There has been an increasing focus over the past decades on defining, identifying and reducing unwarranted variation in clinical practice. Several attempts to monitor and reduce unwarranted variation in utilization rates and outcomes have shown mixed results. An audit was performed to evaluate the compliance of the regional strategy for reducing unwarranted variation in outcome and utilization rates in the hospitals of South-Eastern Norway Health Authority (HSO).
Method
Seventy-five mid- to senior-division and department leaders (level 2 and 3) from 8 hospital trusts in South-Eastern Norway Regional Authority were invited to participate in evaluating the compliance of the regional strategy for reducing unwarranted variation in outcome and utilization rates.
Results
The audit revealed that the aim of reducing unwanted variation was not always clearly communicated by senior management. There is varying uses of data from the national quality registers and health atlases for quality improvement. Many clinical leaders experience lack of scrutiny of their work and were insufficiently aware of HSO's top-management and hospital boards strategic expectations on the importance of reducing unwarranted hospital utilization variation.
Conclusions
In conclusion, hospital top management and boards should focus on reducing unwarranted variation in hospital outcomes and utilization rates of medical interventions. The hospitals included in the audit need to strengthen their efforts to reduce their unwarranted variation in utilization rates as a key element in improving health care quality and patient safety. We believe that the findings of the audit may be relevant for other healthcare organizations when trying to improve quality and reduce unnecessary interventions.
To examine rates of publicly financed knee arthroscopic surgery in Norway between 2012 and 2016.Analysis of anonymised data from the National Patient Registry.Beginning in 2012, South-Eastern Norway Regional Health Authority implemented administrative measures to bring down rates of knee arthroscopy. Similar measures were not introduced in the other three Regional Health Authorities.We analysed annual national rates of publicly financed knee arthroscopies in 2012 and 2016. We compared the rates in South-Eastern Norway Regional Health Authority with corresponding rates in the rest of the country. Variations by county, public hospital versus publicly reimbursed private hospital, gender and age were also assessed.The overall annual rate of arthroscopic procedures declined by 33% from 2012 to 2016, from 310 to 207 per 100 000 inhabitants, respectively. Hospitals in South-Eastern Norway Regional Health Authority reported a 48% reduction, compared with mean 13% in the other three Regional Health Authorities. In public hospitals, rates decreased nationally by 42%, while rates in publicly reimbursed private hospitals increased by 12%. Rates in publicly reimbursed private hospitals decreased by 30% in South-Eastern Norway Regional Health Authority but increased by 63% in the other Regional Health Authorities. The proportion of patients ≥50 years (excluding meniscal repairs) in Norway was 54% in 2012 and fell to 46% in 2016. Average rates per county varied by a factor of 3:1.We report a marked overall reduction of knee arthroscopic procedures from 2012 to 2016 in publicly funded hospitals. The largest decrease was reported in South-Eastern Norway Regional Health Authority, and this coincides in time with implemented administrative measures. The results suggest that the trend of increasing rates of knee arthroscopies can be reversed through purposeful professional and administrative interventions.
Development of new technology has led to the introduction of many new high-tech surgical treatment modalities. It has been claimed that the use of high-tech medicine is a potent inductor of placebo effect; in fact, many new treatment modalities have been established before they have been evaluated in placebo-controlled trials. However, there are several ways to minimize the confounding effects of placebo in surgical trials.This is a review based on a thoroughly performed search on Medline of Norwegian and English language publications published up until August 2000.Several studies have demonstrated that surgical treatment induces significant placebo effect. To minimize the confounding effects of placebo in trials evaluating new surgical modalities, it is important to use adequate blinding, neutral patient information, objective end-points, and correction for estimated placebo effects. The use of placebo surgery has been a source of lively controversy; many consider it ethically unacceptable.
This prospective study evaluated the muscle strength recovery during a two year follow-up, assessed the relationship between different funtional outcome measurements and compared the outcome between younger (< 25 years) and older (\geq 25 years) p
It has previously been shown that transmyocardial revascularization with laser (TMR) prior to coronary artery occlusion decreases the occurrence of ischemia-induced arrhythmias. The aim of the present study was to determine the effects of TMR on ventricular fibrillation and other arrhythmias during the early (1a) and late phase (1b) of ischemia in pigs.In six pigs TMR was performed in the anterior wall of the left ventricle 60 minutes prior to occlusion of the proximal LAD. Six other pigs were subjected to coronary occlusion without preceding TMR and served as controls.During the 30 min period with LAD occlusion ventricular fibrillation occurred 22 times in 5 of 6 control animals (20 episodes in phase la, 2 in phase 1b), whereas none of the animals subjected to TMR prior to the coronary artery occlusion developed ventricular fibrillation (p<0.01). The total number of premature beats per animal was lower during the early phase (la) after LAD occlusion in the TMR group than in the control group (18+/-13 vs 248+/-82, p<0.05).TMR prior to occlusion of LAD reduced the occurrence of early phase (la) ischemia-induced ventricular fibrillation and premature beats. This anti-fibrillatory effect might explain the improved survival observed in experimental studies after TMR prior to coronary artery occlusion found by others.
