Influence on screening performance of second reading strategies in two lowvolume programs

BACKGROUND: The European Guidelines specify a minimum of 5,000 screening cases to be read yearly by radiologists carrying out second reading in non-centralized programs. This professional requirement is difficult to reach and/or to implement in regional programs covering a sparse population with a high number of participating radiology units, so that alternative blind double reading strategies must be devised. OBJECTIVE: To evaluate the effect on breast cancer screening performances of two second reading strategies used in non-centralized, low-volume programs. METHODS: Reading performances in two Swiss regional breast cancer screening programs (cantons of Wallis and Vaud), covering female populations, aged 50-69, of about 31'000 and 72'000 inhabitants were computed and compared. Both programs had similar screening regimens and organizations, but differed with respect to second reading. One setting applied a selective strategy whereby only experienced radiologists performed second reading; the other elicited not to restrict second readers on the basis of their individual screening activity. Analysis included some 140,000 mammograms performed between 1999 and 2005. RESULTS: Overall, screening performances improved with increasing total volume of reading, albeit not in a linear fashion. Regardless of setting, radiologists attained a higher level of screening accuracy when performing second rather than first readings, and incident rather than prevalent screening cases. The effect of a selective, small group of second readers appeared to impact favorably on the false-positive rate and other indicators of screening quality. As the learning curve depends on the number of mammograms read, these distinct strategies may bear different outcome in the long run. Implications and practical issues for low-volume programs are discussed.

Variation in performance across Swiss mammography screening programmes: the influence of reading strategy and experience.

[Abstract] Reading volume and mammography screening performance appear positively correlated. Performance was compared across organised Swiss screening programmes, which target relatively small populations. Except for accreditation of 2nd readers radiologists (restrictive vs non-restrictive strategy), Swiss programmes have similar screening regimen/procedures and duration, which maximises comparability. Variation in performance was explored in order to improve mammography practice and optimise screening performance. Indicators of quality and effectiveness were evaluated for about 200,000 screens performed over 4 screening rounds in the 3 longest-standing Swiss cantonal programmes (of Vaud, Geneva and Valais). Interval cancers were identified by linkage with cancer registries records. Most European standards of performance were met with a favourable cancer stage shift. Several performance indicators showed substantial variation across programmes. In subsequent rounds, compared with programmes (Vaud and Geneva) which accredited few 2nd readers to increase their individual reading volume, proportions of in situ lesions and of small cancers (? 1cm) were one third lower and halved, respectively, and the proportion of advanced lesions (stage II+) nearly 50% higher in the programme without a restrictive selection strategy. Discrepancy in second-year proportional incidence of interval cancers appears to be multicausal. Differences in performance could partly be explained by a selective strategy for 2nd readers and a prior experience in service screening, but not by the levels of opportunistic screening and programme attendance. This study provides clues for enhancing mammography screening performance in low-volume Swiss programmes.

Variation in performance in low-volume mammography screening programmes: experience from Switzerland.

BACKGROUND: Reading volume and mammography screening performance appear positively correlated. Quality and effectiveness were compared across low-volume screening programmes targeting relatively small populations and operating under the same decentralised healthcare system. Except for accreditation of 2nd readers (restrictive vs non-restrictive strategy), these organised programmes had similar screening regimen/procedures and duration, which maximises comparability. Variation in performance and its determinants were explored in order to improve mammography practice and optimise screening performance. METHODS: Circa 200,000 screens performed between 1999 and 2006 (4 rounds) in 3 longest standing Swiss cantonal programmes (of Vaud, Geneva and Valais) were assessed. Indicators of quality and effectiveness were assessed according to European standards. Interval cancers were identified through linkage with cancer registries records. RESULTS: Swiss programmes met most European standards of performance with a substantial, favourable cancer stage shift. Up to a two-fold variation occurred for several performance indicators. In subsequent rounds, compared with programmes (Vaud and Geneva) that applied a restrictive selection strategy for 2nd readers, proportions of in situ lesions and of small cancers (≤1cm) were one third lower and halved, respectively, and the proportion of advanced lesions (stage II+) nearly 50% higher in the programme without a restrictive selection strategy. Discrepancy in second-year proportional incidence of interval cancers appears to be multicausal. CONCLUSION: Differences in performance could partly be explained by a selective strategy for second readers and a prior experience in service screening, but not by the levels of opportunistic screening and programme attendance. This study provides clues for enhancing mammography screening performance in low-volume programmes.

