Heart failure events, and case fatalities in Switzerland based on hospital statistics and cause of death statistics

In Switzerland there is a shortage of population-based information on heart failure (HF) incidence and case fatalities (CF). The aim of this study was to estimate HF event rates and both in- and out-of-hospital CF rates.

Electronic medical record systems, data quality and loss to follow-up: survey of antiretroviral therapy programmes in resource-limited settings

OBJECTIVE: To describe the electronic medical databases used in antiretroviral therapy (ART) programmes in lower-income countries and assess the measures such programmes employ to maintain and improve data quality and reduce the loss of patients to follow-up. METHODS: In 15 countries of Africa, South America and Asia, a survey was conducted from December 2006 to February 2007 on the use of electronic medical record systems in ART programmes. Patients enrolled in the sites at the time of the survey but not seen during the previous 12 months were considered lost to follow-up. The quality of the data was assessed by computing the percentage of missing key variables (age, sex, clinical stage of HIV infection, CD4+ lymphocyte count and year of ART initiation). Associations between site characteristics (such as number of staff members dedicated to data management), measures to reduce loss to follow-up (such as the presence of staff dedicated to tracing patients) and data quality and loss to follow-up were analysed using multivariate logit models. FINDINGS: Twenty-one sites that together provided ART to 50 060 patients were included (median number of patients per site: 1000; interquartile range, IQR: 72-19 320). Eighteen sites (86%) used an electronic database for medical record-keeping; 15 (83%) such sites relied on software intended for personal or small business use. The median percentage of missing data for key variables per site was 10.9% (IQR: 2.0-18.9%) and declined with training in data management (odds ratio, OR: 0.58; 95% confidence interval, CI: 0.37-0.90) and weekly hours spent by a clerk on the database per 100 patients on ART (OR: 0.95; 95% CI: 0.90-0.99). About 10 weekly hours per 100 patients on ART were required to reduce missing data for key variables to below 10%. The median percentage of patients lost to follow-up 1 year after starting ART was 8.5% (IQR: 4.2-19.7%). Strategies to reduce loss to follow-up included outreach teams, community-based organizations and checking death registry data. Implementation of all three strategies substantially reduced losses to follow-up (OR: 0.17; 95% CI: 0.15-0.20). CONCLUSION: The quality of the data collected and the retention of patients in ART treatment programmes are unsatisfactory for many sites involved in the scale-up of ART in resource-limited settings, mainly because of insufficient staff trained to manage data and trace patients lost to follow-up.

Tuberculosis in a Swiss army training camp: contact investigation using an Interferon gamma release assay

BACKGROUND: In tuberculosis (TB), the risk of exposure is determined mainly by the proximity to and the hours of direct contact with an infectious patient. We describe the contact investigation after detection of an infectious form of TB in a military camp using an Interferon-g-Release-Assay (IGRA, QuantiFERON-TB Gold In Tube [QTF-GIT]) eight weeks after detection of the index case. INDEX PATIENT: The index patient presented with fever, cough and weight loss in the military hospital six weeks after entering the camp. TB was suspected and anti-tuberculous therapy given immediately. Subsequently, TB was microbiologically confirmed. METHODS: Four exposure groups were formed a priori based on the proximity and the hours of direct contact to the index case. 168 (95.5%) agreed to be investigated: - Group A: sharing the same dormitory (15 persons) - Group B: same platoon, but not sharing the dormitory (20 persons) - Group C: staff and patients of the military hospital (22 persons) - Group D: other three platoons and senior military staff (111 persons). RESULTS: 34 (20.2%) out of 168 contacts tested positive in the QFT-GIT assay. For the exposure groups, the respective QFT-GIT testing results were: group A, 14/15 (93%); group B, 4/20 (20%); group C, 5/22 (22.7%); and group D, 11/111 (9.9%). No secondary TB cases were identified. CONCLUSIONS: In our study, test results show a correlation with the risk of exposure, suggesting that IGRA may be useful for the assessment of TB infection in TB contacts. The high mobility of recruits reduced traceability of contacts. In this context, QFT-GIT allowed for an efficient screening of contacts at a single time point.

