Set Of Clinical Indicators Research Articles

Clinical Validation of the Nursing Diagnosis 'Inadequate Health Self-Efficacy' in People With Hypertension.

To test the clinical validity of clinical indicators and causal relationships of aetiological factors of the new nursing diagnosis of inadequate health self-efficacy in people with hypertension. The diagnosis of inadequate health self-efficacy has both theoretical and content validity. However, a clinical validation study is needed to establish an appropriate framework for distinguishing individuals who manifest this unique human response. The study adopts a cross-sectional clinical validation approach, adhering strictly to the STROBE guidelines throughout its design and implementation. Naturalistic sampling was used to identify 302 adults diagnosed with hypertension. Their data were subjected to latent class analysis, which facilitated the identification of a comprehensive set of clinical indicators that demonstrated better diagnostic accuracy and established posterior probabilities to guide the inference of inadequate health self-efficacy. In addition, logistic regression analysis was used to assess the magnitude of the impact of aetiological factors. The prevalence of inadequate health self-efficacy was 76.61%. Among the 13 indicators examined, seven demonstrated notable sensitivity: 'risk-prone health behaviour', 'failure to take action that prevents health problems', 'inadequate self-control', 'avoidance behaviours', 'negative health self-perception', 'inadequate health-related quality of life' and 'difficulty feeling good about adopting a healthy lifestyle'. Additionally, two indicators showed high specificity: 'difficulty feeling good about adopting a healthy lifestyle' and 'inadequate adherence to treatment regimen'. Notably, 15 aetiological factors were identified as significantly associated with an increased risk of inadequate health self-efficacy. A clinical framework consisting of eight clinical indicators and 15 aetiological factors was developed to characterise inadequate health self-efficacy in individuals with hypertension. Clinical validation provides insight into the precision of clinical indicators and the magnitude of the effect of putative causal elements, thereby facilitating identification and tailored intervention for individuals with hypertension and inadequate health self-efficacy.

Reduced drug use as an alternative valid outcome in individuals with stimulant use disorders: Findings from 13 multisite randomized clinical trials.

Total abstinence has historically been the goal of treatment for substance use disorders; however, there is a growing recognition of the health benefits associated with reduced use as a harm reduction measure in stimulant use disorders treatment. We aimed to assess the validity of reduced stimulant use as an outcome measure in randomized controlled trials (RCTs) of pharmacological interventions for stimulant use disorder. We conducted a secondary analysis of a pooled dataset of 13 RCTs. Participants were individuals seeking treatment for cocaine or methamphetamine use disorders (N = 2062) in a wide range of treatment facilities in the United States. We validated reduced stimulant use against a set of clinical indicators drawn from harmonized measurements, including severity of problems caused by drug use, comorbid depression, global severity of substance use and improvement, severity of drug-seeking behavior, craving and high-risk behaviors, all assessed at the end of the trial, as well as follow-up urine toxicology. A series of mixed effect regression models was conducted to validate reduction in frequency of use against no reduction in use and abstinence. More participants reduced frequency of primary drug use than achieved abstinence (18.0% vs. 14.2%, respectively). Reduced use was significantly associated with decreases in craving for the primary drug [60.1%, 95% confidence interval (CI) = 54.3%-64.7%], drug seeking behaviors (41.0%, 95% CI = 36.6%-45.7%), depression severity (39.9%, 95% CI = 30.9%-48.3%), as well as multiple measures of global improvement in psychosocial functioning and severity of drug-related problems, albeit less strongly so than abstinence. Moreover, reduced use was associated with sustained clinical benefit at follow-up, as confirmed by negative urine tests (adjusted odds ratio compared with those with no reduction in use: 0.50, 95% CI = 0.35-0.71). Reduced frequency of stimulant use appears to be associated with meaningful improvement in various clinical indicators of recovery. Assessment of reduced use, in addition to abstinence, could broaden the scope of outcomes measured in randomized controlled trials of stimulant use disorders and facilitate the development of more diverse treatment approaches.

A meta-analysis of wenxin granule and metoprolol for the treatment of coronary heart disease and arrhythmia.

