The ends of outcomes assessment

Outcomes assessment holds great promise to improve the quality and efficiency of health care. By subjecting practices to rigorous and systematic analysis, we should be in a position to make judgments about what does and does not work in clinical practice. However, the outcomes of outcomes assessment themselves should be approached with the same critical eye. Among the many sorts of criteria by which to evaluate outcomes assessment are several key parameters: foremost among them are cognitive outcomes, ethical outcomes, and economic outcomes. Only when these outcomes are thoroughly explored and taken into account will the fullest potential of outcomes assessment be realized.     

Some issues in the assessment of clinical practice: a review of the literature

? This paper focuses on some issues in the assessment of clinical practice of particular interest to the author. ? The assessment of students of nursing in clinical practice is acknowledged as a long-standing and difficult problem. ? There is little consensus as to what is meant by the term competence when applied to clinical nursing practice, making the assessment of clinical practice a mainly subjective process. ? The English National Board (1989) has distinguished the term mentor as meaning counsellor and guide, nevertheless the roles of mentor and assessor are frequently confused. ? It is suggested that nurses are equally accountable for the accurate assessment of student nurses' clinical skills as they are for their own practice. ? The validity and reliability of tools used to assess clinical practice are difficult to establish, making objective assessment complex at best, and impossible at worst. ? The assessment of the reflective process has been suggested as one way out of the dilemma, but the ability to think and to write does not necessarily translate into competent clinical practice.     

Can communication skills be assessed independently of their context?

In many examinations, communication skills tend to be treated as if they are a single attribute independent of the context of the communication. However, it is clear that such assessments are confounded by candidates' knowledge or lack of knowledge of the medical issues about which they are communicating. In the 1990 Part One examination for Membership of the Royal New Zealand College of General Practitioners candidates were provided with all the essential knowledge relevant to the problem they were to communicate about. Despite this, performance was still seen to be context specific, demonstrating that such specificity is not purely knowledge related. Candidates completing the examination were observed to share information about the cases with candidates about to commerce. There was no evidence that performance was enhanced by such breaches in examination security.     

The routine assessment of sperm motility at room temperature and 37°C

The World Health Organization (WHO) laboratory manual (1992) states that assessment of sperm motility can be performed at either 37^OC or room temperature (20–24^OC). The motility of spermatozoa in 44 semen samples (22 fresh samples and 22 frozen-thawed samples) was assessed at both of these temperatures and a significant difference in the motility profiles was noted, specifically an increase at 37^OC in the percentage (expressed here as median and ranges) of spermatozoa with excellent progressive motility and an overall increase in the percentage with total progressive motility. With fresh samples the excellent progressive motility increased from 41 (19–53) to 54 (30–66) and the overall motility from 58.5 (39–74) to 65.0 (40–79). With the frozen—thawed samples the excellent motility increased from 14 (1–33) to 25 (6–45) and the overall motility from 30.5 (14–51) to 33.0 (16–52). As the WHO laboratory manual was published. 'In response to a growing need for the standardisation of procedures for the examination of human spermatozoa' it is proposed that only one temperature for routine analysis should be used, namely 37^OC, which may have more physiological relevance and eliminate effects of fluctuations in ambient laboratory temperature.     

论AB类医疗设备使用率考核方法

对AB类医疗设备使用率的考核是了解设备使用情况和效益的有效方法。本文通过几年来对南京总医院AB类医疗设备使用率的年度考核，摸索总结出一套行之有效的考核方法，为今后新型医疗设备使用率考核提供了可循的依据。     

Cholinergic balance in dementia with Lewy bodies: reversible worsening of Parkinsonism at rivastigmine dosage modulation

We describe a patient with probable dementia with Lewy bodies (DLB) whose Parkinsonism worsened after administration of rivastigmine within the therapeutic dose range. Some extrapyramidal signs (EPS) then reversed to pre-treatment level after rivastigmine dose reduction. We draw attention to the need of EPS monitoring during titration of cholinesterase inhibitors in patients with DLB. This is the first report to our knowledge of iatrogenic worsening of Parkinsonism which was successfully managed by dose reduction.

