Fourteen years of quality improvement education in healthcare: a utilisation-focused evaluation using concept mapping.

Background: The need for training in quality improvement for healthcare staff is well acknowledged, but long-term outcomes of such training are hard to evaluate. Behaviour change, improved organisational performance and results are sought for, but these variables are complex, multifactorial and difficult to assess. Aim: The purpose of this article is to explore the personal and organisational outcomes identified by participants over 14 years of university-led QI courses for healthcare professionals. Method: Inspired by the Kirkpatrick model for evaluation, we used concept mapping, a structured mixed method that allows for richness of data to be captured and visualised by inviting stakeholders throughout the process. In total, 331 previous course participants were included in the study by responding to two prompts, and 19 stakeholders taking part in the analysis process by doing the sorting. Result: Two maps, one for personal outcomes and one for organisational outcomes, show clusters of the responses from previous course participants and how the outcomes relate to each other in meta-clusters. Both maps show possible long-term outcomes described by the previous course participants. Conclusion: The results of this study indicate that it is possible that training in quality improvement with a strong experiential pedagogical approach fosters a long-term improvement capability for the course participants and, even more important, a long-term improvement capability (and increased improvement skill) in their respective organisations.

From process management towards dynamic capability.

No abstract available.

Is early treatment of acute chest pain provided sooner to patients who speak the national language?

OBJECTIVE: Identify differences in the early treatment of acute chest pain patients with regard to the language proficiency of patients and thus identify opportunities for improving equity in cardiac care. DESIGN: Retrospective cross-sectional study comparing care delivered to Swedish-speaking (SS) and non-Swedish-speaking (NSS) patients. SETTING: A Swedish university hospital that provides highly specialized care to 1.6 million inhabitants. PARTICIPANTS: All patients with acute chest pain or symptoms suggestive of acute coronary syndrome who sought care between mid-September and mid-December 2008 (2588 visits). Missing data on the patient group to which study subjects belonged were 2% (45 visits). NSS represented 8% of the 2543 visits (NSS = 2334; NNSS = 209). MAIN OUTCOME MEASURE(S): Delay times from arrival in hospital to admission to catheterization laboratory or ward (ΔTHOSP-PCI), first physical contact to first electrocardiogram (ΔTCONTACT-ECG), first physical contact to first aspirin (ΔTCONTACT-ASA) and arrival in hospital to coronary angiography (ΔTHOSP-ANGIO). Also included baseline characteristics of patients, diagnosis and findings in hospital and secondary preventive activities. RESULTS: The median ΔTHOSP-PCI was longer for NSS by 43 min [254 versus 211, 95% confidence interval (CI), odds ratio (OR) = (1.3; 2.8)]. The median ΔTCONTACT-ECG and ΔTHOSP-ANGIO were longer for NSS by 4 min [17 versus 13, 95% CI, OR = (0.8; 1.8)] and 14 h [44 versus 30, 95% CI, OR = (0.6; 3.6)], respectively. Conversely, the median ΔTCONTACT-ASA was longer for SS by 20 min [81 versus 61, 95% CI, OR = (0.3; 1.6)]. CONCLUSIONS: Poorer language proficiency was associated with longer delay time from arrival in hospital to admission to catheterization laboratory or ward. No other delay times were found to be statistically significantly different with respect to the language proficiency of patients.

Patients admitted to hospital with chest pain--changes in a 20-year perspective.