Background:This meta-analysis aimed to systematically and comprehensively assess the effectiveness and safety of wenxin granule (WXG) and metoprolol in the treatment of elderly patients with coronary heart disease (CHD) and arrhythmia.Methods:We searched the electronic databases of the Cochrane Library, PUBMED, EMBASE, CNKI, Wangfang, and CBM from initiation to May 1, 2022, and selected a set of clinical indicators for WXG and metoprolol for CHD and arrhythmia. The methodological quality of the included studies was analyzed using the Cochrane risk-of-bias tool. Data were pooled using a fixed-effects or random-effects model, and a meta-analysis was conducted.Results:Eight randomized controlled trials involving 722 patients with CHD and arrhythmia were included. Our findings showed that WXG and metoprolol showed better effects than metoprolol alone on electrocardiogram change (odds ratio [OR] = 7.21, 95% confidence interval [CI] [1.48, 35.07]), clinical symptom improvement (OR = 5.83, 95% CI [1.52, 22.35]), overall clinical effect (OR = 5.51, 95% CI [2.65, 11.44], P < .001), atrial premature beat (mean difference [MD] = −109.85, 95% CI [−171.25, −48.46], P < .001), ventricular premature beat (MD = −195.43, 95% CI [−334.09, −56.77], P < .001), borderline premature beat (MD = −42.92, 95% CI [−77.18, −8.67], P = .01), short-burst ventricular tachycardia (MD = −35.98, 95% CI [−39.66, −32.30], P < .001), ST segment reduction (MD = −0.47, 95% CI [−0.54, −0.40], P < .001), ST segment decrease duration (MD = −0.76, 95% CI [−0.95, −0.57], P < .001). However, no significant differences were observed in adverse reactions (OR = 0.54, 95% CI [0.27, 1.09], P = .09).Conclusion:Compared to metoprolol alone, WXG and metoprolol can more effectively manage patients with CHD and arrhythmia. However, additional large-scale, multicenter, rigorous, and high-quality randomized controlled trials are warranted to verify the present findings.

Alprostadil for hypertensive nephropathy: A systematic review and meta-analysis of randomized controlled trials.

We performed a meta-analysis to evaluate the efficacy of alprostadil in the treatment of hypertensive nephropathy. Seven online databases (PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure [CNKI] database, Wanfang Data Knowledge Service Platform, VIP Information Resource Integration Service Platform [cqVIP], and China Biology Medicine Disc [SinoMed]) were searched from inception to January 31, 2022, and a set of clinical indicators for hypertensive nephropathy was selected. The main indicators were 24-h urinary protein, serum creatinine, endogenous serum creatinine clearance rate, blood urea nitrogen, cystatin C, and mean arterial pressure. The methodological quality of the included trials was analyzed using a risk of bias assessment according to the Cochrane Manual guidelines, and a meta-analysis was performed. A random-effects model was implemented to pool the results. A total of 20 randomized controlled trials involving 1441 patients with hypertensive nephropathy were included in this review. Our findings showed that alprostadil had a positive effect on 24-h urinary protein (mean difference [MD] = −0.79, 95% confidence interval [CI] [−1.16, −0.42], P < 0.0001), serum creatinine (MD = −13.83, 95% CI [−19.34, −8.32], P < 0.00001), endogenous serum creatinine clearance rate (MD = 6.09, 95% CI [3.59, 8.59], P < 0.00001), blood urea nitrogen (MD = −6.42, 95% CI [−8.63, −4.21], P < 0.00001), cystatin C (MD = −0.26, 95% CI [−0.34, −0.18], P < 0.00001), and mean arterial pressure levels(MD = −13.65, 95% CI [−16.08, −11.21], P < 0.00001). Compared to conventional treatment alone, alprostadil combined with conventional treatment can improve renal function in patients with hypertensive nephropathy more effectively. However, additional large-scale, multicenter, rigorously designed randomized controlled trials are needed to verify these results. This is the first meta-analysis to evaluate the efficacy of alprostadil for hypertensive nephropathy, and the results may guide clinical practice.

Designing clinical indicators for common residential aged care conditions and processes of care: the CareTrack Aged development and validation study.

