Developing mental health research in sub-Saharan Africa: capacity building in the AFFIRM project.

BACKGROUND: There remains a large disparity in the quantity, quality and impact of mental health research carried out in sub-Saharan Africa, relative to both the burden and the amount of research carried out in other regions. We lack evidence on the capacity-building activities that are effective in achieving desired aims and appropriate methodologies for evaluating success. METHODS: AFFIRM was an NIMH-funded hub project including a capacity-building program with three components open to participants across six countries: (a) fellowships for an M.Phil. program; (b) funding for Ph.D. students conducting research nested within AFFIRM trials; (c) short courses in specialist research skills. We present findings on progression and outputs from the M.Phil. and Ph.D. programs, self-perceived impact of short courses, qualitative data on student experience, and reflections on experiences and lessons learnt from AFFIRM consortium members. RESULTS: AFFIRM delivered funded research training opportunities to 25 mental health professionals, 90 researchers and five Ph.D. students across 6 countries over a period of 5 years. A number of challenges were identified and suggestions for improving the capacity-building activities explored. CONCLUSIONS: Having protected time for research is a barrier to carrying out research activities for busy clinicians. Funders could support sustainability of capacity-building initiatives through funds for travel and study leave. Adoption of a train-the-trainers model for specialist skills training and strategies for improving the rigor of evaluation of capacity-building activities should be considered.

Integrated decision support in a hospital cancer registry.

In this paper we present (a) a shell for integrated knowledge-based functions that is destined to support decision processes of the users of the Giessener Tumordokumentationssystem (GTDS) and (b) some results we obtained during a 6-month observation period at one of the customers of the GTDS. A special characteristic of the provided decision support is the high degree of integration in the underlying information system GTDS, i.e. the functions are triggered by events in the patient database, existing patient data is reused as input for the reasoning process and generated alerts are presented instantly to the end-user. The first routine field of application was supporting registrars to adhere to integrity constraints as defined by the International Agency of Research on Cancer (IARC) during the documentation process. This information is important for the registrars since the checks of the IARC are an accepted standard for data quality in cancer registries. The expected benefit of this application area is less effort in achieving adherence to the specification of the IARC by preventing the costly rectification at a later time. During the last 5 months of the observation period 164 alerts were displayed. About 65% of the assessed alerts were considered to be correct. Especially, the analysis of the incorrect alerts revealed some shortcomings in the knowledge behind some of the integrity constraints of the IARC. The general feedback from the end-users indicate positive user satisfaction. Currently, the shell is in use in six hospital cancer registries.

Hospitalization and total medical costs for privately insured persons with schizophrenia.

This study used data from the 1991-1993 MarketScan files, a large database of private sector inpatient, outpatient, and prescription drug medical claims, to identify a sample of 665 patients with schizophrenia. Descriptive and multivariate analyses were conducted on the subsamples with hospitalizations (N = 185) and without hospitalizations (N = 480) in the 1-year period following the initial diagnosis for schizophrenia observed in the 1991-1993 time period. After controlling for patient demographic characteristics, medical co-morbidities, and other factors, the cost of hospitalization itself was found to be $15,805.

[Current approaches for the implementation of guidelines by means of information technologies]. / Aktuelle Ansätze zur Implementierung von Leitlinien mittels Informationstechnologien.

Clinical practice guidelines (CPGs) play an increasingly important role in the harmonisation process of health care delivery and disease management. It is known that nationally or internationally produced guidelines that have no consistent implementation strategy, have limited impact in changing physicians' behaviour and patterns of care. The literature provides evidence for the effectiveness of computerisation of CPGs for increasing compliance and improving patient outcomes. The integration of knowledge-based functions for decision support or monitoring in clinical information systems is one effective way. Another approach relies on the original, mostly text-based, guidelines. By structuring these resources with the eXtensible Markup Language (XML) we are able to improve the availability of clinically relevant knowledge at the point of care. XML allows for in-context searching and the customized presentation of guideline content. We are confident that this new approach will improve the acceptance and the benefits of the increasing number of guidelines in medicine.

[Selection, problems and perspective of quality indicators]. / Auswahl, Probleme und Perspektiven von Qualitätsindikatoren.

