Interinstitutional Variation Research Articles

Prevalence and Variation of Physical Restraint Use in Acute Care Settings in the US

To describe physical restraint (PR) rates and contexts in U.S. hospitals. This 2003-2005 descriptive study was done to measure PR prevalence and contexts (census, gender, age, ventilation status, PR type, and rationale) at 40 randomly selected acute care hospitals in six U.S. metropolitan areas. All units except psychiatric, emergency, operative, obstetric, and long-term care were included. On 18 randomly selected days between 0500 and 0700 (5:00 am and 7:00 am), data collectors determined PR use and contexts via observation and nurse report. PR prevalence was 50 per 1,000 patient days (based on 155,412 patient days). Preventing disruption of therapy was the chief reason cited. PR rates varied by unit type, with adult ICU rates the highest obtained. Intra- and interinstitutional variation was as high as 10-fold. Ventilator use was strongly associated with PR use. Elderly patients were over-represented among the physically restrained on some units (e.g., medical) but on many unit types (including most ICUs) their PR use was consistent with those of other adults. Wide rate variation indicates the need to examine administratively mediated variables and the promotion of unit-based improvement efforts. Anesthetic and sedation practices have contributed to high variation in ICU PR rates. Determining the types of units to target to achieve improvements in care of older adults requires study of PR sequelae rate by unit type.

Biological Intercomparison Using Gut Crypt Survivals for Proton and Carbon-Ion Beams

Charged particle therapy depends on biological information for the dose prescription. Relative biological effectiveness or RBE for this requirement could basically be provided by experimental data. As RBE values of protons and carbon ions depend on several factors such as cell/tissue type, biological endpoint, dose and fractionation schedule, a single RBE value could not deal with all different radiosensitivities. However, any biological model with accurate reproducibility is useful for comparing biological effectiveness between different facilities. We used mouse gut crypt survivals as endpoint, and compared the cell killing efficiency of proton beams at three Japanese facilities. Three Linac X-ray machines with 4 and 6 MeV were used as reference beams, and there was only a small variation (coefficient of variance < 2%) in biological effectiveness among them. The RBE values of protons relative to Linac X-rays ranged from 1.0 to 1.11 at the middle of a 6-cm SOBP (spread-out Bragg peak) and from 0.96 to 1.01 at the entrance plateau. The coefficient of variance for protons ranged between 4.0 and 5.1%. The biological comparison of carbon ions showed fairly good agreement in that the difference in biological effectiveness between NIRS/HIMAC and GSI/SIS was 1% for three positions within the 6-cm SOBP. The coefficient of variance was < 1.7, < 0.6 and < 1.6% for proximal, middle and distal SOBP, respectively. We conclude that the inter-institutional variation of biological effectiveness is smaller for carbon ions than protons, and that beam-spreading methods of carbon ions do not critically influence gut crypt survival.

Heterogeneity and the evaluation of efficiency: the case of Italian universities

A random parameters stochastic frontier model is applied to Italian data in order to evaluate the cost function and efficiency of higher education institutions. The method yields useful information about inter-institutional variation in cost structure and technical efficiency. Returns to scale and scope are evaluated for the typical university, and it is found that these returns are almost ubiquitously decreasing, a finding with clear policy implications.

Standardization of the assay method for anti-A/B antibody titers and its problems

