Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men: study protocol for a randomised controlled trial.

BACKGROUND: Lower urinary tract symptoms (LUTS) comprise storage symptoms, voiding symptoms and post-voiding symptoms. Prevalence and severity of LUTS increase with age and the progressive increase in the aged population group has emphasised the importance to our society of appropriate and effective management of male LUTS. Identification of causal mechanisms is needed to optimise treatment and uroflowmetry is the simplest non-invasive test of voiding function. Invasive urodynamics can evaluate storage function and voiding function; however, there is currently insufficient evidence to support urodynamics becoming part of routine practice in the clinical evaluation of male LUTS. DESIGN: A 2-arm trial, set in urology departments of at least 26 National Health Service (NHS) hospitals in the United Kingdom (UK), randomising men with bothersome LUTS for whom surgeons would consider offering surgery, between a care pathway based on urodynamic tests with invasive multichannel cystometry and a care pathway based on non-invasive routine tests. The aim of the trial is to determine whether a care pathway not including invasive urodynamics is no worse for men in terms of symptom outcome than one in which it is included, at 18 months after randomisation. This primary clinical outcome will be measured with the International Prostate Symptom Score (IPSS). We will also establish whether inclusion of invasive urodynamics reduces rates of bladder outlet surgery as a main secondary outcome. DISCUSSION: The general population has an increased life-expectancy and, as men get older, their prostates enlarge and potentially cause benign prostatic obstruction (BPO) which often requires surgery. Furthermore, voiding symptoms become increasingly prevalent, some of which may not be due to BPO. Therefore, as the population ages, more operations will be considered to relieve BPO, some of which may not actually be appropriate. Hence, there is sustained interest in the diagnostic pathway and this trial could improve the chances of an accurate diagnosis and reduce overall numbers of surgical interventions for BPO in the NHS. The morbidity, and therapy costs, of testing must be weighed against the cost saving of surgery reduction. TRIAL REGISTRATION: Controlled-trials.com - ISRCTN56164274 (confirmed registration: 8 April 2014).

Validating risk-adjusted surgical outcomes: site visit assessment of process and structure. National VA Surgical Risk Study.

BACKGROUND: Risk-adjusted mortality and morbidity rates are often used as measures of the quality of surgical care. This study was conducted to determine the validity of risk-adjusted surgical morbidity and mortality rates as measures of quality of care by assessing the process and structure of care in surgical services with higher-than-expected and lower-than-expected risk-adjusted 30-day mortality and morbidity rates. STUDY DESIGN: A structural survey of 44 Veterans Affairs Medical Center surgical services and site visits to 20 surgical services with higher-than-expected and lower-than-expected risk-adjusted outcomes were conducted. Main outcome measures included assessment of technology and equipment, technical competence of staff, leadership, relationship with other services, monitoring of quality of care, coordination of work, relationship with affiliated institutions, and overall quality of care. RESULTS: Surgical services with lower-than-expected risk-adjusted surgical morbidity and mortality rates had significantly more equipment available in surgical intensive care units than did services with higher-than-expected outcomes (4.3 versus 2.9, p < 0.05). Site-visitor ratings of overall quality of care were significantly higher for surgical services with lower-than-expected morbidity and mortality rates (6.1 versus 4.5 for high outliers, p < 0.05); technology and equipment were rated significantly better among low-outlier services (7.1 versus 4.8 for high outliers, p < 0.001). Masked site-visit teams correctly predicted the outlier status (high versus low) of 17 of the 20 surgical services visited (p < 0.001). CONCLUSIONS: Significant differences in several dimensions of process and structure of the delivery of surgical care are associated with differences in risk-adjusted surgical morbidity and mortality rates among 44 Veterans Affairs Medical Centers.

Patterns of coordination and clinical outcomes: a study of surgical services.

