子宫肌瘤行阴式全子宫切除术的临床观察

目的:对子宫肌瘤行阴式全子宫切除术的可行性进行临床研究。方法:选择子宫肌瘤具有全子宫切除手术指征,无阴式全子宫切除术禁忌症的患者作为实验组,以手术指征相近行腹式全子宫切除术的病人为对照组,进行临床分析。结果:实验组较对照组术后疼痛轻,起床活动早,恢复快,平均住院时间短,但平均手术时间稍长,术中平均出血量稍多。结论:阴式全子宫切除术具有损伤小,恢复快,疼痛轻,腹壁无疤痕等优点,手术病人选择恰当,子宫肌瘤行阴式全子宫切除术是可行的。     

局部应用5-氟尿嘧啶对子宫颈上皮内瘤变锥切后人乳头状瘤病毒阳性者病变转归的影响

目的了解5-氟尿嘧啶(5-fluorouracil,5-FU)对子宫颈上皮内瘤变(cervical intraepithelial neoplasia,CIN)锥切后人乳头状瘤病毒(human papilloma virus,HPV)持续阳性者的治疗效果。方法选择2008年12月至2010年12月在西安市第四医院门诊因子宫颈CINⅡ和CINⅢ而行子宫颈锥型切除术的患者,术后2月复查高危型HPV和宫颈细胞并行阴道镜检查。将阴道镜检查无异常但高危型HPV仍然为阳性者随机分为治疗组和对照组,各35例。治疗组术后子宫颈涂抹5-FU,每周1次,共4次。对照组不采取任何治疗措施。两组患者半年后再次复查子宫颈HPV,对比两组子宫颈HPV的转阴率。结果半年后治疗组子宫颈HPV阴性者24例(68.57%),对照组HPV阴性者3例(8.57%),两组转阴率比较差异有统计学意义(P<0.05)。结论子宫颈局部涂抹5-FU是消除子宫颈HPV的有效方法。     

Metastatic breast cancer in the uterine cervix: two cases of a rare occurrence

Authors report on the recurrence of breast cancer to the uterine cervix in two patients. In the first patient the tumor recurrence was suspected by cytology 43 months after she was cured for breast cancer. An ultrasound examination revealed the recurrence in the second patient who have been cured for the breast cancer for 53 months. The final diagnoses was proved by cervical conisation in the first patient and by hysterectomy in the second one. Authors call attention for the possibility of the rare site of symptom free recurrence.     

Quasi-experimental evaluation of the health impacts of the New Deal for Communities Urban Regeneration scheme

The challenge of measuring outcomes associated with area-based regeneration initiatives has been discussed extensively in the literature. Key issues relate to the availability of appropriate data and the need to have some indication of the counter-factual–that is, what would have happened in the absence of the initiative. In this paper, we offer an assessment of the utility of a method to construct virtual area models that can be used as ‘controls’ in the quasi-experimental evaluation of an urban regeneration initiative and comment on the availability of appropriate health outcome data to populate such models.     

Frailty bias in comorbidity risk adjustments of community-dwelling elderly populations.

Our objective was to describe distortion in outcome studies due to "frailty bias" or differential susceptibility to adverse health outcomes due to frailties but attributed to other factors. We linked an administrative database to survey data (n = 5934) containing functional, condition, and outcome measures. The disease classification scheme of an empirically derived mortality model was used to categorize 7500 ICD-9-CM codes into five risk levels. Cox and logistic regressions were used to compare outcomes. Commonly employed measures differ in their sensitivity to detect and control frailty bias across a spectrum of major chronic diseases. Survival is inversely related to increasing functional impairment after adjusting for age, race, gender, education, number of comorbid conditions, and highest disease risk occurring during follow-up. Functional status appears to be a superior and essential element for control of the frailty bias that threatens comparability of outcome measures across community-dwelling populations containing chronically-ill disabled elderly.     

Methodological issues in evaluating mental health outcomes of a children’s mental health managed care demonstration

A key question of the Fort Bragg Evaluation was whether the continuum of care model implemented at the Demonstration produced better mental health outcomes for children and adolescents than a traditional system of care. This article describes a few of the key methodological issues that were addressed to help ensure that findings about mental health outcomes were valid. The research design was quasi-experimental and longitudinal. Nearly 1,000 families participated, and attrition was low throughout the study. Multiple informants responded to a comprehensive array of widely used instruments in the area of children’s mental health and mental health services. Despite the absence of random assignment, sites were comparable upon entry to the study on numerous factors that might affect outcome. Further, data lost through the course of study did not vary appreciably across sites. Finally, some evidence suggests that the findings of the Outcome Study may generalize to other populations of low-middle to middle-class youth in treatment.     