Introduction of effective treatments such as (double filtration) plasmapheresis, splenectomy, intravenous immunoglobulin and potent immunosuppressive agents including anti-CD20 monoclonal antibody, has greatly improved graft outcome in ABO-incompatible transplantation. The measurement of anti-blood group A/B antibody titers is considered to be important, because it would provide useful information on prognosis and indication of transplantation, selection of treatments and prediction of acute rejection. Isohemagglutinin assay in serial-doubling dilutions of serum sample by tube test has been basically used in most institutions. However, detailed assay procedure seemed to vary between institutions. Furthermore, the determination by visual observation might cause a problem of inter-examiner variability. The Japanese ABO-Incompatible Transplantation Committee has conducted a series of nationwide surveys to assess the current status of inter-institutional variation in measurement of anti-A/B antibody titer. In the first survey, serum samples from 6 healthy volunteers with blood groups A ( n = 2), B ( n = 2) and O ( n = 2) were sent to 29 institutions where ABO-incompatible kidney or liver transplantation has been performed. Anti-A/B antibody titer was measured by its own protocol. Inter-institutional difference of measured values reached to 32-fold and 256-fold in IgM and IgG, respectively. As this variability was too wide for detailed analysis, the provisional standard protocol for the assay was determined according to the result of questionnaire survey. Next, 38 and 40 institutions participated in the second (in 2004) and the third survey (in 2005), respectively. Anti-A/B antibody titers of serum samples were measured by the standard procedure. Analysis of survey revealed that intra-institutional variation was reduced to below 8-fold (mostly 2- to 4-fold), although several institutions still needed some guidance. Standardization of the assay procedure and quality control survey would be necessary to improve the accuracy of measurement. Significance of measurement of anti-A/B antibody titer in ABO-incompatible transplantation should be discussed after the result of multi-center study is obtained.

Quality assurance of radiotherapy in the Japan Clinical Oncology Group trial 0211 concerning concurrent chemoradiotherapy for localized nasal NK/T-cell lymphoma: The individual case review

17561 Background: It is challenging to conduct a high quality multi-institutional clinical trial for localized nasal NK/T-cell lymphoma due to the anatomical complexity and its rarity. The purpose of this study was to evaluate the compliance with protocol guidelines in concurrent chemoradiotherapy for this disease among radiotherapy institutions participating in a multi-center phase I/II JCOG trial 0211. Methods: The treatment consisted of radiotherapy 50 Gy and 3 cycles of DeVIC chemotherapy [carboplatin, etoposide, ifosfamide, dexamethasone] (Yamaguchi M, et al.: Proc ASH, 2005). CT-based three-dimensional treatment planning was required to cover adequately target volumes and to minimize doses to organs at risk such as the eyes, the brain stem and the spinal cord. Patient data were sent to the review center after the treatments have been finalized. The following parameters were evaluated by the quality assurance review board: treatment records and charts; simulation films; portal images; prescribed dose; dose fractionation and overall treatment time; dose distributions; and dose to risk organs. Results: At the time of phase I analysis, 10 patients were enrolled in this study. In 2 of 10 cases, process of treatment planning was not available. There was no protocol violation. Major deviations were identified as follows: Delineation of clinical target volume (&lt; 2 cm from the edge of the gross tumor volume at any direction), 2/10; dose distribution (not covered by 90%-115% isodose line), 1/10; and dose to optic chiasm (&gt;40 Gy), 1/10. All cases were compliant in prescribed dose, dose fractionation, and overall treatment time. In the last 4 of 10 cases, attending radiation oncologists at the participating institutions were contacted by the radiation oncology study chair and they discussed the treatment planning just after patient enrollment. These 4 cases were all protocol compliant compared to 6 cases with 4 major deviations. Conclusions: Individual case review is essential in a multi-center clinical trial to keep enrolled cases protocol compliant and minimize inter-institutional variations. We expect that our quality assurance program will maintain the quality of the JCOG trial 0211. No significant financial relationships to disclose.

A series of surveys on assay for anti‐A/B antibody by Japanese ABO‐incompatible Transplantation Committee

