Quality Assessment Improvement Research Articles

Assessment of the water chemical quality improvement based on human health risk indexes: Application to a drinking water treatment plant incorporating membrane technologies

A methodology has been developed in order to evaluate the potential risk of drinking water for the health of the consumers. The methodology used for the assessment considered systemic and carcinogenic effects caused by oral ingestion of water based on the reference data developed by the World Health Organisation (WHO) and the Risk Assessment Information System (RAIS) for chemical contaminants. The exposure includes a hypothetical dose received by drinking this water according to the analysed contaminants. An assessment of the chemical quality improvement of produced water in the Drinking Water Treatment Plant (DWTP) after integration of membrane technologies was performed.Series of concentration values covering up to 261 chemical parameters over 5years (2008–2012) of raw and treated water in the Sant Joan Despí DWTP, at the lower part of the Llobregat River basin (NE Spain), were used. After the application of the methodology, the resulting global indexes were located below the thresholds except for carcinogenic risk in the output of DWTP, where the index was slightly above the threshold during 2008 and 2009 before the upgrade of the treatment works including membrane technologies was executed. The annual evolution of global indexes showed a reduction in the global values for all situations: HQ systemic index based on RAIS dropped from 0.64 to 0.42 for surface water and from 0.61 to 0.31 for drinking water; the R carcinogenic index based on RAIS was negligible for input water and varied between 4.2×10−05 and 7.4×10−06 for drinking water; the W systemic index based on the WHO data varied between 0.41 and 0.16 for surface water and between 0.61 and 0.31 for drinking water. A specific analysis for the indexes associated with trihalomethanes (THMs) showed the same pattern.

Assessment of the management of the Family Health Strategy via the tool Assessment for Quality Improvement in municipalities of Minas Gerais, Brazil.

The self-assessment of the quality ofthe Family Health Strategy(FHS) was assessed in the context ofmanagement and its correlation with characteristics of FHS and of the municipality. Managers, coordinators and Family Health Unit managers of municipalities in the Northeast region of Minas Gerais replied with tools 1, 2 and 3 of the Assessment for Improving the Quality of Family Health Strategy (AIQ). Scores were defined for each subdimension, according to the number of features compliant with the standards of the AIQ. We tested the correlation of this score with coverage and the deployment time of the FHS, with the municipal population and the HDI (Human Development Index). The lowest scores were for Work Management, Permanent Education and Inputs, Immunobiologicals and Medicines. There was a positive correlation between the municipal population and Strengthening of Coordination, Support for Teams, Permanent Education Management and Standardization and a negative one with Infrastructure and Equipment. The use of the AIQ tools permitted the identification of subdimensions and municipalities which will require greater attention and intervention by the municipal management.

Quality control of microbiota metagenomics by k-mer analysis.

BackgroundThe biological and clinical consequences of the tight interactions between host and microbiota are rapidly being unraveled by next generation sequencing technologies and sophisticated bioinformatics, also referred to as microbiota metagenomics. The recent success of metagenomics has created a demand to rapidly apply the technology to large case–control cohort studies and to studies of microbiota from various habitats, including habitats relatively poor in microbes. It is therefore of foremost importance to enable a robust and rapid quality assessment of metagenomic data from samples that challenge present technological limits (sample numbers and size). Here we demonstrate that the distribution of overlapping k-mers of metagenome sequence data predicts sequence quality as defined by gene distribution and efficiency of sequence mapping to a reference gene catalogue.ResultsWe used serial dilutions of gut microbiota metagenomic datasets to generate well-defined high to low quality metagenomes. We also analyzed a collection of 52 microbiota-derived metagenomes. We demonstrate that k-mer distributions of metagenomic sequence data identify sequence contaminations, such as sequences derived from “empty” ligation products. Of note, k-mer distributions were also able to predict the frequency of sequences mapping to a reference gene catalogue not only for the well-defined serial dilution datasets, but also for 52 human gut microbiota derived metagenomic datasets.ConclusionsWe propose that k-mer analysis of raw metagenome sequence reads should be implemented as a first quality assessment prior to more extensive bioinformatics analysis, such as sequence filtering and gene mapping. With the rising demand for metagenomic analysis of microbiota it is crucial to provide tools for rapid and efficient decision making. This will eventually lead to a faster turn-around time, improved analytical quality including sample quality metrics and a significant cost reduction. Finally, improved quality assessment will have a major impact on the robustness of biological and clinical conclusions drawn from metagenomic studies.Electronic supplementary materialThe online version of this article (doi:10.1186/s12864-015-1406-7) contains supplementary material, which is available to authorized users.