OBJECTIVES: To describe the differences in characteristics and outcome between two consecutive series of patients admitted to hospital with chest pain in a 20-year perspective. Particular emphasis is placed on changes in outcome in relation to the initial electrocardiogram (ECG). SUBJECTS: In the two periods, 1986-1987 and 2008, all patients with chest pain admitted to the study hospitals in Gothenburg, Sweden, were included. RESULTS: Five thousand and sixteen patients were registered in a period of 21 months in 1986-1987 and 2287 patients were registered during 3 months in 2008. In a comparison of the two time periods, the age of chest pain patients was not significantly different (mean age 60.1 ± 17.8 years in 1986-1987 and 59.8 ± 19.1 years in 2008, p=0.50). There was a lower prevalence of previous angina pectoris, congestive heart failure and current smoking in the second period, whereas a history of acute myocardial infarction, hypertension and diabetes mellitus had become more prevalent. The use of cardio-protective drugs increased and ECG changes indicating acute myocardial ischemia on admission to hospital decreased. Length of hospitalisation was reduced from a median of 5 days to 3 days (p<0.0001). A significant decrease in 30-day and 1-year mortality was found (3.8% in 1986-1987 vs 2.0% in 2008 and 9.9% vs 6.3% respectively, p<0.0001 for both comparisons). CONCLUSIONS: During a period of 20 years, the characteristics and outcome of patients admitted to hospital with chest pain changed. The most important changes were a lower prevalence of ECG signs indicating acute myocardial ischemia on admission, shorter hospitalisation time and a lower 30-day and 1-year mortality.

Characteristics of and outcome for patients with chest pain in relation to transport by the emergency medical services in a 20-year perspective.

AIM: The aims of this study were to describe the characteristics of and outcome of patients with chest pain in relation to transport by the emergency medical services (EMS) and to describe possible changes in this relationship in a 20-year perspective. METHODS: In the 2 periods, 1986 to 1987 and 2008, all patients with chest pain admitted to hospitals in Gothenburg, Sweden, were retrospectively evaluated in terms of previous history, final diagnosis, and mortality. P values were age adjusted. RESULTS: In 1986 to 1987 and 2008, 34% of 4270 patients with chest pain and 39% of 2286 patients, respectively, were transported to the hospital by the EMS (P = .0001). In both periods, patients who used EMS were older and had a higher prevalence of previous cardiovascular diseases and more often had a final diagnosis of acute myocardial infarction (AMI) than those who did not use EMS. The EMS users were more frequently hospitalized in 1986 to 1987 than in 2008 (P < .0001). Emergency medical service use was related to a significantly higher age-adjusted 1-year mortality in both periods for all patients with chest pain as well as for those hospitalized. Among hospitalized patients with myocardial ischemia and among patients with a final diagnosis of AMI, EMS use was associated with a higher 30-day mortality in 1986 to 1987. Regardless of the use of EMS, there was a decrease in the proportion of patients developing AMI as well as the rate of death at 30 days and 1 year in 2008 as compared with 1986 to 1987. CONCLUSIONS: For 20 years, the proportion of patients with chest pain using the EMS increased. EMS users were more frequently hospitalized in 1986 to 1987 than in 2008. In overall terms, mortality was higher among EMS users than among nonusers in both periods. Among hospitalized patients with myocardial ischemia and among patients with a final diagnosis of AMI, EMS use was associated with a higher 30-day mortality only in 1986 to 1987.

Inequalities in the early treatment of women and men with acute chest pain?

PURPOSE: The aim of this study was to identify sex differences in the early chain of care for patients with chest pain. DESIGN: This is a retrospective study performed at 3 centers including all patients admitted to the emergency department because of chest pain, during a 3-month period in 2008, in the municipality of Göteborg. Chest pain or discomfort in the chest was the only inclusion criterion. There were no exclusion criteria. DATA SOURCES: Data were retrospectively collected from ambulance and medical records and electrocardiogram (ECG), echocardiography, and laboratory databases. MAIN FINDINGS: A total of 2588 visits (1248 women and 1340 men) made by 2393 patients were included. When adjusting for baseline variables, female sex was significantly associated with a prolonged delay time (defined as above median) between (a) admission to hospital and admission to a hospital ward (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.25-2.03), (b) first physical contact and first dose of aspirin (OR, 2.22; 95% CI, 1.30-3.82), and (c) admission to hospital and coronary angiography (OR, 2.50; 95% CI, 1.29-5.13). Delay time to the first ECG recording did not differ significantly between women and men. PRINCIPAL CONCLUSIONS: Among patients hospitalized due to chest pain, when adjusting for differences at baseline, female sex was associated with a prolonged delay time until admission to a hospital ward, to administration of aspirin, and to performing a coronary angiography. There was no difference in delay to the first ECG recording.