Nationwide rates of conversion from laparoscopic or vaginal hysterectomy to open abdominal hysterectomy in Germany

The aim of this study was to provide population-based German-wide hysterectomy rates based on the national hospitalization file and to estimate the rate of conversion from laparoscopical or vaginal hysterectomy to open abdominal hysterectomy. Nationwide population-based DRG (diagnosis related groups) data of the years 2005 and 2006 were used to calculate hysterectomy rates by indication group and type of surgical approach. Overall 305,015 hysterectomies were performed during the study period (4.5 out of 1,000 women aged 20 years or more). The hysterectomy rate for benign diseases of the genital tract among women aged 20 years or more (3.6 out of 1,000 women) is higher than in Sweden but lower than in the US or Australia. Only 6 and 5% of all hysterectomies were performed by laparoscopically assisted vaginal hysterectomy and laparoscopic hysterectomy, respectively. Twenty-six percent of hysterectomies for benign diseases among women aged 50 years or more included bilateral oophorectomy. 10% of laparoscopical hysterectomies and 1% of vaginal hysterectomies necessitated a conversion to an abdominal hysterectomy. For both types of hysterectomies, the conversion rates were highest for primary malignant genital tract cancer and other cancers compared to the other indication groups. Whereas the conversion rate for laparoscopical hysterectomies increased by age, this rate did not change by age for vaginal hysterectomies. Conversion from laparoscopically or vaginal hysterectomy to open abdominal hysterectomy is associated with the indication and type of hysterectomy started with and is considerably higher for laparoscopic than vaginal hysterectomies.     

Comparative ability of comorbidity classification methods for administrative data to predict outcomes in patients with chronic obstructive pulmonary disease

PurposeAdministrative healthcare databases are used for health services research, comparative effectiveness studies, and measuring quality of care. Adjustment for comorbid illnesses is essential to such studies. Validation of methods to account for comorbid illnesses in administrative data for patients with chronic obstructive pulmonary disease (COPD) has been limited. Our objective was to compare the ability of the Charlson index, the Elixhauser method, and the Johns Hopkins' Aggregated Diagnosis Groups (ADGs) to predict outcomes in patients with COPD.MethodsRetrospective cohorts constructed using population-based administrative data of patients with incident (n = 216,735) and prevalent (n = 638,926) COPD in Ontario, Canada, were divided into derivation and validation datasets. The primary outcome was all-cause death within 1 year. Secondary outcomes included all-cause hospitalization, COPD-specific hospitalization, non-COPD hospitalization, and COPD exacerbations.ResultsIn both the incident and prevalent COPD cohorts, the three methods had comparable discrimination for predicting mortality (c-statistics in the validation sample of incident patients of 0.819 for the Charlson method versus 0.822 for the Elixhauser method versus 0.830 for the ADG method). All three methods had lower predictive accuracy for predicting nonfatal outcomes.ConclusionsIn a disease-specific cohort of COPD patients, all three methods allowed for accurate prediction of mortality, with the Johns Hopkins ADGs having marginally higher discrimination.     

Development and deployment of the Computer Assisted Neighborhood Visual Assessment System (CANVAS) to measure health-related neighborhood conditions

Public health research has shown that neighborhood conditions are associated with health behaviors and outcomes. Systematic neighborhood audits have helped researchers measure neighborhood conditions that they deem theoretically relevant but not available in existing administrative data. Systematic audits, however, are expensive to conduct and rarely comparable across geographic regions. We describe the development of an online application, the Computer Assisted Neighborhood Visual Assessment System (CANVAS), that uses Google Street View to conduct virtual audits of neighborhood environments. We use this system to assess the inter-rater reliability of 187 items related to walkability and physical disorder on a national sample of 150 street segments in the United States. We find that many items are reliably measured across auditors using CANVAS and that agreement between auditors appears to be uncorrelated with neighborhood demographic characteristics. Based on our results we conclude that Google Street View and CANVAS offer opportunities to develop greater comparability across neighborhood audit studies.     