The advances in information technology offer new possibilities to gather and analyse health-related information in order to get an inside view into the quality of medical care. Applied medical interventions and the related outcome for the patient can be evaluated if information of a certain degree of complexity is available. Performance measures are based on collection and aggregation of data. They try to abstract medical performances in order to get objective and comparable variables. These variables are useful in evaluating and monitoring the different dimensions of patient care. Performance measurement can inform people about the outcomes they can expect from certain treatments. Beside formal criteria such as validity and reliability, the specific objectives determine the selection of a relevant performance measure. This article describes actual problems and solutions in the data collection and the analysis of performance measures for the domain of oncology. This way, we want to encourage the meaningful, but critical use of performance measures in medicine. The provision of such information can build the basis for the process of medical decision making by physicians, the selection of a suitable medical institution by patients, and the allocation of resources by providers.

[Patient-oriented, treatment-accompanying documentation as a basis for evaluation with medical oncology as an example]. / Patientenorientierte, behandlungsbegleitende Dokumentation als Basis der Versorgungsforschung am Beispiel der Onkologie.

The documentation of patient characteristics, procedures of care and follow-up of the disease plays an important role in monitoring quality of care and support of clinical research. In order to evaluate the use of Clinical Practice Guidelines and their positive implications towards quality of care (especially patient's outcome), some closer reflections are needed to meet the special requirements. Our intention is to optimise content and extent of the collected information to characterise the different dimensions of the quality of medical care best possible. During the past two decades a comprehensive infrastructure concerning tumour documentation has evolved in Germany. To ensure the possibility to compare and evaluate diagnostic and therapeutic approaches in different medical institutions or health care systems, the systematic, patient-oriented treatment accompanying tumour documentation is a compelling requirement. It is a difficult task to describe pattern of care and measure both performance and outcome objectively. The paradigm of a patient-oriented treatment accompanying documentation includes the collection of clinical relevant process and outcome data in order to reflect the intention and way of thinking of the treating physicians and to get an impression of the "real world effectiveness" of the applied interventions.

Analysis of medical-decision making and the use of standards of care in oncology.

Guidelines in medicine have been proposed as a way to assist physicians in the clinical decision-making process. Increasingly, they form the basis for assessing accountability in the delivery of healthcare services. However, experiences with their evaluation, as the most important step in the continuous guidelines process, are rare. Patient Care Evaluation Studies have been developed by the Commission on Cancer in the United States. As they reflect the "real-world" medical practice they are helpful in evaluating the quality of diagnosis, therapy and follow-up of tumor diseases in hospitals and cancer center and the compliance with current standards of care. In this context, they can provide an infrastructure for the analysis of the decision-making process.

The workforce in otolaryngology-head and neck surgery: moving into the next millennium.

OBJECTIVE: The goal was to examine the current scope of otolaryngologists' practices, their geographic distribution, and the roles otolaryngologists and other specialists play in caring for patients with otolaryngic and related conditions of the head and neck. STUDY DESIGN: A large national survey and administrative claims databases were examined to develop practice profiles and compile a physician supply for otolaryngology. A focus group of otolaryngologists provided information to model future scenarios. RESULTS: The current and predicted workforce supply and demographics are at a satisfactory level and are decreasing as a proportion of the increasing population. Empiric data analysis supports the diverse nature of an otolaryngologist's practice and the unique role for otolaryngologists that is not shared by many other providers. Together with the focus group results, the study points to areas for which more background and training are warranted. CONCLUSIONS: This study represents a first step in a process to form coherent workforce recommendations for the field of otolaryngology.

Patterns of care for patients with primary differentiated carcinoma of the thyroid gland treated in Germany during 1996. U.S. and German Thyroid Cancer Group.