Interdisciplinary pain management is beneficial for refractory orchialgia in children

Idiopathic testicular/groin pain can be a difficult entity for children, their families, and caregivers. The role of interdisciplinary pain management has previously been demonstrated in treating chronic orchialgia at the present pediatric pain clinic. To evaluate the role of interdisciplinary pain management in managing refractory orchialgia. It was hypothesized that children with refractory orchialgia might respond well. Interdisciplinary care was defined as that which crosses two medical disciplines such as a surgical specialty and specialist in analgesia. Pediatric patients were identified who were: ≥ 10 years old; evaluated in the pediatric urology clinic between 2002 and 2012; were diagnosed wtih ICD code 608.9 or had the diagnosis of male genital disorder NOS. Children were included if they presented with orchialgia without an identifiable cause and failed conservative management (rest, scrotal support, Sitz bath, timed voiding, constipation avoidance) including conventional anti-nociceptive analgesics (acetaminophen, non-steroidal anti-inflammatory drugs, opioids). Patient electronic medical records were reviewed retrospectively. Twenty-two children met inclusion criteria. Mean age was 13.7 years (range 10-17). Nearly half (45%) of the children had chronic medical conditions such as asthma, allergies, and obesity. Twenty-one of the 22 children were referred to the pediatric pain clinic; 15 were evaluated, and one refused treatment. All children evaluated in the pediatric pain clinic were initially offered an empiric anti-neuropathic anti-convulsant (i.e. gabapentin) and/or an anti-depressant (i.e. amitriptyline) before being offered a nerve block. Of the 14 children accepting treatment in the pediatric pain clinic, six were treated solely with an empiric anti-neuropathic anti-convulsant and/or anti-depressant; eight received medications followed by nerve block (seven ilioinguinal-iliohypogastric blocks, one spinal and ilioinguinal-iliohypogastric block) (see Fig. 1). A total of eight of the 14 children (57%) treated by the pain clinic had resolution of pain, with 50% of those treated with medications alone (three out of six children) responding (two responding to gabapentin and a tricyclic antidepressant, one to gabapentin alone); and five out of eight (63%) treated with medications and then nerve block (ilioinguinal-iliohypogastric block) responding. Of the eight children undergoing nerve block, five required more than one block. The time between each block ranged from 4 to 22.6 weeks. Response to nerve block required an average of 1.4 procedures (range 1-2); mean follow-up after nerve block was 2.4 months (range 0.1-4.8). Children with refractory orchialgia often have comorbidities that suggest a multidisciplinary approach would be useful for treating them. The present study found that the majority of children with refractory orchialgia treated in the pediatric pain clinic responded to management. Major limitations, however, included small cohort size and short follow-up, particularly in those children undergoing nerve block. There was also no objective assessment of pain improvement or improvement in quality of life, which could be rectified with a prospective study. Collaboration and early referral for interdisciplinary pain management as one of these multidisciplinary approaches may help to coordinate care and ease patient suffering.

Defining and assessing quality improvement outcomes: a framework for public health.

We describe an evidence-based framework to define and assess the impact of quality improvement (QI) in public health. Developed to address programmatic and research-identified needs for articulating the value of public health QI in aggregate, this framework proposes a standardized set of measures to monitor and improve the efficiency and effectiveness of public health programs and operations. We reviewed the scientific literature and analyzed QI initiatives implemented through the Centers for Disease Control and Prevention's National Public Health Improvement Initiative to inform the selection of 5 efficiency and 8 effectiveness measures. This framework provides a model for identifying the types of improvement outcomes targeted by public health QI efforts and a means to understand QI's impact on the practice of public health.