The measurement of anti-blood groups A and B antibody (Ab) titers is considered to be important in ABO-incompatible transplantation. However, no standard method for quantitative determination has yet been established in Japan. Inter-examiner variability was likely because Ab titer was determined mainly by visual observation. In order to assess inter-institutional variation in the measurement of anti-A/B Ab titer, a series of surveys was conducted by the Japanese ABO-incompatible Transplantation Committee. In 2003, the first national survey was conducted. Serum samples from six healthy volunteers with blood groups A (n = 2), B (n = 2) and O (n = 2) were sent to 29 institutions and anti-A/B Ab titer was measured by their customary methods. Isohemagglutinin assay in serial-doubling dilutions of serum using a test tube was widely used in all institutions. Inter-institutional difference between maximum and minimum value reached as much as 32-fold in immunoglobulin M (IgM) and 256-fold in IgG. As detailed protocol for assay seemed to be different between institutions, we attempted to standardize the protocol based on the result of a questionnaire survey. In 2004, a second survey was conducted in the same manner as the previous one, except participation involved 38 institutions and the measurement was performed in a uniform way using a provisional standard protocol. Analysis of the survey revealed that intra-institutional variation was reduced to below eightfold, except that several institutions showed a large difference from the mean titer and required some guidance. A periodical quality control survey is considered necessary to improve the accuracy of measurement. Anti-A/B Ab titer would provide useful information towards the prediction of rejection and the indication of treatments such as (double filtration) plasmapheresis, splenectomy, anti-CD20 monoclonal antibody and intravenous immunoglobulin. Standardization of the assay for anti-A/B Ab titer is essential for the fulfillment of a precise multicenter study, which will elucidate the significance of the measurement of anti-A/B Ab titer.

Five years to the term breech trial: The rise and fall of a randomized controlled trial

On the basis of the end points of neonatal morbidity and death, the authors of the term breech trial concluded unequivocally that cesarean delivery was safer for breech babies. Analysis of the original and new data gives rise to serious concerns as far as study design, methods, and conclusions are concerned. In a substantial number of cases, there was a lack of adherence to the inclusion criteria. There was a large interinstitutional variation of standard of care; inadequate methods of antepartum and intrapartum fetal assessment were used, and a large proportion of women were recruited during active labor. In many instances of planned vaginal delivery, there was no attendance of a clinician with adequate expertise. Most cases of neonatal death and morbidity in the term breech trial cannot be attributed to the mode of delivery. Moreover, analysis of outcome after 2 years has shown no difference between vaginal and abdominal deliveries of breech babies. The original term breech trial recommendations should be withdrawn.

Commentary: Classification and grading of pituitary tumors. Observations of two working neuropathologists

As part of the World Health Organization (WHO) ‘‘blue book’’ series, the recently updated endocrine volume includes a 38-page chapter on pituitary tumors [3], divided into concise multi-authored sections. New developments, remaining shortcomings, and future directions of research have been summarized by Al-Shraim and Asa in the current issue [1]. Overall, this newest ‘‘blue book’’ is superbly written, provides a wealth of useful information, and is sold at a readily affordable price, making it a bargain to anyone even remotely interested in pituitary pathology. As with other issues of the WHO series, current molecular data are well integrated with classic pathology and the entities are beautifully illustrated. The pituitary falls under the purview of both endocrine and neuropathology. However, given its intracranial location, the gland is biopsied by neurosurgeons. Therefore, despite crossing subspecialty boundaries, neuropathologists must be well acquainted with this area of endocrine pathology. In the current summary, we attempt to represent the working neuropathologist’s perspective. Pituitary adenomas can be classified on the basis of their gross/radiographic features (macrovs microadenoma, invasive vs noninvasive), hormone status (functional vs nonfunctional), cytology (acidophil, basophil, chromophobe), grade (typical, atypical, carcinoma), immunohistochemical/ultrastructural cell type (lactotroph, somatotroph, corticotroph, gonadotroph, thyrotroph), and molecular attributes (transcription factor, growth factor, and or tumor suppressor gene expression). Practicing neuropathologists are also aware of the wide morphological spectrum encountered routinely. Depending upon the histological pattern, particularly in nonfunctioning adenomas, one can consider diagnoses such as ependymoma, oligodendroglioma, meningioma, or even carcinoma, particularly if one is unaware of the sellar origin of the tissue sample. Despite the limitations of classifying adenomas by their tinctorial characteristics, as discussed in the introductory chapter of the WHO book [3], a more complete discussion of helpful morphological features is worthy of re-emphasis. For example, calcospherites (prolactinomas), eosinophilia or fibrous bodies (growth hormone adenomas), paranuclear vacuolation (acidophil stem cell adenoma), cytoplasmic basophilia or Crooke’s hyaline (corticotroph adenomas), pseudorosette formation (gonadotroph adenomas), and oncocytic change (gonadotroph or null cell adenomas) serve as clues to tumor subtype. Synaptophysin immunoreactivity was also emphasized as a more consistent broad spectrum neuroendocrine marker for pituitary adenoma than chromogranin [3]. This distinctive immunophenotypic feature is generally under appreciated. As common as pituitary adenomas are, it is surprising to see the current inter-institutional variation in diagnostic approach. This ranges from a single hematoxylin and eosin section and a final diagnosis of ‘‘pituitary adenoma’’ in virtually every case, to the ‘‘Cadillac approach’’ of a full pituitary hormone immunostain panel in nearly all instances and electron microscopy in selected cases. An interesting point highlighted in the review of Al-Shraim and Asa [1] is the histogenetic link between transcription factor expression in normal development and pituitary adenomas. Work in this area [4] has advanced our understanding of plurihormonal adenomas, such as the coexpression of growth hormone, prolactin and thyrotropin in the majority of acromegalyassociated adenomas, as well as the gonadotroph-like properties of so-called ‘‘null cell’’ adenomas. NonetheA. Perry (&) Division of Neuropathology, Washington University School of Medicine, Campus Box 8118, 660 S. Euclid Ave, 63110-1093 St. Louis, MO E-mail: aperry@wustl.edu Tel.: +1-314-3627426 Fax: +1-314-3624096