BACKGROUND: To determine current patterns of care and disease characteristics for patients with thyroid carcinoma, a Patient Care Evaluation Study was initiated in 1996 in the U.S. and Germany. This project addresses ongoing concerns with respect to the diagnostic evaluation and treatment of patients diagnosed with thyroid carcinoma and raises questions concerning how physicians are interpreting current standards and acting on the basis of these recommendations. METHODS: Patients with primary thyroid carcinoma were entered into a prospective multicenter observational study with free choice of treatment (no control group) between January 1, 1996 and December 31, 1996 in Germany. This resulted in a total of 2537 cases under observation and analysis; 1685 patients had papillary carcinoma (66.4%), 691 had follicular carcinoma (27.2%), 70 had medullary carcinoma (2.8%), and 91 had anaplastic carcinoma (3.6%). The 2376 patients with carcinoma of either papillary or follicular histology were included in the current analysis. RESULTS: The major symptoms reported for patients with papillary and follicular thyroid carcinoma was neck mass (reported in 76% and 79%, respectively) followed by dysphagia (reported in 25% and 27%, respectively), stridor (reported in 9% and 14%, respectively), and neck pain (reported in 7% and 8%, respectively). Greater than 50% of the patients with papillary thyroid carcinoma were reported to have American Joint Committee on Cancer/International Union Against Cancer Stage I disease. Between 37-39% of the follicular carcinoma patients had Stage I and Stage II disease. Only slight differences in the diagnostic approach to patients with papillary or follicular carcinoma were noted. The majority of patients underwent an ultrasound of the thyroid region (78.1%), which was suggestive of carcinoma in only 39% of the cases. A thyroid scan was performed on 76.6% of patients, and the results were suggestive of carcinoma in 44.8% of the individuals. In contrast, fine-needle aspiration biopsy of the thyroid is highly recommended in the current Clinical Practice Guidelines (CPG) but results were obtained in only 27.4% of the patients. Total thyroidectomy without lymph node dissection was the most commonly used surgical procedure in the treatment of patients with papillary and follicular thyroid carcinoma. Only approximately 2% of patients at low risk in the group with Stage I disease were treated with a lobectomy. In 80% of the patients with Stage I papillary thyroid carcinoma and approximately 90% of those patients diagnosed with Stage II, III, and IV disease treating physicians chose to utilize radioiodine as adjuvant treatment after disease-directed surgery. External beam radiation was added to the treatment regimen for many patients diagnosed with Stage III and IV disease (30% in patients with papillary thyroid carcinoma and 33% in patients with follicular thyroid carcinoma). CONCLUSIONS: To the authors' knowledge no single effective diagnostic test for thyroid carcinoma currently is available and in the majority of cases a combination of ultrasound, thyroid scan, or fine-needle aspiration biopsy together with the clinical findings (e.g., thyroid mass) led to a diagnosis of carcinoma. The authors suspect that the high prevalence of concomitant pathologic findings such as goiter, even in the healthy population in Germany, reduces the accuracy of all diagnostic test methods and may account for the frequent use of imaging techniques. The majority of patients underwent a total or near-total thyroidectomy. Total thyroidectomy with radical lymph node dissection was used very frequently in those patients with papillary thyroid carcinoma (22%). German physicians tend to surgically treat early stage thyroid carcinoma somewhat more radically than recommended in the CPG. With respect to other treatment options employed as part of the first course of treatment, radioiodine appears to play the most important role. [See commentary o

Initial results from a prospective cohort study of 5583 cases of thyroid carcinoma treated in the united states during 1996. U.S. and German Thyroid Cancer Study Group. An American College of Surgeons Commission on Cancer Patient Care Evaluation study.