5S implementation in Indian SME: a case study

The 'lean' approach is applicable more effectively in large-scale manufacturing than in job type small scale manufacturing sector, mainly because of several perceived barriers in the latter environment. This paper describes a case in Indian manufacturing scenario, where lean principles were adapted for a SME application at a tooling manufacturer. Predominantly, 5S was the main tool used to identify the opportunities for improvements as a step zero of lean techniques. Selected TQM factors were considered in assessing quality improvement along with 5S and visual management, to identify potential areas of improvement on the shop floor. Study reveals the reports of audit to highlight the 'before' and 'after' scenarios in detail. The case study also attempts to elaborate the constraints, inadequacy of research and approach of Indian SMEs while implementing the lean philosophy. It is an attempt to 'right size' the small business and in doing so what can be the attitude of an Indian manufacturing unit.

Voluntary peer review as innovative tool for quality improvement in the intensive care unit--a retrospective descriptive cohort study in German intensive care units.

Introduction: Quality improvement and safety in intensive care are rapidly evolving topics. However, there is no gold standard for assessing quality improvement in intensive care medicine yet. In 2007 a pilot project in German intensive care units (ICUs) started using voluntary peer reviews as an innovative tool for quality assessment and improvement. We describe the method of voluntary peer review and assessed its feasibility by evaluating anonymized peer review reports and analysed the thematic clusters highlighted in these reports.Methods: Retrospective data analysis from 22 anonymous reports of peer reviews. All ICUs – representing over 300 patient beds – had undergone voluntary peer review. Data were retrieved from reports of peers of the review teams and representatives of visited ICUs. Data were analysed with regard to number of topics addressed and results of assessment questionnaires. Reports of strengths, weaknesses, opportunities and threats (SWOT reports) of these ICUs are presented. Results: External assessment of structure, process and outcome indicators revealed high percentages of adherence to predefined quality goals. In the SWOT reports 11 main thematic clusters were identified representative for common ICUs. 58.1% of mentioned topics covered personnel issues, team and communication issues as well as organisation and treatment standards. The most mentioned weaknesses were observed in the issues documentation/reporting, hygiene and ethics. We identified several unique patterns regarding quality in the ICU of which long-term personnel problems und lack of good reporting methods were most interestingConclusion: Voluntary peer review could be established as a feasible and valuable tool for quality improvement. Peer reports addressed common areas of interest in intensive care medicine in more detail compared to other methods like measurement of quality indicators.

Improved quality assessment procedure for old truss bridges according to measuring data