A provincial program of blood conservation: The Ontario Transfusion Coordinators (ONTraC)

Purpose Although often life-saving, blood transfusions are associated with significant risk to the patient and escalating costs to the blood system and hospital. Transfusions are often given unnecessarily. Blood conservation represents the use of alternatives to transfusion. The ONTraC program attempts to enhance transfusion practice outside the blood transfusion laboratory, promote blood conservation in surgery patients, and reduce allogeneic red cell use. Methods In the first such large scale program, funding was obtained from the Ontario MOHLTC for a Transfusion Coordinator in 23 Ontario hospitals selected based on blood utilization and geography. At specific time periods, detailed anonymized information was collected in a defined number of all consecutive patients admitted for the three designated surgical procedures: knee arthroplasty ( N = approximately 1200 at each time point), abdominal aortic aneurysm (AAA; N = 300 at each time) and coronary artery bypass graft (CABG) surgery ( N = 300 at each time point). Results Considerable inter-institutional variation was observed in the proportion of patients and amount of blood transfused. At the 12 month analysis, most, although not all, hospitals had decreased use of allogeneic blood and there was an overall 24% reduction in blood use in patients undergoing knee surgery, 14% in AAA and 23% in CABG. In addition to reduction in proportion of patients transfused, transfused patients received fewer units of allogeneic blood. Patients who did not receive allogeneic transfusions had significantly lower postoperative infection rates ( p < 0.05) and length of stay ( p < 0.0001); multivariate analysis showed that allogeneic transfusion was an independent predictor of increased length of stay. Eighteen-month analysis indicates even greater reduction in allogeneic transfusion. The main measures of blood conservation employed were preoperative autologous donation and education, with recent increasing use of erythropoietin and the cell saver. These measures have been demonstrated to be very effective in avoiding allogeneic transfusion. Conclusions The ONTraC have become leaders locally, nationally and internationally in blood conservation. The reduction in allogeneic transfusion associated with the implementation of the ONTraC program represents important savings in costs associated with blood components, hospital stay and work in transfusion laboratories and nursing units, as well as enhancing patient satisfaction and safety.