Outcome and Experience from the Swiss Mammography Screening Pilot Programmes

BACKGROUND:The Swiss breast cancer screening pilot programme was conducted in 3 districts of theFrench-speaking canton of Vaud (ca. 300,000 resident women) between October 1993 and January 1999.Women aged 50 to 69 were invited by mail every 2 years for a free of charge screening mammography (doubleview, multiple reading). This first ever-organised cancer screening programme in Switzerland showed thefeasibility and acceptability of this kind of public health intervention in the liberal Swiss healthcare system, whichwas the main objective of the pilot programme. This mammographic screening programme was extended to thewhole canton in 1999, and contributed to the implementation of similar programmes in 2 neighbouring cantons. OBJECTIVE:To appraise the use, the quality and the effectiveness of the Swiss screening pilot programme. METHODS:About 15,000 women (aged 50-69) were enrolled. Logistic regression analyses were performedseparately to identify determinants of initial and subsequent attendance. Standard indicators of quality,effectiveness and impact of the programme were assessed and compared with European recommendations. Tothis intent, linkage with data from the Vaud Cancer Registry was performed. RESULTS:About half the target population was screened at least once during the pilot trial. Participation washigher among Swiss than foreigners, among widowed or married women than among single, divorced or separatedones. Attendance also increased with age and decreasing distance between residence and the dedicatedscreening centre. Apart from Swiss citizenship, socio-demographic factors were not associated with reattendance.Intensity of prior recruitment, outcome of previous screening test (positive vs. negative) and indicators of women'shealth behaviour (time of last mammography prior to initial screen, smoking status) were the main determinants ofreattendance. Programme performance and quality indicators were, overall, in line with European Guidelines. Theywere overall more favourable among 60-69 than 50-59 year-olds and improved over time. CONCLUSION:The objectives of the pilot programme were met. Even if participation should increase in order toreach European standards, performance indicators overall met quality requirements. Ways to improve screeninguse, quality and effectiveness were devised and taken into account for the generalisation of the programme.

Turnaround across diverse global supply chains using shared metrics and change methodology: The Case of Amer Sports Corporation

Purpose - The purpose of this paper is to document the outcome of a global three-year long supply chain improvement initiative at a multi-national producer of branded sporting goods that is transforming from a holding structure to an integrated company. The case company is comprised of seven internationally well-known sport brands, which form a diverse set of independent sub-cases, on which the same supply chain metrics and change project approach was applied to improve supply chain performance. Design/methodology/approach - By using in-depth case study and statistical analysis the paper analyzes across the brands how supply chain complexity (SKU count), supply chain type (make or buy) and seasonality affect completeness and punctuality of deliveries, and inventory as the change project progresses. Findings - Results show that reduction in supply chain complexity improves delivery performance, but has no impact on inventory. Supply chain type has no impact on service level, but brands with in-house production are better in improving inventory than those with outsourced production. Non-seasonal business units improve service faster than seasonal ones, yet there is no impact on inventory. Research limitations/implications - The longitudinal data used for the analysis is biased with the general business trend, yet the rich data from different cases and three-years of data collection enables generalizations to a certain level. Practical implications - The in-depth case study serves as an example for other companies on how to initiate a supply chain improvement project across business units with tangible results. Originality/value - The seven sub-cases with their different characteristics on which the same improvement initiative was applied sets a unique ground for longitudinal analysis to study supply chain complexity, type and seasonality.

DRGs in hospital management.

One of the traditional tasks of district and hospital managers has been to attempt to explain variations in average length of stay, average cost per day and average cost per case, between different hospitals. The need for such explanations has become more acute as a result of the recent emphasis on 'performance indicators' as measures of the efficiency of hospitals. The task of explaining these differences has not been rendered easier by the lack of appropriate management information for this purpose.