AbstractIn China, many steel truss bridges built at the beginning of the last century are still in service. These bridges have been integrated with the local culture, and demolishing them would be a great pity. Besides, most of them are located in urban centres and their century‐old structures still carry heavy traffic loads. So the safety of these bridges are a serious concern for the local bridge management departments. But the existing evaluation method, which is based on experience, is unreliable.This paper, taking Zhejiang Road Bridge in Shanghai as an example, illustrates an improvement to the evaluation method from the perspectives of traffic load, corrosion and fatigue. The characteristic parameters of traffic loads are first investigated to form a probability density function (PDF) and the traffic load effects spectrum is obtained from a Monte Carlo simulation analysis. Tensile tests on specimens with different degrees of corrosion are performed in order to analyse the effects of corrosion on truss structures. The fitted curve of test data and the degree of corrosion detected on truss components are used to estimate the residual loadbearing capacities of the bridge components.Finally, the fatigue lives of the components are predicted in a study applying fracture mechanics. At the beginning of the study, the crack propagation rate and the fracture toughness are tested and the initial crack is detected using ultrasonic phased arrays. The stress spectrum based on numerical techniques obtained from the previous Monte Carlo simulation is then used to assess the residual fatigue life of each tension components.Verbessertes Bewertungsverfahren für gealterte Fachwerkbrücken auf Grundlage von Messdaten. In China sind noch zahlreiche Stahl‐Fachwerkbrücken in Betrieb, die Anfang des vergangenen Jahrhunderts errichtet wurden. Sie sind ein Teil der örtlichen Kulturgüter geworden und ihr Abriss würde einen großen Verlust darstellen. Viele dieser hundertjährigen Brücken in den Stadtzentren tragen weiterhin große Verkehrslasten. Die Sicherheit dieser Bauwerke ist also ein wichtiges Thema für die örtlich zuständigen Behörden. Jedoch liefert das herkömmliche, erfahrungsbasierte Vorgehen hierfür keine zuverlässigen Bewertungen.Im vorliegenden Beitrag wird am Beispiel der Brücke in der Zhejiang‐Straße in Shanghai gezeigt, wie ein auf Verkehrslast, Korrosion und Ermüdung basierendes Verfahren zuverlässigere Bewertungen ermöglicht. Zuerst werden die charakteristischen Parameter der Verkehrslasten ermittelt und hieraus eine Wahrscheinlichkeitsdichtefunktion (WDF, engl. PDF) berechnet. Das Wirkspektrum der Verkehrslasten wird durch Analyse einer Monte‐Carlo‐Simulation (MC‐Simulation) erstellt. Zugprüfungen an Bauteilproben mit unterschiedlichen Korrosionsstadien dienen dann der Bestimmung der Korrosionseffekte auf das Fachwerk. Anhand einer Ausgleichskurve aus Prüfdaten und ermitteltem Korrosionsgrad von Fachwerkteilen wird die verbleibende Tragfähigkeit der Brückenbauteile abgeschätzt. Abschließend wird die Ermüdungslebensdauer der Bauteile mittels bruchmechanischer Untersuchung vorhergesagt. Eingangs dieser Untersuchung werden Rissausbreitungsrate und Bruchzähigkeit mittels Ultraschall (ultrasonic phased array) ermittelt. Die Restlebensdauer der Bauteile wird dann mit numerischen Verfahren auf Grundlage des aus der MC‐Simulation erhaltenen Lastspektrums bestimmt.

Supporting meaningful advance care planning: A quality-improvement initiative to enhance number and preparedness of individuals selected as medical power of attorney.

201 Background: Few health care organizations have successfully implemented a systematic process for meaningful advance care planning (ACP). An available and capable medical power of attorney (MPOA) allows early engagement in the process and is a foundation for successful ACP. As a first step, we implemented a quality improvement (QI) initiative to systematically offer patients (pts) an opportunity to select a MPOA that is valid*, incorporating quality measures to better prepare selected individuals for medical decision-making in a manner that supports the patient’s values and goals. Here we report on yield of valid MPOA documents (MPOAD) obtained. Methods: After QI Assessment Board approval was obtained, baseline data were collected for all head and neck medical oncologists (HNMO) over a 2-week period. In cycle 1, electronic health records (EHR) of pts seen by 2 HNMO were screened by clinic RN for MPOA. Those with MPOAD that were not available in EHR underwent RN follow up. All others were referred to social work (SW) for education regarding value of MPOA and factors important to preparation of decision maker. In cycle 2, revisions made to process included limiting targeted pts to new pts and consults (NPC). Results: See Table. Conclusions: Systematic SW contact and counseling increases the yield of valid MPOA, but is still insufficient for optimal results. Additional measures to be evaluated in future cycles include scheduled appointments for all NPC to increase SW contact, tighter follow up after initial SW contact and MD discussion with NPC to indicate importance of selecting a prepared MPOA. [Table: see text]

Reducing the time from diagnosis to treatment of patients with stage II/III rectal cancer at a large county hospital.

