Preliminary report of data collection in hospital quality assurance programs--a project of the Association of Hospitals of the Czech Republic.

OBJECTIVES: This was the first attempt of the association representing all acute care hospitals in the Czech Republic to collect mutual data which might be used for quality assurance (QA) purposes and which might lead to the development of national standards of care which could be used for hospital accreditation. Data collected included information which was available universally and which could be measured; in addition, information was intended to be similar in each hospital. In most cases, the data collection systems were based on financial information and data had to be identified which might be used for QA purposes, rather than being able to design a system specific for QA purposes. DESIGN: Since the hospital payment system was established in 1992, hospitals have had to develop data collection systems to measure clinical activity; this current study was based on this data collection, adapted to QA purposes. SETTING: The Executive Committee of the Hospital Association agreed to a pilot study of hospitals in 1993; data were collected from approximately 40 hospitals, beginning in 1994. STUDY PARTICIPANTS: Hospitals were chosen based on their ability to collect data and participate in the program, and it was determined that there should be variability in the hospitals, in size, location and activities, but that the data collected should be generic. INTERVENTIONS: Raw data included 33 different items, most of which were irrelevant to QA. Using a computer program, various combinations of data were reviewed and evaluated to ascertain the most appropriate for QA purposes. MAIN OUTCOME MEASURES: Data were chosen for study which included (a) data from the largest departments in the individual hospitals; (b) length of stay for patients hospitalized in these departments; (c) number of occupied beds/physician in the department and (d) mortality/1000 admissions to the department. RESULTS: The combination of (1) a long length of stay; (2) a high occupied bed/doctor ratio; and (3) a high mortality rate/1000 admissions might be indicators of poor quality. Additional factors to consider include: the type of department-emergency, cancer, geriatric, etc.; the nature of the medical activity-acute, referral, primary care, etc.; whether or not "social" beds are included and, generally, comparability among departments. However, as a pilot study, certain indicators can be determined which then can be used for future study to determine quality of care. The ability to cooperate and collect seemingly comparable data indicates reason for optimism in the future; more detailed and accurate studies can be carried out which will enable assessment of the quality of care given in comparable situations in hospitals throughout the Czech Republic.

Health-related quality of life in inflammatory bowel disease.

Inflammatory bowel disease (IBD) is characterised by a chronic, but frequently remitting, clinical course involving significant morbidity. As medical and surgical advances have occurred, focus has shifted from merely reducing mortality to efforts on decreasing morbidity and improving health status. With this paradigm shift has come the need for qualitative and quantitative assessment of outcomes important to the individual patient. Existing disease activity measures fall short in this area. Health-related quality of life encompasses the areas of physical function, somatic sensation, psychological state and social interactions that are affected by one's health status. Instruments have recently been developed for both generic and disease-specific health states, such as IBD. These psychometric measures have proven to be useful tools for patient assessment. Both medical and surgical trials have incorporated these measures as salient outcomes. An additional outcome that has come under closer scrutiny is the cost of medical interventions. The literature on the cost of IBD is sparse but is likely to increase logarithmically in the future. Quality of life and cost issues are becoming central to the study of not just IBD but all of medicine.

Family relationships of adults with borderline personality disorder.

Current, ongoing interactions between adults exhibiting borderline personality disorder (BPD) traits and their families of origin may influence and maintain self-destructive behavior. Family interactions in such patients are often characterized by coexisting extremes of overinvolvement and underinvolvement by parental figures. Such parental behavior may trigger preexisting role relationship schemata in vulnerable individuals. Negative family reactions to new behavior patterns may make change difficult. A model for how present-day interpersonal patterns lead to self-destructive behavior, based on clinical observations, is proposed and case examples are presented.

Effect of probabilistic inputs on neural network-based electric load forecasting.

This paper presents a novel method to include the uncertainties or the weather-related input variables in neural network-based electric load forecasting models. The new method consists of traditionally trained neural networks and a set of equations to calculate the mean value and confidence intervals of the forecasted load. This method was tested for daily peak load forecasts for one year by using modified data from a large power system. The tests indicate that in addition to the confidence interval, the new method provides a more accurate mean forecast than a multilayer perceptron networks alone.

Development of patient satisfaction surveys in the Czech Republic: a new approach to an old theme.