Stroke events, and case fatalities in Switzerland based on hospital statistics and cause of death statistics

OBJECTIVE: In Switzerland there is a shortage of population-based information on stroke incidence and case fatalities (CF). The aim of this study was to estimate stroke event rates and both in- and out-of-hospital CF rates. METHODS: Data on stroke diagnoses, coded according to I60-I64 (ICD 10), were taken from the Federal Hospital Discharge Statistics database (HOST) and the Cause of Death database (CoD) for the year 2004. The number of total stroke events and of age- and gender-specific and agestandardised event rates were estimated; overall CF, in-hospital and out-of-hospital, were determined. RESULTS: Among the overall number of 13 996 hospital discharges from stroke (HOST) the number was lower in women (n = 6736) than in men (n = 7260). A total of 3568 deaths (2137 women and 1431 men) due to stroke were recorded in the CoD database. The number of estimated stroke events was 15 733, and higher in women (n = 7933) than in men (n = 7800). Men presented significantly higher age-specific stroke event rates and a higher age-standardised event rate (178.7/100 000 versus 119.7/100 000). Overall CF rates were significantly higher for women (26.9%) than for men (18.4%). The same was true of out-of-hospital CF but not of in-hospital CF rates. CONCLUSION: The data on estimated stroke events obtained indicate that stroke discharge rate underestimates the stroke event rate. Out-of-hospital deaths from stroke accounted for the largest proportion of total stroke deaths. Sex differences in both number of total stroke events and deaths could be explained by the higher proportion of women than men aged 55+ in the Swiss population.

Incidence and direct medical costs of hospitalizations due to osteoporotic fractures in Switzerland

The objective of this study was to estimate the annual direct medical costs of hospitalizations due to osteoporotic fractures in Switzerland. Days of hospital stay in 1992 were quantified using the casuistic of the medical statistics department of VESKA (Vereinigung Schweizerischer Krankenhäuser, the Swiss Hospital Association), which covers 43% of all hospital beds of that country. Number and incidence of total hospitalizations due to fractures were calculated by extrapolating to 100% the 43% VESKA-selected sample. To estimate number and incidence of hospitalizations due to osteoporotic fractures, internationally accepted age-specific osteoporosis attribution rates were applied. According to the latter the probability of a fracture being caused by osteoporosis increases with age. Mean length of stay for all fractures was calculated (= total hospital days divided by number of cases). By multiplying these mean lengths of stay by the number of osteoporosis-related fracture cases, the number of bed-days due to osteoporotic fractures was calculated. To compare the direct medical costs of hospitalization due to osteoporosis with those due to other frequent diseases, days of hospital stay caused by chronic obstructive pulmonary disease (COPD), stroke, acute myocardial infarction and breast cancer were estimated using the same methodology. A total estimate of 63,170 (f: 33,596, m: 29,574) hospitalizations due to fractures (and other osteoporosis-related diagnoses) was calculated, thus leading to overall annual incidence rates of hospitalizations for fractures of 950/100,000 women and 877/100,000 men. In women, 548,615 hospital days were found to be caused by osteoporosis, 353,654 days by COPD, 352,062 days by stroke, 200,669 days by breast carcinoma and 131,331 days by myocardial infarction. In men, COPD caused more hospitalization days (537,164) than myocardial infarction (196,793), stroke (180,524) or osteoporosis (152,857). Taking a mean price for a hospital day in Switzerland of 845 Swiss francs, the annual costs of acute hospitalizations due to osteoporosis and its complications were approximately 600 million Swiss francs (f: 464, m: 130 million Swiss francs) in 1992. We conclude that there is enough economic evidence to justify wide-scale interventions against osteoporosis in Switzerland.

Epidemiology and direct medical costs of osteoporotic fractures in men and women in Switzerland