141 Background: The treatment of stage II/III rectal cancer is complex and requires multidisciplinary collaboration. Delays in definitive treatment may increase morbidity and compromise outcomes. The goal was to reduce the time from pathologic diagnosis to initiation of treatment by 30% for patients with stage II/III rectal cancer at Lyndon B. Johnson General Hospital (LBJGH), which provides care to uninsured and underinsured patients in Harris County, TX. Methods: The charts of 32 patients with rectal cancer diagnosed between July 2012 and December 2013 were reviewed. Baseline data regarding diagnostic and treatment time points were collected. Potential areas for improvement were identified through analysis of the baseline data, affinity sorting, and fishbone diagrams. A multidisciplinary rectal cancer working group with all relevant administrative and subspecialty stakeholders was created to discuss potential interventions and implementation strategies. The project was approved by the MD Anderson Quality Improvement Assessment Board. Results: Twenty-four of the thirty-two patients reviewed had stage II/III rectal cancer and were eligible for multimodality therapy with curative intent. The median time from pathologic diagnosis to treatment initiation was 62 days. The referral process was identified as the greatest source of delays. The median times from diagnosis to medical oncology and radiation oncology referral were 15 and 32 days, respectively. The median time for eligibility verification and clinical review by Case Management was 13 days. Conclusions: Based on these findings, two primary interventions have been instituted: (1) A synchronized referral process that will result in simultaneous consultation of all involved subspecialty services (surgery, medical oncology, and radiation oncology) was created for patients with rectal cancer; (2) Redundancy in the clinical review process was eliminated by coordination between Case Management and the Medical Oncology Chief Fellow. In tandem, these interventions are projected to reduce the time from diagnosis to treatment by approximately 50% (from 62 to 29 days).

PS-161 Severe Intraventricular Haemorrhage And Periventricular Leukomalacia Rates In Very Low Gestational Age Infants Admitted To Euroneonet Participant Units

Background/Aim To describe rates and time trends of severe (Grade III/IV) intraventricular haemorrhage (IVH) and cystic periventricular leukomalacia (PVL) and to investigate associated perinatal factors in EuroNeoNet Neonatal Intensive Care Units. Methods Data from 36,607 VLBWI admitted to 194 NICUs from 19 countries (2006–2012). IVH and PVL rates were separately analysed using logistic regression models for clustered data, with a derivation sample to look for associated factors and a validation sample to verify these (70%/30%). Calibration (Hosmer-Lemeshow test) and discrimination (AUC analysis) were assessed. Significance level was 0.05. Results There was a marked, significant difference in severe IVH and PVL rates between Northern, Western and Eastern European regions (IVH rates 5%, 9.3% and 14.5% respectively; PVL: 2%, 3.7% 8.8%). Severe IVH and/or PVL had common risk factors: lower GA, 5’ Apgar score, antenatal steroid use, male gender and need for surfactant. PVL was associated with major birth defects, and IVH with vaginal delivery, multiple birth, lower 1’ Apgar score and need for DR resuscitation manoeuvres. A significant time trend to decreasing IVH rates was found in Western countries (from 10.5% in 2006 to 7.3% in 2012) (H-L; ROC (95% CI): Severe IVH: 0.870; 0.805 (0.797 to 0.813); PVL. 0.198; 0.664 (0.649 to 0.679). Conclusions There is wide variability in IVH and PVL rates across European regions. IVH rates may be decreasing in Western countries. Although both scores could be used to assess quality improvement initiatives, the perinatal model has better predictive value for IVH. Funded by EC DG-SANCO (Contract number:530078).

