Internal quality audit and quality standards as a method of quality improvement at the Department of Ophthalmology, University Hospital.

Quality assessment of clinical health care with the programme of quality standard is a method of health management, through which better efficiency and safety of health outcomes can be achieved. In the period from 2002 to 2004, a pilot program of quality has been carried out on the Department of Ophthalmology, University Hospital Center in Zagreb. Seven internal audit teams of hospital commission and teams of hospital departments were evaluating introducing practice for quality standards every three months. In the period of two years improvement in all standards of quality has been noticed (expressed in percent of progress towards the ideal result of 100%): personnel 20%, patient rights 15%, medical equipment 40%, quality of emergency service 60%, implementation of clinical guidelines and criteria for elective admission 55%, quality of risk prevention 70%, quality of medical records 60%. The two-years-improvement dynamics of about 46%, first year 24%.

Target intraocular pressure in the management of glaucoma.

Achievement of target intraocular pressure is the goal of every efficient antiglaucoma therapy. Target intraocular pressure is the level of intraocular pressure which is associated with minimal likelihood of visual field or optic nerve lesion, or an existing lesion progression due to elevated intraocular pressure. Results of large clinical studies which have offered some new concepts on target intraocular pressure in the management of glaucoma are reviewed. An association between the curve of intraocular pressure decrease and glaucoma progression was demonstrated in these studies. Generally, a lower value of target intraocular pressure implies better protection from the loss of vision and visual field impairment in glaucoma patients. In advanced glaucoma, the greatest possible reduction from the initial intraocular pressure should be attempted. A 20% reduction from the initial intraocular pressure or decrease to < 18 mmHg in advanced glaucoma has been recognized as a favorable strategy to reach target intraocular pressure. In normal tension glaucoma, a lower value of target intraocular pressure is associated with a slower disease progression. In patients with initial glaucoma, 25% reduction from the initial intraocular pressure will slow down the disease progression by 45%. The value of target intraocular pressure depends on the pretreatment level of intraocular pressure, optic nerve condition, glaucoma disease state, rate of glaucoma progression, patient's age, and other risk factors for the development of glaucoma.

A contribution to the surgery of the trachomatous entropion and trichiasis.

Although the WHO document WHO/PBL/93.29 recommends the bilamellar tarsal rotation operation for trachomatous entropion, we will describe another operation that has proved to be very reliable. It is a combined method, consisting of the modified tarsal wedge resection and the eversion splinting-grey line incision. A possible additional correction of the grey line incision on the first postoperative day improves the results. A total of 708 eyes with moderate trachomatous entropion and major trichiasis underwent this surgery, but only 508 of these were followed up during a 6-month period. The rate of failed operations, which consisted of incomplete closure of the lids or more than two inverted lashes remaining, was 6.9%.

Two ophthalmology departments financed by compulsory health insurance: what is it that makes a difference in costs and clinical effectiveness?

AIM: To identify factors contributing to significant differences between two university hospital departments of ophthalmology, one in Paris, France, and the other in Zagreb, Croatia, in their clinical effectiveness and cost-efficiency. METHOD: Structural, clinical, and financial characteristics of a Croatian and French ophthalmology department were compared for the 1996-2000 period. We used Paris ophthalmology department reports from 1996-2000 period as data source. Data on the Zagreb department performance for the same time period were obtained from the financial department. After comparative analysis of performance to show consistency and comparability of the two departments according to the type and prevalence of pathology, case-mix, and approaches to therapeutic, educational, and research activities, hospital budget analysis was performed, with special reference to the length of hospital stay according to diagnosis, number of examinations, material expenses, salaries, and investment. The variables analyzed were the number of emergency, regular, and hospitalized patients; number of physicians; number and type of surgical procedures; number of patients and length of hospital stay according to diagnosis; hospital budget distribution; and usage of hospital beds. RESULTS: Although the structure, technology, level of education, organization, and patient profile at the two departments were similar, the mean number of operative procedures per specialist per year was different (109.4 for Zagreb vs 199.2 for Paris). Hospital bed occupancy was 99.4% in Zagreb and 74.9% in Paris. The mean duration of hospital stay was 7.5 days in Zagreb and 2.2 days in Paris. Zagreb had considerably longer hospital stay for all diagnoses except severe infections. Zagreb had lower investment in new technologies (0.4%) than Paris (20.1%), and higher material expenses (33.2% vs 10.1%, respectively). CONCLUSION: Different instruments of hospital services payment result in different clinical and organizational behavior of the hospital personnel and management. The three-fold longer stay in Zagreb can be explained by the mechanism of service payment, which is based on payment for capacity and structure and process in Zagreb instead of payment for service and service-related outcomes in Paris. Comparison of the two departments indicates that clinical efficiency and effectiveness cannot and should not be separated from financial incentives that can stimulate (Paris) or discourage (Zagreb) rational and evidence-based clinical behavior.