Role of the physician in the prehospital setting

Despite the initial successes achieved in early emergency medical services (EMS) systems, many prehospital care services have developed without the intense involvement of physicians whose interest fueled the first experimental medical programs of prehospital care. Among a myriad of variables affecting EMS is the important element of intense, authoritative physician involvement in education, field supervision, and research. Recognizing this problem, many states now have legislated that EMS systems be closely supervised by medical directors. Political and financial constraints often have diluted medical influence and authority, and intense, direct field supervision is the exception rather than the rule. successful EMS systems can demonstrate their influence on morbidity and mortality through appropriate data collection and quality assurance programs. Such programs appear to have in common the element of direct involvement of competent physicians in initial training, field supervision, and policy decisions. Until recently, full-time compensated physician involvement in EMS has been regarded as unnecessary or impractical. Certainly in large urban centers such full-time involvement is mandatory. While in smaller municipalities full-time commitments may be unnecessary, partial compensation for time dedicated to EMS pursuits should be part of the EMS budget. It has been the experience of major urban EMS systems that field participation by physicians has lent irrefutable credibility to the authority of medical directors. Beyond the obvious benefits of quality assurance and supervision, the in-field EMS physician provides the impetus and leadership for EMS research conducted at the street level. Because EMS is the practice of medicine through physician surrogates in a prehospital setting, it sets the stage and tone for subsequent patient care and outcome.(ABSTRACT TRUNCATED AT 250 WORDS)     

A computer-assisted quality assurance system for an emergency medical service

A busy urban emergency medical service answering more than 50,000 calls each year developed a plan for quality assurance using a computer-assisted model designed to employ a full-time quality assurance officer whose work was supplemented with computer evaluation of EMS field reports. The development of standardized reporting formats, protocols and computer programs enabled a significant improvement in detection of errors of documentation and patient care. Investigated cases rose dramatically in the month following implementation of the system, from five patient care errors per month to 35 (P less than .05), and from 50 documentation errors to 265 per month (P less than .05). Our experience indicates that computer-assisted evaluation of field performance, as judged by prehospital records, is a useful tool to ensure standards in patient care and EMS recordkeeping.     

Quality validation of data in national haemovigilance systems in Europe: report of a survey on current state of practice

European Union member states must have national haemovigilance reporting of serious adverse reactions and events. We sent national competent authorities an email questionnaire about data validation. Responses were received from 23/27 countries. Nine previously had no national haemovigilance system. In 13 (57%), the serious adverse reactions and events can be verified. Coverage of blood establishments is documented in 20 systems (87%) and of hospitals in 15 systems (65%). Although all member states have implemented haemovigilance systems, there are currently wide variations in data quality assurance, not allowing comparisons between countries.     

Uses and limitations of microcomputers for epidemiological research in occupational health

The rapid improvements in microcomputer systems have contributed to ease of performance of epidemiological research in occupational health. Computers now available can aid in all stages of research- from the early stages of literature review to data collection, analysis and presentation. Optical storage devices now allow large occupational health data bases to be stored on a single compact disc, with the information accessible by microcomputer. Hand-held computers and optical scanners allow paperless collection of field data. Epidemiological analysis and data presentation is easily done with software packages, some of which are in the public domain. However, there are limitations in the use of computers for any epidemiological research. Investment of time is required to learn the use of a computer. Care needs to be taken to ensure accurate data entry, and correct choice has to be made of methods for subsequent statistical analysis. Microcomputers are valuable as labour saving devices, but cannot replace proper planning, execution and appropriate data analysis in epidemiological research in occupational health.     

Are we nearer to curing patients with MDS?

Myelodysplastic syndromes (MDS) are a heterogeneous collection of clonal hematopoietic disorders derived from abnormal multipotent progenitor cells. They have been classified by the World Health Organization as myeloid neoplasms with several different subtypes based on morphology and cytogenetics. Because MDS was only recently recognized as a cancer, epidemiological data is tentative and incidence and prevalence will probably increase as reporting improves. Prognosis for MDS patients is calculated using the International Prognostic Scoring System, though this system is currently being revised by several groups. Therapy for MDS varies based on pathobiology, prognosis, and cytogenetics, such as the deletion of 5q. Treatment options range from supportive care, to disease-modifying chemotherapeutic agents, to stem cell transplantation, to therapies that may affect quality of life, improve survival, or even cure the disease.     