The meaning of variation to healthcare managers, clinical and health-services researchers, and individual patients.

Healthcare managers, clinical researchers and individual patients (and their physicians) manage variation differently to achieve different ends. First, managers are primarily concerned with the performance of care processes over time. Their time horizon is relatively short, and the improvements they are concerned with are pragmatic and 'holistic.' Their goal is to create processes that are stable and effective. The analytical techniques of statistical process control effectively reflect these concerns. Second, clinical and health-services researchers are interested in the effectiveness of care and the generalisability of findings. They seek to control variation by their study design methods. Their primary question is: 'Does A cause B, everything else being equal?' Consequently, randomised controlled trials and regression models are the research methods of choice. The focus of this reductionist approach is on the 'average patient' in the group being observed rather than the individual patient working with the individual care provider. Third, individual patients are primarily concerned with the nature and quality of their own care and clinical outcomes. They and their care providers are not primarily seeking to generalise beyond the unique individual. We propose that the gold standard for helping individual patients with chronic conditions should be longitudinal factorial design of trials with individual patients. Understanding how these three groups deal differently with variation can help appreciate these three approaches.

Five main processes in healthcare: a citizen perspective.

A citizen point of view on the healthcare system, its processes and their improvement is emphasised. From this point of view, five main processes are identified: Keeping Healthy, Detecting Health Problems, Diagnosing Diseases, Treating Diseases and Providing for a Good End of Life. The citizen should be looked upon as a cocreator of value and improvement of these processes.

Problems and promises of innovation: why healthcare needs to rethink its love/hate relationship with the new.

Innovation is often regarded as uniformly positive. This paper shows that the role of innovation in quality improvement is more complicated. The authors identify three known paradoxes of innovation in healthcare. First, some innovations diffuse rapidly, yet are of unproven value or limited value, or pose risks, while other innovations that could potentially deliver benefits to patients remain slow to achieve uptake. Second, participatory, cooperative approaches may be the best way of achieving sustainable, positive innovation, yet relying solely on such approaches may disrupt positive innovation. Third, improvement clearly depends upon change, but change always generates new challenges. Quality improvement systems may struggle to keep up with the pace of innovation, yet evaluation of innovation is often too narrowly focused for the system-wide effects of new practices or technologies to be understood. A new recognition of the problems of innovation is proposed and it is argued that new approaches to addressing them are needed.

Personality disorders are not associated with nonrecovery in patients with traffic-related minor musculoskeletal injuries.

BACKGROUND: Personality disorders (PDs) have been suggested to be one of the determinants that might influence recovery after injuries but has rarely been measured. This study describes the occurrence of PDs among patients with minor traffic-related musculoskeletal injuries and relates these disorders to nonrecovery 12 months after the injury. METHODS: This is a single-center, prospective, cohort study. We included patients with minor traffic-related musculoskeletal injuries at a general hospital in Stockholm, Sweden, with a catchment area of 0.6 million people. Structured Clinical Interview II screen questionnaire was used to measure PD. Outcome measure were self-reported recovery at 12 months (yes/no). RESULTS: Fifty-one percent of all patients (102 of 200) had at least one PD, and 20% had at least two. The proportion of nonrecovered was 50% (51 of 102) among those with one or more PD compared with 39% (38 of 98) among those without any PD (p = 0.12). Patients with a Cluster A (paranoid, schizoid, and schitzotypal) or Cluster B (borderline, histrionic, narcissistic, and antisocial) PD were associated with nonrecovery. When compared with patients without any PD, patients with a Cluster A or Cluster B PD had an increased risk of nonrecovery (OR: 2.5; 95% CI: 1.0 -5.9 and OR: 2.1; 95% CI: 1.2-3.8, respectively). However, after adjusting for mental health factors at the time of the injury, these associations were no longer significant. DISCUSSION: PDs are common among patients with minor traffic-related musculoskeletal injuries. Our study does not support the view that PDs are associated with nonrecovery. The patient's mental health status at the time of the crash seems to be more important for nonrecovery than a PD.