People who live in aged care homes have high rates of illness and frailty. Providing evidence-based care to this population is vital to ensure the highest possible quality of life. In this study (CareTrack Aged, CT Aged), we aimed to develop a comprehensive set of clinical indicators for guideline-adherent, appropriate care of commonly managed conditions and processes in aged care. Indicators were formulated from recommendations found through systematic searches of Australian and international clinical practice guidelines (CPGs). Experts reviewed the indicators using a multiround modified Delphi process to develop a consensus on what constitutes appropriate care. From 139 CPGs, 5609 recommendations were used to draft 630 indicators. Clinical experts (n = 41) reviewed the indicators over two rounds. A final set of 236 indicators resulted, mapped to 16 conditions and processes of care. The conditions and processes were admission assessment; bladder and bowel problems; cognitive impairment; depression; dysphagia and aspiration; end of life/palliative care; hearing and vision; infection; medication; mobility and falls; nutrition and hydration; oral and dental care; pain; restraint use; skin integrity and sleep. The suite of CT Aged clinical indicators can be used for research and assessment of the quality of care in individual facilities and across organizations to guide improvement and to supplement regulation or accreditation of the aged care sector. They are a step forward for Australian and international aged care sectors, helping to improve transparency so that the level of care delivered to aged care consumers can be rigorously monitored and continuously improved.

Developing clinical indicators for oncology: the inaugural cancer care indicator set for the Australian Council on Healthcare Standards.

The Australian Council on Healthcare Standards (ACHS) sponsored an expert-led, consensus-driven, four-stage process, based on a modified Delphi methodology, to determine a set of clinical indicators as quality measures of cancer service provision in Australia. This was done in response to requests from institutional health care providers seeking accreditation, which were additional and complementary to the existing radiation oncology set. The steering group members comprised multidisciplinary key opinion leaders and a consumer representative. Five additional participants constituted the stakeholder group, who deliberated on the final indicator set. An initial meeting of the steering group scoped the high level nature of the desired set. In stage 2, 65 candidate indicators were identified by a literature review and a search of international metrics. These were ranked by survey, based on ease of data accessibility and collectability and clinical relevance. The top 27 candidates were debated by the stakeholder group and culled to a final set of 16 indicators. A user manual was created with indicators mapped to clinical codes. The indicator set was ratified by the Clinical Oncology Society of Australia and is now available for use by health care organisations participating in the ACHS Clinical Indicator Program. This inaugural cancer clinical indicator set covers high level assessment of various critical processes in cancer service provision in Australia. Regular reviews and updates will ensure usability. This is the inaugural indicator set for cancer care for use across Australia and internationally under the ACHS Clinical Indicator Program. Multidisciplinary involvement through a modified Delphi process selected indicators representing both generic and specific aspects of care across the cancer journey pathway and will provide a functional tool to compare health care delivery across multiple settings. It is anticipated that this will drive continual improvement in cancer care provision.

Twenty-year trends in the prescription costs of Type 2 diabetes: Real world data and empirical analysis in Greece

AimsTo estimate and compare the prescription costs for the management of patients with diabetes over a period of 20 years in Greece, based on real world data. MethodsThe records of outpatients with T2D, monitored at three diabetes centres, were examined in four cross-sections (1998, 2006, 2012, 2018). Prescribed medicines per patient, along with a set of clinical indicators were recorded. Annual costs of pharmaceutical treatment per patient were calculated by using each year’s nominal retail prices, as well as by adjusting for 2018 price levels, in order to account for price differences over time. Results4066 patients were included in the analysis. Prescription patterns indicate a quick uptake of the new classes of glucose-lowering drugs and a reduction in the proportional use of sulfonylurea and glitazone. Adjusting for 2018 prices, the average total annual prescription cost per patient was 381.54 Euros (s.d. 297.44) in 1998 and 1147.21 Euros (s.d. 814.39) in 2018. Glucose-lowering drug costs per patient increase from 1998 onwards, whereas the costs of antihypertensive, antiplatelet and lipid-lowering treatment declined gradually, especially after 2006. ConclusionsPer patient prescription costs for glucose-lowering drugs present a steep increase, in Greece over the last 20 years. Real-world evidence studies that compare this increase with the changes in patient outcomes are essential in order to examine whether a costs-vs-outcomes balance is optimal.

Adaptation of potentially preventable medication-related hospitalisation indicators for Indigenous populations in Australia using a modified Delphi technique

ObjectivesOne of the outcomes of a medication review service is to identify and manage medication-related problems (MRPs). The most serious MRPs may result in hospitalisation, which could be preventable if...

Identification of Clinical Indicators of Opioid Overdose using innovative EMS software analytics.

