Clinical management and prioritization criteria. Finnish experiences

The aim of this study was to investigate the acceptability of 14 prioritization criteria from nurses', doctors', local politicians' and the general public's perspective. Respondents (nurses, n = 682, doctors, n = 837 politicians, n = 1,133 and the general public, n = 1,178) received a questionnaire with 16 imaginary patient cases, each containing 2-3 different prioritization criteria. The subjects were asked to indicate how important it was for them that the treatments in the presented patient cases be subsidized by the community. All respondents preferred treatments for poor people and children. With the exception of the doctors, the three other study groups also prioritized elderly patients. Treatment for institutionalised patients, those with self-induced disease, diseases with both poor and good prognosis, and mild disease were given low priorities. Priority setting in health care should be regarded as a continuous process because of changes in attitudes. However, the best method for surveying opinions and ethical principles concerning prioritization has not yet been discovered.     

Reasons for cataract surgery cancellation]

To study the reasons for cancelling cataract surgeries, and to suggest actions to improve the efficiency of patient care. A cross-sectional study was carried out in a university hospital's ophthalmology clinic of the state of S?o Paulo, Brazil. Two hundred subjects were randomly selected. The mean age was 68+/- 11.4 years old. The reasons for cancelling surgery were: unpropitious clinical condition (23.1%); tight schedule (35.9%); and patient non-attendance (41%). Most of the reasons related to social issues and the hospital's administrative aspects.     

Development of appropriateness explicit criteria for cataract extraction by phacoemulsification

Background  

Consensus development techniques were used in the late 1980s to create explicit criteria for the appropriateness of cataract extraction. We developed a new appropriateness of indications tool for cataract following the RAND method. We tested the validity of our panel results.     

Ambulatory cataract surgery

The purpose of this study is to show the result of outpatient cataract surgery and its differences or advantages with inpatient cataract surgery. PATIENTS AND METHODS: The retrospective study concern 722 consecutives patients collected from June 1995 till May 1997; 388 underwent outpatient cataract surgery and 384 underwent inpatient cataract surgery. RESULTS: There were non significant difference between the two groups in type of cataract surgery. Immediate postoperative complications and final visual acuity did not show any significant difference in both groups. CONCLUSION: This analysis shows the great advantages of this simple surgical procedure such an increase in cataract operation leading to a decrease of patients in waiting list.     

Judgment analysis of surgeons' prioritization of patients for elective general surgery.

BACKGROUND: Access to elective general surgery in New Zealand is governed by clinicians' judgment of priority using a visual analog scale (VAS). This has been criticized as lacking reliability and transparency. Our objective was to describe this judgment in terms of previously elicited cues. METHODS: We asked 60 general surgeons in New Zealand to assess patient vignettes using 8 VAS scales to determine priority. They then conducted judgment analysis to determine agreement between surgeons. Cluster analysis was performed to identify groups of surgeons who used different cues. Multiple regression for the combined surgeons was undertaken to determine the predictability of the 8-scale VAS. RESULTS: Agreement between surgeons was poor (ra=0.48). The cause of poor agreement was mostly due to poor consensus (G) between surgeons in how they weighted criteria. Using cluster analysis, we classified the surgeons into 2 groups: 1 took more account of quality of life and diagnosis, whereas the other group placed more weight on the influence of treatment. The 8-scale VAS showed good predictability in assigning a priority score (R2=0.66). DISCUSSION: The level of agreement reflects surgeons' practice variation. This is exemplified by 2 distinct surgeon groups that differ in how criteria were weighted.     

Modeling utility of second-eye cataract surgery

OBJECTIVES: To study the impact on public health in terms of utility of various proportions of first-eye and second-eye cataract surgery. METHODS: A model was used to study the impact on a population of a fixed cataract surgical rate (9,250 operations/1,000,000 people) with varying proportions of first-eye and second-eye cataract operations. The study population was the County of Blekinge with a known incidence of previous cataract surgery. The prevalence of cataract, the estimated need for cataract surgery, and the utility values were taken from the literature. The population was grouped by disability stage of cataract and previous cataract surgery in accordance with prevalence studies and data from a large national database on cataract surgery and patients' self-assessed visual function. The mortality rate was taken from real data for the study population. RESULTS: Given a fixed cataract surgical rate over a period of five years, a high percentage of second-eye cataract surgery (42 percent) resulted in a mean utility of 0.82239 in the population forty years of age and older and the corresponding number for a low percentage of second-eye cataract surgery (25 percent) was 0.82253. A high percentage of second-eye surgeries resulted in 421 more individuals who were well compared with a low percentage of second-eye surgeries. On the other hand, a low percentage of second-eye surgeries resulted in 152 fewer individuals with disability and 118 fewer individuals with dependence compared with a high percentage of second-eye surgeries. CONCLUSIONS: A high frequency of first-eye cataract surgeries instead of second-eye surgeries affects more individuals and means an optimized improvement of utility in a population. This should be recommended if the cataract surgical rate is very insufficient. If the cataract surgical rate is high, more second-eye surgeries should be performed to optimize quality of life to as many as possible.     

