The Consumer Quality Index in an accident and emergency department: internal consistency,validity and discriminative capacity

Background

Patients’ experiences are an indicator of health‐care performance in the accident and emergency department (A&E). The Consumer Quality Index for the Accident and Emergency department (CQI A&E), a questionnaire to assess the quality of care as experienced by patients, was investigated. The internal consistency, construct validity and discriminative capacity of the questionnaire were examined.

Methods

In the Netherlands, twenty‐one A&Es participated in a cross‐sectional survey, covering 4883 patients. The questionnaire consisted of 78 questions. Principal components analysis determined underlying domains. Internal consistency was determined by Cronbach''s alpha coefficients, construct validity by Pearson''s correlation coefficients and the discriminative capacity by intraclass correlation coefficients and reliability of A&E‐level mean scores (G‐coefficient).

Results

Seven quality domains emerged from the principal components analysis: information before treatment, timeliness, attitude of health‐care professionals, professionalism of received care, information during treatment, environment and facilities, and discharge management. Domains were internally consistent (range: 0.67–0.84). Five domains and the ‘global quality rating’ had the capacity to discriminate among A&Es (significant intraclass correlation coefficient). Four domains and the ‘global quality rating’ were close to or above the threshold for reliably demonstrating differences among A&Es. The patients’ experiences score on the domain timeliness showed the largest range between the worst‐ and best‐performing A&E.

Conclusions

The CQI A&E is a validated survey to measure health‐care performance in the A&E from patients’ perspective. Five domains regarding quality of care aspects and the ‘global quality rating’ had the capacity to discriminate among A&Es.     

Evaluation of three physiologically based pharmacokinetic (PBPK) modeling tools for emergency risk assessment after acute dichloromethane exposure

Introduction

Physiologically based pharmacokinetic (PBPK) models may be useful in emergency risk assessment, after acute exposure to chemicals, such as dichloromethane (DCM). We evaluated the applicability of three PBPK models for human risk assessment following a single exposure to DCM: one model is specifically developed for DCM (Bos) and the two others are semi-generic ones (Mumtaz and Jongeneelen).

Materials and methods

We assessed the accuracy of the models’ predictions by simulating exposure data from a previous healthy volunteer study, in which six subjects had been exposed to DCM for 1 h. The time-course of both the blood DCM concentration and percentage of carboxyhemoglobin (HbCO) were simulated.

Results

With all models, the shape of the simulated time course resembled the shape of the experimental data. For the end of the exposure, the predicted DCM blood concentration ranged between 1.52–4.19 mg/L with the Bos model, 1.42–4.04 mg/L with the Mumtaz model, and 1.81–4.31 mg/L with the Jongeneelen model compared to 0.27–5.44 mg/L in the experimental data. % HbCO could be predicted only with the Bos model. The maximum predicted % HbCO ranged between 3.1 and 4.2% compared to 0.4–2.3% in the experimental data. The % HbCO predictions were more in line with the experimental data after adjustment of the Bos model for the endogenous HbCO levels.

Conclusions

The Bos Mumtaz and Jongeneelen PBPK models were able to simulate experimental DCM blood concentrations reasonably well. The Bos model appears to be useful for calculating HbCO concentrations in emergency risk assessment.     

Transoesophageal echocardiographic evaluation of atrial morphology in children with congenital heart disease.

In a prospective study, atrial morphology was evaluated by both transoesophageal and precordial echocardiography in 86 unoperated children with congenital heart disease (age range = 0.2 to 14.8 years, mean = 3.8 years) to determine what advantages, if any, might be inherent in the transoesophageal approach. The information derived from both ultrasound approaches was correlated and compared to information obtained during subsequent cardiac catheterization (78 patients) and, or, surgical inspection (53 patients). Atrial appendage morphology and hence atrial situs was determined by transoesophageal echocardiography in every case (82 solitus, two right atrial isomerism, two left atrial isomerism). In addition, the transoesophageal approach indicated left juxtaposition in four patients, compared to only one by precordial examination. Probe patency of the foramen ovale was correctly predicted in 21 patients by transoesophageal imaging, but in only 10 by precordial imaging. In two children significant secundum defects, undetected by the precordial route, were identified. Multiple atrial septal defects were correctly defined in four patients by transoesophageal study but in only one by precordial study. Sinus venosus defects were documented in four by the transoesophageal approach, but in only one by the precordial. Primum defects were equally well documented (nine patients) by either technique, but the associated valve leaflet morphology was better documented by transoesophageal study in 5/9. A subtotal cor triatriatum was diagnosed in one child only by transoesophageal investigation. Transoesophageal echocardiography allows a much more detailed evaluation of atrial morphology than precordial imaging even in infants. It provides direct diagnosis of atrial situs, detection of juxtaposed atrial appendages and improved demonstration or definitive exclusion of atrial septal defects.     

