Specific Aspects Of Care Research Articles

Learning in student-run clinics: a systematic review.

Student-run clinics (SRCs) have existed for many years and may provide the most realistic setting for context-based learning and legitimate early clinical experiences with responsibility for patient care. We reviewed the literature on student outcomes of participation in SRCs. A systematic literature review was performed using the PubMed, EMBASE, PsycINFO and ERIC databases. Included articles were reviewed for conclusions and outcomes; study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI). A total of 42 articles met the inclusion criteria and were included in the quantitative synthesis. The effects of participation on students' attitudes were mainly positive: students valued the SRC experience. Data on the effects of SRC participation on students' skills and knowledge were based mainly on expert opinions and student surveys. Students reported improved skills and indicated that they had acquired knowledge they were unlikely to have gained elsewhere in the curriculum. The quality of specific aspects of care delivered by students was comparable with that of regular care. The suggestion that students should be trained as medical professionals with responsibility for patient care early in the curriculum is attractive. In an SRC this responsibility is central. Students valued the early training opportunity in SRCs and liked participating. However, little is known about the effect of SRC participation on students' skills and knowledge. The quality of care provided by students seemed adequate. Further research is needed to assess the effect of SRC participation on students' skills, knowledge and behaviour.

Paediatric trainees and end-of-life care: a needs assessment for a formal educational intervention

BackgroundLiterature suggests a paucity of formal training in end-of-life care in contemporary American medical education. Similar to trainees in adult medicine, paediatric trainees are frequently involved in end-of-life cases.ObjectiveTo determine current experience and comfort levels among paediatric trainees when caring for dying patients with the hypothesis that more clinical experience alone would not improve comfort.MethodsPaediatric residents, subspeciality fellows and programme directors at the University of Chicago completed a voluntary electronic needs assessment in June and July 2013. Ten question pairs determined frequency of experiencing various aspects of end-of-life care in clinical practice and comfort levels during these encounters.Results118 respondents participated (63.8 % response rate): 66.4 % were female; 53 % had previous education in end-of-life care. The proportion of those with experience in end-of-life care increased through the third year of training, and remained at 1.0 thereafter. Conversely, positive comfort scores increased gradually throughout all six years of training to a maximum proportion of 0.45. Comfort in many specific aspects of care lagged behind experience. Previous education had a significant positive effect on comfort levels of most, but not all, aspects of care. 58 % or more of trainees desired further education on specific end-of-life topics.ConclusionsPaediatric trainees are often involved in end-of-life care but may not be comfortable in this role. More experience alone does not improve comfort levels; however, there is a positive correlation with comfort and previous education. Trainees had a strong interest in further education on a variety of end-of-life care topics.Electronic supplementary materialThe online version of this chapter (doi: 10.1007/s40037-015-0161-4) contains supplementary material, which is available to authorized users.

Factors associated with maternal death from direct pregnancy complications: a UK national case-control study.

ObjectiveTo investigate the factors associated with maternal death from direct pregnancy complications in the UK.DesignUnmatched case–control analysis.SettingAll hospitals caring for pregnant women in the UK.PopulationA total of 135 women who died (cases) between 2009 and 2012 from eclampsia, pulmonary embolism, severe sepsis, amniotic fluid embolism, and peripartum haemorrhage, using data from the Confidential Enquiry into Maternal Death, and another 1661 women who survived severe complications (controls) caused by these conditions (2005–2013), using data from the UK Obstetric Surveillance System.MethodsMultivariable regression analyses were undertaken to identify the factors that were associated with maternal deaths and to estimate the additive odds associated with the presence of one or more of these factors.Main outcome measuresOdds ratios associated with maternal death and population-attributable fractions, with 95% confidence intervals. Incremental risk of death associated with the factors using a ‘risk factors’ score.ResultsSix factors were independently associated with maternal death: inadequate use of antenatal care (adjusted odds ratio, aOR 15.87, 95% CI 6.73–37.41); substance misuse (aOR 10.16, 95% CI 1.81–57.04); medical comorbidities (aOR 4.82, 95% CI 3.14–7.40); previous pregnancy problems (aOR 2.21, 95% CI 1.34–3.62); hypertensive disorders of pregnancy (aOR 2.44, 95% CI 1.31–4.52); and Indian ethnicity (aOR 2.70, 95% CI 1.14–6.43). Of the increased risk associated with maternal death, 70% (95% CI 66–73%) could be attributed to these factors. Odds associated with maternal death increased by three and a half times per unit increase in the ‘risk factor’ score (aOR 3.59, 95% CI 2.83–4.56).ConclusionsThis study shows that medical comorbidities are importantly associated with direct (obstetric) deaths. Further studies are required to understand whether specific aspects of care could be improved to reduce maternal deaths among women with medical comorbidities in the UK.