Validation of tissue microarray immunohistochemistry staining and interpretation in diffuse large B-cell lymphoma

Tissue microarrays (TMAs) show concordance with whole tissue sections in the immunohistochemical evaluation of tumor cells. However, potential inter-institutional variability among observers and immunohistochemical staining methods has not been fully addressed. We selected 21 cases of diffuse large B-cell lymphoma (DLBCL) to process for TMAs. Immunohistochemical stains were performed in 3 laboratories, and reviewed independently by 3 hematopathologists at the 3 institutions. Stains were scored on a 4-point scale. Statistical analyses of variation in the scoring among observers and among different institutions' stains were performed. Stains for CD3, CD10, CD20, BCL-2, BCL-6, MIB-1, and FOX-P1 revealed little variation among observers, with an average 51-82% complete agreement and 82-100% agreement +/- 1 numerical score. The rate of concordance when evaluating most stains performed in different laboratories was also relatively good, with an average of 55-72% complete agreement and 70-97% agreement +/- 1 score. However, scoring of MUM-1 and p53 stains showed wider variation, with an average of only 37 and 30% complete agreement among observers, and 11 and 45% agreement when stains from different institutions were examined. Further statistical analyses were performed to compare the observers' scoring of their own institution's stains (self-review) vs. observers' scoring of other institutions' stains (non-self). The agreement rate for the p53 stain was significantly higher when based on self-review (average 58% complete agreement) compared with an agreement rate of only 10.5% when based on a review of stains performed in another laboratory, non-self review, P < 0.01. This difference in the self- vs. non-self review was not seen when data for MUM-1 were analysed. In conclusion, most phenotypic markers used in the analysis of DLBCL can be evaluated in TMAs with adequate agreement among observers and laboratories. These include CD3, CD20, CD10, BCL-2, BCL-6, MIB-1, and FOX-P1. However, some markers, such as p53 and MUM-1, are more prone to inter-institutional variation. Variations in interpretation can be partially overcome by self-adjusted/adapt tendency, as seen with p53. Especially with newly developed markers, such as MUM-1, the development of standardized techniques for staining and interpretation is critical to reduce inter-observer variability.

Burnsurgery.org: a starting point for intensivists

Intensivists may provide initial management to patients with major burns, despite lacking extensive knowledge and experience. Burnsurgery.org is a free website designed to provide comprehensive, up-to-date educational tools for burn care professionals throughout the world. The site is operated by a nonprofit educational group, with editors from Brigham and Women's Hospital in Boston, MA, USA. Potential conflicts of interest are not disclosed, although the site is linked to some commercial sites promoting anabolic and wound care products. Like many health information websites, this site does not report certification by any quality rating organization or adherence to any of the available quality codes of conduct [1]. The site is divided into educational modules, beginning with burn prevention. The most useful sections discuss initial management priorities, including airway assessment, fluid resuscitation, and burn wound size and depth assessment. Overall, the information focuses on resuscitation issues relevant to intensivists and is consistent with current practice. The sample admission order set, which is presented with the rationale for specific orders, is a useful reminder of important initial therapies. Two significant content errors are the failure to caution against cutting the endotracheal tube prior to intubation (in order to prevent disappearance of the tube into the mouth when facial edema becomes massive) and the recommendation to administer intravenous fluids via peripheral veins (which are often impossible to access in a major burn injury and are prone to dislodgement during patient transfer). This section also includes special issues in initial wound management, chemical burns, electrical burns, comanagement of burns and major trauma, and indications for transfer to a burn facility. The site has some limitations. The authors should acknowledge the limited contribution of methodologically robust clinical evidence to most treatment recommendations and the extensive interinstitutional variation in some aspects of care (e.g. wound management). Most of the resuscitation information is not referenced, except for that in the section on burn orders. The discussion of pulmonary issues, such as acute respiratory distress syndrome, is limited and does not incorporate current evidence from the critical care literature. Multiple errors of grammar and spelling distract from the information presented. Although the site appears to be recent, with content posted between 2000 and 2002, the authors do not state the frequency of updating. Finally, it would be very useful to review management recommendations in the context of 'best practices', such as the American Burn Association's practice guidelines for burn care. The website is reasonably functional. Navigation within the site starts from a detailed table of contents on the home page. Similar pages are unfortunately not linked (e.g. initial management to orders), thus requiring a return to the home page to transfer between different sections. This process often entails using the browser's back button because some pages are not linked to the home page. There are no irritating pop-up advertisements or requests for personal information. Most links to other sites are functional. Overall, this site provides an excellent starting point for intensivists involved in the resuscitation and stabilization of burn patients, especially in situations where immediate consultation and transfer to a major burn center is not possible.