OBJECTIVE: To test the hypothesis that surgical services combining relatively high levels of feedback and programming approaches to the coordination of surgical staff would have better quality of care than surgical services using low levels of both coordination approaches as well as those surgical service using low levels of either coordination approach. STUDY SETTING: A study sample of 44 academically affiliated surgical services that are part of the Department of Veterans Affairs. STUDY DESIGN: In a cross-sectional analysis, surgical services were assigned to one of three groups based on their scores on feedback and programming coordination measures: high on both measures; high on one measure, low on the other; and low on both. Univariate and multivariate analyses were used to assess differences among these groups with respect to three quality indicators: risk-adjusted mortality, risk-adjusted morbidity, and staff perceptions of quality. DATA COLLECTION/EXTRACTION METHODS: Risk-adjusted mortality and morbidity came from an outcomes reporting program within the Department of Veterans Affairs that entails the prospective collection of clinical data from patient charts. Data on coordination practices and perceived quality came from a survey of surgical staff at each of the 44 participating surgical services. PRINCIPAL FINDINGS: The group of surgical services using high feedback and high programming had the best perceived quality. This group also had the lowest morbidity, but the difference was statistically significant with respect to only one of the two other groups: the group with low feedback and low programming. No significant group differences were found for mortality. CONCLUSIONS: Study results provide partial support for the hypothesis that high levels of feedback and programming should be combined for optimal quality of care. Study results also suggest that staff coordination is more important for improving morbidity than mortality in surgical services.

Cleavage in vivo and in culture in the Dasyurid marsupial Antechinus stuartii (macleay).

Cleavage in the brown marsupial mouse, Antechinus stuartii, from the zygote to the unilaminar blastocyst, was observed in vivo and in culture and in sections of embryos. The first three divisions were meridional and passed from the yolk pole to the opposite pole. Deutoplasmolysis, resulting in a distinct yolk mass, occurred during the first two divisions. Prior to the third and fourth divisions, the blastomeres elongated and flattened against the zona pellucida. The fourth division was latitudinal and resulted in two histologically distinct rings of eight blastomeres which were at first rounded and then became flattened against the zona. Further divisions and flattening of the blastomeres resulted in a complete unilaminar blastocyst by the time the blastocyst numbered 22 to 30 cells. Some expansion, causing compression of the zona and mucoid layers, occurred before completion of the blastocyst, but most expansion occurred once the blastocyst was complete. No histological differences could be detected between the blastomeres at this stage. Embryos were successfully cultured from the zygote to the rounded four-cell stage and from the flattened four-cell stage to the completed unilaminar blastocyst of around 32 cells. Total estimated cleavage times were slower in culture than in vivo, but the relative lengths of time for each division were approximately the same.

Implementing quality improvement in hospitals: the role of leadership and culture.

Many advocates of quality improvement (QI) suggest that there is a link between an organization's leadership commitment and culture and its ability to implement a QI initiative. This paper reports empirical evidence from a study of QI implementation in Veterans Health Administration (VHA) hospitals that supports this hypothesized linkage. The findings suggest that the extent to which top management becomes directly involved in QI activities determines the degree of QI implementation. Additionally, study findings suggest that a culture emphasizing innovation and teamwork provides an important foundation for implementing a QI initiative. We discuss the implications of these findings for organizational leaders interested in implementing QI.

Clinical practice guidelines in the nursing home.

Clinical practice guidelines are an important tool for improving quality of care. This study determined whether and how guidelines are being used in nursing homes. We surveyed staff at 36 Department of Veterans Affairs (VA) nursing homes. Employees were asked whether they were familiar with guidelines as well as whether 5 specific guidelines had been read, were available, and had been adopted. Among 1065 respondents (60% of those surveyed), 79% reported familiarity with guidelines. The proportion of staff at a facility reporting adoption was generally less than 50%. Those nursing homes in which a high percentage of the staff reported adoption of one guideline were more likely to have adopted other guidelines. However, staff were not more likely to report adoption of a specific guideline when the nurse manager stated that it was adopted. We conclude that staff at VA nursing homes are familiar with guidelines. Guideline adoption at individual nursing homes, however, is not a systematic process involving the entire staff.

Insider representation on the governing boards of nonprofit hospitals: trends and implications for charitable care.