EVOLUTION OF A REGIONAL STEMI REPERFUSION MODEL: THE 6-YEAR VANCOUVER COASTAL HEALTH AUTHORITY EXPERIENCE

BACKGROUND: Guidelines strongly recommend that regional systems of STEMI care include the assessment and continuous quality improvement of EMS and hospitalbased activities. We describe the evolution of the Vancouver Coastal Health Authority (VCHA) STEMI program, including the impact of individual care components on reperfusion times and clinical outcomes over a 75-month period. METHODS: All patients with confirmed STEMI presenting within the VCHA from June 2007 to September 2013 were included (n 1⁄4 2041). Primary analysis was performed by care component phase: Phase 1, regionalization of the STEMI program (n 1⁄4 278, June 2007 to May 2008); Phase 2, introduction of pre-hospital ECGs (n 1⁄4 979, May 2008 to May 2011); and Phase 3, implementation of an inter-facility transfer protocol for primary PCI (pPCI) (n 1⁄4 784, May 2011 to September 2013)). A total of 1353 patients received pPCI across all phases. RESULTS: Baseline clinical characteristics were similar between phases. Amongst patients receiving pPCI, median first medical contact-to-device times decreased over the 3 phases, whether the initial presentation was at a PCI capable hospital (116 min, 92 min, 95 min; p < 0.001 for trend) or PCI non-capable hospital (174 min, 146 min, 123 min; p < 0.001 for trend) (Figure). Moreover, the proportion of STEMI patients receiving successful pPCI increased across each phase (44.2%, 63.8%, 74.5%; p < 0.001). Overall in-hospital mortality was not significantly different across each phase (9.4%, 8.8%, 10.6%; p 1⁄4 0.44). However, overall rates of in-hospital congestive heart failure (15.8%, 19.7%, 23.9%; p 1⁄4 0.008) and major bleeding (9.0%, 16.0%, 14.8%; p 1⁄4 0.014) increased over time. CONCLUSION: Within a geographically defined cohort of STEMI patients, a phased roll out of regional pPCI significantly reduced reperfusion times and increased the proportion of patients receiving timely pPCI over a 6-year period. However, in-hospital mortality was unchanged during this same period despite improvements in pPCI performance and access, and both in-hospital congestive heart failure and major bleeding increased over this time period. This suggests that variables beyond receiving timely pPCI are important in determining clinical endpoints. Therefore, in addition to optimizing reperfusion strategies, further understanding and optimization of these variables will be critical to improve STEMI outcomes. 122 DELAYED EDUCATIONAL REMINDERS FOR LONG-TERM MEDICATION ADHERENCE IN ST-ELEVATION MYOCARDIAL INFARCTION (DERLA -STEMI)

Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis.

Frequent users of health care services are a relatively small group of patients who account for a disproportionately large amount of health care utilization. We conducted a meta-analysis of the effectiveness of interventions to improve the coordination of care to reduce health care utilization in this patient group. We searched MEDLINE, Embase and the Cochrane Library from inception until May 2014 for randomized clinical trials (RCTs) assessing quality improvement strategies for the coordination of care of frequent users of the health care system. Articles were screened, and data abstracted and appraised for quality by 2 reviewers, independently. Random effects meta-analyses were conducted. We identified 36 RCTs and 14 companion reports (total 7494 patients). Significantly fewer patients in the intervention group than in the control group were admitted to hospital (relative risk [RR] 0.81, 95% confidence interval [CI] 0.72-0.91). In subgroup analyses, a similar effect was observed among patients with chronic medical conditions other than mental illness, but not among patients with mental illness. In addition, significantly fewer patients 65 years and older in the intervention group than in the control group visited emergency departments (RR 0.69, 95% CI 0.54-0.89). We found that quality improvement strategies for coordination of care reduced hospital admissions among patients with chronic conditions other than mental illness and reduced emergency department visits among older patients. Our results may help clinicians and policy-makers reduce utilization through the use of strategies that target the system (team changes, case management) and the patient (promotion of self-management).

Improving Care Coordination Between Nephrology and Primary Care: A Quality Improvement Initiative Using the Renal Physicians Association Toolkit

Individuals at risk for chronic kidney disease (CKD), including those with diabetes mellitus and hypertension, are prevalent in primary care physician (PCP) practices. A major systemic barrier to mitigating risk of progression to kidney failure and to optimal care is failure of communication and coordination among PCPs and nephrologists. Quality improvement. Longitudinal practice-level study of tool-based intervention in nephrology practices and their referring PCP practices. 9 PCP and 5 nephrology practices in Philadelphia and Chicago. Tools from Renal Physicians Association toolkit were modified and provided for use by PCPs and nephrologists to improve identification of CKD, communication, and comanagement. CKD identification, referral to nephrologists, communication among PCPs and nephrologists, comanagement processes. Pre- and postimplementation interviews, questionnaires, site visits, and monthly teleconferences were used to ascertain practice patterns, perceptions, and tool use. Interview transcripts were reviewed for themes using qualitative analysis based on grounded theory. Chart audits assessed CKD identification and referral (PCPs). PCPs improved processes for CKD identification, referral to nephrologists, communication, and execution of comanagement plans. Documentation of glomerular filtration rate was increased significantly (P=0.01). Nephrologists improved referral and comanagement processes. PCP postintervention interviews documented increased awareness of risk factors, the need to track high-risk patients, and the importance ofearly referral. Final nephrologist interviews revealed heightened attention to communication and comanagement with PCPs and increased levels of satisfaction among all parties. Nephrology practices volunteered to participate and recruit their referring PCP practices. Audit tools were developed for quality improvement assessment, but were not designed to provide statistically significant estimates. The use of specifically tailored tools led to enhanced awareness and identification of CKDamong PCPs, increased communication between practices, and improvement in comanagement and cooperation between PCPs and nephrologists.