Building a bioresource for esophageal research: lessons from the early experience of an academic medical center

The establishment of biorepositories, linked to clinical and epidemiologic data, are central to the goals of personalized medicine and individualized cancer therapy. Repositories of DNA, RNA, and serum samples are valuable resources for cancer research, enabling the investigation of the underlying causes of cancer development, progression, and prognosis, as well as providing a resource for the investigation of biomarkers for early detection and prediction of response. With a greater reliance on sample‐derived data for molecular‐based research and clinical care, improved standards and informatics for sample procurement, storage, and analysis are necessary to maximize the value of tissue collection for research participants, investigators, and academic medical centers. We present herein the experience of an academic medical center in establishing a repository for esophageal research, with discussion of elements to be considered when establishing such a resource, from the quality assurance of samples to the organized collection and storage of associated clinical data. The development of this biorepository required significant planning to identify and consent participants by dedicated clinical and research personnel. Ensuring the quality of any biobank is of utmost importance, and one must understand the sample variability that exists during the acquisition of biospecimens. The time and type of fixative have been optimized in our unit by standard operating protocols. Methods for biomolecule extraction were tested by examining both the quality and the quantity of recovered sample. These procedures were overseen by a designated biobank manager, responsible for the acquisition of the sample from surgery, which limits variability in sample collection. Our unit also has a dedicated database manager for the maintenance of quality clinical data linked to the bioresource. The development and expansion of such repositories, at local and national levels, is required to enable leading academic medical centers and their investigators to provide optimal and molecularly guided care to their patients.     

Standardized colonoscopy reporting and data system: report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable

BACKGROUND: Standardized reporting systems for diagnostic and screening tests facilitate quality improvement programs and clear communication among health care providers. Although colonoscopy is commonly used for screening, diagnosis, and therapy, no standardized reporting system for this procedure currently exists. The Quality Assurance Task Group of the National Colorectal Cancer Roundtable developed a reporting and data system for colonoscopy based on continuous quality improvement indicators. DESIGN: The Task Group systematically reviewed quality indicators recommended by the Multi-Society Task Force on Colorectal Cancer and developed consensus-based terminology for reporting and data systems to capture these data elements. The Task Group included experts in several disciplines: gastroenterology, primary care, diagnostic imaging, and health care delivery. RESULTS AND CONCLUSIONS: The standardized colonoscopy reporting and data system provides a tool that can be used for efforts in continuous quality improvement within and across practices that use colonoscopy.     

中药治疗癌痛临床文献41篇的分析

目的:本文通过对41篇中药治疗癌痛的临床研究文献进行分析,讨论提高中医论文质量的重要性和必要性.方法:检索《中国生物医学文献数据库》(CBM),《中国生物医学期刊文献数据库》(Chinese Medical Current Contents,CMCC)和维普中文数据库以及PubMed和荷兰医学文摘数据库(Excerpta Medical Datebase,EMBASE)英文数据库在1986年至2006年中医药治疗癌痛的文献.根据the National Cancer Institute(NCI)"补充和替代医学领域中癌症临床研究循证医学的强度等级"筛选出属于随机对照临床研究的论文41篇,并以Gagnier et al的"中药治疗随机对照试验的报道质量"一文为参考,进行论文质量分析.结果:41篇论文中一些必要信息如随机方法,纳入和排除标准,研究结果测定,盲法应用,中药制剂的质量控制和评价.以及药物的不良反应等表述不足.结论:科研论文报告的信息量是影响论文质量的因素,也是阻碍中医药在癌痛治疗领域被广泛接受的原因之一.     

Assessment of Electronic Health Information System Use and Need in US Adult Congenital Heart Disease Centers

Objectives. Efforts to improve care for adult congenital heart disease (ACHD) patients necessitates collection of accurate, detailed, longitudinal data. We sought to document what electronic health record systems are currently available at ACHD centers and to assess national interest in a uniform ACHD‐focused system. Design. Directors of ACHD centers in the United States were invited to complete an online questionnaire regarding current health information systems at their institution both for general cardiology and for ACHD. Topics that were surveyed included utility and perceived limitations of currently available systems. The survey also assessed the level of interest in an ACHD‐specific system, and its optimal functions. Results. Thirty‐four centers responded, representing both pediatric and adult institutions that care for patients with ACHD. Of these, 80% reported using a variety of commercially supported electronic medical record products, whereas only 50% employed an ACHD‐specific noncommercial database to supplement their institutional system. Comparison of the two systems revealed that most clinical activities are pursued through the institutional electronic medical record system. Research and tracking of clinical activities were the primary uses of ACHD‐specific systems, which have several noted limitations. Strong interest in an integrated ACHD‐specific system was found among responders. Conclusions. There is both an unmet need and a strong interest in an ACHD‐oriented electronic health record that could facilitate research, outcome tracking, quality assurance, and inter‐institutional collaboration, all functions that are lacking in electronic health systems currently in use.     