BACKGROUND: The American College of Surgeons Commission on Cancer (CoC) has conducted national Patient Care Evaluation (PCE) studies since 1976. METHODS: Over 1500 hospitals with CoC-approved cancer programs were invited to participate in this prospective cohort study of U.S. thyroid carcinoma cases treated in 1996. Follow-up will be conducted through the National Cancer Data Base. RESULTS: Of the 5584 cases of thyroid carcinoma, 81% were papillary, 10% follicular, 3.6% Hürthle cell, 0.5% familial medullary, 2.7% sporadic medullary, and 1.7% undifferentiated/anaplastic. Demographics and suspected risk factors were analyzed. Fine-needle aspiration of the thyroid gland (53%) or a neck lymph node (7%), thyroid nuclear scan (39%), and ultrasound (38%) constituted the most frequently utilized diagnostic modalities. The vast majority of patients with differentiated thyroid carcinoma presented with American Joint Committee on Cancer Stage I and II disease and relatively small tumors. For all histologies, near-total or total thyroidectomy constituted the dominant surgical treatment. No lymph nodes were examined in a substantial proportion of cases. Residual tumor after the surgical event could be documented in 11% of cases, hypocalcemia in 10% of cases, and recurrent laryngeal nerve injury in 1.3% of cases. Complications were most frequently associated with total thyroidectomy combined with lymph node dissection. Thirty-day mortality was 0.3%; when undifferentiated/anaplastic cancer cases were eliminated, it decreased to 0.2%. Adjuvant treatment, probably underreported in this study, consisted of hormonal suppression (50% overall) and radioiodine (50% overall). CONCLUSIONS: In addition to offering information concerning risk factors and symptoms, the current PCE study compliments the survival information from previous NCDB reports and offers a surveillance snapshot of current management of thyroid carcinoma in the U.S. Identified opportunities for improvement of care include 1) more frequent use of fine-needle aspiration cytology in making a diagnosis; 2) more frequent use of laryngoscopy in evaluating patients preoperatively, especially those with voice change; and 3) improved lymph node resection and analysis to improve staging and, in some situations, outcomes.

Use of ototopical antibiotics in treating 3 common ear diseases.

Prompted by rising rates of antibiotic resistance, lack of standardized treatment regimens, and new treatment alternatives, the American Academy of Otolaryngology-Head and Neck Surgery convened an expert consensus panel to consider recommendations for the responsible use of antibiotics in chronic suppurative otitis media, tympanostomy tube otorrhea, and otitis externa. The Panel concluded that in the absence of systemic infection or serious underlying disease, topical antibiotics alone constitute first-line treatment for most patients with these conditions, finding no evidence that systemic antibiotics alone or in combination with topical preparations improve treatment outcomes compared with topical antibiotics alone. Topical preparations should be selected on the basis of expected bacteriology and informed knowledge of the risk-benefit of each available preparation. The use of nonototoxic preparations in treating acute otitis externa (when the tympanic membrane is perforated or its status is unknown), chronic suppurative otitis media, and tympanostomy tube otorrhea should be considered.

[Patient care evaluation studies--a comprehensive concept for evaluation of oncologic patient management]. / Patient Care Evaluation Studies--ein umfassendes Konzept zur Evaluation der onkologischen Patientenversorgung.

As part of the oncological patient care, tumor documentation has been attributed growing importance as a means of quality assurance. The extended organ specific tumor documentation can serve to answer some specific clinical questions. The rational of the so called Patient Care Evaluation Studies (PCES) carried out by the Commission on Cancer of the American College of Surgeons in the US will be shown in this article and the objectives of an initial study being carried out in the Federal Republic of Germany simultaneously with the US-study will be demonstrated. PCES are a way to compare actual patient care with idealized recommendations of Clinical Practice Guidelines. Thus, the application of Practice Guidelines in the clinical routine as one aspect of evidence based medicine can be analyzed.

Role of the specialty society in outcomes assessment: the development of COG*ENT.

The Cooperative Outcomes Group for ENT (COG*ENT), a clinical outcomes project of the American Academy of Otolaryngology--Head and Neck Surgery Foundation, was established to assess clinical outcomes of otolaryngological care of patients with two diseases, otitis media and rhinosinusitis. COG*ENT has produced an assessment tool with many potential applications. The development and early experience of the Foundation with this project are described, emphasizing the factors the authors believe are important for success.

Diagnosis and treatment of uncomplicated acute bacterial rhinosinusitis: summary of the Agency for Health Care Policy and Research evidence-based report.

PURPOSE: The goal was to critically examine evidence regarding the performance of diagnostic tests and the efficacy of antibiotic and other treatments for uncomplicated acute bacterial rhinosinusitis (ABR). METHODS: Scientific literature was reviewed, and meta-analysis methods were used to assess diagnostic test and antibiotic efficacy. A decision analysis and cost-effective analysis were performed. RESULTS: Although more sensitive than clinical examination for diagnosis of ABR, sinus radiograms are not cost-effective as an initial management strategy. Antibiotics reduce the incidence of clinical failures by one half compared to no treatment and, when coupled with clinical criteria-based diagnosis, present the most cost-effective treatment strategy. However, without antibiotics, symptoms in two thirds of patients improve by 14 days with no serious complications. The risk of treatment failure does not differ significantly between amoxicillin or folate inhibitors and newer, more expensive antibiotics. CONCLUSIONS: The current literature shows that treatment of uncomplicated ABR with amoxicillin or folate inhibitors and based on clinical criteria is the most cost-effective strategy.