Evidence indicates that the traditional, nonprofit hospital governing board, which is heavily comprised of community representatives, is changing to favor more insiders from the hospital's senior management and medical staff. In this study, I examine this trend, as well as the relationship between insider representation and the amount of charitable care hospitals provide to their community. Study results indicate that insider representation on hospital boards increased substantially during the 1980s. The findings also imply that the relationship between insider representation and the provision of charitable care depends on contextual factors related to the hospital's viability.

Inequities in hospital care, the Massachusetts experience.

This study examined the relationship between patient insurance status and the process and outcome of hospital care in Massachusetts, a state that has had an uncompensated care pool for paying hospitals since 1986. This study examined data on 4,972 patients admitted to a Massachusetts hospital on an emergency basis in 1987 and diagnosed with acute myocardial infarction. We classified these patients into three groups: having fee-for-service insurance, having prepaid coverage through a health maintenance organization (HMO), or being uninsured at the time of hospital admission. Results showed treatment differences by insurance status and significantly greater mortality rates for uninsured patients than for either fee-for-service or HMO patients. Our findings indicate that in Massachusetts the process and outcome of hospital care do differ by insurance status.

The process and outcome of hospital care for Medicaid versus privately insured hospital patients.

Some have argued that low Medicaid payment rates compromise the accessibility and quality of medical care for Medicaid beneficiaries. In this study we compare the process and outcome of hospital care for Medicaid versus privately insured hospital patients. We studied 4,033 emergency patients admitted with a principal diagnosis of acute myocardial infarction, to Massachusetts hospitals in 1987. After we statistically adjusted for differences among patients relating to clinical and demographic characteristics and the type of hospital where treatment occurred, we found that the Medicaid patients had longer hospital stays but were less likely to receive three selected coronary procedures. Moreover, after controlling for confounding variables, we found the risk of death for Medicaid patients to be almost twice as high as for privately insured patients.

Bridging public and private sector quality assurance.

Just as the private sector has emerged as the predominant force the greater efficiency in the delivery of health care services, so too is the private sector gaining importance as a source of quality oversight strategies. Public reliance on private sector quality assurance efforts is being fueled by such developments as the growth in the number and diversity of private health care accrediting agencies, and the increase in consumer and purchaser-driven demands for comparative information about the quality of health care providers.

Clinical service lines in integrated delivery systems: an initial framework and exploration.

The increasing pressures on integrated healthcare delivery systems (IDSs) to provide coordinated and cost-effective care focuses attention on the question of how to best integrate across multiple sites of care. One increasingly common approach to this issue is the development of clinical service lines that integrate specific bundles of services across the operating units of a system. This article presents a conceptual model of service lines and reports results from a descriptive investigation of service line development among members of the Industry Advisory Board--a research consortium comprising IDSs. The experiences of these IDSs (1) provide valuable insights into the range of organizational arrangements and implementation issues that are associated with service line management in healthcare systems and (2) suggest aspects of service line management worthy of further inquiry.

Reflex sympathetic dystrophy syndrome.

Reflex sympathetic dystrophy syndrome is a troublesome, complex disorder that presents with chronic, unexplained aching or burning pain, the intensity of which is incommensurable with the original injury. Six diagnostic criteria have been described by Genant et al: pain and tenderness in the extremities; swelling of soft tissue; diminished motor function; trophic skin changes; vasomotor instability; and patchy osteoporosis. Currently, the most widely accepted etiology is an initial vasomotor reflex spasm occurring after an injury to the extremity, followed by a loss of vascular tone, persistent vasodilation, and rapid bone resorption.

Fast, flexible, and fluid: the continuing success of the Charlotte-Mecklenburg Hospital Authority in an era of public hospital crisis.

The changing face of health care delivery continues to challenge public hospitals, and many of these hospitals are in danger of closing. Increasing numbers of uninsured patients, coupled with state and federal cuts in Medicaid spending, threaten to worsen the situation. These facilities' survival may well depend upon their ability to create integrated delivery systems (IDSs). However, public hospitals are likely to face significant barriers in forming and participating in IDSs. This article present some of the barriers facing public hospitals as they attempt to form an IDS. Additionally, the authors present a brief case study of a public hospital whose successful efforts to form an IDS began before the IDS concept became popular. In forming an IDS this public hospital has strengthened its commitment to research, education, and the delivery of quality public health care.