MDS-based state Medicaid reimbursement and the ADL-decline quality indicator

PURPOSE: We examined the relationship between the quality indicator for decline in activities of daily living (ADL) and the use of the Minimum Data Set (MDS) for determining Medicaid skilled nursing facility reimbursement. DESIGN AND METHODS: We conducted a cross-sectional analysis using the 2004 National MDS Facility Quality Indicator reports as the dependent variable in a multilevel regression model. Our primary explanatory variable was a state-level binary variable distinguishing whether or not the state used an MDS-based Medicaid-reimbursement system in 2004. We obtained control variables through the Online Survey, Certification, and Reporting System. RESULTS: Skilled nursing facilities located in states that used the MDS for Medicaid reimbursement reported more ADL decline than did facilities in states that did not use the MDS for reimbursement. IMPLICATIONS: The finding suggests that the ADL-decline quality indicator captures more than just quality, including state-level policy differences. Therefore, the ADL-decline quality indicator should be investigated and refined prior to being relied on for pay-for-performance initiatives.     

Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee

Since 2002, 4 states have enacted legislation that requires health care organizations to publicly disclose health care-associated infection (HAI) rates. Similar legislative efforts are underway in several other states. Advocates of mandatory public reporting of HAIs believe that making such information publicly available will enable consumers to make more informed choices about their health care and improve overall health care quality by reducing HAIs. Further, they believe that patients have a right to know this information. However, others have expressed concern that the reliability of public reporting systems may be compromised by institutional variability in the definitions used for HAIs, or in the methods and resources used to identify HAIs. Presently, there is insufficient evidence on the merits and limitations of an HAI public reporting system. Therefore, the Healthcare Infection Control Practices Advisory Committee (HICPAC) has not recommended for or against mandatory public reporting of HAI rates. However, HICPAC has developed this guidance document based on established principles for public health and HAI reporting systems. This document is intended to assist policymakers, program planners, consumer advocacy organizations, and others tasked with designing and implementing public reporting systems for HAIs. The document provides a framework for legislators, but does not provide model legislation. HICPAC recommends that persons who design and implement such systems 1) use established public health surveillance methods when designing and implementing mandatory HAI reporting systems; 2) create multidisciplinary advisory panels, including persons with expertise in the prevention and control of HAIs, to monitor the planning and oversight of HAI public reporting systems; 3) choose appropriate process and outcome measures based on facility type and phase in measures to allow time for facilities to adapt and to permit ongoing evaluation of data validity; and 4) provide regular and confidential feedback of performance data to healthcare providers. Specifically, HICPAC recommends that states establishing public reporting systems for HAIs select one or more of the following process or outcome measures as appropriate for hospitals or long-term care facilities in their jurisdictions: 1) central-line insertion practices; 2) surgical antimicrobial prophylaxis; 3) influenza vaccination coverage among patients and healthcare personnel; 4) central line-associated bloodstream infections; and 5) surgical site infections following selected operations. HICPAC will update these recommendations as more research and experience become available.     

Early audit of renal complications in a new cardiac surgery service in Australia

OBJECTIVE: To assess the incidence of renal failure in a cardiac surgery service commencing in Australia. DESIGN: Prospective data collection and retrospective database analysis. SETTING: A tertiary referral, university teaching hospital in the state of Victoria, Australia. PARTICIPANTS: The first 502 patients undergoing cardiac surgery in this institution from commencement of the service. RESULTS: The overall rate of renal failure was low in comparison to other studies at 0.2% (95% CI 0.04-1.3%). The rate of postoperative renal dysfunction was also low at 4.2% (95% CI 2.7-6.5%). CONCLUSIONS: The safety of the new service with respect to this complication of cardiac surgery was good when compared with published data. However the lack of uniform definitions of renal failure following cardiac surgery make comparisons between studies difficult. Uniform reporting of this complication would facilitate comparisons between units and quality assurance activities in this field.     

Standardization of antituberculosis drug resistance surveillance in Europe. Recommendations of a World Health Organization (WHO) and International Union Against Tuberculosis and Lung Disease (IUATLD) Working Group.