ObjectiveTo develop a set of clinical indicators of opioid overdose using Emergency Medical Services (EMS) records that included data from Computer Aided Dispatch (CAD), ProQA systems, Electronic Patient Care Reporting (ePCR) and Hospital Medical Records.IntroductionIn North America we experience the highest rate of drug related mortality in the world. In the US, overdose is now the leading cause of death among adults under 50. Each day more than 115 people in the United States die due to an opioid overdose. The opioid overdose national crisis is rapidly evolving due to changes in drug availability and the presence of adulterated fentanyl in some areas leading to a critical need for innovative methods to identify opioid overdoses for both surveillance and intervention purposes. As an effort to strengthen our understanding of the epidemic through surveillance of Emergency Medical Services (EMS) we have developed a set of clinical indicators that identify opioid overdose within the information provided by an Electronic Patient Care Reporting (ePCR), Computer Aided Dispatch (CAD), ProQA systems and Hospital Medical Records.MethodsWe initially created a set of EMS agency specific opioid overdose filters using FirstWatch® software as part of a public health research study. Following that initial development, we have built a generic set of opioid overdose identifiers. In the initial approach we used a Zoll Data System software for ePCR and TriTech Inform CAD to define 3 set of identifiers: (T1) captured calls in which naloxone was administered and a positive clinical response was documented, (T2) had the same criteria as T1 except there was no positive response to the administration of naloxone, and (T3) consisted of calls in which one or more drug-related keywords were present within the narrative of the ePCR. Because the initial analysis was conducted in the context of a single research study, we aimed to create a more generalizable set of identifiers of opioid overdose that would function across different EMS agencies, software, and data sources. In addition, we included variables provided by Hospital Medical Records to our filtering criteria to provide a more robust and complete set of opioid overdose clinical indicators.ResultsUtilizing the EMS data sources CAD, ProQA and ePCR as well as Hospital Medical Records we have developed a set of identifiers of opioid overdose. Utilizing FirstWatch® software analytics the following variables where coded into the software: 1. CAD Data.- Chief Complaint and Opioid Overdose Keyword search; 2. ProQA.- Protocols 6, 9, 23, 31 and 32; 3. ePCR.- Primary and Secondary Impressions, Chief Complaint, Intervention of Narcan (Naloxone) Administration, Vital Signs and Opioid Overdose Keyword search; 4. Medical Records.- Patient's Admission and Discharge Diagnosis (Diagram 1). The clinical indicators obtained from this analysis where created to be utilized across different EMS specific software vendors for CAD, ProQA and ePCR systems. For the Medical Records variables a single software vendor was available to be integrated into the analysis. Nonetheless, as we used the International Statistical Classification of Diseases and Related Health Problems codes on their 10th revision (ICD-10) our determining variable codes could be generalized to other Hospital Record system if they would become available.ConclusionsCorrectly identifying an opioid overdose can a be a challenge. Its clinical features are non-specific and bystanders fear repercussions of disclosing the nature of the 911 call. Determining the correct number of opioid overdoses requires a tailored identification process. A combination of clinical determinants and incorporation of multiple EMS data sources appears to be feasible in determining opioid overdose related 911 calls.

Clinical indicators for common paediatric conditions: Processes, provenance and products of the CareTrack Kids study.

BackgroundIn order to determine the extent to which care delivered to children is appropriate (in line with evidence-based care and/or clinical practice guidelines (CPGs)) in Australia, we developed a set of clinical indicators for 21 common paediatric medical conditions for use across a range of primary, secondary and tertiary healthcare practice facilities.MethodsClinical indicators were extracted from recommendations found through systematic searches of national and international guidelines, and formatted with explicit criteria for inclusion, exclusion, time frame and setting. Experts reviewed the indicators using a multi-round modified Delphi process and collaborative online wiki to develop consensus on what constituted appropriate care.ResultsFrom 121 clinical practice guidelines, 1098 recommendations were used to draft 451 proposed appropriateness indicators. In total, 61 experts (n = 24 internal reviewers, n = 37 external reviewers) reviewed these indicators over 40 weeks. A final set of 234 indicators resulted, from which 597 indicator items were derived suitable for medical record audit. Most indicator items were geared towards capturing information about under-use in healthcare (n = 551, 92%) across emergency department (n = 457, 77%), hospital (n = 450, 75%) and general practice (n = 434, 73%) healthcare facilities, and based on consensus level recommendations (n = 451, 76%). The main reason for rejecting indicators was ‘feasibility’ (likely to be able to be used for determining compliance with ‘appropriate care’ from medical record audit).ConclusionA set of indicators was developed for the appropriateness of care for 21 paediatric conditions. We describe the processes (methods), provenance (origins and evolution of indicators) and products (indicator characteristics) of creating clinical indicators within the context of Australian healthcare settings. Developing consensus on clinical appropriateness indicators using a Delphi approach and collaborative online wiki has methodological utility. The final indicator set can be used by clinicians and organisations to measure and reflect on their own practice.