The clinical effectiveness of nurse practitioners' management of minor injuries in an adult emergency department: a systematic review

Background The increasing cost of healthcare in Australia demands changes in the way healthcare is delivered. Nurse practitioners have been introduced into specialty areas including emergency departments. Specific interventions are known to include the treatment and management of minor injuries, but little has been reported on their work. Objectives Examine the best available evidence to determine the clinical effectiveness of emergency department nurse practitioners in the assessment, treatment and management of minor injuries in adults. Inclusion criteria For inclusion studies had to include adult patients treated for minor injuries by nurse practitioners in emergency departments. All study designs were included. Search strategy English language articles from 1986 onwards were sought using MEDLINE, CINAHL, Embase and Science Citation Index. Methodological quality Two independent reviewers critically appraised the quality of the studies and extracted data using standardised tools. Data collection Two independent reviewers assessed the eligibility of each study for inclusion into the review and the study design used. Where any disagreement occurred, consensus was reached by discussion with an independent researcher. Data synthesis Studies were assessed for homogeneity by considering populations, interventions and outcomes. Where heterogeneity was present, synthesis was undertaken in a narrative format; otherwise a meta-analysis was conducted. For each outcome measure, results were tabulated by intervention type and discussed in a narrative summary. Results from randomised controlled trials were pooled in meta-analyses where appropriate. Results Nine studies from a total of 55 participants met the inclusion criteria. Two were randomised controlled trials. Metasynthesis of research findings generated five synthesised findings derived from 16 study findings aggregated into seven categories. Evidence comparing the clinical effectiveness of nurse practitioners to mainstream management of minor injuries was fair to poor methodological quality. When comparable data were pooled, there were no significant differences (P?相似文献   

Comparing health outcomes among hospitals: the experience of the Lombardy Region

In recent years, governments and other stakeholders have increasingly used administrative data for measuring healthcare outcomes and building rankings of health care providers. However, the accuracy of such data sources has often been questioned. Starting in 2002, the Lombardy (Italy) regional administration began monitoring hospital care effectiveness on administrative databases using seven outcome measures related to mortality and readmissions. The present study describes the use of benchmarking results of risk-standardized mortality from Lombardy regional hospitals. The data usage is part of a general program of continuous improvement directed to health care service and organizational learning, rather than at penalizing or rewarding hospitals. In particular, hierarchical regression analyses - taking into account mortality variation across hospitals - were conducted separately for each of the most relevant clinical disciplines. Overall mortality was used as the outcome variable and the mix of the hospitals’ output was taken into account by means of Diagnosis Related Group data, while also adjusting for both patient and hospital characteristics. Yearly adjusted mortality rates for each hospital were translated into a reporting tool that indicates to healthcare managers at a glance, in a user-friendly and non-threatening format, underachieving and over-performing hospitals. Even considering that benchmarking on risk-adjusted outcomes tend to elicit contrasting public opinions and diverging policymaking, we show that repeated outcome measurements and the development and dissemination of organizational best practices have promoted in Lombardy region implementation of outcome measures in healthcare management and stimulated interest and involvement of healthcare stakeholders.     

Comparing hospitals that perform coronary artery bypass surgery: the effect of outcome measures and data sources.

OBJECTIVES. The relative quality of hospital care often is judged by comparing risk-adjusted rates of adverse outcomes. This study evaluated whether hospital quality comparisons are affected by the choice of outcome and the use of administrative data instead of clinical data. METHODS. The data were collected from 2687 coronary artery bypass surgery patients from 17 hospitals. All patients were on Medicare. For 10 hospitals with 94 to 713 patients, risk-adjusted outcomes for death, major complications, and any complications were derived from a clinically rich database and an administrative database. RESULTS. The correlations between adjusted hospital rankings derived from the clinical and administrative databases were not significant: .48 for mortality, .21 for major complications, and -.14 for any complication. When only the clinical database was used, the correlation between risk-adjusted hospital rankings for mortality and major complications was .77 (P < .01) and the correlation between major complications and any complication was -.45. CONCLUSIONS. These results suggest assessing quality of care by the use of administrative data may not be adequate and that quality assessment by the use of clinical data may depend greatly on the outcome chosen.     