Surveillance of antituberculosis drug resistance is an essential tool for evaluating the quality of tuberculosis control programmes. Consensus-based recommendations on uniform reporting of antituberculosis drug resistance surveillance data in Europe have been developed by a Working Group of the World Health Organization (WHO) and the International Union Against Tuberculosis and Lung Disease (IUATLD). Laboratories should use standardized methods for testing drug susceptibility with a quality assurance programme including national and international proficiency testing. The proportion of drug resistance, particularly resistance to isoniazid, rifampicin or both (multidrug resistance) among all definite, i.e. culture-positive, tuberculosis cases at the start of treatment is the major indicator of interest. It should be calculated separately among patients treated previously and among those who have never been treated with > or = 1 month of combined antituberculosis drugs. The Working Group recommends that, in countries in which resources allow, laboratories report drug susceptibility test results on all isolates of the Mycobacterium tuberculosis complex. Test results of the specimen at the start of treatment and clinical data from the notification should be linked using a suitable identifier. Results should be presented by calendar year and analysed by age, sex, place of birth, site of disease and sputum smear results. In countries in which a routine system cannot be organized, representative surveys or sentinel systems are possible alternatives. In some countries, the annual prevalence of multidrug-resistant tuberculosis may be estimated through a national laboratory reporting system.     

Evaluation of EMS management training offered during emergency medicine residency training

Physician involvement in the provision of both direct and indirect medical control to emergency medical providers is critical to the effective operation of an emergency medical services (EMS) system. We conducted a survey of all accredited emergency medicine residency programs in the United States to determine the content of EMS instruction provided to these physicians-in-training. The majority of programs provide an introduction to direct medical control, to EMS organizational structure, and the opportunity to participate in EMS-related research. Less than 65%, however, provide formal instruction in EMS risk management or quality assurance or the opportunity to observe policy-making bodies related to EMS. The importance placed on EMS during residency training is variable. EMS is the domain of emergency medicine, and adequate training of residents for these responsibilities is imperative.     

A contemporary overview of percutaneous coronary interventions. The American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR)

The American College of Cardiology (ACC) established the National Cardiovascular Data Registry (ACC-NCDR) to provide a uniform and comprehensive database for analysis of cardiovascular procedures across the country. The initial focus has been the high-volume, high-profile procedures of diagnostic cardiac catheterization and percutaneous coronary intervention (PCI).Several large-scale multicenter efforts have evaluated diagnostic catheterization and PCI, but these have been limited by lack of standard definitions and relatively nonuniform data collection and reporting methods.Both clinical and procedural data, and adverse events occurring up to hospital discharge, were collected and reported according to uniform guidelines using a standard set of 143 data elements. Datasets were transmitted quarterly to a central facility for quality-control screening, storage and analysis. This report is based on PCI data collected from January 1, 1998, through September 30, 2000.A total of 139 hospitals submitted data on 146,907 PCI procedures. Of these, 32% (46,615 procedures) were excluded because data did not pass quality-control screening. The remaining 100,292 procedures (68%) were included in the analysis set. Average age was 64 +/- 12 years; 34% were women, 26% had diabetes mellitus, 29% had histories of prior myocardial infarction (MI), 32% had prior PCI and 19% had prior coronary bypass surgery. In 10% the indication for PCI was acute MI < or =6 h from onset, while in 52% it was class II to IV or unstable angina. Only 5% of procedures did not have a class I indication by ACC criteria, but this varied by hospital from a low of 0 to a high of 38%. A coronary stent was placed in 77% of procedures, but this varied by hospital from a low of 0 to a high of 97%. The frequencies of in-hospital Q-wave MI, coronary artery bypass graft surgery and death were 0.4%, 1.9% and 1.4%, respectively. Mortality varied by hospital from a low of 0 to a high of 4.2%.This report presents the first data collected and analyzed by the ACC-NCDR. It portrays a contemporary overview of coronary interventional practices and outcomes, using uniform data collection and reporting standards. These data reconfirm overall acceptable results that are consistent with other reported data, but also confirm large variations between individual institutions.     