Assessing the Quality of the Management of Tonsillitis among Australian Children: A Population-Based Sample Survey.

The aims of this study were twofold: (1) to design and validate a set of clinical indicators of appropriate care for tonsillitis and (2) to measure the level of tonsillitis care that is in line with guideline recommendations in a sample of Australian children. A set of tonsillitis care indicators was developed from available national and international guidelines and validated in 4 stages. This research used the same design as the CareTrack Kids study, which was described in detail elsewhere. Samples of patient records from general practices, emergency departments, and hospital admissions were assessed. Patient records of children aged 0 to 15 years were assessed for the presence of, and adherence to, the indicators for care delivered in 2012 and 2013. Eleven indicators were developed. The records of 821 children (mean age, 5.0 years; SD, 4.0) with tonsillitis were screened. The reviewers conducted 2354 eligible indicator assessments across 1127 visits. Adherence to 6 indicators could be assessed and ranged from 14.3% to 73.2% (interquartile range 31.5% to 72.2%). Our main findings are consistent with the international literature: the treatment of many children who present with confirmed or suspected tonsillitis is inconsistent with current guidelines. Future research should consider how the indicators could be applied in a structured and automated manner to increase the reliability and efficiency of record reviews and help raise clinicians' awareness of appropriate tonsillitis management.

Quality Indicators for Global Benchmarking of Localized Prostate Cancer Management

We sought to develop a core set of clinical indicators to enable international benchmarking of localized prostate cancer management using data available in the TrueNTH Global Registry. An international expert panel completed an online survey and participated in a face-to-face meeting. Participants included 3 urologists, 3 radiation oncologists, 2 psychologists, 1 medical oncologist, 1 nurse and 1 epidemiologist with prostate cancer expertise from a total of 7 countries. Current guidelines on prostate cancer treatment and potential quality indicators were identified from a literature review. These potential indicators were refined and developed through a modified Delphi process during which each panelist independently and repeatedly rated each indicator based on importance (satisfying the indicator demonstrated a provision of high quality care) and feasibility (the likelihood that data used to construct the indicator could be collected at a population level). The main outcome measure was items with panel agreement indicated by a disagreement index less 1, median importance 8.5 or greater and median feasibility 9 or greater. The expert panel endorsed 33 indicators. Seven of these 33 prostate cancer quality indicators assessed care relating to diagnosis, 7 assessed primary treatment, 1 assessed salvage treatment and 18 assessed health outcomes. We developed a set of quality indicators to measure prostate cancer care using numerous international evidence-based clinical guidelines. These indicators will be pilot tested in the TrueNTH Global Registry. Reports comparing indicator performance will subsequently be distributed to groups at participating sites with the purpose of improving the consistency and quality of prostate cancer management on a global basis.

Ineffective Health Management in Hemodialysis Patients: Diagnostic Accuracy Study.

This study analyzed the accuracy of clinical indicators of ineffective health management in hemodialysis patients. A diagnostic accuracy study was performed in 200 chronic kidney disease patients undergoing hemodialysis during the first half of 2015. Measures of sensitivity and specificity were calculated using latent class analysis. Ineffective health management was present in 66.28% of patients. Accurate clinical indicators included expressed nonadherence to treatment, daily life choices ineffective to achieve health goals, expression of difficulty with prescribed regimens, inappropriate use of medicines, lack of expression of willingness to control the disease, irregular attendance of dialysis sessions, and infection. Hemodialysis may trigger a set of clinical indicators that predict the presence of ineffective health management. This knowledge provides evidence to clinical practices for hemodialysis patients and contributes to the best clinical performance of nurse practitioners.