Four post-and-core combinations as abutments for fixed single crowns: a prospective up to 10-year study.

PURPOSE: In the present prospective study, four different post-and-core systems were evaluated over a period of up to 10 years. MATERIALS AND METHODS: Fifty endodontically treated teeth in 31 patients were randomized to one of four groups for post-and-core placement: Group 1 received conventional tapered cast posts and cores (n = 14); group 2 received ParaPost system prefabricated gold posts with cast cores (n = 13); group 3 received ParaPost system cast posts and cores (n = 13); and group 4 received Radix-Anchor posts (n = 10). Clinical and radiologic evaluations were made. RESULTS: One post and core in group 2 was functioning well 58 months after placement when the patient died. No posts and cores in groups 1 or 2 had been lost or had any complications, one in group 3 had been lost because of a root fracture after 108 months, and two in group 4 had been lost after 54 and 88 months, respectively, because of loss of retention. The final treatment result for 46 of the 49 remaining posts (30 patients) was successful. The overall failure rate was 6%. There were no statistically significant differences between the four groups. CONCLUSION: If recommended procedures are strictly followed, posts and cores can serve as abutments for fixed single crowns with satisfactory long-term results.

An intraindividual clinical comparison of two metal-ceramic systems: a 5-year prospective study.

PURPOSE: Earlier studies on low-fusing ceramics have shown the occurrence of changes over time regarding surface and color. The present prospective study is an ongoing follow-up of an intraindividual comparison between two metal-ceramic systems, the Procera system (titanium copings veneered with a low-fusing ceramic) and noble-alloy copings veneered with a medium-fusing ceramic. MATERIALS AND METHODS: Twenty-one crown pairs were fabricated for 18 patients. After 5 years, 18 crown pairs in 15 patients were available for comparison. The crowns were examined shortly after cementation (baseline), and after 1, 2, and 5 years. The crowns were rated according to the CDA system. Bleeding index and margin index were also evaluated. RESULTS: Obvious changes regarding surface and color were noted for the titanium-ceramic crowns. The difference between the two types of crowns was statistically significant at 5 years (P = .004). The differences between the two systems regarding anatomic form, margin integrity, bleeding index, and margin index were small. CONCLUSION: Within the limitations of this study, it is concluded that low-fusing ceramic-veneered titanium copings are inferior to medium-fusing ceramic-veneered conventional copings regarding surface and color of the ceramic. Therefore, conventional ceramic-veneered crowns seem to be preferable, at least in the anterior area, where the esthetic requirements are greater than in premolar and molar regions. Whether possible changes in the properties of low-fusing ceramics will reduce the differences between the two types of metal-ceramic crowns remains to be proven.

A four-year follow-up study of male alcoholics: factors affecting the risk of readmission.

This study is based on a consecutive series of 52 male alcoholics who have been followed up for 4 years after inpatient detoxification. The aim was to identify risk factors for readmission for alcohol detoxification. Information was collected individually, and psychiatric status, physiologic conditions at admission, personality profile, platelet monoamine oxidase (MAO) activity level, current psychosocial living conditions, as well as those during childhood/adolescence, and a history of alcohol and drug abuse were comprised. This information was supplemented by register data on hospital admissions covering the period of 4 years before the admission in question to 4 years after it. The main findings of this follow-up study revealed five risk factors for readmission; namely, heavy drinking before admission, a high gamma-glutamyltransferase level at admission, previous somatic care, and a sensation-seeking behavior in combination with a low platelet MAO activity level (odds ratios ranging from 4.2 to 10.2). The second year after admission seemed to be the most critical time for readmission.