Clinicians' perceptions of how burnout affects their work.

The aim of this mixed-methods study was to identify ways that professional burnout may affect clinical work and consumer outcomes. Clinicians (N=120) participating in a burnout intervention trial completed a survey before the intervention, rating their level of burnout and answering open-ended questions about how burnout may affect their work. Responses were analyzed with team-based content analysis. Clinicians reported specific ways that burnout affects work, including empathy, communication, therapeutic alliance, and consumer engagement. Clinicians acknowledged negative impacts on outcomes, although few consumer outcomes were specified. Clinicians with higher levels of depersonalization were more likely to report that burnout affects how staff work with consumers (r=.21, p<.05); however, emotionally exhausted clinicians were less likely to report an impact on consumer outcomes (r=-.24, p=.01). Reducing professional burnout may have secondary gains in improving quality of services and consumer outcomes; findings point to specific aspects of care and outcome domains that could be targeted.

Is the readmission rate a valid quality indicator? A review of the evidence.

Introduction Hospital readmission rates are increasingly used for both quality improvement and cost control. However, the validity of readmission rates as a measure of quality of hospital care is not evident. We aimed to give an overview of the different methodological aspects in the definition and measurement of readmission rates that need to be considered when interpreting readmission rates as a reflection of quality of care.Methods We conducted a systematic literature review, using the bibliographic databases Embase, Medline OvidSP, Web-of-Science, Cochrane central and PubMed for the period of January 2001 to May 2013.Results The search resulted in 102 included papers. We found that definition of the context in which readmissions are used as a quality indicator is crucial. This context includes the patient group and the specific aspects of care of which the quality is aimed to be assessed. Methodological flaws like unreliable data and insufficient case-mix correction may confound the comparison of readmission rates between hospitals. Another problem occurs when the basic distinction between planned and unplanned readmissions cannot be made. Finally, the multi-faceted nature of quality of care and the correlation between readmissions and other outcomes limit the indicator's validity.ConclusionsAlthough readmission rates are a promising quality indicator, several methodological concerns identified in this study need to be addressed, especially when the indicator is intended for accountability or pay for performance. We recommend investing resources in accurate data registration, improved indicator description, and bundling outcome measures to provide a more complete picture of hospital care.

Current Trends in Clinical Studies of Allogeneic Hematopoietic Stem Cell Transplantation

Allogeneic hematopoietic stem cell transplantation (HSCT) is a specialized intervention performed at select centers worldwide. The extent to which specific aspects of care in allogeneic HSCT have been studied and the types of studies performed for different aspects of care remains incompletely documented. Studies in allogeneic HSCT were systematically identified from selected high-profile transplant journals between July 2010 and June 2011 and previously reported in a study addressing the definition of clinical outcomes in HSCT. All articles were retrieved and assessed for study characteristics and categorized by specific aspects of care related to allogeneic HSCT. One hundred sixteen articles were retrieved and reviewed in detail by 2 investigators. The most studied aspect of care was conditioning regimens. Transfusion practices were the most understudied aspect of care. Interestingly, most studies included both adult and pediatric patients. Studies involving all hematological malignancies were encountered more often than disease-specific studies. Geographically, most patients described in the published reports were treated only in North America or only in Europe. Most studies were retrospective (78), and 25 reported on multicenter registry data. Of the 38 prospective studies, 8 were randomized controlled trials (RCTs) and predominantly focused on prevention and treatment of graft-versus-host disease (GVHD) and infections. Median follow-up was longer in retrospective registry studies (54 months) and shortest in RCTs (32 months). The proportion of positive outcomes in retrospective and prospective studies was remarkably high (>80% for all categories) and not significantly different across all aspects of care (P > .05). When comparing RCTs and registry data studies, this proportion was similar and high (95% and 100%, respectively, P > .05). Our study highlights the established and important role of retrospective registry studies for many aspects of care and suggests RCTs may be most relevant for studies on infectious complications and GVHD.

