Technical advances in flow cytometry-based diagnosis and monitoring of paroxysmal nocturnal hemoglobinuria / Avanços técnicos no diagnóstico e no monitoramento de hemoglobinúria paroxística noturna por citometria de fluxo

ABSTRACT Objective: To discuss the implementation of technical advances in laboratory diagnosis and monitoring of paroxysmal nocturnal hemoglobinuria for validation of high-sensitivity flow cytometry protocols. Methods: A retrospective study based on analysis of laboratory data from 745 patient samples submitted to flow cytometry for diagnosis and/or monitoring of paroxysmal nocturnal hemoglobinuria. Results: Implementation of technical advances reduced test costs and improved flow cytometry resolution for paroxysmal nocturnal hemoglobinuria clone detection. Conclusion: High-sensitivity flow cytometry allowed more sensitive determination of paroxysmal nocturnal hemoglobinuria clone type and size, particularly in samples with small clones.

RESUMO Objetivo: Discutir as melhorias técnicas no diagnóstico e no acompanhamento laboratorial de hemoglobinúria paroxística noturna para a validação da técnica de citometria de fluxo de alta sensibilidade. Métodos: Estudo retrospectivo, que envolveu a análise de dados laboratoriais de 745 pacientes com hipótese diagnóstica e/ou acompanhamento de hemoglobinúria paroxística noturna por citometria de fluxo. Resultados: Os avanços técnicos não só reduziram o custo do ensaio, mas também melhoraram a identificação e a resolução da citometria de fluxo para a detecção de clone hemoglobinúria paroxística noturna. Conclusão: A citometria de fluxo de alta sensibilidade possibilitou a identificação do tipo e do tamanho de clone de hemoglobinúria paroxística noturna, especialmente em amostras com pequeno clone.

Estrategia integral de formación para la mejora continua de la calidad de los servicios de salud / Organizational capacity for continuous improvement of health services

El sistema de salud mexicano ha tenido logros importantes que se reflejan en la mejora creciente del nivel de salud. Empero, la heterogeneidad en la calidad de los servicios y su repercusión en la salud de diferentes grupos poblacionales continúan siendo un reto. Los costos de fallos en la calidad representan de 20 a 40% del gasto de los sistemas de salud. Es necesario desarrollar la capacidad organizacional para implementar sistemas de gestión de calidad que permitan identificar, evaluar, superar y prevenir los retos del sistema de salud. Para ello, se propone una estrategia integral de formación de recursos humanos basada en competencias y responsabilidades, que incluye programas de pregrado, posgrado y educación continua para favorecer el ejercicio efectivo de la función de calidad en los diversos niveles de responsabilidad del sistema de salud. La estrategia responde a las necesidades del sistema mexicano, pero puede ser adaptada a diferentes sistemas y contextos.

While the Mexican health system has achieved significant progress, as reflected in the growing improvement in population health, heterogeneity in the quality of services and its impact on health in different population groups is still a challenge. The costs or poor quality represent about 20 to 40% of the health system's expenditure. We need to develop organizational capacity to implement quality management systems in order to identify, evaluate, prevent and eventually overcome the health system's challenges. A competency-based comprehensive strategy for training human resources is proposed including undergraduate and graduate education as well as continuing education, which will contribute to improve the quality function at the various levels of responsibility in the health system. The proposed strategy responds to the context of the Mexican health system, but it could be adapted to other systems and contexts.

Payment for performance in the Family Health Programme: lessons from the UK Quality and Outcomes Framework / Pagamento para desempenho no Programa Saúde da Família: lições do Quality and Outcomes Framework da Inglaterra

OBJECTIVE: Payment for performance financial incentive schemes reward doctors based on the quality and the outcomes of their treatment. In Brazil, the Ministry of Health is looking to scale up its use in public hospitals and some municipalities are developing payment for performance schemes even for the Family Health Programme. In this article the Quality and Outcomes Framework used in the UK since 2004 is discussed, as well as its experience to elaborate some important lessons that Brazilian municipalities should consider before embarking on payment for performance scheme in primary care settings.