Inter-institutional variation in risk-adjusted paediatric cardiac surgical outcomes

Plans to reduce from four to two the number of hospitals performing paediatric cardiac surgery in Sweden prompted an inter-institutional comparison of risk-adjusted 30-day post-operative mortality. Pre-operative, intra-operative and follow-up data were abstracted from medical records of all patients listed by the hospitals as having undergone ‘complex’ paediatric cardiac surgery in 1992, based on previously established criteria. Surgeon-investigators abstracted clinical data to place all cases meeting these criteria into four preoperative risk categories. Discrepancies were resolved by consensus. Odds ratios were used to compare mortality in three hospitals relative to the fourth hospital, before and after adjusting for risk group distribution. Of 320 admission records submitted by the hospitals, 284 admissions involving 261 patients were considered complex procedures by criteria that included some re-operations but excluded heart transplants. Mortality risks and odds ratios increased in higher-risk groups, indicating the validity of the risk grouping. One-stage procedures or the initial components of multi-stage interventions were performed in 196 patients. Mortality odds ratios unadjusted for pre-operative risk in three other centres relative to the centre with the most patients were 0.72, 0.37 and 0.32, respectively (P=0.2750 by log-likelihood Chi-square). Risk-adjusted mortality odds ratios among the three centres (relative to the baseline hospital and the lowest risk category) were 0.44, 0.17 and 0.30, respectively (P=0.0001). For all 261 patients, unadjusted odds ratios for the three centres were 0.44, 0.27 and 0.39 (P=0.1130), while risk-adjusted odds ratios were 0.24, 0.12 and 0.32, respectively (P=0.0001). In this study, higher institutional volumes of complex procedures were not consistently associated with increased survival. Adjusting for preoperative risk did significantly alter institutional mortality odds ratios. Formal approaches for comparing specific–specific mortality following paediatric cardiac surgery are evolving, and adjusting for risk may enhance the validity of inter-institutional comparisons. Independent review of risk classification and mortality data submitted by hospitals may enhance the consistency of such analyses.

Six-year trends in laboratory computer availability.

Abstract Context.—Failure of a clinical laboratory computer system can disrupt work flow and charge capture and affect patient care. The first comprehensive survey of computer downtime was conducted in 1995 and demonstrated significant interinstitutional variation in system availability. Despite numerous changes in the laboratory and computer industries since 1995, no follow-up study has been reported. Objectives.—To quantify current laboratory computer availability and compare it with 1995 performance. Design.—Ninety-seven laboratories prospectively recorded the frequency and duration of computer downtime during 30 days in 2001. Results were compared with 1995 survey data. Results.—For the median facility, the number of downtime episodes decreased from 8 events per 30 days during 1995 to 3 events per 30 days during 2001 (P < .01). The frequency of unscheduled downtime also improved, from a median of 2 to 0.5 events per 30 days (P < .01). Reduced downtime events were paralleled by reduced cumulative downt...