Exploring Patient Satisfaction: A Secondary Analysis of a Randomized Clinical Trial of Spinal Manipulation, Home Exercise, and Medication for Acute and Subacute Neck Pain

ObjectiveThe purpose of this study was to assess satisfaction with specific aspects of care for acute neck pain and explore the relationship between satisfaction with care, neck pain, and global satisfaction. MethodsThis study was a secondary analysis of patient satisfaction from a randomized trial of spinal manipulation therapy (SMT) delivered by doctors of chiropractic, home exercise and advice (HEA) delivered by exercise therapists, and medication (MED) prescribed by a medical doctors for acute/subacute neck pain. Differences in satisfaction with specific aspects of care were analyzed using a linear mixed model. The relationship between specific aspects of care and (1) change in neck pain (primary outcome of the randomized trial) and (2) global satisfaction were assessed using Pearson's correlation and multiple linear regression. ResultsIndividuals receiving SMT or HEA were more satisfied with the information and general care received than MED group participants. Spinal manipulation therapy and HEA groups reported similar satisfaction with information provided during treatment; however, the SMT group was more satisfied with general care. Satisfaction with general care (r = −0.75 to −0.77; R2 = 0.55-0.56) had a stronger relationship with global satisfaction compared with satisfaction with information provided (r = −0.65 to 0.67; R2 = 0.39-0.46). The relationship between satisfaction with care and neck pain was weak (r = 0.17-0.38; R2 = 0.08-0.21). ConclusionsIndividuals with acute/subacute neck pain were more satisfied with specific aspects of care received during spinal manipulation therapy or home exercise interventions compared to receiving medication. The relationship between neck pain and satisfaction with care was weak.

Survey of women׳s experiences of care in a new freestanding midwifery unit in an inner city area of London, England: 2. Specific aspects of care

Objectiveto describe and compare women׳s experiences of specific aspects of maternity care before and after the opening of the Barkantine Birth Centre, a new freestanding midwifery unit in an inner city area. Designtelephone surveys undertaken in late pregnancy and about six weeks after birth. Two separate waves of interviews were conducted, Phase 1 before the birth centre opened and Phase 2 after it had opened. SettingTower Hamlets, a deprived inner city borough in east London, 2007–2010. Participants620 women who were resident in Tower Hamlets and who satisfied the Barts and the London Trust’s eligibility criteria for using the birth centre. Of these, 259 women were recruited to Phase 1 and 361 to Phase 2. Measurements and findingsthe replies women gave show marked differences between the model of care in the birth centre and that at the obstetric unit at the Royal London Hospital with respect to experiences of care and specific practices. Women who initially booked for birth centre care were more likely to attend antenatal classes and find them useful and were less likely to be induced. Women who started labour care at the birth centre in spontaneous labour were more likely to use non-pharmacological methods of pain relief, most notably water and less likely to use pethidine than women who started care at the hospital. They were more likely to be able to move around in labour and less likely to have their membranes ruptured or have continuous CTG. They were more likely to be told to push spontaneously when they needed to rather than under directed pushing and more likely to report that they had been able to choose their position for birth and deliver in places other than the bed, in contrast to the situation at the hospital. The majority of women who had a spontaneous onset of labour delivered vaginally, with 28.6 per cent of women at the birth centre but no one at the hospital delivering in water. Primiparous women who delivered at the birth centre were less likely to have an episiotomy. Most women who delivered at the birth centre reported that they had chosen whether or not to have a physiological third stage, whereas a worrying proportion at the hospital reported that they had not had a choice. A higher proportion of women at the birth centre reported skin to skin contact with their baby in the first two hours after birth. Key conclusions and implications for practicesignificant differences were reported between the hospital and the birth centre in practices and information given to the women, with lower rates of intervention, more choice and significant differences in women’s experiences. This case study of a single inner-city freestanding midwifery unit, linked to the Birthplace in England Research Programme, indicates that this model of care also leads to greater choice and a better experience for women who opted for it.

