Successful demand management in diagnostic immunology testing.

AIMS: We investigated whether we could have a material and sustained impact on immunology test ordering by primary care clinicians by building evidence-based and explanatory algorithms into test ordering software. METHODS: A service evaluation revealed cases of over-requesting of antinuclear antibody, allergen-specific IgE and total IgE tests, and under-requesting of urine protein electrophoresis. We conducted a quality improvement programme to address this. We determined the most effective and efficient intervention would be to embed evidence-based and advice-based decision-support algorithms in the ordering software. Consultation with general practitioners revealed lack of knowledge and confidence about testing, and an appetite for support. We iteratively designed and implemented algorithms for the four sets of tests for the primary care practices in our catchment and made them available to other hospital trusts in our region. The ordering system now contains links to advice sheets for clinicians and their patients and to an email address for queries to the lab. RESULTS: We observe large (36% to 88%) reductions in testing activity (workload) for the over-requested tests and large (28%-135%) increases for the under-requested test. We show that these changes are sustained. There have been no complaints from the clinicians and queries to the lab are now minimal (less than one per month on average). CONCLUSIONS: Embedding algorithms in the ordering software can be acceptable to clinicians and have a major and sustained impact on overuse or underuse of tests. The algorithms can be replicated by other hospital trusts.

Oxidative stress in alcohol-related liver disease.

Alcohol consumption is one of the leading causes of the global burden of disease and results in high healthcare and economic costs. Heavy alcohol misuse leads to alcohol-related liver disease, which is responsible for a significant proportion of alcohol-attributable deaths globally. Other than reducing alcohol consumption, there are currently no effective treatments for alcohol-related liver disease. Oxidative stress refers to an imbalance in the production and elimination of reactive oxygen species and antioxidants. It plays important roles in several aspects of alcohol-related liver disease pathogenesis. Here, we review how chronic alcohol use results in oxidative stress through increased metabolism via the cytochrome P450 2E1 system producing reactive oxygen species, acetaldehyde and protein and DNA adducts. These trigger inflammatory signaling pathways within the liver leading to expression of pro-inflammatory mediators causing hepatocyte apoptosis and necrosis. Reactive oxygen species exposure also results in mitochondrial stress within hepatocytes causing structural and functional dysregulation of mitochondria and upregulating apoptotic signaling. There is also evidence that oxidative stress as well as the direct effect of alcohol influences epigenetic regulation. Increased global histone methylation and acetylation and specific histone acetylation inhibits antioxidant responses and promotes expression of key pro-inflammatory genes. This review highlights aspects of the role of oxidative stress in disease pathogenesis that warrant further study including mitochondrial stress and epigenetic regulation. Improved understanding of these processes may identify novel targets for therapy.

Baptist Memorial Hospital for Women: quality lifelines for a lifetime.

OVERALL APPROACH TO QUALITY AND SAFETY: At Baptist Women's, a not-for-profit, 140-bed free-standing hospital, the Institute of Medicine's six quality dimensions are embedded into the quality blueprint and strategic plan. Quality initiatives and dashboards are shared through an established shared drive, which is accessible for all employees, to track performance on identified dashboards. IMPROVING MAMMOGRAPHY CYCLE TIME AT THE WOMEN'S HEALTH CENTER: Cycle time (arrival to departure) for mammography was identified as the top improvement priority. Increasing the percentage of patients who had preregistered reduced admission time, and process changes were made to move the patient through the center more efficiently. For example, patients with orders for additional films were flagged to ensure that these exams were completed before a new patient's exam. The ultrasound schedule was blocked during peak times to ensure that add-on exams could be performed in a timely manner. The cycle time was reduced for screening mammography (from 2 hours in 2003 to 30 minutes in April 2006) and diagnostic screenings, including review of films and reports with radiologist at departure, decreased from > 3 hours in 2003 to 2.5 hours in April 2006. CONCLUSION: Expectations of teamwork, proactive problem resolution, communication on all levels, and customer service are the cornerstone of Baptist Women's culture of quality.