Clinical descriptors for the recognition of central sensitization pain in patients with knee osteoarthritis

Background: Despite growing awareness of the contribution of central pain mechanisms to knee osteoarthritis pain in a subgroup of patients, routine evaluation of central sensitization is yet to be incorporated into clinical practice.Aim: The objective of this perspective is to design a set of clinical descriptors for the recognition of central sensitization in patients with knee osteoarthritis that can be implemented in clinical practice.Methods: A narrative review of original research papers was conducted by nine clinicians and researchers from seven different countries to reach agreement on clinically relevant descriptors.Results: It is proposed that identification of a dominance of central sensitization pain is based on descriptors derived from the subjective assessment and the physical examination. In the former, clinicians are recommended to inquire about intensity and duration of pain and its association with structural joint changes, pain distribution, behavior of knee pain, presence of neuropathic-like or centrally mediated symptoms and responsiveness to previous treatment. The latter includes assessment of response to clinical test, mechanical hyperalgesia and allodynia, thermal hyperalgesia, hypoesthesia and reduced vibration sense.Conclusions: This article describes a set of clinically relevant descriptors that might indicate the presence of central sensitization in patients with knee osteoarthritis in clinical practice. Although based on research data, the descriptors proposed in this review require experimental testing in future studies.Implications for RehabilitationLaboratory evaluation of central sensitization for people with knee osteoarthritis is yet to be incorporated into clinical practice.A set of clinical indicators for the recognition of central sensitization in patients with knee osteoarthritis is proposed.Although based on research data, the clinical indicators proposed require further experimental testing of psychometric properties.

A Review of the ACHS Clinical Indicator Program after 20 years

The Clinical Indicator Program, which was introduced into the Australian Council on Healthcare Standards’ accreditation program two decades ago, has grown from one set addressed by 115 healthcare organisations to 22 sets with data received from over 800 healthcare organisations, resulting in a national database which is unique in its clinical diversity, reflecting every major medical discipline involved in hospital practice. The process for Clinical Indicator selection and review remains with the providers of the care, but the selection criteria are better defined and the evidence base strengthened. Early responses to their introduction were encouraging as improvements in patient management and outcomes were sought and achieved following review of comparative data, and some examples of these are provided. Clinical Indicator revision remains an important and major task and the original Hospital- Wide set of Clinical Indicators is now in its 12th version. The development and use of Clinical Indicators is increasing world-wide, and in Australia there are other organisations, including the Australian Commission on Safety and Quality in Healthcare, looking at Clinical Indicators to further understand the performance of healthcare organisations.&#x0D; As clinical care changes, the challenges for the Australian Council on Healthcare Standards are to ensure the Clinical Indicators continue to reflect current practice, to retain clinician support, and also to ensure that the existence of its extensive and long-standing national clinical database is more widely known and utilised.&#x0D; Abbreviations: ACHS: Australian Council of Healthcare Standards; ACIR – Australasian Clinical Indicator Report; ANZICS – Australian and New Zealand Intensive Care Society; APD – Adult Patient Database; CI – Clinical Indicators; HCO – HealthCare Organisation; PIRT – Performance Indicator Reporting Tool; RACMA - Royal Australian College of Medical Administrators.

First Clinical Investigation of Cone Beam Computed Tomography and Deformable Registration for Adaptive Proton Therapy for Lung Cancer

An adaptive proton therapy workflow using cone beam computed tomography (CBCT) is proposed. It consists of an online evaluation of a fast range-corrected dose distribution based on a virtual CT (vCT) scan. This can be followed by more accurate offline dose recalculation on the vCT scan, which can trigger a rescan CT (rCT) for replanning. The workflow was tested retrospectively for 20 consecutive lung cancer patients. A diffeomorphic Morphon algorithm was used to generate the lung vCT by deforming the average planning CT onto the CBCT scan. An additional correction step was applied to account for anatomic modifications that cannot be modeled by deformation alone. A set of clinical indicators for replanning were generated according to the water equivalent thickness (WET) and dose statistics and compared with those obtained on the rCT scan. The fast dose approximation consisted of warping the initial planned dose onto the vCT scan according to the changes in WET. The potential under- and over-ranges were assessed as a variation in WET at the target's distal surface. The range-corrected dose from the vCT scan reproduced clinical indicators similar to those of the rCT scan. The workflow performed well under different clinical scenarios, including atelectasis, lung reinflation, and different types of tumor response. Between the vCT and rCT scans, we found a difference in the measured 95% percentile of the over-range distribution of 3.4 ± 2.7 mm. The limitations of the technique consisted of inherent uncertainties in deformable registration and the drawbacks of CBCT imaging. The correction step was adequate when gross errors occurred but could not recover subtle anatomic or density changes in tumors with complex topology. A proton therapy workflow based on CBCT provided clinical indicators similar to those using rCT for patients with lung cancer with considerable anatomic changes.