Although patient satisfaction surveys have become well established features of Western healthcare systems, free expression was suppressed for much of the past 50 years in the Czech Republic. As part of a quality assurance program established at the University Hospital Kralovske Vinohrady in Prague, and under the direction of a sociologist, a patient satisfaction pilot study was instituted as a precursor to a broader and ongoing survey. A cohort of 150 patients who were discharged following hospitalization on one of three medical or surgical services were given the opportunity to respond to a 36 item questionnaire devised as a result of study of similar instruments, 101 completed the questionnaire. Patients who responded were comparable to those hospitalized on these services, and other factors, demographic and otherwise, were likewise comparable. Once the concerns regarding the opportunity for free expression were addressed, it was found that interpersonal interactions with physicians, nurses, and other healthcare personnel provided the greatest satisfaction for patients and greatly exceeded amenities such as the quality of the hospital room and food. As a result of this pilot study, a subsequent survey of more than 500 patients has begun. It is believed that such surveys will provide useful data for quality assurance as well as involving patients in an assessment of the care provided.

Efficacy of depot leuprolide in premenstrual syndrome: effect of symptom severity and type in a controlled trial.

OBJECTIVE: To determine whether depot leuprolide is effective in premenstrual syndrome (PMS) and whether symptom type or severity affects therapeutic or hormonal responses and the incidence of adverse events. METHODS: Twenty-five women who met strict diagnostic criteria for PMS completed a double-blind, placebo-controlled, 6-month crossover trial at a university medical center. Depot leuprolide (3.75 mg/month) or saline was administered intramuscularly for three consecutive treatment cycles. Efficacy, adverse events, and hormone concentrations were assessed at each visit. Repeated-measures analysis of variance was used to analyze continuous data, and ordinal and binary data were analyzed using nonparametric techniques. RESULTS: Depot leuprolide treatment was significantly more effective than placebo on all rating scales. Irritability, neurologic symptoms, breast tenderness, and fatigue were most responsive to treatment. Symptoms were reduced to follicular phase levels only in women without premenstrual depression. Those with moderate premenstrual depression improved but remained clinically symptomatic, whereas the group with severe premenstrual depression showed no improvement on any efficacy measure. Adverse events were lowest in those without premenstrual depression and highest in those with severe depression. Leuprolide suppressed estradiol and progesterone in most premenstrual depression groups but had varying effects on gonadotropins. CONCLUSIONS: Leuprolide treatment reduced both behavioral and physical symptoms and was well tolerated in the absence of severe premenstrual depression. Women should be evaluated for depression severity before receiving a GnRH agonist. The differential response to leuprolide suggests that it may possess diagnostic value in determining distinct subtypes of PMS.

Health care in Armenia today.

Although one of the smallest of the new independent states of the former Soviet Union, the Republic of Armenia has an ancient tradition and a strong ethnic identification, greatly enhanced by the diaspora. In addition to the problems following the dissolution of the Soviet Union, Armenia has had to contend with a draining war in Nagorno-Karabakh and the after-effects of a devastating earthquake in 1988. Humanitarian efforts have ranged from emergency supply deliveries to longer-term sustainable health care partnerships. The United States government, through the Agency for International Development, has organized such partnerships, partially as a result of a multinational mission in 1992 and a subsequent hospital-to-hospital program developed by the American International Health Alliance. We describe the current state of health care in Armenia and some of the problems that need to be addressed to improve health care services to its citizens.

The physician manager in Eastern Europe and the former Soviet Union.

The physician manager feels hassled. There are increasing budgetary restraints, concerns over the appropriateness of resource utilization, and steadily increasing worry over governmental bureaucracy. In addition, there are concerns over patient satisfaction and increasing dissatisfaction by health care personnel. For all of this, the physician manager feels responsible. Sound familiar? Except that this physician manager is in one of the countries behind what formerly was called the "Iron Curtain," in Central and Eastern Europe or in one of the New Independent States of the former Soviet Union. Despite the striking political, economic, social, and organizational issues currently present, many of the problems faced by the physician manager in Central and Eastern Europe and in the New Independent States are remarkably similar to those encountered in the United States and Western Europe.

Health care and public health in the former Soviet Union, 1992. Ukraine--a case study.

The dissolution of the Soviet Union created many problems for the health care systems of the New Independent States (NIS). To address these problems, the U.S. Secretary of State convened a coordinating conference in Washington, D.C., on 22-23 January 1992 at which more than 50 nations and organizations were represented. After this conference, an expert medical working group visited 10 republics of the NIS during February and March 1992. Hospitals, public health facilities, and pharmaceutical plants and distribution sites were visited to assess the health care needs of a large population in a vast geographic area. It was concluded that the massive health care system of the Soviet Union remains largely intact but has major economic and supply deficiencies. The assessment process and findings in one republic, Ukraine, are presented. Ukraine was chosen because of its size, location, and representativeness.

Clinical patterns, natural history, and progression of ulcerative colitis. A long-term follow-up of 1116 patients.