Six-Year Trends in Laboratory Computer Availability

Failure of a clinical laboratory computer system can disrupt work flow and charge capture and affect patient care. The first comprehensive survey of computer downtime was conducted in 1995 and demonstrated significant interinstitutional variation in system availability. Despite numerous changes in the laboratory and computer industries since 1995, no follow-up study has been reported. To quantify current laboratory computer availability and compare it with 1995 performance. Ninety-seven laboratories prospectively recorded the frequency and duration of computer downtime during 30 days in 2001. Results were compared with 1995 survey data. For the median facility, the number of downtime episodes decreased from 8 events per 30 days during 1995 to 3 events per 30 days during 2001 (P <.01). The frequency of unscheduled downtime also improved, from a median of 2 to 0.5 events per 30 days (P <.01). Reduced downtime events were paralleled by reduced cumulative downtime (14.3 vs 4.0 hours per 30 days; P <.01). Improvements were not restricted to the median facility; laboratories performing in the bottom quartile in 2001 recorded substantially less downtime than laboratories in the bottom quartile in 1995. When the comparison was restricted to the 37 institutions that participated in both the 1995 and 2001 surveys, a significant reduction in overall downtime and unscheduled downtime events was still evident (P <.01). More recent installation of vendor software patches was associated with a reduced frequency of downtime events in the 2001 data set. Laboratory computer downtime was less frequent in 2001 than in 1995; industry performance appears to be improving.

Variations in central venous catheter-related infection risks among Canadian neonatal intensive care units.

The objective of this study was to examine central venous catheter (CVC)-related nosocomial blood stream infection risks of umbilical venous, percutaneous and Broviac catheters, as well as variations in CVC use and CVC-related risk for nosocomial blood stream infection in the neonatal intensive care unit (NICU). A cohort study was performed based on 19,507 infants admitted to 17 NICUs in the Canadian Neonatal Network from January, 1996, through October, 1997. Information on these subjects was prospectively collected by trained abstractors. Incidence of infection was measured as infection episodes per 1000 patient days. The risk ratio (RR) of CVC use for nosocomial blood stream infection was calculated as the infection rate during catheter days divided by the infection rate during noncatheter days. Using a Poisson regression model we examined the adjusted RR of CVC use for nosocomial blood stream infection, controlling for patient characteristics and illness severity at admission. Interinstitutional variations in CVC-related infection risks were examined by stratified analyses. CVC were used in 22.5% of patients. The incidence of nosocomial blood stream infection was 2.9 per 1000 noncatheter days, 7.2 per 1000 umbilical venous catheter days, 13.1 per 1000 percutaneous catheter days and 12.1 per 1000 Broviac catheter days. The RR for nosocomial blood stream infection, adjusted for differences in patient characteristics and admission illness severity, was 2.5 for umbilical venous catheter, 4.6 for percutaneous catheter and 4.3 for Broviac catheter (P < 0.05). There were significant (P < 0.05) risk-adjusted variations in CVC-related infection risks among NICUs. CVC use increased the risk of nosocomial blood stream infection. The risk of nosocomial blood stream infection in percutaneous and Broviac catheters was 70 to 80% higher than in umbilical venous catheters. There was significant variation in CVC-related infection risks among Canadian NICUs.

Medicare financing of graduate medical education.

The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require "all-payer" support.

Interlaboratory reproducibility of standard accelerated aging methods for oxidation of UHMWPE

During accelerating aging, experimental uncertainty may arise due to variability in the oxidation process, or due to limitations in the technique that is ultimately used to measure oxidation. The purpose of the present interlaboratory study was to quantify the repeatability and reproducibility of standard accelerated aging methods for ultra-high molecular weight polyethylene (UHMWPE). Sections (200 μm thick) were microtomed from the center of an extruded rod of GUR 4150 HP, gamma irradiated in air or nitrogen, and circulated to 12 institutions in the United States and Europe for characterization of oxidation before and after accelerated aging. Specimens were aged for 3 weeks at 80°C in an air circulating oven or for 2 weeks at 70°C in an oxygen bomb (maintained at 503 kPa (5 atm.) of O 2) in accordance with the two standard protocols described in ASTM F 2003-00. FTIR spectra were collected from each specimen within 24 h of the start and finish of accelerated aging, and oxidation indices were calculated by normalizing the peak area of the carbonyl region by the reference peak areas at 1370 or 2022 cm −1. The mean relative interlaboratory uncertainty of the oxidation data was 78.5% after oven aging and 129.1% after bomb aging. The oxidation index measurement technique was not found to be a significant factor in the reproducibility. Comparable relative intrainstitutional uncertainty was observed after oven aging and bomb aging. For both aging methods, institutions successfully discriminated between air-irradiated and control specimens. However, the large interinstitutional variation suggests that absolute performance standards for the oxidation index of UHMWPE after accelerated aging may not be practical at the present time.

