Safety is part of quality: a proposal for a continuum in performance measurement

Objectives Safer care is a strategic priority for health care organizations worldwide. Yet, the measurement and evaluation of key processes and outcomes associated with safer care remains challenging, even with existing performance measurement indicators. The multi‐national Quality Indicator Project (QI Project^®) data are analysed to [ 1 ] document the patterns of safety indicators used between 1999 and 2006 among hospitals in Asia, Europe and the USA; and [ 2 ] to identify trends in using both organization‐level and patient‐level data in hospital performance improvement. Design and setting Retrospective data are used to ascertain how the use of safety indicators has changed in comparison to other QI Project^® indicators. ‘Continent’ rather than ‘hospital’ is used as the unit of analysis and P‐values of the differences in use percentages across Asia, Europe and the USA are calculated. Results There was a significant increase in the use of QI Project^® indicators in Asia between 1999 and 2006. Measured as the mean percentage of usage, the safety versus ‘all other’ indicators' increase in Asia was 43.7% versus 27% (P < 0.05) and 37.2% versus 24.4% (P < 0.05), respectively, during the study's time period. The European participants used both safety and all other indicators less frequently, 14.7% versus 18% (P < 0.05) and 9.5% versus 19.8% (P < 0.05), respectively. Finally, USA hospitals demonstrated a larger difference in the decrease of QI Project^® indicator use than European hospitals between the ‘safety’ and ‘all other’ indicators, 12.7% decrease for safety indicators and 7.1% for all others (P < 0.05). These findings are consistent with trends reported in a previous study. Conclusion Traditional performance measures continue to assist hospitals in identifying crucial aspects of safety in the delivery of care. Building on the findings of a previous study, there are emerging trends in the type of measures used in hospitals in Asia, Europe and the USA pursuing the improvement of overall performance. The increasing use of patient‐level data specifically, in tandem with organizational level indicators, may signal the continuum of measurement strategies, now still predominately in the USA but anticipated to be adopted both in Europe and Asia.     

The role of overexpressed DYRK1A protein in the early onset of neurofibrillary degeneration in Down syndrome

The gene encoding the minibrain kinase/dual-specificity tyrosine phosphorylated and regulated kinase 1A (DYRK1A) is located in the Down syndrome (DS) critical region of chromosome 21. The third copy of DYRK1A is believed to contribute to abnormal brain development in patients with DS. In vitro studies showing that DYRK1A phosphorylates tau protein suggest that this kinase is also involved in tau protein phosphorylation in the human brain and contributes to neurofibrillary degeneration, and that this contribution might be enhanced in patients with DS. To explore this hypothesis, the brain tissue from 57 subjects including 16 control subjects, 21 patients with DS, and 20 patients with sporadic Alzheimer's disease (AD) was examined with two antibodies to the amino-terminus of DYRK1A (7F3 and G-19), as well as two polyclonal antibodies to its carboxy-terminus (X1079 and 324446). Western blots demonstrated higher levels of full-length DYRK1A in the brains of patients with DS when compared to control brains. Immunocytochemistry revealed that DYRK1A accumulates in neurofibrillary tangles (NFTs) in subjects with sporadic AD and in subjects with DS/AD. Overexpression of DYRK1A in patients with DS was associated with an increase in DYRK1A-positive NFTs in a gene dosage-dependent manner. Results support the hypothesis that overexpressed DYRK1A contributes to neurofibrillary degeneration in DS more significantly than in subjects with two copies of the DYRK1A gene and sporadic AD. Immunoreactivity with antibodies against DYRK1A not only in NFTs but also in granules in granulovacuolar degeneration and in corpora amylacea suggests that DYRK1A is involved in all three forms of degeneration and that overexpression of this kinase may contribute to the early onset of these pathologies in DS.     