Relatives’ perspectives on the quality of care in an Intensive Care Unit: The theoretical concept of a new tool

ObjectiveTo examine the potential of a questionnaire (CQI ‘R-ICU’) to measure the quality of care from the perspective of relatives in the Intensive Care Unit (ICU). MethodsA quantitative survey study has been undertaken to explore the psychometric properties of the instrument, which was sent to 282 relatives of ICU patients from the Erasmus MC, an academic hospital in Rotterdam, the Netherlands. Factor-analyses were performed to explore the underlying theoretical structure. ResultsSurvey data from 211 relatives (response rate 78%) were used for the analysis. The overall reliability of the questionnaire was sufficiently high; two of the four underlying factors, namely ‘Communication’ and ‘Involvement’, were significant predictors. Two specific aspects of care that needed the most improvement were missing information about meals and offering an ICU diary. There is a significant difference in mean communication with nurses among the four wards in Erasmus MC. ConclusionsThe CQI ‘R-ICU’ seems to be a valid, reliable and usable instrument. The theoretical fundament appears to be related to communication. Practice implicationsThe newly developed instrument can be used to provide feedback to health care professionals and policy makers in order to evaluate quality improvement projects with regard to relatives in the ICU.

Wert-Abjektion als grundlegende Herrschaftsform des patriarchalen Kapitalismus – ‘Sorge(n)freie’ Gesellschaft als Resultat

The article delivers a contribution to theorise (the devaluation of ) care-work in patriarchal capitalism and to connect the theorization with the empirical analysis of the German ambulant care sector in neoliberal times. The central theorem of ‘value-abjection’ transforms Marxist value theory and conceptualizes the abjection of care work as constitutive mechanism of domination in patriarchal capitalism. Transferred to a concrete level of argumentation the theoretical perspective of value-abjection helps not only to analyse the structural tendency of abjection of care work. It also enables to identify empirically- concrete which specific aspects of care and for what reason are structured as abject.

Comparison of Family Satisfaction in Australian Ethno-Specific and Mainstream Aged Care Facilities

The aim in this study was to identify specific aspects of care that increased satisfaction of family members of Greek and Italian residents with dementia in mainstream or ethno-specific aged care facilities in Australia. Relatives of 83 aged care residents with Greek or Italian backgrounds who were also cognitively impaired were interviewed. They rated their satisfaction with the facility and suggested improvements regarding the care provided. Family members with relatives in ethno-specific care were more satisfied, in terms of the facility's ability to meet the resident's language and cultural needs, social/leisure activities, and the food provided. The presence of a bilingual staff member and greater perceived reduction in family caregiver stress upon admission were associated with higher satisfaction. Results implicate the role of activities programs, catering, resident interaction, supporting caregivers upon admission, and bilingual staff members to increase family satisfaction, with the potential to improve the care provided to residents in mainstream care.

British residents’ views about general practice care in France – a telephone survey

BackgroundMany studies have been published over the past decade on patients’ views about the provision of health care. Though there is a high level of migration within the European Union, there are no studies on migrants’ views about the provision of care in the country to which they moved. Given the wide spectrum of primary care in Europe, we hypothesised, without prejudging the outcome, that patients’ confidence in the system they left, used as a proxy of ‘the experience of care’, may influence their preferences regarding specific aspects of care in the host country. The objective of the study was to analyse British migrants’ views on general practice care in France.MethodsA telephone survey was conducted with a random sample of the adult population of British people residing in France. Participants were 437 women and 423 men, aged 18 and over, who had consulted a general practitioner at least once during the past 12 months. The main outcome measures were the responses to the 23-item Europep questionnaire evaluating different aspects of general practice care, using a five-point answering scale with the extremes labelled as “poor” and “excellent”.ResultsParticipants were generally satisfied with the GP care provided. The aspects that were rated the highest were related to the doctor-patient relationship which over 80% of the respondents judged as excellent or very good. Some aspects of the organisation of services received relatively negative evaluations. For instance, “waiting time in the waiting room” was evaluated as excellent or very good by only 40% of the respondents. Twenty seven percent of the respondents were not confident in the National Health Service (NHS) when they were still living in UK. After adjusting for age, sex and number of years of residence in France, the respondents who were not confident in the NHS provided a score of “excellent” significantly more frequently (on 11 out of the 23 aspects of care) than did the patients who were confident in the NHS. Most of these aspects concerned the doctor-patient relationship and information and support during the consultation.ConclusionsBritish migrants’ views on general practice care in France varied with the degree of confidence they had in the NHS. This finding is in line with the discussion on whether the ‘experience of care’ influences patient satisfaction. A better understanding of this phenomenon should provide valuable insights to make the services more responsive to the patients.

