Independent Peer Review Research Articles

Variations in lengths of stay and rates of day case surgery: implications for the efficiency of surgical management.

Variability in lengths of acute hospital stay and rates of day case surgery is shown to be a continuing pattern which occurs both between and within countries. A model of the determinants of health service activity is presented and the contribution of different factors to the observed variations is assessed. Differences in methods of funding health services are identified as a major determinant of the between country variations, while the within country variations largely reflect the influence of local differences in facilities and services and the organisation of care at a hospital level, as well as the independent effects of differences in clinical practice style. The main rationale for advocating a reduction in length of stay and increased use of day surgery is to increase efficiency by reducing costs per case while maintaining the quality of care. These criteria of costs, clinical outcomes and patient acceptability are examined in relation to day case surgery for an intermediate surgical procedure (inguinal hernia repair) and short stay surgery for cholecystectomy. The precise cost savings are shown to depend on the methods of costing, assumptions made and facilities employed, while factors influencing the outcomes achieved include the criteria of patient selection, the surgical techniques employed, and the adequacy of preoperative communication. Barriers to the more widespread adoption of short stay and day case surgery include practical and organisational constraints on clinical practice at a hospital level, lack of awareness among clinicians as to how far their practices differ from current norms, and clinical barriers raised by surgeons who do not see short stay policies as advantageous. Mechanisms to promote changes in clinical practice styles include independent professional audit, peer review, and involvement of clinicians in budgeting and resource allocation. Assessing quality requires that attention is given to patient acceptability and satisfaction as well as to the monitoring of clinical outcomes.

Independent Engineer Peer Review for Seismic Isolation Projects

Seismic isolation for buildings is an evolving state-of-the-art concept that is gaining acceptance for reducing seismic response of structures as well as the equipment housed therein. As there are no standards or codes covering this concept, owners are using independent engineer reviewers to help ensure that the isolation concept is viable for their buildings and the resulting design and construction meets the agreed-upon project needs. The responsibilities and scope of review, types of data reviewed, and questions asked by the reviewer are important ingredients of a successful project.

Proposed Criteria for Independent Peer Reviewers

Because of the complexity of craniomandibular claims, it is difficult for insurance adjusters to keep up with all of the advances and techniques regarding craniomandibular disorders. Insurance companies have found that they can process claims more quickly and economize by having claims reviewed. Because of this, independent insurance reviews have become routine for TMJ claims. Many practitioners contend that the current review system appears to be lacking in impartiality, criteria for reviewers, and standardized fees for various geographical locations. The author offers suggestions for objective reviews that ensure the use of qualified and responsible reviewers. Setting guidelines for reviewers will bring about more equitable reviews and assist in dismantling the confusion surrounding head and neck claims.

Periodic competency review. An assessment and policy model.

Periodic review of professional competence or performance is on the public agenda as a response to rising malpractice suits, iatrogenic morbidity, and mortality resulting directly from professional incompetence, and the inadequacy of current licensing and discipline systems. This article reviews several continuing competency programs, such as mandatory education, as well as recent experiments in selective performance evaluation. The evaluation literature suggests that mandatory continuing education and most peer review programs are not sufficiently related to improvement of performance. An Ontario experiment provides useful data and insight about a positive reinforcement (nonpunitive) independent peer review process. Policymakers should consider, as an alternative to mandatory continuing education, directing professional associations, professional schools, and regulatory boards to design cost effective review procedures which selectively monitor performance.

Radiation standards and A-bomb survivors

For more than 33 years, the US government has supported the Life Span Study of Japanese survivors as a follow-up of the 1945 nuclear bombings of Hiroshima and Nagasaki. Since 1975, the study has been funded jointly by the United States and Japan under the auspices of the Radiation Effects Research Foundation. In the May issue of this bulletin radiation epidemiologists Dr. Alice Stewart and George Kneale raise perhaps the most fundamental question of all: Does the Japanese A-bomb survivor study have any value in deriving risk estimates for low-level radiation. On the basis of data published by the Radiation Effects Research Foundation in 1978, Stewart and Kneale suggest that Foundation analysts have confused long-term effects of tissue-destructive high doses with single-cell low-dose effects. If they are correct, the method of linear extrapolation from high-dose studies for low-level radiation risk estimates is invalid. The author feels the A-bomb survivors study should be opened up to an independent peer review process.

The treatment of carcinoma of the nasopharynx in hyperbaric oxygen: An outside assessment

This paper describes a series of 51 patients with cancer of the nasopharynx who were treated by chance either in air or hyperbaric oxygen. The results suggest that there may be an advantage to be obtained from treatment in hyperbaric oxygen as shown by the death rate between 1 and 2 years, the two year survival rate, and the local recurrence rate. There was increased operability rate of lymph nodes and also a higher proportion of those treated in hyperbaric oxygen died of metastases compared with the air series. It is suggested that an approach should be developed, using large irradiation treatment volumes and systemic anticancer therapy. The difficulty in arriving at formal statistical conclusions in the treatment of rare diseases, even by involving multicentre trials, is noted. The approach of independent peer review in difficult problems such as these, is proposed.