OBJETIVO: Esquemas de pagamento para desempenho recompensam o médico baseado na qualidade e no resultado do tratamento dos seus pacientes. O Ministério da Saúde brasileiro analisa seu uso em hospitais públicos e alguns municípios estão desenvolvendo estratégias de pagamento por desempenho para o Programa de Saúde da Família. No artigo discute-se o Quality and Outcomes Framework - esquema de pagamento para desempenho usado no Reino Unido desde 2004, bem como sua experiência para elaborar algumas lições importantes que os municípios brasileiros devem considerar antes de empreender o esquema de pagamento por desempenho na atenção primária.

Korean National Health Insurance Value Incentive Program: Achievements and Future Directions / 예방의학회지

Since the reformation of the National Health Insurance Act in 2000, the Health Insurance Review and Assessment Service (HIRA) in the Republic of Korea has performed quality assessments for healthcare providers. The HIRA Value Incentive Program (VIP), established in July 2007, provides incentives for excellent-quality institutions and disincentives for poor-quality ones. The program is implemented based on data collected between July 2007 and December 2009. The goal of the VIP is to improve the overall quality of care and decrease the quality gaps among healthcare institutions. Thus far, the VIP has targeted acute myocardial infarction (AMI) and Caesarian section (C-section) care. The incentives and disincentives awarded to the hospitals by their composite quality scores of the AMI and C-section scores. The results of the VIP showed continuous and marked improvement in the composite quality scores of the AMI and C-section measures between 2007 and 2010. With the demonstrated success of the VIP project, the Ministry of Health and Welfare expanded the program in 2011 to include general hospitals. The HIRA VIP was deemed applicable to the Korean healthcare system, but before it can be expanded further, the program must overcome several major concerns, as follows: inclusion of resource use measures, rigorous evaluation of impact, application of the VIP to the changing payment system, and expansion of the VIP to primary care clinics.

Lessons From Healthcare Providers' Attitudes Toward Pay-for-performance: What Should Purchasers Consider in Designing and Implementing a Successful Program? / 예방의학회지

We conducted a systematic review to summarize providers' attitudes toward pay-for-performance (P4P), focusing on their general attitudes, the effects of P4P, their favorable design and implementation methods, and concerns. An electronic search was performed in PubMed and Scopus using selected keywords including P4P. Two reviewers screened target articles using titles and abstract review and then read the full version of the screened articles for the final selections. In addition, one reference of screened articles and one unpublished report were also included. Therefore, 14 articles were included in this study. Healthcare providers' attitudes on P4P were summarized in two ways. First, we gathered their general attitudes and opinions regarding the effects of P4P. Second, we rearranged their opinions regarding desirable P4P design and implementation methods, as well as their concerns. This study showed the possibility that some healthcare providers still have a low level of awareness about P4P and might prefer voluntary participation in P4P. In addition, they felt that adequate quality indicators and additional support for implementation of P4P would be needed. Most healthcare providers also had serious concerns that P4P would induce unintended consequences. In order to conduct successful implementation of P4P, purchaser should make more efforts such as increasing providers' level of awareness about P4P, providing technical and educational support, reducing their burden, developing a cooperative relationship with providers, developing more accurate quality measures, and minimizing the unintended consequences.

Designing an Effective Pay-for-performance System in the Korean National Health Insurance / 예방의학회지

The challenge facing the Korean National Health Insurance includes what to spend money on in order to elevate the 'value for money.' This article reviewed the changing issues associated with quality of care in the Korean health insurance system and envisioned a picture of an effective pay-for-performance (P4P) system in Korea taking into consideration quality of care and P4P systems in other countries. A review was made of existing systematic reviews and a recent Organization for Economic Cooperation and Development survey. An effective P4P in Korea was envisioned as containing three features: measures, basis for reward, and reward. The first priority is to develop proper measures for both efficiency and quality. For further improvement of quality indicators, an electronic system for patient history records should be built in the near future. A change in the level or the relative ranking seems more desirable than using absolute level alone for incentives. To stimulate medium- and small-scale hospitals to join the program in the next phase, it is suggested that the scope of application be expanded and the level of incentives adjusted. High-quality indicators of clinical care quality should be mapped out by combining information from medical claims and information from patient registries.