Are Current Approaches to Improving LTC Quality Hits or Errors?

Are Current Approaches to Improving LTC Quality Hits or Errors?

Does the ‘Liverpool Care Pathway’ facilitate an improvement in quality of care for dying cancer patients?

Background:The Liverpool Care Pathway for the Dying Patient (LCP) aims to transfer hospice principles of care for dying patients to other health-care sectors. This post-bereavement survey explored the LCP's effectiveness in improving quality of care for cancer patients.Methods:Postal self-completion questionnaires were sent to 778 next-of-kin to consecutive deceased patients who had died an ‘expected' cancer death in a hospice and acute tertiary hospital.Results:Following exclusions (n=53), 255 of the 725 next-of-kin agreed to participate (35.2% response rate). Overall hospice participants reported the best quality of care, and hospital participants, for whom care was not supported by the LCP, reported the worst quality of care. Multivariate analysis showed the hospice was an independent predictor for patients being treated with dignity (OR 8.46) and receiving adequate family support (OR 7.18) (P<0.0001). Care supported by the LCP and the hospital specialist palliative care team were both associated with good family support, but neither was an independent predictor.Conclusions:From the bereaved relatives' perspective, within the hospital, the LCP is effective in improving specific aspects of care, such as symptom control for dying patients. Further improvement is required, however, to attain the hospice standard of care.

Family satisfaction in the ICU: why should ICU clinicians care?

Family satisfaction in the ICU: why should ICU clinicians care?

A Systematic Review of Recent Clinical Practice Guidelines on the Diagnosis, Assessment and Management of Hypertension

BackgroundDespite the availability of clinical practice guidelines (CPGs), optimal hypertension control is not achieved in many parts of the world; one of the challenges is the volume of guidelines on this topic and their variable quality. To systematically review the quality, methodology, and consistency of recommendations of recently-developed national CPGs on the diagnosis, assessment and the management of hypertension.Methodology/Principal FindingsMEDLINE, EMBASE, guidelines' websites and Google were searched for CPGs written in English on the general management of hypertension in any clinical setting published between January 2006 and September 2011. Four raters independently appraised each CPG using the AGREE-II instrument and 2 reviewers independently extracted the data. Conflicts were resolved by discussion or the involvement of an additional reviewer. Eleven CPGs were identified. The overall quality ranged from 2.5 to 6 out of 7 on the AGREE-II tool. The highest scores were for “clarity of presentation” (44.4% −88.9%) and the lowest were for “rigour of development” (8.3%–30% for 9 CGPs). None of them clearly reported being newly developed or adapted. Only one reported having a patient representative in its development team. Systematic reviews were not consistently used and only 2 up-to-date Cochrane reviews were cited. Two CPGs graded some recommendations and related that to levels (but not quality) of evidence. The CPGs' recommendations on assessment and non-pharmacological management were fairly consistent. Guidelines varied in the selection of first-line treatment, adjustment of therapy and drug combinations. Important specific aspects of care (e.g. resistant hypertension) were ignored by 6/11 CPGs. The CPGs varied in methodological quality, suggesting that their implementation might not result in less variation of care or in better health-related outcomes.Conclusions/SignificanceMore efforts are needed to promote the realistic approach of localization or local adaptation of existing high-quality CPGs to the national context.