Structured clinical documentation for the assessment of medical care.

The developing infrastructure for tumour documentation in Germany offers the unique opportunity to provide the physicians with useful clinical information, to evaluate standards of care, and get an impression about the "real-world-effectiveness" of cancer care. In order to compare and evaluate diagnostic and therapeutic approaches in different medical institutions or health care systems, the systematic, patient-oriented, treatment accompanying tumour documentation is a compelling requirement. Our intention is to optimise content and extent of the collected information to characterise the different dimensions of the quality of medical care the best possible. We found that most of the problems are deriving from the contextually and timely correct documentation of medical procedures which includes diagnostic as well as therapeutic interventions. The content of the documentation together with standards of care, such as Clinical Practice Guidelines, should be parallel developed in interdisciplinary co-operation. This way, the fundamental domains of performance, such as appropriateness, availability, continuity, safety, effectiveness, and timeliness of medical care can described and evaluated objectively.

XML structured clinical information: a practical example.

At Giessen university, a drug formulary comprising drug data and treatment guidelines is supplied to clinical users who can access the drug information by an index of drug substances and drug substance groups. The guideline itself is a textual description with related information such as drug substances and drug brand names. Since clinical users also want to access the information by drug names, we had to extract this information from the textual descriptions. The extraction however caused some effort. In order to not repeat this effort in the future, we used the eXtensible Markup Language (XML) to restructure the information sources. This paper describes our experiences with this kind of legacy to XML conversion and outlines a possible migration path towards the XML technology.

Integrated knowledge-based functions in a hospital cancer registry--specific requirements for routine applicability.

The background of the presented work is the design, realization, and routine use of integrated knowledge-based functions in the context of a hospital cancer registry. The first field of application was supporting registrars to detect data inconsistencies and incompleteness timely during the documentation process. Especially, we focused on the acceptance of the administrator of the underlying information system and on the phenomenon of duplicate and outdated messages. These aspects are specific for integrated knowledge based functions and a precondition for obtaining a routine applicability and acceptance.

Data warehousing as a tool for quality management in oncology.

At present, physicians are constrained by their limited skills to integrate and understand the growing amount of electronic medical information. To handle, extract, integrate, analyse and take advantage of the gathered information regarding the quality of patient care, the concept of a data warehouse seems to be especially interesting in medicine. Medical data warehousing allows the physicians to take advantage of all the operational data they have been collecting over the years. Our purpose is to build a data warehouse in order to use all available information about cancer patients. We think that with the sensible use of this tool, there are economic benefits for the Society and an improvement of quality of medical care for patients.

Costs and duration of care for lower extremity ulcers in patients with diabetes.

Medical and pharmaceutical insurance claims associated with lower extremity diabetic ulcers were examined retrospectively to better understand the costs and duration of treatment in clinical practice. The study population consisted of working-age individuals (18 to 64 years old) with health care benefits provided through private employer-sponsored insurance plans. Diagnostic information contained in the claims database was used to identify the severity of the ulcers, and the charges associated with treatment were based on claims data. Claims for lower extremity ulcers were found in 5.1% of individuals with diabetes. Although many lower extremity ulcers heal with standard treatment, some are more resistant to treatment and require costly ongoing medical care. Almost half of these cases were associated with deep infection, osteomyelitis, or amputation. Total payments for treatment of lower extremity ulcers in this population averaged $2687 per patient per year, or $4595 per ulcer episode, with inpatient expenditures accounting for more than 80% of these costs. Costs were significantly higher for patients with more severe ulcers or with inadequate vascular status in the affected limb. We concluded that lower extremity ulcers occur in a large number of working-age people with diabetes and contribute significantly to the morbidity associated with this disease. The high cost of treating diabetic foot ulcers suggested by this analysis argues for the development of better treatment strategies and outcomes assessments for these patients.