Cost-effectiveness of improving pediatric hospital care in Nicaragua / Costo-eficacia de la mejora de la atención hospitalaria pediátrica en Nicaragua

OBJECTIVE: To determine the costs and cost-effectiveness of an intervention to improve quality of care for children with diarrhea or pneumonia in 14 hospitals in Nicaragua, based on expenditure data and impact measures. METHODS: Hospital length of stay (LOS) and deaths were abstracted from a random sample of 1294 clinical records completed at seven of the 14 participating hospitals before the intervention (2003) and 1505 records completed after two years of intervention implementation ("post-intervention"; 2006). Disability-adjusted life years (DALYs) were derived from outcome data. Hospitalization costs were calculated based on hospital and Ministry of Health records and private sector data. Intervention costs came from project accounting records. Decision-tree analysis was used to calculate incremental cost-effectiveness. RESULTS: Average LOS decreased from 3.87 and 4.23 days pre-intervention to 3.55 and 3.94 days post-intervention for diarrhea (P = 0.078) and pneumonia (P = 0.055), respectively. Case fatalities decreased from 45/10 000 and 34/10 000 pre-intervention to 30/10 000 and 27/10 000 post-intervention for diarrhea (P = 0.062) and pneumonia (P = 0.37), respectively. Average total hospitalization and antibiotic costs for both diagnoses were US$ 451 (95 percent credibility interval [CI]: US$ 419-US$ 482) pre-intervention and US$ 437 (95 percent CI: US$ 402-US$ 464) post-intervention. The intervention was cost-saving in terms of DALYs (95 percent CI: -US$ 522- US$ 32 per DALY averted) and cost US$ 21 per hospital day averted (95 percent CI: -US$ 45- US$ 204). CONCLUSIONS: After two years of intervention implementation, LOS and deaths for diarrhea decreased, along with LOS for pneumonia, with no increase in hospitalization costs. If these changes were entirely attributable to the intervention, it would be cost-saving.

OBJETIVO: Determinar el costo y la eficacia en función del costo de una intervención para mejorar la calidad de la atención de ni±os con diarrea o neumonía en 14 hospitales de Nicaragua, sobre la base de la información sobre gastos y la medición de las repercusiones. MÉTODOS: Se compilaron datos sobre la duración de la hospitalización y la mortalidad de una muestra aleatoria de 1 294 historias clínicas compiladas en 7 de los 14 hospitales participantes antes de la intervención (2003) y 1 505 historias clínicas compiladas después de dos a±os de ejecución de la intervención ("postintervención", 2006). Los a±os de vida ajustados en función de la discapacidad (AVAD) se obtuvieron de los resultados asistenciales. Se calcularon los costos de hospitalización según los registros de los hospitales y del Ministerio de Salud, y datos del sector privado. Los costos de la intervención se obtuvieron de los registros contables del proyecto. Para calcular la relación costo-eficacia incremental se usó un anßlisis de ßrbol de decisiones. RESULTADOS: La duración promedio de la hospitalización disminuyó de 3,87 y 4,23 días antes de la intervención a 3,55 y 3,94 días después de la intervención para la diarrea (P = 0,078) y la neumonía (P = 0,055), respectivamente. La letalidad disminuyó de 45/10 000 y 34/10 000 antes de la intervención a 30/10 000 y 27/10 000 después de la intervención para la diarrea (P = 0,062) y la neumonía (P = 0,37), respectivamente. Los costos totales promedio de la hospitalización y de los antibióticos para ambos diagnósticos fueron de US$ 451 (intervalo de confianza [IC] de 95 por ciento: US$ 419 a US$ 482) antes de la intervención y US$ 437 (IC 95 por ciento: US$ 402-US$ 464) después. La intervención representó un ahorro de costos en cuanto a los AVAD (IC 95 por ciento: -US$ 522 a US$ 32 por cada AVAD evitado) y costó US$ 21 por cada día de hospitalización evitado (IC 95 por ciento: -US$ 45 a US$2 04). CONCLUSIONES: Después de dos...