[Compression dressing after hip joint replacement reduces the need of allogeneic blood transfusion]. / Kompressionsförband minskar behovet av allogent blod vid höftproteskirurgi.

Allogeneic blood transfusion may increase the risk for postoperative infections, allergic reactions and transmission of diseases. The aim with the present study was to evaluate the effect on blood saving with a new type of compression dressing after hip joint replacement surgery. 50 patients undergoing after hip joint replacement surgery were prospectively allocated to postoperatively get a standard dressing (n = 24) or the new type of a compression dressing (n = 26). The peroperative bleeding was similar in both groups. The need for allogeneic blood transfusions were significantly higher in the group of patients that got standard dressing. This study indicates that the compression dressing reduces the need for allogeneic blood transfusions after after hip joint replacement surgery.

Alcohol Withdrawal, Psychological Symptoms, and Treatment Success.

Twenty-nine chronic male alcoholics were examined with the Profile of Mood States (POMS). Tests with the POMS scale were carried out on the ward on Days 1 and 5 and after 21 days of sobriety. Our aim was to study the mood change in chronic alcoholics during detoxification and after 3 weeks of sobriety compared with a standard group (college students) and with psychiatric outpatients. A further aim was to study whether the patients who later underwent a Minnesota treatment program(n = 6) differed in mood compared with those who did not. An improvement was observed over time regarding all six POMS factors. The results for Day 21 were generally better than the expected normal values for the POMS profile sheet with regard to both psychiatric outpatients and college norms. The follow-up based on the patients' records 1.5-2 years after the detoxification occasion in question showed that 18 patients had been hospitalized, generally for alcohol detoxification. The 6 patients who participated in a Minnesota treatment program had no documented relapses. A comparison of these 6 patients with the rest showed that the former had significantly lower values on five of the subscales.

Tratamiento prostodóntico para el parcialmente desdentado

El medio parcialmente desdentado. Preparación de pacientes para la atención prostodóncica fija e removible. Principios de la oclusión y el uso de articuladores en prostodoncia parcial. Propiedades biomecánicas de los materiales empleados. Prostodoncia parcial fija: protocolo clínico y de laboratorio. Prostodoncia parcial removible: protocolo clínico y de laboratorio. Técnicas clínicas diferentes para el desdentado parcial. prostodoncia maxilofacial y el parcialmente desdentado

Tratamiento prostodóntico para el parcialmente desdentado

El medio parcialmente desdentado. Preparación de pacientes para la atención prostodóncica fija e removible. Principios de la oclusión y el uso de articuladores en prostodoncia parcial. Propiedades biomecánicas de los materiales empleados. Prostodoncia parcial fija: protocolo clínico y de laboratorio. Prostodoncia parcial removible: protocolo clínico y de laboratorio. Técnicas clínicas diferentes para el desdentado parcial. prostodoncia maxilofacial y el parcialmente desdentado

Tratamiento prostodóntico para el parcialmente desdentado

El medio parcialmente desdentado. Preparación de pacientes para la atención prostodóncica fija e removible. Principios de la oclusión y el uso de articuladores en prostodoncia parcial. Propiedades biomecánicas de los materiales empleados. Prostodoncia parcial fija: protocolo clínico y de laboratorio. Prostodoncia parcial removible: protocolo clínico y de laboratorio. Técnicas clínicas diferentes para el desdentado parcial. prostodoncia maxilofacial y el parcialmente desdentado

Tratamiento prostodóntico para el parcialmente desdentado

El medio parcialmente desdentado. Preparación de pacientes para la atención prostodóncica fija e removible. Principios de la oclusión y el uso de articuladores en prostodoncia parcial. Propiedades biomecánicas de los materiales empleados. Prostodoncia parcial fija: protocolo clínico y de laboratorio. Prostodoncia parcial removible: protocolo clínico y de laboratorio. Técnicas clínicas diferentes para el desdentado parcial. prostodoncia maxilofacial y el parcialmente desdentado