The outcome of esophagogastroduodenoscopy (EGD) in asymptomatic outpatients with iron deficiency anemia after a negative colonoscopy

Background: Both iron deficiency and iron deficiency anemia require extensive investigation because of their possible association with gastrointestinal malignancy. If no other sources of blood loss are apparent, the gastrointestinal tract is examined to detect sources of occult blood loss. In the absence of gastrointestinal symptoms, the colon is first examined, especially in the elderly. The aim of this study was to determine the outcome of esophagogastroduodenoscopy (EGD) after a prior negative colonoscopy in outpatients without gastrointestinal complaints, referred due to iron deficiency anemia. Methods: Thirty-five patients (22 female and 13 male) with a median age of 71 years were studied over a 2-year period. Anemia was defined as a hemoglobin (Hb) level below 7.4 mmol/l in women or below 8.0 mmol/l in men and iron deficiency if one of the following was present: ferritin level equal to or below 20 μg/l for men and equal to or below 10 μg/l for women, a serum iron concentration equal to or below 45 μg/dl (8.1 μmol/l) with a transferrin saturation of 10% or less, or the absence of iron stores in bone marrow biopsy specimens. Patients with prior gastrointestinal disease or surgery, gastrointestinal symptoms, or other obvious causes of blood loss were excluded. Lesions that were considered to be potential sources of blood loss were clearly defined. Results: The mean Hb level of the 35 patients studied was 5.5 mmol/l (range 1.8-7.8 mmol/l). Abnormalities were found in 10 patients (28.6%), all of which were benign. Erosive and ulcerative lesions in the stomach, in a hiatal hernia, or in the esophagus were diagnosed in eight patients, benign villous adenoma was seen in one patient, and celiac disease in another, although duodenal biopsies were taken in only 15 patients. Erosions and/or ulcerations were found in four of 11 patients (36%) using NSAIDs and/or salicylates (ASA). Seventy percent of the lesions were found in elderly patients (>65 years), 56% of whom were using NSAIDs and/or ASA. Conclusions: EGD should always be performed in patients with iron deficiency anemia after a negative colonoscopy, although upper gastrointestinal malignancy will probably be an infrequent finding. The presence of a significant, treatable lesion is most likely in the elderly and in those with a history of NSAID or ASA use. Routine duodenal biopsies should be performed to further increase the outcome of EGD.     

Comparison of costs of percutaneous transluminal coronary angioplasty and coronary bypass surgery for patients with angina pectoris

To determine the costs of a procedure, the total costs of the department that provides the service must be considered and, in addition, the direct cost of the specific procedure. Applying this principle to the cost accounting of angioplasty and bypass surgery results in a direct, i.e. procedural, cost, including the initial hospital stay, of respectively 8694 Dfl and 20,987 Dfl. A review of the follow-up data for the first year after the original intervention revealed a 2% reintervention rate for bypass surgery, while this percentage was 29% for angioplasty. Adding the first year costs involved with reinterventions to the procedural costs results in a 1-year cost of angioplasty and bypass operation of 13,625 Dfl and 21,363 Dfl, respectively. It is concluded that because of reinterventions in the first year, a mark up of 57% on the procedural cost of angioplasty must be added to cover 1-year costs, while for bypass surgery this is only 1%. Nevertheless, the 1-year cost for angioplasty is still 36% less than for bypass surgery. As reinterventions after PTCA may stay considerably higher than for CABG for several years, the mark-up percentages will be substantially higher for longer time spans. This may tend to equalize the total costs of PTCA and CABG over time spans of perhaps 5-8 years. Sufficient data are not available to verify this statement. Clinicians must realize that choosing the most appropriate procedure is not only a matter of medical assessment but also a matter of cost effectiveness. CABG can be seen as an 'investment decision' while PTCA tends to become a decision with characteristics of 'maintenance planning'!     

Subclavian flap aortoplasty for treatment of coarctation of the aorta in infants less than 3 months of age

Over a period of 3 years, 21 infants under 3 months of age were operated upon for coarctation of the aorta by subclavian flap aortoplasty. Associated intracardiac defects were present in 13 patients (62%), VSD being the most frequently encountered (10 patients, 48%). In 8 patients coarctation of the aorta, with or without patent ductus arteriosus, was the only cardiovascular malformation. The indication for surgical treatment was intractable congestive heart failure despite intensive medical treatment. Eight patients were on mechanical ventilatory support prior to surgery. There was no early operative mortality. One patient died in congestive heart failure due to valvular aortic stenosis 3 months after surgery for correction of the coarctation. During a follow-up of from 2 months to 3 years, 5 patients underwent a second operation for correction of intracardiac defects. Nineteen of the surviving 20 patients are in good clinical condition. One patient has clinical evidence of residual coarctation; a blood pressure difference of more than 10 mmHg between right arm and leg is presented in 4 patients. Early subclavian flap aortoplasty is recommended for patients with coarctation of the aorta, with or without associated intracardiac defects, who remain in congestive heart failure despite medical therapy.     

One-year hemodynamic comparison of Perimount Magna with St Jude Epic aortic bioprostheses

Introduction

Cardiac surgeons are using more bioprosthetic valves due to the ageing population as well as to improvements that have been made to these implants. We sought to compare the 1-year hemodynamics of two commercially available valves by echocardiographic parameters.

Material and methods

Retrospective review of our institutional database revealed 69 patients who received either Perimount Magna (n = 33) or St Jude Epic (n = 36) valves in the aortic position with no other valve surgery between June 2004 and March 2006. All patients received transthoracic echocardiography at 1 year. Comparisons between groups were made at baseline and at 1-year follow-up. In addition, a pairwise comparison was performed in each patient to determine the change in echocardiographic parameters between baseline and follow-up.

Results

Mean implanted valve size was similar (Magna 24.3 ±2.0 mm vs. Epic 24.1 ±2.2 mm). Pre- and intraoperative patient variables were similar between the two groups. There were lower peak and mean pressure gradients in the Magna group, both at discharge and one year after surgery. This correlated with a larger indexed effective orifice area (Magna 0.8 ±0.2 cm²/m² vs. Epic 0.67 ±0.2 cm²/m², p = 0.02). In spite of these findings, left ventricular mass regression was not different.

Conclusions

These findings suggest that in a series with relatively low indexed effective orifice areas, the peak and mean gradients obtained were acceptable. More clinical follow-up of these patients is required to assess the true impact of prosthesis patient mismatch.