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Sommario Si descrive il caso di un paziente affetto da Demenza a corpi di Lewy (Dementia with Lewy Bodies, DLB) probabile, in cui si è assistito ad un peggioramento del parkinsonismo dopo somministrazione di rivastigmina a dosi terapeutiche. Alcuni segni extrapiramidali sono regrediti al livello pre-trattamento con una riduzione posologica di rivastigmina. Si sottolinea la necessità di un monitoraggio dei segni extrapiramidali durante la titolazione della terapia con inibitori dell’acetilcolinesterasi cerebrale in pazienti con DLB. Questo è il primo caso descritto, a nostra conoscenza, di un peggioramento iatrogeno di parkinsonismo efficacemente gestito con una riduzione posologica della terapia con rivastigmina.

     

Prediction of outcome from intensive care after gastroenterologic emergency

Prognostic factors determining the outcome from intensive care were studied in 952 patients admitted to 25 Finnish ICUs after gastroenterologic emergency. Logistic regression analysis was used to create predictive models based on the APACHE II–system. The models were constructed by using data from a random two–thirds of the study population and validated in the remaining independent one–third together with the original APACHE II–index. The Acute Physiology Score, age, and a pre–existing liver disease were the three most important determinants of outcome. The inclusion of the TISS score describing the intensity of treatment into a model did not enhance the accuracy of the prediction. Our models were better calibrated than the original APACHE II–equation when tested by the goodness–of–fit –statistics. These statistical models may help the clinicians to predict the outcome for an individual patient by providing them information about the relative impacts of predictive factors or about the probability of death. These probabilities should be interpreted cautiously, taking into acount the limitations of statistical methods. This is especially important when assessing the highrisk patients. Their number in our study was too low for accurate outcome prediction.     

Fear of falling and postural control in Parkinson's disease.

This study investigated the relationship between fear of falling (FOF) and qualitative and quantitative postural control in Parkinson's disease (PD). Fifty-eight nondemented PD patients were studied along with age-matched healthy controls. The degree of FOF was estimated using the Activities-specific Balance Confidence scale. Qualitative postural control was evaluated using a component of the Unified Parkinson Disease Rating Scale. Postural control was quantified, using centre of pressure measures obtained from a force plate, for eight standing balance tests of different challenges. The results showed that FOF was more evident for PD patients when compared with healthy individuals of similar age. Furthermore, FOF was significantly associated with a qualitative estimate of postural control in PD; individuals with PD who had a greater degree of posture impairment reported greater FOF. The results also showed that an estimate of FOF may help to explain quantitative postural instability in PD. FOF, when coupled with a qualitative estimate of postural control, was able to explain a greater amount of variation in quantitative balance performance for five of the eight balance tests. When considered independently, the qualitative measure of postural control, in general, could not well predict quantitative balance performance. The greater degree of FOF and its possible association with altered postural control suggests that FOF should be considered as an important, independent risk factor in the assessment and treatment of postural instability in patients with PD.     

Effect of cognitive and motor tasks on postural stability in Parkinson's disease: a posturographic study.

To analyse the effect of concomitant cognitive or motor task performance on balance control in Parkinson's disease (PD), we performed a posturographic study in 24 PD patients and in 20 sex- and age-matched control subjects. Postural sway was measured with eyes open (EO) and eyes closed (EC) during quiet stance and during performance of calculation or motor sequence of thumb opposition to the other fingers. No difference of centre of foot pressure (COP) parameters was observed during quiet standing (either EO or EC) between patients and controls, but visual deprivation induced in both groups a worsening of postural stability. COP area was significantly increased in PD patients during dual task performance, whereas no difference of COP path and x-y axes was observed. The effects induced by the performance of cognitive or motor task were significantly more evident in PD patients with clinical evidence of postural instability (presence of prior falls in the history). This study demonstrates that dual task interference on postural control can be observed in PD patients during performance of cognitive as well as motor tasks. The balance deterioration during dual task performance was significantly enhanced in patients with history of prior falls. These findings have some implications for the strategies to be used in reducing the risk of fall in PD.