Choosing Wisely: Determining performance of unjustified imaging in a large healthcare system.

AIMS: The Choosing Wisely Campaign identifies procedures and treatments that lack clinical justification for routine use according to expert opinion and evidence-based medicine. This study describes the rates and features of two such examples over a 10-year period. METHODS: This is a cross-sectional rolling cohort study between 2008 and 2017 in Clalit Health Services, the largest healthcare delivery system in Israel, with seven main hospitals and over 4.5 million members nationwide. All adult members who visited a Clalit Emergency Department (ED), and all children members who visited a Clalit ED for abdominal pain or appendicitis were eligible to be included in this study. Our measures were routine chest radiograph (CXR) in the context of pre-admission assessment for adults and abdominal computed tomography (CT) to rule out appendicitis for children. RESULTS: Of the 3 689 869 adult visits without a clinical indication for a CXR, 9.1% or 337 058 of them received a chest radiograph. Of the 35 973 children visits for presumed appendicitis, 7.2% of them had no imaging performed, 82.3% had an ultrasound (US), 6.9% had an US followed by a CT, and 3.6% or 1293 of them received a CT. There were several independent risk factors such as BMI, hospital, sex, year and diagnosis that are associated with having imaging that is not clinically indicated. CONCLUSIONS: Overall, this study found that diagnostic imaging practices are applied inconsistently by hospital and by population. Intervention efforts should be focused on subpopulations at greatest risk to further reduce exposure to such imaging.

[The accreditation program in hospitals: Clalit Health Services experience].

Accreditation is a process for assessing the healthcare organization, to determine if it meets a set of requirements designed to improve quality of care. White research regarding the benefits of accreditation is lacking, accreditation has been shown to be associated with promoting quality. Accreditation differs from licensing and quality assurance audits such as ISO. In various countries, the accreditation processes have been in operation in heaLthcare organization for decades. In the U.S.A., the Leading organization for accreditation of healthcare organizations is the Joint Commission. Accreditation Canada is the leading authority for accreditation in Canada. The Australian Council for Healthcare Standards and the King's Fund in the United Kingdom are other noted authorities for accreditation. Several European countries have initiated accreditation programs and some are in the process of implementing such programs. In Israel, no national accreditation system exists, although the Ministry of Health conducts audits on specific issues, and for relicensing of hospitals, and the Scientific Council of the Israel Medical Association conducts audits for recognizing a department as suitable for residency. Clalit Health Services is the first healthcare organization in Israel to gain Joint Commission International (JCI) accreditation. Three hospitals run by Clalit (Ha'emek, Meir and Soroka) have been accredited by JCI, and another four are in the process of accreditation by JCI. An organized national accreditation scheme in Israel is a challenging process, yet it appears to be a central act for promoting the quality of care in hospitals.

Antioxidant therapy in acute central nervous system injury: current state.

Free radicals are highly reactive molecules generated predominantly during cellular respiration and normal metabolism. Imbalance between cellular production of free radicals and the ability of cells to defend against them is referred to as oxidative stress (OS). OS has been implicated as a potential contributor to the pathogenesis of acute central nervous system (CNS) injury. After brain injury by ischemic or hemorrhagic stroke or trauma, the production of reactive oxygen species (ROS) may increase, sometimes drastically, leading to tissue damage via several different cellular molecular pathways. Radicals can cause damage to cardinal cellular components such as lipids, proteins, and nucleic acids (e.g., DNA), leading to subsequent cell death by modes of necrosis or apoptosis. The damage can become more widespread due to weakened cellular antioxidant defense systems. Moreover, acute brain injury increases the levels of excitotoxic amino acids (such as glutamate), which also produce ROS, thereby promoting parenchymatous destruction. Therefore, treatment with antioxidants may theoretically act to prevent propagation of tissue damage and improve both the survival and neurological outcome. Several such agents of widely varying chemical structures have been investigated as therapeutic agents for acute CNS injury. Although a few of the antioxidants showed some efficacy in animal models or in small clinical studies, these findings have not been supported in comprehensive, controlled trials in patients. Reasons for these equivocal results may include, in part, inappropriate timing of administration or suboptimal drug levels at the target site in CNS. Better understanding of the pathological mechanisms of acute CNS injury would characterize the exact primary targets for drug intervention. Improved antioxidant design should take into consideration the relevant and specific harmful free radical, blood brain barrier (BBB) permeability, dose, and time administration. Novel combinations of drugs providing protection against various types injuries will probably exploit the potential synergistic effects of antioxidants in stroke.