Utility and importance of new echocardiographic screening methods in diagnosis of anomalous coronary origins in the pediatric population: assessment of quality improvement.

Anomalous aortic origin of coronaries from the contralateral sinus (AAOCA) is rare but an important cause of cardiac death in the otherwise healthy young athlete. This necessitates prompt, accurate identification; transthoracic echocardiography (TTE) remains the primary screening tool. Assessment of accuracy is difficult since the true prevalence of the disease is unknown, with estimates at 0.3-1.07%. The incidence by TTE remains much lower, between 0.09 and 0.17% even with sophisticated equipment and a high index of suspicion. Our goal was to incorporate two new screening views to our standard TTE protocol and assess improvement in diagnosis of AAOCA by TTE in our laboratory. Recently (2011), we incorporated two new screening methods to standard protocol. The parasternal short axis sweep is extended to visualize the anomalous segment arising superiorly from the ascending aorta before exiting the root at a site close to a 'normal' origin. Secondly, the anomalous, interarterial coronary demonstrates an anterior, steep-angled course visualized in the parasternal long axis between the aorta and pulmonary artery. The echocardiogram database was searched for patients newly diagnosed with AAOCA in 2010 (prior to incorporation of new methods) and 2012. AAOCA incidence in our patient population improved from 0.02% (2010) to 0.22% (2012), age range from 4 days to 17 years. Teenagers and symptomatic patients with anomalous right coronary origin (6) underwent additional confirmatory imaging, and three underwent surgery. One patient with anomalous left coronary origin underwent surgical repair. Addition of the screening views can significantly increase the sensitivity of TTE in diagnosing AAOCA in the asymptomatic patients. We propose that these views be incorporated into the standard TTE evaluation of coronary arteries.

Identification and Assessment of Childhood Obesity by School-Based Health Center Providers

IntroductionSchool-based health centers (SBHCs) serve many overweight/obese children, yet little is known about provider adherence to obesity guidelines. The purpose of this descriptive study was to evaluate obesity care assessment practices of SBHC providers prior to completing training on obesity guidelines. MethodProviders (n = 33) from SBHCs in six states (AZ, CO, NM, MI, NY, and NC) completed The International Life Science Institute Research Foundation Assessment of Overweight in Children and Adolescents Survey. ResultsMost providers reported using body mass index percentile (93.9%) to assess weight. In caring for overweight/obese children, providers reported screening for hypertension 100% of the time and cardiovascular disease 93.9% of the time, and approximately two thirds reported requesting total cholesterol and lipid profile laboratory assessments. Some assessment guidelines were not routinely followed. DiscussionSBHCs serve a high-risk population, and providers in this study may benefit from additional training on assessment guidelines and quality improvement processes to improve adherence to current guidelines.

The effectiveness of computer reminders versus postal reminders for improving quality assessment for point-of-care testing in primary care: a randomized controlled trial.

This study aimed to evaluate the relative effectiveness of electronic and postal reminders for increasing adherence to the quality assurance programme for the international normalized ratio (INR) point-of-care testing (POCT) device in primary care. All 213 family practices that use the Elective Laboratory of the Capital Region, Denmark, and regularly conduct INR POCT were randomly allocated into two similarly sized groups. During the 4-month intervention, these practices were sent either computer reminders (ComRem) or computer-generated postal reminders (Postal) if they did not perform a split test to check the quality of their INR POCT for each calendar month. The adherence of the practices was tracked during the subsequent 8 months subdivided into two 4-month periods both without intervention. Outcomes were measures of split test procedure adherence. Both interventions were associated with an increase in adherence to the split test procedure - a factor 6.00 [95% confidence interval (CI) 4.46-7.72] and 8.22 [95% CI 5.87-11.52] for ComRem and Postal, respectively - but there is no evidence that one of the interventions was more effective than the other. In the ComRem group, the expected number of split tests (out of four) was 2.54 (95% CI 2.33-2.76) versus 2.44 (95% CI 2.24-2.65) in the Postal group, P = 0.14. There was a slight decrease in adherence over the two follow-ups, but neither intervention was better than the other in achieving a lasting improvement in adherence. Computer reminders are as efficient as postal reminders in increasing adherence to a quality assurance programme for the INR POCT device in primary care.