The aim of this study was to estimate the hospitalization incidence and the total number of hospital days related to all fractures and osteoporotic fractures in the year 2000 in Switzerland and to compare these with data from other frequent disorders in men and women. The official administrative and medical statistics database of the Swiss Federal Office of Statistics (SFOS) from the year 2000 was used. It covered 81.2% of all registered patient admissions and was considered to be representative of the entire population. We included the ICD-10 codes of 84 diagnoses that were compatible with an underlying osteoporosis and applied the best matching age-specific osteoporosis attribution rates published for the ICD-9 diagnosis codes to the individual ICD-10 codes. To preserve comparability with previously published data from 1992, we grouped the data related to the ICD-10 fracture codes into seven diagnosis pools (fractures of the axial skeleton, fractures of the proximal upper limbs, fractures of the distal upper limbs, fractures of the proximal lower limbs, fractures of the distal lower limbs, multiple fractures, and osteoporosis) and analyzed them separately for women and men by age group. Incidences of hospitalization due to fractures were calculated, and the direct medical costs related to hospitalization were estimated. In addition, we compared the results with those from chronic pulmonary obstructive disease (COPD), stroke, acute myocardial infarction, heart failure, diabetes and breast carcinoma from the same database. In Switzerland during 2000, 62,535 hospitalizations for fractures (35,586 women and 26,949 men) were registered. Fifty-one percent of all fractures in women and 24% in men were considered as osteoporotic. The overall incidences of hospitalization due to fractures were 969 and 768 per 100,000 in women and men, respectively. The hospitalization incidences for fractures of the proximal lower limbs and the axial skeleton increased exponentially after the age of 65 years. The direct medical cost of hospitalization of patients with osteoporosis and/or related fractures was 357 million CHF. Hip fractures accounted for approximately half of these costs in women and men. Among other common diseases in women and men, osteoporosis ranked number 1 in women and number 2 (behind COPD) in men. When compared with data from 1992, the average length of stay had shortened by 8.4 days for women and 4.7 days for men, leading to a decrease of almost 40% in direct medical costs related to acute hospitalizations. This apparent decrease in cost might result from a shift into the ambulatory cost segment, for which the assessment and management tools need to be developed. We conclude that, in 2000, osteoporosis continued to be a heavy burden on the Swiss healthcare system. Lack of awareness of the disease and its consequences prevents widespread use of drugs with anti-fracture efficacy. This limits their potential to reduce costs.

Dual dispatch early defibrillation in out-of-hospital cardiac arrest in a mixed urban–rural population

Aims The effects of a system based on minimally trained first responders (FR) dispatched simultaneously with the emergency medical services (EMS) of the local hospital in a mixed urban and rural area in Northwestern Switzerland were examined. Methods and results In this prospective study 500 voluntary fire fighters received a 4-h training in basic-life-support using automated-external-defibrillation (AED). FR and EMS were simultaneously dispatched in a two-tier rescue system. During the years 2001–2008, response times, resuscitation interventions and outcomes were monitored. 1334 emergencies were included. The FR reached the patients (mean age 60.4 ± 19 years; 65% male) within 6 ± 3 min after emergency calls compared to 12 ± 5 min by the EMS (p < 0.0001). Seventy-six percent of the 297 OHCAs occurred at home. Only 3 emergencies with resuscitation attempts occurred at the main railway station equipped with an on-site AED. FR were on the scene before arrival of the EMS in 1166 (87.4%) cases. Of these, the FR used AED in 611 patients for monitoring or defibrillation. CPR was initiated by the FR in 164 (68.9% of 238 resuscitated patients). 124 patients were defibrillated, of whom 93 (75.0%) were defibrillated first by the FR. Eighteen patients (of whom 13 were defibrillated by the FR) were discharged from hospital in good neurological condition. Conclusions Minimally trained fire fighters integrated in an EMS as FR contributed substantially to an increase of the survival rate of OHCAs in a mixed urban and rural area.

Challenges for medical educators: results of a survey among members of the German Association for Medical Education

BACKGROUND Despite the increasing interest in medical education in the German-speaking countries, there is currently no information available on the challenges which medical educators face. To address this problem, we carried out a web-based survey among the members of the Association for Medical Education (Gesellschaft für medizinische Ausbildung, GMA). METHODS A comprehensive survey was carried out on the need for further qualifications, expertise and the general conditions of medical educators in Germany. As part of this study, the educators were asked to list the three main challenges which they faced and which required urgent improvement. The results were analysed by means of qualitative content analysis. RESULTS The questionnaire was completed by 147 of the 373 members on the GMA mailing list (response rate: 39%). The educators named a total of 346 challenges and emphasised the following areas: limited academic recognition for engagement in teaching (53.5% of educators), insufficient institutional (31.5%) and financial support (28.4%), a curriculum in need of reform (22.8%), insufficient time for teaching assignments (18,9%), inadequate teacher competence in teaching methods (18.1%), restricted faculty development programmes (18.1%), limited networking within the institution (11.0%), lack of teaching staff (10.2%), varying preconditions of students (8.7%), insufficient recognition and promotion of medical educational research (5.5%), extensive assessment requirements (4.7%), and the lack of role models within medical education (3.2%). CONCLUSION The medical educators found the biggest challenges which they faced to be limited academic recognition and insufficient institutional and financial support. Consequently, improvements should be implemented to address these issues.