The utility of knee releases in arthrogryposis

BACKGROUND: Knee contractures are difficult deformities to manage in arthrogryposis. There is little information regarding the long-term functional outcomes. METHODS: Patients with a diagnosis of arthrogryposis who had knee releases performed at a single institution with at least 2 years of follow-up were identified retrospectively. Patients were called back prospectively for a clinical examination and administration of the Pediatric Outcomes Data Collection Instrument (PODCI), Pediatric Evaluation of Disability Inventory (PEDI), and the WeeFIM instruments. Functional mobility was quantified using the Functional Mobility Scale (FMS). RESULTS: Thirty-two patients were identified with a total of 50 knees. There were 45 flexion contractures and 5 extension contractures. Average length of follow-up was 11.9 years (range, 2.2-23.6 years). Amount of extension on final follow-up correlated with all final FMS scores (P < 0.02). The FMS demonstrated decreases in mobility as distance increased. Twenty-two of 32 patients completed functional outcomes measures. Pediatric Evaluation of Disability Inventory Mobility scores, Functional Independence Measure for Children (WeeFIM) Mobility, and WeeFIM Self-Care scores were decreased compared with norms, and Normative PODCI scores at final follow-up showed significant impairment in Upper Extremity Function, Transfers/Mobility, Sports/Physical Function, and Global Function Domains. When patients were subdivided by length of follow-up, patients showed decline in scores for all FMS distances; PEDI Mobility Domains; WeeFIM Self-Care and Mobility Domains; and Transfer/Mobility, Sports/Physical Function, and Global Function Domains, as length of follow-up increased. CONCLUSIONS: Whereas knee releases may improve function in the short term, function and outcomes decline as patients age. Patients with arthrogryposis demonstrated significant impairment in normative scores for Upper Extremity/Physical Function, Transfers/Mobility, Sports/Physical Function, and Global Function Domains. In addition, function as measured by the PODCI, WeeFIM, and PEDI showed decreased scores as length of follow-up increased. We strongly advise that when counseling parents on this surgical intervention, parents are made aware that ambulatory ability may improve short term but may decline as patients age and contractures recur. LEVEL OF EVIDENCE: Therapeutic Level 4.     

The effect of the annular ligament on kinematics of the radial head

PURPOSE: There is evidence that the radial head translates during pronation and supination. This study measured radial head movement and the location of the pronation-supination axis of the forearm with and without the annular ligament. METHODS: Thirteen cadaveric arms were attached to a custom-built frame. Pronation and supination were achieved by actuation of the pronator teres and biceps tendons, respectively. Motion was captured by video cameras via marker arrays attached to the distal radius, distal ulna, humerus, and radial head. Three pronation-supination trials were performed with the annular ligament intact and the elbow positioned at 90 degrees . The sequence was repeated after transection of the annular ligament. RESULTS: The radial head traveled an average of 2.1 mm in the anteroposterior direction and 1.6 mm in the mediolateral direction during forearm rotation. After annular ligament resection, travel of the radial head increased by an average of 44% in the mediolateral direction and by 24% in the anteroposterior direction. On average, the mean pronation-supination axis (screw displacement axis) passed 1.4 mm +/- 1.9 medial to the center of the capitellum and through the center of the ulnar head. Loss of the annular ligament did not change the location of the pronation-supination axis. CONCLUSIONS: During forearm rotation, the radial head travels to a greater extent in the anteroposterior direction than in the mediolateral direction. Loss of the stabilizing effect of the annular ligament increases the travel mediolaterally more than anteroposteriorly. The pronation-supination axis of the forearm is nearly constant and is not affected by annular ligament transection.     

A Wakeup Call to the Prevention Field: Are Prevention Programs for Substance Use Effective for Girls?

Substance misuse in adolescent girls has increased dramatically since 1992. This article reviews trends in use rates and etiological theories tested by gender that suggest that family protective factors have more influence on girls. Next, a literature review reveals that few prevention programs have published their outcomes by gender or developed gender-specific programs. Nationwide community coalition results found positive effects on boys but increased drug use in young girls. The most effective programs are family focused targeting family bonding, supervision, and communication. Recent gender-specific prevention programs with positive results address stress, depression, social assertiveness, and body image. The authors recommend additional research testing programs by gender and also gender-specific versus generic versions of evidence-based programs to determine how to improve prevention program effectiveness for girls.