Investing for Impact: The Global Fund Approach to Measurement of AIDS Response

The Global Fund raises and invests nearly US$4 billion a year to support programs run in more than 140 countries. The Global Fund strategy 2012–2016 is focused on “Investing for Impact”. In order to accomplish this, timely and accurate data are needed to inform strategies and prioritize activities to achieve greater coverage with quality services. Monitoring and evaluation is intrinsic to the Global Fund’s system of performance-based funding. The Global Fund invests in strengthening measurement and reporting of results at all stages of the grant cycle. The Global Fund approach to measurement is based on three key principles—(1) simplified reporting: the Global Fund has updated its measurement guidance to focus on impact, coverage and quality with the use of a harmonized set of indicators. (2) Supporting data systems—based on a common framework developed and supported by partners, it promotes investment in five common data systems: routine reporting including HMIS; Surveys—population based and risk group surveys; Analysis, reviews and transparency; Administrative and financial data sources; and, Vital registration systems. (3) Strengthen data use: the Global Fund funding encourages use of data at all levels—national, subnational and site level. Countries do not automatically prioritize M&E but when guidance, tools and investments are available, there is high level utilization of M&E systems in program design, planning, implementation, and results reporting. An in-depth analysis of the available data helps the Global Fund and countries to direct investments towards interventions where impact could be achieved and focus on target population groups and geographic areas that are most affected.     

Quality of study methods in individual- and group-level HIV intervention research: critical reporting elements.

To facilitate research synthesis and the identification of effective interventions, we reviewed and summarized critical reporting elements related to quality of study methods (QSM) specifically for individual- and group-level HIV intervention research. In developing these elements, we considered three sources of information: threats to validity, criteria and recommendations from review projects, and criteria and recommendations from published reviews relevant to HIV intervention research. Suggested QSM elements include, thoroughly describing intervention activities, using comparable outcome measures at preintervention and postintervention assessments, reporting data in detail for each study group, reporting participant refusal rates, including a comparison group, demonstrating study group comparability, clearly describing assignment to study groups, using appropriate statistical controls, collecting follow-up data from at least a 3-month postintervention period, reporting attrition in detail, and describing in detail whether the study sample size is adequate for detecting the expected effect size. Reporting on these QSM elements will assist in identifying effective behavioral interventions.     

The IMPACT Act of 2014: Standardizing patient assessment data to support care coordination,quality outcomes,and interoperability

The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) addressed the need for uniform, clinical, and demographic data in post-acute care (PAC) settings. Structured, uniform data enables potential interoperable data exchange, quality comparisons across PAC provider types, and the capacity to explore a Medicare unified PAC payment system. Standardized patient assessment data elements were developed for clinical domains such as cognitive function and mental status, special services, treatments, and interventions, and medical conditions and comorbidities to create a common language that can be used to bolster a patient's needs and goals to improve clinical outcomes. Clinical care, decision making, and care planning were at the center of all decisions made to standardize specific data elements. In addition, all standardized data were mapped to nationally accepted vocabulary standards to support electronic health information exchange. The standardized patient assessment data elements present the foundation for uniform language across the PAC continuum to promote a greater quality of care for every patient.     

Effectiveness of Emergency Medical Services for Victims of Out-of-Hospital Cardiac Arrest: A Metaanalysis