The Pre-entry Program at UTMSH: Effect on Academic Performance of First-Year Medical Students

Introduction: The Pre-Entry Program at The University of Texas Medical School at Houston is presented to assist entering students who are judged to be at risk for academic difficulty. It requires a significant commitment of time on the part of faculty, staff and students. The effectiveness of this program needs to be evaluated. [See PDF for complete abstract]

Evaluating Learner Perceptions of Use of Simulations for New nurses – A Collaboration Between the UT SON and the Methodist Hospital

The purpose of this evaluation project was to describe the integration of simulation into a nursing internship program and to help prepare new graduate nurses for patient care. Additionally, learning styles and perceptions of active learning, collaboration among peers, ways of learning, expectation of simulation, satisfaction, self-confidence, and design of simulation were examined. [See PDF for complete abstract]

Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?

BACKGROUND: Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic imaging results remains a challenge. We hypothesized that an electronic medical record (EMR) that facilitates the transmission and availability of critical imaging results through either automated notification (alerting) or direct access to the primary report would eliminate this problem. METHODS: We studied critical imaging alert notifications in the outpatient setting of a tertiary care Department of Veterans Affairs facility from November 2007 to June 2008. Tracking software determined whether the alert was acknowledged (ie, health care practitioner/provider [HCP] opened the message for viewing) within 2 weeks of transmission; acknowledged alerts were considered read. We reviewed medical records and contacted HCPs to determine timely follow-up actions (eg, ordering a follow-up test or consultation) within 4 weeks of transmission. Multivariable logistic regression models accounting for clustering effect by HCPs analyzed predictors for 2 outcomes: lack of acknowledgment and lack of timely follow-up. RESULTS: Of 123 638 studies (including radiographs, computed tomographic scans, ultrasonograms, magnetic resonance images, and mammograms), 1196 images (0.97%) generated alerts; 217 (18.1%) of these were unacknowledged. Alerts had a higher risk of being unacknowledged when the ordering HCPs were trainees (odds ratio [OR], 5.58; 95% confidence interval [CI], 2.86-10.89) and when dual-alert (>1 HCP alerted) as opposed to single-alert communication was used (OR, 2.02; 95% CI, 1.22-3.36). Timely follow-up was lacking in 92 (7.7% of all alerts) and was similar for acknowledged and unacknowledged alerts (7.3% vs 9.7%; P = .22). Risk for lack of timely follow-up was higher with dual-alert communication (OR, 1.99; 95% CI, 1.06-3.48) but lower when additional verbal communication was used by the radiologist (OR, 0.12; 95% CI, 0.04-0.38). Nearly all abnormal results lacking timely follow-up at 4 weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment. CONCLUSIONS: Critical imaging results may not receive timely follow-up actions even when HCPs receive and read results in an advanced, integrated electronic medical record system. A multidisciplinary approach is needed to improve patient safety in this area.

A trilocus sequence typing scheme for hospital epidemiology and subspecies differentiation of an important nosocomial pathogen, Enterococcus faecalis.

In this study, we present a trilocus sequence typing (TLST) scheme based on intragenic regions of two antigenic genes, ace and salA (encoding a collagen/laminin adhesin and a cell wall-associated antigen, respectively), and a gene associated with antibiotic resistance, lsa (encoding a putative ABC transporter), for subspecies differentiation of Enterococcus faecalis. Each of the alleles was analyzed using 50 E. faecalis isolates representing 42 diverse multilocus sequence types (ST(M); based on seven housekeeping genes) and four groups of clonally linked (by pulsed-field gel electrophoresis [PFGE]) isolates. The allelic profiles and/or concatenated sequences of the three genes agreed with multilocus sequence typing (MLST) results for typing of 49 of the 50 isolates; in addition to the one exception, two isolates were found to have identical TLST types but were single-locus variants (differing by a single nucleotide) by MLST and were therefore also classified as clonally related by MLST. TLST was also comparable to PFGE for establishing short-term epidemiological relationships, typing all isolates classified as clonally related by PFGE with the same type. TLST was then applied to representative isolates (of each PFGE subtype and isolation year) of a collection of 48 hospital isolates and demonstrated the same relationships between isolates of an outbreak strain as those found by MLST and PFGE. In conclusion, the TLST scheme described here was shown to be successful for investigating short-term epidemiology in a hospital setting and may provide an alternative to MLST for discriminating isolates.

Ambulatory care adverse events and preventable adverse events leading to a hospital admission.