Monitoring Quality of Care in Men Diagnosed with Prostate Cancer: Developing Consensus Quality Indicators Using Modified-Delphi Methodology

Objective: To develop a core set of clinical indicators to measure the quality of care provided to men with prostate cancer. Design: A modified Delphi study involving interviews of key informants and two rounds of survey to obtain consensus on the indicator set. Setting: Melbourne, Australia Participants: n=20, including specialists involved in prostate cancer management (urology, radiation oncology, medical oncology, nursing, psychology, palliative care) epidemiologists, scientists, consumers and a policy advisor. Intervention(s): A literature review was undertaken to identify potential quality indicators. Interviews were undertaken to ensure completeness of the set and explore potential for inclusion of novel indicators. Survey of Delphi panel participants was conducted to refine the list.

Call for information, call for quality in mental health care

The quality of routine mental health care is not optimal, it can vary greatly from region to region and among providers; in many occasions, it does not correspond to the standards of evidence-based mental health. To bridge this gap, the promotion of a systematic use of the information available for quality assurance would be most helpful, but measuring the quality of mental health care is particularly challenging. Quality measurement can play a key role in transforming health care systems, and the routine measurement of quality, using clinical indicators derived from evidence-based practice guidelines, is an important step to this end. In Italy, the use of clinical indicators is still sporadic: over the last 5 years only three projects have been aimed at analysing, in a structured way, the quality of care in severe mental illness, and two of these were led by the Italian Society of Psychiatric Epidemiology. Not only in Italy but also at global level there is an urgent need for the implementation of mental health information systems that could lead to a substantial improvement in information technology. Once this has been achieved, a common set of clinical indicators, agreed upon at the regional and national level and useful for benchmarking and for comparing mental health services, could be defined. Finally, using the implementation strategies, a system of quality improvement at both regional and local levels will be built.

Clinical indicators in surgery: a critical review of the Australian experience

A set of clinical measures (indicators), developed by an Australian Council on Healthcare Standards (ACHS) and Royal Australasian College of Surgeons (RACS) working party, was introduced into the accreditation programme in 1997. Although early qualitative and quantitative reporting by health-care organizations (HCOs) reflected their value in stimulating change, the number of HCOs reporting data on this set of clinical indicators (CIs) has declined, despite an increase in the number of HCOs reporting data on the CIs programme overall. Possible reasons for this decline were sought. A retrospective review of prospectively collected surgical CI data was performed, a national survey of stakeholders in the ACHS programme was conducted and a comparison was made with published international data. From a maximum of 247 HCOs reporting data in 2002, the number fell to 168 by 2011. While favourable trends were evident with some CIs, for example, a decline in the rate of negative histology in childhood appendicectomy and in the rate of in-hospital infection in total hip joint replacement, there was minimal change with many of the CIs, suggesting limited responsiveness as measures of care. In the national survey, stakeholder's response was positive overall, but there was a requirement for regular review of CIs. Although some colleges viewed the CIs as simplistic and not reliable, comparisons with similar measures available in the international literature were favourable. Possible reasons for the declining number of HCOs reporting surgical CI data are a lack of a recent revision of the CIs and a lack of engagement of clinicians from the RACS. Revision of the surgical CI set is required.

A Method for Reviewing the Accuracy and Reliability of a Five-Level Triage Process (Canadian Triage and Acuity Scale) in a Community Emergency Department Setting: Building the Crowding Measurement Infrastructure

Objectives. Triage data are widely used to evaluate patient flow, disease severity, and emergency department (ED) workload, factors used in ED crowding evaluation and management. We defined an indicator-based methodology that can be easily used to review the accuracy of Canadian Triage and Acuity Scale (CTAS) performance. Methods. A trained nurse reviewer (NR) retrospectively triaged two separate month's ED charts relative to a set of clinical indicators based on CTAS Chief Complaints. Interobserver reliability and accuracy were compared using Kappa and comparative statistics. Results. There were 2838 patients in Trial 1 and 3091 in Trial 2. The rate of inconsistent triage was 14% and 16% (Kappa 0.596 and 0.604). Clinical Indicators “pain scale, chest pain, musculoskeletal injury, respiratory illness, and headache” captured 68% and 62% of visits. Conclusions. We have demonstrated a system to measure the levels of process accuracy and reliability for triage over time. We identified five key clinical indicators which captured over 60% of visits. A simple method for quality review uses a small set of indicators, capturing a majority of cases. Performance consistency and data collection using indicators may be important areas to direct training efforts.