Parental Involvement in Neonatal Comfort Care

To explore how parents interact with their infants and with nurses regarding the provision of comfort care in a Neonatal Intensive Care Unit (NICU). Focused ethnography. A regional NICU in the United Kingdom. Eleven families (10 mothers, 8 fathers) with infants residing in the NICU participated in the study. Parents were observed during a caregiving interaction with their infants and then interviewed on up to four occasions. Twenty-five periods of observation and 24 semistructured interviews were conducted between January and November 2008. Five stages of learning to parent in the NICU were identified. Although the length and duration of each stage differed for individual parents, movement along the learning trajectory was facilitated when parents were involved in comforting their infants. Transfer of responsibility from nurse to parents for specific aspects of care was also aided by parental involvement in pain care. Nurses' encouragement of parental involvement in comfort care facilitated parental proximity, parent/infant reciprocity, and parental sense of responsibility. Findings suggest that parental involvement in comfort care can aid the process of learning to parent, which is difficult in the NICU. Parental involvement in infant comfort care may also facilitate the transfer of responsibility from nurse to parent and may facilitate antecedents to parent/infant attachment.

The ENDOCARE questionnaire guides European endometriosis clinics to improve the patient-centeredness of their care

How patient-centered are two included specialized endometriosis clinics relative to each other and how can they improve the patient-centeredness of their care? The validated ENDOCARE questionnaire (ECQ) reliably concluded that the adjusted overall patient-centeredness did not differ between the clinics, that each clinic was significantly more patient-centered for 2 out of 10 dimensions of patient-centered endometriosis care and that clinics 1 and 2 had to improve 8 and 13 specific care aspects, respectively. Patient-centered endometriosis care is essential to high-quality care and is defined by 10 dimensions. The ECQ was developed, validated and proved to be reliable in a European setting of self-reported endometriosis patients but had not yet been used at a clinic level for quality management. A cross-sectional survey was disseminated in 2011 to all 514 women diagnosed with endometriosis during a laparoscopy indicated for pain and/or infertility during a retrospective 2-year period (2009-2010) in two university clinics from two different European countries. In total 337 patients completed the ECQ (216 and 121 per clinic). Respondents had a mean age of 34.3 years. Three in four reported a surgical diagnosis of moderate or severe endometriosis and the majority reported surgical treatment by a multidisciplinary team. The ECQ assessed the 10 dimensions of patient-centeredness, more specifically whether the health-care performance, as perceived by patients, measured up to what is important to patients in general. The ECQ was completed by 337 respondents (response rate = 65.6%). Reliability and validity of the ECQ for use on clinic level were confirmed. Clinics did not differ in overall mean importance scores; importance rankings of the ECQ dimensions were almost identical. The overall patient-centeredness scores (PCS), adjusted for education level, did not discriminate between the clinics. However, the adjusted PCS for the dimensions 'clinic staff' and 'technical skills' were significantly better in clinic 1, whereas the dimensions 'physical comfort' and 'access to care' were significantly better in clinic 2. There were 8 (clinic 1) and 13 (clinic 2) targets identified for joint and cross-clinic improvement. Response rates were relatively high. Recall bias was the most important limitation and research in more clinics is needed to define the statistical discriminative value of the ECQ. European endometriosis clinics can use the validated ECQ for reliable assessment of their 'patient-centeredness', for comparison with others and for setting specific targets to improve the patient-centeredness of their endometriosis care, to plan interventions, and to evaluate their effectiveness. This work was funded by KU Leuven and European Network of Endometriosis (ENE), supported by the European Commission (Public Health Executive Agency). No competing interests are declared.

Monitoring children after hypospadias repair: What is the best plan of action?