We studied the natural history of ulcerative colitis (UC) by following 1116 patients in whom UC had been diagnosed or confirmed at The Cleveland Clinic Foundation between 1960 and 1983. Data before 1973 were obtained retrospectively. Criteria for inclusion in the study were: a diagnosis of UC confirmed by clinical, radiographic, endoscopic, and histologic examination; disease location that could be defined as one of three categories (proctosigmoiditis, pancolitis, or left-sided colitis); and a follow-up of at least five years (mean = 12.7 years). Mean age at diagnosis was 32 years. Of the 1116 patients, 46.2% (516) had proctosigmoiditis; 36.7% (410) had pancolitis (colitis of the entire large intestine); and 17.0% (190) had left-sided colitis (from the dentate line to the splenic flexure). Early complications (within two years of diagnosis) included colonic hemorrhage (16.7%) and toxic colitis (12.7%). Complications were highest among patients with pancolitis. Surgery was required for 37.6% of the patients. Primary indications for surgery included chronic or intractable disability (40.2%), fulminating medical failure (16.9%), and colonic dilatation (18.4%). At the most recent follow-up, the disease had extended (progressed to a more serious category) in 53.8% of the patients, although 67.2% were asymptomatic and only 37.0% were on medications. Both the final disease destination and the initial diagnosis impacted cumulative colectomy-ileostomy rates. Factors associated with extension were toxic colitis (P < 0.0001); extent of disease at diagnosis (P < 0.0001); joint symptoms (P = 0.0008); younger age at diagnosis (P = 0.06); and severe bleeding (P = 0.07).

Quality of life in multiple sclerosis. Comparison with inflammatory bowel disease and rheumatoid arthritis.

Multiple sclerosis (MS) and other chronic illnesses can drastically decrease quality of life (QOL), but there has been little systematic study of QOL in patients with chronic medical diseases. We analyzed QOL in 68 patients with MS, 164 patients with inflammatory bowel disease, and 75 patients with rheumatoid arthritis. The previously validated test instrument was a standardized interview consisting of 41 questions clustered in four subscales: functional and economic scale, social and recreational scale, affect and life in general scale, and medical problems scale. Patients were included in the study if they had a definite medical diagnosis and disease duration of 10 years or longer. In the patients with MS, Kurtzke's Expanded Disability Status Scale correlated strongly only with the medical problems score. Of Kurtzke's Functional System Scales, only the visual Functional System Scores was correlated with total QOL and subscale scores, suggesting that vision is strongly related to QOL. Duration of MS was unrelated to QOL scores. There were significant differences between patients with MS, inflammatory bowel disease, and rheumatoid arthritis on the subscale and total QOL scores. Results suggested that QOL was best in the inflammatory bowel disease group and worst in the MS group. Numerous statistically significant differences on individual questions were evident, suggesting that unique clinical profiles differentially characterize these diseases. Assessments of QOL are a meaningful addition to impairment scales, such as Kurtzke's Expanded Disability Status Scale. Furthermore, QOL scores may meaningfully measure the impact of a chronic medical disease, such as MS, compare the impacts of different diseases, and assess the effects of therapeutic intervention.

Colonic vasoactive intestinal peptide nerves in inflammatory bowel disease.

Vasoactive intestinal peptide is a neuropeptide with potent modulatory activity on intestinal immunity and may be implicated in the pathogenesis of inflammatory bowel disease (IBD). Previous studies have reported abnormal morphology of vasoactive intestinal peptide-stained enteric nerves, in addition to increased, normal or decreased levels of extractable peptide in Crohn's disease (CD) and ulcerative colitis (UC) tissues. These observations have not been correlated with the amount of enteric nerve fibers or the degree of mucosal inflammation. The investigation was intended to determine whether abnormalities of vasoactive intestinal peptide in IBD are related to quantitative changes of enteric nerve fibers or mucosal inflammation, and whether they are specific for CD or UC. To do this, digitized morphometric analysis was applied to a large number of IBD and control colonic surgical specimens that were immunostained for vasoactive intestinal peptide and S100 protein and scored for severity of inflammation. The results showed that, as compared with controls, there is a marked decrease of vasoactive intestinal peptide-immunoreactive nerve fibers in the lamina propria and submucosa (P less than 0.0001), and of S100-immunoreactive nerve fibers in the lamina propria (P less than 0.0001) of patients with IBD. In the lamina propria but not the submucosa, the variation of decrease is significantly associated with the severity (P less than 0.0001) but not the type (P greater than 0.9) of IBD because it is detected in both CD and UC. We conclude that in IBD there is loss of mucosal neuropeptidic innervation that is intimately associated with inflammation. This loss probably represents a nonspecific event subsequent to damage to enteric nerve fibers but may contribute to disruption of local immunoregulation.