Occurrence of nosocomial bloodstream infections in six neonatal intensive care units.

Nosocomial bloodstream infections (NBSIs) occur frequently in neonatal intensive care units (NICUs) and are associated with substantial morbidity and mortality. Little has been published regarding variation in NBSI among institutions. To determine NBSI incidence among six NICUs and to explore how much variation is explained by patient characteristics and NICU practice patterns. From October, 1994, to June, 1996, six regional NICUs prospectively abstracted clinical records of all neonates weighing <1,500 g. Occurrence of NBSI, defined as first positive culture occurring >48 h after admission, was analyzed in relation to baseline patient characteristics and several common therapeutic interventions. Variables significant in univariate analyses were analyzed by Cox proportional hazards regression. There were 258 NBSIs (incidence, 19.1%) among 1,354 inborn first admissions. Incidence varied significantly by site, from 8.5 to 42%. Birth weight, Broviac catheter use and parenteral nutrition were significantly associated with NBSI (P < 0.05). When controlling for these variables interinstitutional variation in NBSI occurrence decreased but remained significant. Neonatal NBSI incidence varies substantially among institutions despite adjustment for length of stay and some known risk factors. The uses of Broviac catheters and especially intravenous nutrition supplements were significant determinants of NBSI risk.

Interinstitutional variation in the performance of Baysian Belief Network for the diagnosis of acute renal graft rejection

Interinstitutional variation in the performance of Baysian Belief Network for the diagnosis of acute renal graft rejection

Use of laxatives in institutions for the mentally retarded.

To study, in institutionalized mentally retarded patients, the prevalence of regular laxative use, and to identify its correlates. Twenty-one of the 22 institutions for the mentally retarded in Flanders (Belgium) provided the setting for the study, which included a population of 3712 residents with an IQ of < 50. This was a descriptive cross-sectional study of a random sample of 20 patients per institution, consisting of a structured interview of the personnel responsible for daily care of the selected patients. The study population consisted of 420 mentally retarded patients. Their median age was 29 years (range 2-72 years). Twenty-six percent of patients had an IQ of 35-49, 40% an IQ of 20-34 and 34% an IQ of <20. Sixteen percent of the patients were non-ambulant. Regular laxative use was found in 26.4% (111/420) of the residents. In addition, occasional laxative use was found in 2% (10/420) of the residents. Oral laxatives were used daily by 13% (56/420) and oral laxatives daily in combination with enemas were used by 9% (39/420). Enemas but no oral laxatives were used by 3% (11/420); manual evacuation in combination with oral laxatives and enemas was used by 1% (5/420). Seventy-eight percent (78/100) of the oral laxative users used them for more than 1 year. Seventy-one percent (71/100) used one laxative, 23% two and 6% three. Thirty different brands of oral laxatives were used. Sixty-seven percent (67/100) used osmotic laxatives alone or in combination, 30% used stimulant laxatives, 19% used bulk forming laxatives and 19% mineral oil. Oral laxatives were always prescribed by attending physicians, while enemas were also initiated by nurses in 35% (18/52). Laxative use was positively and independently correlated with female gender, with being non-ambulant, with oral motor dysfunction and with the use of medication other than laxatives. It did not correlate with age. Within the institutions, laxative use varied from one to 15 users out of the 20 randomly selected patients (median 4/20). Laxative use is frequent in institutions for the mentally retarded, with a large inter-institution variation, indicating that constipation is an important problem and underlining the need for research into cost-effective treatment.