某院妇科手术部位感染目标性监测及干预

目的了解某院妇科手术部位感染（SSI）现状,分析可能的危险因素,探讨降低SSI发病率的有效措施。方法2011年1月1日-12月31日,对该院两个妇科病区行剖腹子宫切除术、阴式子宫切除术、腹腔镜下子宫切除术的所有患者进行监测,定期汇总分析,比较采取干预措施前（2011年1月1日-6月30日监测的病例,设为对照组）和干预措施落实后（2011年7月1日-12月31日监测的病例,设为干预组）的SSI率。结果 对照组共1 120例患者,其中剖腹子宫切除术648例,SSI率为4.94%;阴式子宫切除术212例,SSI率为9.43%;腹腔镜下子宫切除术260例,未发生SSI。干预前妇科病区平均SSI率为4.64%（52/1 120）,两个妇科病区平均SSI率(5.38% vs 4.00%)对比,差异无统计学意义（χ2=1.206,P＞0.05）;采取针对性干预措施后,干预组SSI率下降至1.57%（20/1 272）,显著低于对照组的4.64%（χ2=19.23,P＜0.001）。结论 采取目标性监测方式,对监测项目的危险因素进行汇总分析,并采取针对性的干预措施,能够达到降低SSI率的目的。     

Decomposing differences in acute myocardial infarction fatality in Italian regions

The paper develops a general method for evaluating geographical differences in the outcome of acute myocardial infarction patients, by looking at the process of disease occurrence from infarction to hospitalization and possible death or recovery. The method is applied to regional data in Italy, where the long history of geographical diversities in economical, social and cultural fields is reflected in health care. Specific features of AMI, such as high fatality and fast course of the disease, make it a suitable tracer condition to investigate into the differences of regional health systems during the acute phase of hospitalization. The paper combines administrative and official statistics by region and offers a tool providing suggestions to policy-makers where further eventual investigations are needed around the care pathway and also what possible actions might be undertaken to improve the outcomes.     

Epidemiological issues in perinatal outcomes research

Outcomes research takes an expansive view of health and seeks to improve the science of evaluating the quality of health care by refining traditional clinical measures and including measures of overall patient well-being. This broader view of health (rather than disease) is especially appropriate in perinatal research. Attention to the perinatal period requires recognition that pregnancy is in most cases a healthy life event, that there is a predictable progression and time course with a key definable outcome (delivery) and that there are two patients, mother and infant. Two issues stand out as methodological challenges in the design and conduct of perinatal outcomes studies. The first is to establish baseline comparability across study groups with regard to case-mix or perinatal risk, and also comparability of services other than the one under study. The second is the refinement of traditional perinatal outcomes, such as low birthweight and Caesarean section, and the inclusion of patient-based health status measures, such as health-related quality of life, for the peripartum woman and her newborn.     

Effects of DRG-based hospital payment in Poland on treatment of patients with stroke

A prospective payment system based on Diagnosis Related Groups (DRGs) presents strong financial incentives to healthcare providers. These incentives may have intended as well as unintended consequences for the healthcare system. In this paper we use administrative data on stroke admissions to Polish hospitals in order to demonstrate the response of hospitals to the incentives embedded in the design of stroke-related groups in Poland. The design was intended to motivate hospitals for the development of specialized stroke units by paying significantly higher tariffs for treatment of patients in these units. As a result, an extensive network of stroke units has emerged. However, as it is shown in the paper, there is no evidence that outcomes in hospitals with stroke units are significantly different from outcomes in hospitals without stroke units. It is also demonstrated that the reliance on the length of stay as a major grouping variable provides incentives for regrouping patients into more expensive groups by extending their length of stay in stroke units. The results of the study are limited by the incompleteness of the casemix data. There is a need to develop information and audit systems which would further inform a revision of the DRG system aimed to reduce the risk of regrouping and up-coding.     

Randomization and baseline transmission in vaccine field trials

In randomized trials, the treatment assignment mechanism is independent of the outcome of interest and other covariates thought to be relevant in determining this outcome. It also allows, on average, for a balanced distribution of these covariates in the vaccine and placebo groups. Randomization, however, does not guarantee that the estimated effect is an unbiased estimate of the biological effect of interest. We show how exposure to infection can be a confounder even in randomized vaccine field trials. Based on a simple model of the biological efficacy of interest, we extend the arguments on comparability and collapsibility to examine the limits of randomization to control for unmeasured covariates. Estimates from randomized, placebo-controlled Phase III vaccine field trials that differ in baseline transmission are not comparable unless explicit control for baseline transmission is taken into account.     

医院管理部门绩效考核指标体系构建路径与效果评价

医院管理部门作为医院运营的中枢环节和执行系统,是医院决策的具体执行层、推动层,其效能的高低,在很大程度上将影响医院整体运营的效率和效益。运用平衡计分卡理念,通过对公立医院管理部门的工作进行梳理,阐述医院管理部门绩效考核的构建路径和方法,设计绩效考核指标体系,并实施有效的绩效考核制度．为医院对管理部门的工作行为和结果实施评价提供参考依据。