Impacto de la estrategia Plan de Invierno en el uso de medicamentos en el Hospital Pediátrico del Centro Hospitalario Pereira Rossell (CHPR) / Impact of the Winter Plan strategy on the use of medications in the Pediatric Hospital of the Pereira Rossell Hospital Center (CHPR)

Introducción: Con el objetivo de mejorar la calidad de la atención hospitalaria de los niños que ingresan por infección respiratoria aguda baja al Centro Hospitalario Pereira Rossell, se aplicó entre mayo y setiembre de 1999 una estrategia que se denominó Plan de Invierno. Objetivo: Evaluar el impacto que tuvo esta estrategia en el gasto en antibióticos (ATB), broncodilatadores (?2 agonistas) y corticoides en el Hospital Pediátrico. Metodología: Se compararon las unidades consumidas y el gasto (en pesos uruguayos) en ATB, ?2 agonistas y corticoides en el período enero-setiembre 1998 versus enero-setiembre 1999. Los datos fueron obtenidos del programa de uso de medicamentos de la farmacia clínica del hospital. Resultados: El gasto, entre enero y setiembre de 1999, fue menor que en el mismo período de 1998 (28,6% versus 37,6%). El gasto en ATB y corticoides disminuyó en los servicios de pediatría general (PG) y unidad de cuidados intensivos pediátricos (UCIN). El gasto en ?2 disminuyó sólo en UCIN. El gasto por día cama ocupado (DCO) en ATB disminuyó en PG y aumentó en UCIN. Conclusión: Es posible que el cumplimiento de las pautas terapéuticas recomendadas y la mejoría en la calidad de los diagnósticos realizados durante la aplicación de esta estrategia asistencial hayan contribuido a un menor gasto en ATB, ?2 y corticoides en los niños con infección respiratoria aguda baja (IRAB) que ingresaron al hospital.

Summary Introduction: A strategy called Plan de Invierno was developed between May and September of 1999 in order to improve the attention at the Centro Hospitalario Pereira Rossell on children affected by low respiratory tract infections. Objective: To evaluate the impact of this strategy on the spending related to the purchase of antibiotics (ATB), bronchodilators (2agonists) and corticosteroids in the Paediatric Hospital. Methods: Numbers of consumed units and money spent on ATB, (2agonistas) and corticosteroids were compared during the periods of January to September of 1998 and January to September of 1999. Data were obtained from the hospital clinical pharmacy. Results: During the period January - September of 1999, the spending was lower than during the period January - September 1998 (28.6% and 37.6% respectively). Spending on ATB and corticosteroids diminished in the general paediatric service (GP) and in the intensive paediatric care unit (UCIN). Spending related to ?2 agonists diminished only at the UCIN. Bed/day spending (DCO) on ATB decreased at the GP but was increased at the UCIN. Conclusions: Following of the recommended therapeutic guidelines and the improvement of quality of diagnoses performed during the period of this assistance strategy probably contributed to reduce ATB, ?2 agonists, and expenses.

Résumé Introduction: Afin d'améliorer la qualité de l'assistance hospitalière des enfants qui sont admis au Centre Hospitalier Pereira Rossell avec infection respiratoire aigüe, on met en marche une stratégie appelée Plan d'Hiver entre mai et septembre 1999. But: Evaluer l'impact que cette stratégie a eu dans le frais d'antibiotiques(ATB),broncho-dilatateurs(?2 agonistes) et corticoïdes à l'Hôpital Pédiatrique. Méthodologie: On compare les unités consommées et les frais (en monnaie uruguayenne)de ATB, ?2 agonistes et de corticoïdes pendant la période janvier-septembre 1998 versus janvier-septembre 1999. Les données ont été tirées du programme de la pharmacie clinique de l'hôpital. Résultats: Les frais ont été moins grands en 1999 qu'en 1998 (28,6% versus 37,6%). Les frais de ATB et de corti-coïdes ont diminué dans les services de pédiatrie générale (PG) et UCIN. Conclusion: Il est possible que le respect des lignes thérapeutiques recommandées et l'amélioration de la qualité des diagnostics réalisés pendant l'application de cette stratégie d'assistance, aient contribué à diminuer les frais de ATB, ?2 et de corticoïdes chez les enfants avec IRAB admis à l'hôpital.