Improving globally distributed software development and support processes - A workflow view

We propose a new approach and related indicators for globally distributed software support and development based on a 3-year process improvement project in a globally distributed engineering company. The company develops, delivers and supports a complex software system with tailored hardware components and unique end-customer installations. By applying the domain knowledge from operations management on lead time reduction and its multiple benefits to process performance, the workflows of globally distributed software development and multitier support processes were measured and monitored throughout the company. The results show that the global end-to-end process visibility and centrally managed reporting at all levels of the organization catalyzed a change process toward significantly better performance. Due to the new performance indicators based on lead times and their variation with fixed control procedures, the case company was able to report faster bug-fixing cycle times, improved response times and generally better customer satisfaction in its global operations. In all, lead times to implement new features and to respond to customer issues and requests were reduced by 50%.

Towards actionable international comparisons of health system performance: expert revision of the OECD framework and quality indicators.

OBJECTIVE: To review and update the conceptual framework, indicator content and research priorities of the Organisation for Economic Cooperation and Development's (OECD) Health Care Quality Indicators (HCQI) project, after a decade of collaborative work. DESIGN: A structured assessment was carried out using a modified Delphi approach, followed by a consensus meeting, to assess the suite of HCQI for international comparisons, agree on revisions to the original framework and set priorities for research and development. SETTING: International group of countries participating to OECD projects. PARTICIPANTS: Members of the OECD HCQI expert group. RESULTS: A reference matrix, based on a revised performance framework, was used to map and assess all seventy HCQI routinely calculated by the OECD expert group. A total of 21 indicators were agreed to be excluded, due to the following concerns: (i) relevance, (ii) international comparability, particularly where heterogeneous coding practices might induce bias, (iii) feasibility, when the number of countries able to report was limited and the added value did not justify sustained effort and (iv) actionability, for indicators that were unlikely to improve on the basis of targeted policy interventions. CONCLUSIONS: The revised OECD framework for HCQI represents a new milestone of a long-standing international collaboration among a group of countries committed to building common ground for performance measurement. The expert group believes that the continuation of this work is paramount to provide decision makers with a validated toolbox to directly act on quality improvement strategies.

Adiposity indicators and blood pressure in children: nothing beyond body mass index?

Obesity is a major risk factor for elevated blood pressure in children. For instance, in a school-based study of 5207 children aged 10-12 years, the prevalence of hypertension, which is sustained elevated blood pressure over several visits, was 1.5%, 3.9% and 17.5% in normal weight, overweight and obese children, respectively. High body mass index (BMI) is commonly used to define overweight and obesity. However, because BMI is merely a proxy for adiposity, there is a longstanding debate about its performance to predict elevated blood pressure (or any other health conditions associated with adiposity) and whether other adiposity indicators, such as waist circumference, waist-to-hip ratio or hip circumference, should not be preferred... In this study, 7.4% of boys and 6.4% of girls had elevated blood pressure. The adiposity indicators were highly correlated to each other, apart from weight, waist-to-hip ratio and skinfold thickness z-scores. All indicators were associated with blood pressure. The ability to identify children with elevated blood pressure, assessed by the area under the receiver operating curve (AUC) statistic, was superior for BMI, body adiposity index and waist-to-height ratio z-scores compared with other indicators. BMI z-scores had a slightly higher AUC than other indicators. The authors concluded that BMIz-scores could be a better predictor of elevated blood pressure in children than other adiposity indicators.

Paper 3: EUROCAT data quality indicators for population-based registries of congenital anomalies.

The European Surveillance of Congenital Anomalies (EUROCAT) network of population-based congenital anomaly registries is an important source of epidemiologic information on congenital anomalies in Europe covering live births, fetal deaths from 20 weeks gestation, and terminations of pregnancy for fetal anomaly. EUROCAT's policy is to strive for high-quality data, while ensuring consistency and transparency across all member registries. A set of 30 data quality indicators (DQIs) was developed to assess five key elements of data quality: completeness of case ascertainment, accuracy of diagnosis, completeness of information on EUROCAT variables, timeliness of data transmission, and availability of population denominator information. This article describes each of the individual DQIs and presents the output for each registry as well as the EUROCAT (unweighted) average, for 29 full member registries for 2004-2008. This information is also available on the EUROCAT website for previous years. The EUROCAT DQIs allow registries to evaluate their performance in relation to other registries and allows appropriate interpretations to be made of the data collected. The DQIs provide direction for improving data collection and ascertainment, and they allow annual assessment for monitoring continuous improvement. The DQI are constantly reviewed and refined to best document registry procedures and processes regarding data collection, to ensure appropriateness of DQI, and to ensure transparency so that the data collected can make a substantial and useful contribution to epidemiologic research on congenital anomalies.