Quality of life assessment by patients with inflammatory bowel disease.

Using a direct-interview technique, 164 ambulatory patients with inflammatory bowel disease were evaluated for quality of life. The sample comprised 94 patients with ulcerative colitis and 70 with Crohn's disease, and included both surgical and nonsurgical patients. The interview questionnaire consisted of 47 items in four categories: functional/economic, social/recreational, affect/life in general, and medical/symptoms. Patients with ulcerative colitis had better quality of life than those with Crohn's disease, and patients without surgery had better quality of life than those with surgery. These results are of value in assessing the results of medical and surgical therapy. Quality of life assessment by patients with inflammatory bowel disease gives information not usually obtained by physicians and has implications for quality assurance and outcome measurement.

Lower gastrointestinal bleeding in inflammatory bowel disease.

An increasing number of patients with inflammatory bowel disease (IBD) have been observed over the past two to three decades at the Cleveland Clinic. This has allowed extensive follow-up and determination of long-term prognosis. The diseases are chronic, require medication over a long period of time, are frequently associated with the need for operation, and often have complications and recurrences. In addition, a substantial number of patients have onset disease at a young age and thus, the propensity for recurrences and complications makes IBD of significant clinical importance. The symptoms of IBD are chronic and usually include diarrhea and often malnutrition. Rectal bleeding is found in almost all patients with ulcerative colitis and in about 25% of patients with Crohn's disease. However, severe hemorrhage in IBD occurs in a small number (1-5%) of patients. When this occurs, it often does so as an episode which may be associated with severe illness systemically as well as creating diagnostic confusion. For patients with ulcerative colitis, the progressive severity of bleeding may be an important indication for surgery (colectomy); in Crohn's disease, patients with ileocolic location of disease are more likely to have severe hemorrhage, and may require resection as a result. Despite the similarities of Crohn's disease and ulcerative colitis, there are significant differences particularly in the long-term (greater than 10 years) follow-up. For patients with Crohn's disease, the major long-term problem is the need for surgery (2/3-3/4 of patients) and recurrence (+/- 50%).(ABSTRACT TRUNCATED AT 250 WORDS)

Management of inflammatory bowel disease: 30 years of observation.

Management of inflammatory bowel disease has become more precise and effective in the last 30 years, ensuring long, productive lives for most patients. Data such as family history, duration of disease, the onset of complications, and type of therapy are presented from 450 patients with inflammatory bowel disease treated during a 10-year period ending in 1984. The incidence of general complications over three decades is compared. Perianal disease and intestinal obstructions dominate complications of Crohn's disease. The most common nongastrointestinal complication for patients with either disease is monarticular large joint arthritis. Approximately 75% of patients with Crohn's disease will eventually undergo surgery. In the first decade of data collection, 50% of patients with ulcerative colitis had surgery; in the second decade, 26%; and in the third decade, 39%. The changing percentages correspond initially to advances in medical therapy and then to advances in surgical therapy.

Surgical treatment of enterovesical fistulas in Crohn's disease.

A review of the surgical treatment of enterovesical fistula in Crohn's disease was undertaken to evaluate its effectiveness and long-term results. Sixty-three patients, 39 men and 24 women, with a mean age of 34.4 years were identified with enterovesical fistula. They had documented Crohn's disease for a mean period of 7.0 years. Distribution of anatomic pattern was 34.9 percent ileal, 7.9 percent colonic, and 57.2 percent ileocolic. Nineteen (30.1 percent) had previous abdominal surgery for Crohn's disease. Presenting symptoms included frequency and dysuria in 93.6 percent, pneumaturia in 79.3 percent, and fecaluria in 63.4 percent; 60.3 percent of patients had all three features. Enterovesical fistula was confirmed preoperatively in 43 patients, suspected clinically in 15 patients, and diagnosed intraoperatively in 5 patients. Sixty-one of 63 patients underwent surgery with resection of the phlegmon or abscess with the diseased bowel and curettage or resection of the fistula. After curettage of the bladder defect, pelvic and bladder drainage was instituted. Coexistent fistulas, most commonly ileosigmoid, occurred in 31 patients. Intra-abdominal abscesses were found in 21 patients, of whom 15 required two-stage procedures. One patient died (mortality 1.6 percent), urine leak occurred in 3.2 percent, and wound infection occurred in 1.6 percent. Follow-up (mean, 106 months) has identified one recurrence of enterovesical fistula due to Crohn's disease, and a further recurrence from concomitant sigmoid diverticulitis. Enterocutaneous fistulas developed in 6.4 percent and 11 patients (17.4 percent) have required further resections for Crohn's disease. Surgical treatment of enterovesical fistula in Crohn's disease is a safe and effective treatment.