BACKGROUND: Most healthcare in the US is delivered in the ambulatory care setting, but the epidemiology of errors and adverse events in ambulatory care is understudied. METHODS: Using the population-based data from the Colorado and Utah Medical Practices Study, we identified adverse events that occurred in an ambulatory care setting and led to hospital admission. Proportions with 95% CIs are reported. RESULTS: We reviewed 14,700-hospital discharge records and found 587 adverse events of which 70 were ambulatory care adverse events (AAEs) and 31 were ambulatory care preventable adverse events (APAEs). When weighted to the general population, there were 2608 AAEs and 1296 (44.3%) APAEs in Colorado and Utah, USA, in 1992. APAEs occurred most commonly in physicians' offices (43.1%, range 46.8-27.8), the emergency department (32.3%, 46.1-18.5) and at home (13.1%, 23.1-3.1). APAEs in day surgery were less common (7.1%, 13.6-0.6) but caused the greatest harm to patients. The types of APAEs were broadly distributed among missed or delayed diagnoses (36%, 50.2-21.8), surgery (24.1%, 36.7-11.5), non-surgical procedures (14.6%, 25.0-4.2), medication (13.1%, 23.1-3.1) and therapeutic events (12.3%, 22.0-2.6). Overall, 10% of the APAEs resulted in serious permanent injury or death. The proportion of APAEs that resulted in death was 31.8% for general internal medicine, 22.5% for family practice and 16.7% for emergency medicine. CONCLUSION: An estimated 75,000 hospitalisations per year are due to preventable adverse events that occur in outpatient settings in the US, resulting in 4839 serious permanent injuries and 2587 deaths.

Sexual Health Education from the Perspective of School Staff: Implications for Adoption and Implementation of Effective Programs in Middle School

Introduction: US teens are having sex early; however, the vast majority of schools do not implement evidence-based sexual health education (SHE) programs that could delay sexual behavior and/or reduce risky behavior. This study examines middle school staff’s knowledge, attitudes, barriers, self-efficacy, and perceived support (psychosocial factors known to influence SHE program adoption and implementation). Methods: Professional school staff from 33 southeast Texas middle schools completed an internet or paper-based survey. Prevalence estimates for psychosocial variables were computed for the total sample. Chi-square and t-test analyses examined variation by demographic factors. Results: Almost 70% of participants were female, 37% white, 42% black, 16% Hispanic; 20% administrators, 15% nurses/counselors, 31% non-physical education/non-health teachers, 28% physical education/health teachers; mean age = 42.78 years (SD = 10.9). Over 90% favored middle school SHE, and over 75% reported awareness of available SHE curricula or policies. More than 60% expressed confidence for discussing SHE. Staff perceived varying levels of administrator (28%-56%) support for SHE and varying levels of support for comprehensive sex education from outside stakeholders (e.g., parents, community leaders) (42%-85%). Overall, results were more favorable for physical education/health teachers, nurses/counselors, and administrators (when compared to non-physical education/non-health teachers) and individuals with experience teaching SHE. Few significant differences were observed by other demographic factors. Conclusions: Overall, study results were extremely positive, which may reflect a high level of readiness among school staff for adopting and implementing effective middle school SHE programs. Study results highlight the importance of several key action items for schools.

The burnout syndrome among nurses in an urban acute care hospital

Three hundred fifty-four registered nurses from an urban acute care hospital were examined through self-report questionnaires. Nurses from trauma care, critical care and non-critical care nursing specialties participated in the study. The study focuses were (1) whether sociodemographic characteristics were significantly related to burnout; (2) what was the prevalence estimate of burnout among the population; (3) whether burnout levels differed depending upon nursing specialties and; (4) whether burnout as related to nursing stress, work environment, and work relations was mediated by sociodemographic characteristics.^ Race, age, marital status, education, seniority, rank, nursing education, and birthplace were significantly related to one or more aspects of burnout in the total population. With emotional exhaustion alone the prevalence of burnout was 62%. Using emotional exhaustion and depersonalization combined with reduced sense of personal accomplishment as a measure of burnout, thirty-four percent of the nurses were either in the pre-burnout phase or burned out. The relative importance of sociodemographic characteristics indicated that experience and race were highly significant risk factors.^ Burnout levels differed significantly depending upon nursing specialty. Specifically, levels of emotional exhaustion and depersonalization differed significantly between trauma care and critical care, and trauma care and non-critical care. Personal accomplishment did not differ depending upon nursing specialty. Critical care nurses did not differ significantly from non-critical care nurses on aspect of burnout.^ Race, marital status, education, seniority and rank were significant mediators of emotional exhaustion and depersonalization. The study offers possible explanations for the mediating effect of sociodemographic characteristics on nursing stress, work environment, work relations, emotional exhaustion and depersonalization. ^