When Cooperation Stumbles: the effects of grades on indicators of cooperation

(English Abstract) In western societies, grades are to date the most widespread means by which achievement and performance are assessed in educational contexts. Grades are used for their capacity to provide individuals with a clear indicator of success or failure, in particular in comparison to others; in this respect, we study their impact on particular work contexts requiring cooperation. Indeed, students are often exhorted to cooperate and work in groups, while at the same time assessed with grades and focused on inter-individual comparison. However, to the best of our knowledge, no work has investigated the effects of grades on cooperation and on indicators of cooperation, a central question to be addressed given its significance for educational trends encouraging cooperative practices, and which we propose to explore in the experimental parts of this thesis. The first experimental chapter, Chapter 4, investigates the effect of grades with regards to their capacity to highlight individual visibility and at the same time social comparison. It tries to disentangle which of these facets could affect a motivated bias likely to reduce cooperation, namely individuals' preference for information confirming their own choice. In two experiments, results showed that a graded-cooperative situation increased this preference effect in comparison to other conditions where only individual visibility was manipulated, and furthermore increased individuals' perception of a competitive atmosphere. Chapter 5 investigates the effect of grades on direct cooperative inter- individual interactions, namely on group information sharing. Two experiments showed that grades hindered informational communication between individuals, leading them to withhold crucial task-information. Finally, Chapter 6 investigates the effects of grades on another indicator of group cooperation, namely inter-individual coordination. Results indicated that showcasing grades at the onset of a cooperative task necessitating inter-individual coordination decreased group performance and elicited more negative dominant behaviours amongst participants. Together these results provide evidence that grades hamper group cooperation. We conclude by discussing implications for the practice of grading in Education. ------------------------------------------------------- (Résumé en langue française) Dans la plupart des pays occidentaux, les notes sont majoritairement utilisées pour évaluer la performance et rendre compte de la réussite scolaire des individus. Dans cette perspective, elles sont non seulement un indicateur de succès ou d'échec, mais aussi de la valeur comparative des individus. Dans cette thèse nous proposons de tester l'effet des notes lorsque celles-ci sont utilisées dans des contextes bien spécifiques de coopération. En effet, si les notes et la comparaison sociale sont pratique courante, les étudiants sont souvent encouragés et amenés à coopérer en groupe. Cependant, à notre connaissance, point d'études ont testé l'effet des notes sur la coopération; études qui seraient pourtant légitimes étant donné la tendance existante en milieu éducatif à encourager les pratiques coopératives. C'est précisément ce que proposent de faire les chapitres expérimentaux de cette thèse. Le premier (Chapitre 4) teste l'effet des notes au regard de leur capacité à accentuer à la fois la visibilité et la comparaison sociale. Deux expériences investiguent l'effet des notes et tentent de démêler ce qui, de la visibilité individuelle, de la comparaison sociale ou des deux, pourrait affecter un biais motivationnel qui réduit la propension à coopérer: la propension à préférer les informations qui confirment les choix de l'individu. Les résultats montrent qu'en situation coopérative, les notes accroissent ce biais comparativement à des situations où seule la visibilité individuelle est soulignée, suggérant de plus que les notes produisent une focalisation des individus sur une comparaison sociale compétitive. Le second (Chapitre 5) teste l'effet des notes sur les interactions coopératives des individus, précisément sur le partage d'information. Deux expériences montrent que dans un contexte de travail en groupe coopératif, les notes entravent le bon partage des informations entre individus, les amenant à faire de la rétention d'information. Enfin, le troisième (Chapitre 6) investigue l'effet des notes sur un autre indicateur de coopération en groupe: la coordination interindividuelle. Les résultats montrent que les notes réduisent la coordination des individus et les mènent à avoir des comportements de dominance négative entre eux. En somme, les notes entravent la coopération et réduisent les comportements coopératifs entre individus. Enfin, nous discutons des implications pour le milieu éducatif.