Quality of medical care during and shortly after acute care restructuring in Newfoundland and Labrador.

OBJECTIVES: To critically evaluate the quality of hospital medical care at the beginning, during and shortly after regionalization of health boards in Newfoundland and Labrador, and aggregation of hospitals in the St John's region. METHODS: Retrospective chart audits for the years 1995/96, 1998/99 and 2000/01 (at the beginning, during and after restructuring) focused on outcomes in cardiology, respiratory medicine, neurology, nephrology, psychiatry, surgery and women's health programmes. Where possible, quality of care was judged on measurable outcomes in relation to published statements of likely optimal care. Comparisons were made over time within the St John's region, and separately for hospitals in the rest of the province. RESULTS: There was improvement in the use of thrombolytics and secondary measures post-myocardial infarction in both regions. Mortality and appropriateness of initial antibiotic choice for community-acquired pneumonia remained stable in both regions, with an improvement in admission appropriateness based on the severity in St John's. Aspects of stroke management (referral and time to see allied health professionals, imaging and discharge home) improved in both regions, while mortality remained stable. There was improvement in fistula rate, quality of dialysis and anaemia management in haemodialysis patients, and improvement in the peritoneal dialysis patient peritonitis rate. Readmission rate for schizophrenia remained unchanged. Stable mortality rates were observed for frequently performed surgical procedures. The post-coronary artery bypass grafting (CABG) morbid event rate improved, although access to CABG was not optimal. CONCLUSIONS: Aggregation of acute care hospitals was feasible without attendant deterioration in patient care, and in some areas care improved. However, access to services continued to be a major problem in all regions.

Serial change in echocardiographic parameters and cardiac failure in end-stage renal disease.

Echocardiographic abnormalities are the rule in patients starting dialysis therapy and are associated with the development of cardiac failure and death. It is unknown, however, whether regression of these abnormalities is associated with an improvement in prognosis. As part of a prospective cohort study with mean follow-up of 41 mo, 227 patients had echocardiography at inception and after 1 yr of dialysis therapy. Improvements in left ventricular (LV) mass index, volume index, and fractional shortening were seen in 48, 48, and 46%, respectively. Ninety patients had developed cardiac failure by 1 yr of dialysis therapy. Twenty-six percent of the remaining 137 patients subsequently developed new-onset cardiac failure. The mean changes in LV mass index were 17 g/m(2) in those who subsequently developed cardiac failure compared with 0 g/m(2) among those who did not (P = 0.05). The corresponding values were -8 versus 0% for fractional shortening (P < 0.0001). The associations between serial change in both LV mass index and fractional shortening and subsequent cardiac failure persisted after adjusting for baseline age, diabetes, ischemic heart disease, and the corresponding baseline echocardiographic parameter. Regression of LV abnormalities is associated with an improved cardiac outcome in dialysis patients. Serial echocardiography adds prognostic information to one performed at baseline.