphite experiment for the validation of the graphite data. These calculations were performed by the TRANSX/DANTSYS code system. In addition, the substitutions of the JENDL-3.3 and JEFF-3.0 data for Fe, Cr, Cu and Ni, which are very important nuclides for shielding analyses, were investigated to estimate the effects on the benchmark calculation results.

Algorithms↗
PubMed2000

The master clinician project.

This article describes an internal benchmarking process developed and used by the Marshfield Clinic targeting the interface between productivity and service quality. The benchmarking first identified "better performing" physicians using production and service quality measures as benchmarks. This was followed by detailed interviews of "better performers" to discover their "best practices." Based on an analysis of the "best practices" information, a physician curriculum was designed and implemented to improve service quality and provider productivity. Optimal strategies for successful programs are discussed and, finally, recommendations for future research are identified.

Benchmarking↗
PubMedDate not supplied

The Wisconsin outcomes experience: baseline outcomes of the WISCVPR Web-based Outcomes Project.

PURPOSE: The measurement of outpatient cardiac rehabilitation (OCR) outcomes is now considered common practice. Unfortunately, because of the costs involved in purchasing outcomes tracking software, many programs are not able to participate in pooled outcomes analysis and benchmarking. The purpose of this report is to describe the current OCR outcomes data in the state of Wisconsin using a web-based model for outcomes data collection, data pooling, and benchmarking. METHODS: Participating OCR programs collected individual patient outcomes according to protocols developed by the Wisconsin Society for Cardiovascular and Pulmonary Rehabilitation's Outcomes Committee. Programs analyzed their data quarterly and submitted the values to a database via an Internet web site. Aggregate outcomes data from 34 programs were collected over a 27-month period. RESULTS: Aggregate data representing 5235 OCR patients are presented. The mean age for the men was 64 +/- 5 years (N = 3612; 69% of the sample). The mean age for the women was 67 +/- 6 years (N = 1623; 31% of the sample). The completion rate for the group was 89% (95%CI, 86-91). The average number of OCR sessions per patient was 22 +/- 6 over 9 +/- 3 weeks. The clinical and behavioral outcomes for this sample ranged from a median value of 88% for the percentage of patients meeting the blood pressure goal (95%CI, 87-91) to less than 5% for the percentage of patients receiving formal psychosocial counseling (95%CI, 0). The major cardiovascular event rate was 0.17 per 10,000 patient-hours. CONCLUSION: This report describes the baseline OCR outcomes obtained via a state affiliate-sponsored outcomes management program. These data show that this model of OCR outcomes measurement, collection, and interprogram analysis produces data that are comparable with those of published, controlled studies. Determining baseline characteristics of OCR outcomes data will be important in the development of benchmarks and best practice guidelines.

Aged↗