The tubularized incised plate (TIP) urethroplasty has been carefully scrutinized by many, rightfully maintaining its position as the number one technique for most defects, particularly distal ones.1 Nevertheless, while our experience (and the age of patients who have undergone this repair) matures, there continues to be questions related to the quality of the neourethra in terms of diameter and elasticity. Thankfully, most surgeons have now departed from the questionable practice of routine regular urethral “calibration” after surgery,2 favouring non-invasive assessment of toilet-trained children by means of a urinary flow rate and ultrasound determination of post-void residuals. For better or worse, we are then faced with seemingly “asymptomatic” young boys with parameters that are either considered abnormal or fall outside of nomogram curves adjusted for age. These findings can somewhat temper the enthusiastic embrace of the TIP technique due to the possibility of long-term consequences from distal urinary flow impairment. Is this a founded source of worry or an unnecessary concern? There are important issues that come up when reviewing the literature and monitoring children in everyday practice. Aside from questions regarding what a “normal” flow rate in young (recently toilet trained) children represents, and the effect of age and the underlying condition on flow dynamics,3 there are some specific aspects of care I find particularly challenging. First, I struggle with being able to confidently say that a young patient is asymptomatic at an age when that assessment is difficult at best. Kids who grow up with a functional urinary flow abnormality would not necessarily perceive it as an impediment and would likely be considered “asymptomatic.” Perhaps the same postoperative voiding pattern in a young adult would not be labelled as such. I also have a hard time envisioning the “need” for an intervention or why an intervention is “required.” Admittedly some children have significant problems (such as high post-void residuals and recurrent infections), yet most do not. As we dig deeper into the rationale for intervention, it is difficult to quantify the factors that emerge (such as “parental preference” and “surgeon opinion”). Nevertheless, this commonly accepted exclusion criterion eliminates patients who may be identical to those who were monitored, yet not subjected to further surgery. In a retrospective uncontrolled fashion it is hard to envision what dictates taking such a step. Lastly, I question how much of the detected improvement over time is the result of normal development, tissue remodeling or just adaptation to a relative obstruction. This is rather difficult to quantify and may be less important in distal hypospadias, yet probably gains significance as the defects become more severe, the neourethra segment longer, the intraoperative dissection more extensive, and reliance on poorly developed plates more frequent. Unfortunately, it is this latter group that is most worrisome and for which we only have modest amounts of long-term data. Considering the data presented by Eassa and colleagues,4 some could argue that there is little value in obtaining flow rates in asymptomatic children, considering that we either rejoice when we see a normal one, yet are advised to exercise patience and do very little when abnormal. Nevertheless, if a flow rate is obtained, we must then decide on when an abnormality is really something to worry about or act upon. At which point can we rest assured that persistent abnormal findings are likely inconsequential? How will the underlying characteristics of the neourethra (leading to these voiding dynamics) stand the dramatic developmental and functional demands imposed by puberty? Although it is reassuring that many patients improve and do well during short- to medium-term follow-up, some (perhaps very few) do not. Is there a way to tell them apart? Now that we have some reassurance we need selectivity; we need to be able to separate patients who benefit from close monitoring from those who can be safely discharged from regular assessment. Experience with “excellent” results that led to not-so-excellent long-term outcomes5,6 should encourage us to consider prospectively capturing urinary flow dynamics data and satisfaction of hypospadias patients until early adulthood. While we gather more evidence, should we be relieved to see data supporting conservative management and a favourable pattern towards improvement? Yes. Can we apply these findings to all hypospadias patients, including proximal ones? Probably not. Will I continue to regularly monitor patients with an abnormal flow rate after hypospadias repair? You bet!

Women's satisfaction with antenatal care: Comparing women in Sweden and Australia

Satisfaction with antenatal care could differ depending on the organisation and the context of care. To compare antenatal care in Australia and Sweden, to identify deficiencies in the content of antenatal care and what aspects contributed most in dissatisfaction with antenatal care. A longitudinal survey of 123 Australian and 386 Swedish women recruited during one year in regional hospitals in Sweden and Australia. Data collected by three questionnaires. Women in Australia had more antenatal visits, less continuity of midwife caregiver but were more satisfied with antenatal education and the emotional aspects of antenatal care. Although the overall satisfaction was high, deficiencies were found in more than half of the studied variables in the content of care. Women in Sweden were more dissatisfied with information about labour and birth (OR 3.1; 1.8-5.3) and information about the time following birth (OR 3.8; 2.2-6.3), but more satisfied with the involvement of the father (OR 0.3; 0.2-0.6). Factors that contributed most to dissatisfaction with antenatal care overall were deficiency in information about pregnancy related issues (OR 3.4; 1.3-8.7) and not being taken seriously by the midwife (OR 4.1; 1.6-10.1). Satisfaction with antenatal care was high in both groups of women. Australian women were more satisfied than the Swedish women with the emotional aspects of care. Deficiencies were found in more than half of the variables measured relating to the specific aspects of care. Lack of information and not being treated seriously were important factors for not being satisfied.