The aim of the study was to evaluate the effect of clopidogrel on midterm graft patency following off-pump coronary revascularization surgery.Ninety-four consecutive patients who underwent off-pump coronary artery bypass grafting between 1997 and 2002 were studied (58 men, 36 women; 61.7 +/- 9.8 years). The initial 36 patients (control group) received 75 to 160 mg acetyl salicylic acid (ASA) as an antiplatelet agent, whereas the consecutive 58 patients (clopidogrel group) received 75 mg clopidogrel postoperatively in addition to ASA. Intraoperatively, graft flow was assessed with transit-time flowmetry in all patients and the peripheral anastomoses were assessed with epicardial ultrasound in 28 patients. Sixty-two patients underwent angiography after a mean of 185 +/- 92 days. A total of 82 grafts were evaluated angiographically. Grafts with TIMI flow 2 and 3 were assessed as patent.At angiographic follow-up, the overall graft patency rate was 84% (31/37) in the control group and 93% (42/45) in the clopidogrel group (P value was not significant [ns]). Graft patency rates for left internal mammary artery (LIMA) grafts were 92% (23/25) versus 96% (28/29) (ns), and for saphenous vein grafts were 66% (7/11) versus 87% (14/16) (ns), respectively.The observed trend toward higher patency rates in patients treated with clopidogrel did not reach statistical significance. Further larger studies are necessary to confirm these preliminary results.
Objective This study examines the association between profession-specific work environments and the 7-day mortality of patients admitted to these units with acute myocardial infarction (AMI), stroke and hip fracture. Design A cross-sectional study combining patient mortality data extracted from the South-Eastern Norway Health Region, and the work environment scores at the hospital ward levels. A case-mix adjustment model was developed for the comparison between hospital wards. Setting Fifty-six patient wards in 20 hospitals administered by the South-Eastern Norway Regional Health Authority. Participants In total, 46 026 patients admitted to hospitals with AMI, stroke and hip fracture, and supported by 8800 survey responses from physicians, nurses and managers over a 3-year period (2010–2012). Primary and secondary outcome measures The primary outcome measures were the associations between the relative mortality rate for patients admitted with AMI, stroke and hip fractures and the profession-specific (ie, nurses, physicians, middle managers) mean scores on the 19 organisational factors in a validated cross sectional, staff survey conducted annually in Norway. The secondary outcome measures were the mean scores with SD on the organisational factors in the staff survey reported by each profession. Results The Nurse workload (beta 0.019 (95% CI0.009–0.028)) and middle manager engagement (beta 0.024 (95% CI0.010–0.037)) levels were associated with a case-mix adjusted 7-day patient mortality rates. There was no significant association between physician work environment scores and patient mortality rates. Conclusion 7-day mortality rates in hospital wards were negatively correlated with the nurse workload and manager engagement levels. A deeper understanding of the relationships between patient outcomes, organisational structure and their underlying cultural barriers is needed because they may provide a better understanding of the harm and death risks for patients due to organisational characteristics.
Objective. The aim of the study was to evaluate the impact of an additional subcutaneous suture line on the incidence of postoperative (p.o.) infection at the vena saphena magna harvesting site (VSMHS) after coronary artery bypass grafting (CABG). Methods. Two hundred and forty three patients undergoing CABG were included. Patients in Group A (n = 119) all operated by one physical assistant (PA) were prospectively randomised into Group A1 (n = 59) receiving intracutaneous closure suture alone whereas 60 patients (Group A2) received an additional subcutaneous suture line. Group B (n = 120), operated by surgical residents, served as control population. All patients were due to follow-up at six weeks p.o. Results. Subcutaneous suture did not impact the p.o. infection rate (A2 vs. A1; 4/60 vs. 2/59, n.s.). A significant lower p.o. infection rate was observed in Group A vs. Group B (6/119 (5%) vs. 15/120 (13%) p < 0.05). Conclusion. Subcutaneous suture did not impact the p.o. infection rate at VSMHS. The infection rate observed in patients operated by an experienced PA was significantly lower than in patients operated by various surgical residents.