Waste of medical tests in preoperative evaluation for cataract surgery

The objective of this clinical trial was to determine the frequency of medical tests considered unnecessary in routine preoperative evaluation for cataract surgery. Unnecessary costs with these tests were also evaluated. For patients assigned to the selective testing group, it was requested that no preoperative testing be performed unless the patient presented a new or worsening medical problem warranting medical evaluation with testing. For patients assigned to the routine testing group, three tests were requested: a 12-lead electrocardiogram, complete blood count, and serum glucose level. The costs of tests considered unnecessary were calculated. The sample of 1,025 patients consisted of 512 assigned to the routine testing group and 513 to the selective testing group. Cumulative rate of medical events was similar in the two groups (p=0.923). The selective group underwent 60.7% fewer tests. The results suggest that selective preoperative testing in cataract surgery does not harm patients in terms of peri-operative clinical complications and also represents a significant cost reduction compared to routine testing.     

26例儿童白内障手术并发症临床分析

目的总结儿童白内障手术的并发症及处理方法。方法统计26例(26眼)儿童白内障病例的术式,术后视力,并发症情况,并进行临床分析。结果有19眼视力术后比术前有提高,术后6月时17眼在0.3以上。主要并发症为后囊破裂和玻璃体脱出、后囊混浊、前房炎性反应等。结论白内障摘除术是治疗儿童白内障的有效方法,手术并发症有一定的特殊性,适时恰当的处理尤为重要。     

Identification of criteria for the prioritisation of patients for elective general surgery

OBJECTIVE: A single visual analogue scale is used in New Zealand to prioritise patients for elective general surgery. Although it reflects clinical judgement, it has been criticised for its lack of transparency. We wished to elicit generic criteria used by surgeons for prioritisation of patients for elective general surgery in order to improve the transparency of the visual analogue scale. METHODS: Semi-structured interviews were undertaken with 15 general surgeons. Using the repertory grid method, surgeons were asked to explain their rationale for distinguishing between patients they considered a high, medium or low priority for treatment. Interviews were audiotaped, transcribed and analysed for themes. The accuracy of the thematic analysis was checked using a five-point Likert scale to assess surgeons' agreement with the identified themes. Further testing to check for face, content and construct validity was undertaken with a purposive sample of six surgeons prioritising patient vignettes. RESULTS: Eight major themes were deduced: diagnosis; treatment; patient characteristics; symptomatology and sequelae to date; future complications; quality of life; psychological/emotional impact; and socio-political/logistic factors. The utilisation of these themes by surgeons was confirmed. Tests of collinearity indicated good content validity. Factor analysis confirmed the hypothesis of one underlying construct, namely priority. CONCLUSION: Seven of the themes became the basis for a new clinical priority assessment criteria tool using visual analogue scales to determine priority of patients for elective general surgery. Further testing of reliability and validity is needed.     

聚维酮碘皮肤消毒预防白内障手术感染的研究

目的探讨采用0.5%聚维酮碘对眼周皮肤消毒预防白内障术后感染的临床疗效,为临床治疗提供参考依据。方法选取1 200例、1 500眼2012年1月-2013年12月就诊的有白内障手术指征的患者作为研究对象,随机分成试验组和对照组,每组750眼;试验组在清洁擦拭后,用0.5%聚维酮碘消毒,对照组仅用消毒棉签消毒;观察患者有无眼内炎的发生,并嘱患者填写眼部不适情况调查表。结果试验组750眼均未发生眼内感染,对照组750眼中发生眼内炎7眼,其发生率为0.93%,试验组的感染发生率明显低于对照组,差异有统计学意义(P<0.05);试验组术后异物感、刺痛感的发生率低于对照组,差异有统计学意义(P<0.05)。结论对白内障患者术后采用0.5%聚维酮碘进行眼周皮肤消毒,可以降低术后感染的发生,同时还能够减少术后眼部的不适感,安全性良好、临床疗效满意。     

青光眼术后并发白内障临床探析

目的 探究青光眼患者术后并发白内障的临床情况.方法将我院2010年1月-2012年12月接待的46例经青光眼术后并发白内障的患者作为研究对象,回顾性分析他们的临床资料,分析他们并发白内障的原因,并且整理出具体的结果,以便为并发白内障的预防与控制提供参考.结果 经过回顾性分析可知,青光眼术后并发白内障的原因有很多方面,比如说术前就有白内障、术中感染及术后眼压过低等;大部分患者术后并发白内障的时间在术后1~2周,平均为10.6 d,并且个别原因是无法避免的.结论 虽然青光眼最为有效的方法为青光眼手术治疗,但是术后并发白内障的情况却比较常见,引发因素较多,为了提高患者生存质量,在术前、术中及术后都应做好相关因素的防控.