A quality improvement assessment of multiple, concurrent flow cytometry analyses at a tertiary care center.

The utility of flow cytometry (FC) in diagnosis and staging of hematologic malignancy is controversial. Often, multiple specimens from the same patient are processed concurrently for FC analyses, alongside tissue for histomorphologic diagnosis. To assess the diagnostic utility of multiple, concurrent FC analyses, a 10-year retrospective review of cases with ≥2 concurrent specimens (from the same patient) submitted for FC was conducted. Light microscopic (LM) diagnoses were compared to FC findings, and the contribution of FC results to final diagnoses was examined. Of 4058 specimens (predominantly lymph nodes, bone marrows, and oropharyngeal tissues) submitted for FC analyses, 129 (3.2%) represented cases with multiple (average: 2.19) concurrent FC analyses. All were accompanied by tissues and/or aspirates for LM examination. In 115 (89.1%) cases, multiple FC analyses were performed prior to morphologic examination. In 87.0% of those cases, ≥1 FC result(s) aligned with LM findings. In 15 (13.0%) cases where FC results differed from morphologic diagnoses, 86.7% (13/15) failed to detect an abnormal cell population by FC in the presence of a hematologic malignancy by LM. In one case (0.9%), FC detected a lymphoma, without morphologic evidence by LM. Overall, multipart FC failed to demonstrate a significant contribution in initial diagnoses of hematologic malignancies compared with analysis of a single specimen.

Proceedings from Duke Resistant Hypertension Think Tank

To identify patients at increased risk for cardiovascular outcomes, apparent treatment resistant hypertension (aTRH) is defined as having a blood pressure (BP) above goal despite the use of ≥3 antihypertensive therapies of different classes at maximally tolerated doses, ideally including a diuretic. In light of growing scientific interest in the treatment of this group, a multistakeholder think tank was convened to discuss the current state of knowledge, improve the care of these patients, and identify appropriate study populations for future observational and randomized trials in the field. Although recent epidemiologic studies in selected populations estimate that the prevalence of aTRH is 10% to 15% of hypertensive patients, further large-scale observational studies will be needed to better elucidate risk factors. To spur the development of therapies for aTRH, the development of an "aTRH" label for pharmacologic and device therapies with a developmental pathway including treatment added to the use of existing therapies is favored. Although demonstration of adequate BP lowering should be sufficient to gain Food and Drug Administration approval for therapies targeting aTRH, assessment of improvement in quality of life and cardiovascular outcomes is also desirable and considered in Centers for Medicare and Medicaid Services coverage decisions. Device trials under the aTRH label will need uniform and consistent processes for defining appropriate patient populations as well as postapproval registries assessing both long-term safety and duration of responses. Finally, patients with aTRH are likely to benefit from evaluation by a hypertension team to assure proper patient identification, diagnostic work-up, and therapeutic management before consideration of advanced or novel therapies to lower BP.

Objective Assessment of Quality Measurement and Improvement.

Accurate quality measurement that allows for and results in improvement is essential to colon and rectal surgery. Currently, no consensus exists as to which variables are most important in measuring outcomes. Debate continues concerning the "best" variables to measure from a structural, process, and outcomes standpoint. Although American College of Surgeons National Surgical Quality Improvement Program provides an opportunity for outcomes measurement in general and vascular surgery, there is no specific quality improvement tool available for colon and rectal surgery. However, there is growing literature testing the validity of candidate variables to be used in such a data collection system. This article evaluates the current objective assessment measurements used for quality improvement in colon and rectal surgery.