Study objective: To determine the relative effectiveness of differences in response time interval, proportion of bystander CPR, and type and tier of emergency medical services (EMS) system on survival after out of hospital cardiac arrest. Methods: We performed a comprehensive literature search, excluding EMS systems other than those of interest (systems of interest were those comprising one tier with providers of basic life support [BLS] or advanced life support [ALS] and those comprising two tiers with providers of BLS or BLS-defibrillation followed by ALS), patient population of fewer than 100 cardiac arrests, studies in which we could not determine the total number of arrests of presumed cardiac origin, and studies lacking data on survival to hospital discharge. Metaanalysis using generalized linear model with dispersion estimation for random effects was then performed. Results: Increased survival to hospital discharge was significantly associated with tier (P<.01), response time interval (P <.01), and bystander CPR (P=.04). A significant interaction was detected between response time interval and bystander CPR (P=.02). For the studies analyzed, survival was 5.2% in a one-tier EMS system or 10.5% in a two-tier EMS system. A 1-minute decrease in mean response time interval was associated with absolute increases in survival rates of .4% and .7% in a one-tier and two-tier EMS systems, respectively. Conclusion: Increased survival to hospital discharge may be associated with decreased response time interval and with the use of a two-tier EMS system as opposed to a one-tier system. The data available for this analysis were suboptimal. Policymakers need more methodologically rigorous research to have more reliable and valid estimates of the effectiveness of different EMS systems. [Nichol G, Detsky AS, Stiell IG, O'Rourke K, Wells G, Laupacis A: Effectiveness of emergency medical services for victims of out-of-hospital cardiac arrest: A metaanalysis. Ann Emerg Med June 1996;27:700-710.]Heart disease is the most common cause of death in the United States.¹ Such deaths are often due to cardiac arrest, the sudden cessation of cardiac mechanical activity manifested by the absence of a detectable pulse, unresponsiveness, and lack of breathing.² Emergency medical services (EMS) systems have evolved into multifaceted advanced cardiac life support systems involving CPR, defibrillation, artificial ventilation, intubation, and administration of medication.Controversy exists about the effectiveness of different methods of emergency cardiac care because of wide variation in reported survival among centers³, ranging from 0%⁴ to 44%.⁵ This variation may be attributable to differences in the type of EMS system, proportion of victims receiving bystander CPR, response time intervals of providers, or geography of the city in question.⁶ Furthermore, different approaches to reporting survival make comparison of studies difficult. ^{[6] , [7] and [8]} A consensus conference has offered guidelines for uniform reporting of results to facilitate comparison of results.²The purpose of this analysis was to estimate the relative effectiveness of the type and tier of an EMS system, unit response time interval of providers, and rate of bystander CPR on survival after out-of-hospital cardiac arrest. Using a protocol developed a priori, we performed a metaanalysis based on conventional techniques. ^{[9] and [10]} The protocol comprised selection criteria for the primary studies, definitions of the primary endpoints, and an analysis plan.¹¹ The metaanalysis was part of a larger cost-effectiveness analysis of improvements to EMS systems for out-of-hospital cardiac arrest. The results of the cost-effectiveness analysis are reported elsewhere.¹²Definitions of terms The organization of an EMS system may vary both in the degree of training of the health care providers, as well as in the number of vehicles responding to a medical emergency. No universally accepted nomenclature exists for categorizing EMS systems, and some terms may have different meanings for different people.To facilitate clarity and understanding, the following terms are defined. Emergency health care providers vary in the degree of their training and may or may not transport patients to the hospital. Basic life support (BLS) providers administer oxygen and CPR to victims of cardiac arrest. Providers of BLS with defibrillation (BLS-D) defibrillate patients using automated or manual defibrillators. Finally, advanced life support (ALS) providers are trained to perform endotracheal intubation and to administer IV medications. BLS or BLS-D level care may be provided by emergency medical technicians (EMTs) in ambulances or by firefighters in pump vehicles or vans. Generally, ALS care is only provided by EMTs in ambulances. These personnel are referred to by others as "paramedics."The team that responds to a cardiac arrest in a given city may be part of a one-tier or two-tier EMS system. In a one-tier EMS system, a single provider and vehicle type responds to medical emergencies. In a two-tier system, two types of providers and/or vehicles respond. The vehicles may include ambulances, which respond from ambulance bases; or pump vehicles or vans, which respond from fire stations. In two-tier EMS systems, BLS providers (first tier) usually arrive more quickly because more generally are serving a community. In American cities with two-tier EMS systems, the second responding providers (second tier) have ALS capability. About 75% of the American urban population is served by a two-tier rather than by a one-tier EMS system.¹⁴In this analysis we considered five configurations of EMS systems: (1) one tier with BLS providers, (2) one tier with BLS-D providers, (3) one tier with ALS providers, (4) two tiers with BLS followed by ALS (BLS + ALS) providers, and (5) two tiers with BLS-D followed by ALS (BLS-D + ALS) providers.     

Current concepts on hematopoietic stem cell transplantation outcome registries; Emphases on resource requirements for new registries

There is tremendous variability in size, scope, and resource requirements for registries depending on the number of patients and participating sites. The outcome registries are organized systems to collect uniform data using an observational study methodology. Patient registries are used to determine specified outcomes for a population for predetermined scientific, clinical, or policy purposes. Historically, outcome registries established in the development of hematopoietic stem cell transplantation (HSCT) have now evolved into myriads of locoregional and international transplant activity and outcome resources. Over time, these registries have contributed immensely in determining trends, patterns, and treatment outcomes in HSCT. There is wider variation in the goals, mission, objectives, and outcomes of the ongoing registries depending on the organizational structure. There is a growing trend toward overarching relationship of these registries to serve as complementary and interoperable resources for high potential collaborative research. In addition to capacity building, standardized, accredited, and optimally operational registries can provide unmatched and unparalleled research data that cannot be obtained otherwise. Moving forward, HSCT data collection, collation, and interpretation should be an integral part of the treatment rather than an option. Quality assurance and continuous quality improvement of the data are pivotal for credibility, measurable/quantifiable outcomes, clinically significant impact, and setting new benchmarks.