Validation of TIMI and GRACE acute coronary risk scores in Alexandria Governorate and their role in the comparison of quality of care between hospitals.

BACKGROUND: Risk stratification in acute coronary syndrome (ACS) aims to identify those patients who might benefit prognostically from further investigation and treatment. In addition, risk stratification models have been used by health authorities and hospitals in quality management activities. AIM: The present study aimed at validating the Thrombolysis In Myocardial Infarction (TIMI) and The Global Registry of Acute Coronary Events (GRACE) risk scores for prediction of mortality in patients with ACS in Alexandria governorate. In addition, the study aimed also at using one of the validated risk scores to compare risk adjusted mortality among participating hospitals. MATERIAL AND METHODS: The study was conducted at hospitals belonging to 3 different health care organizations in Alexandria. All admitted patients with the diagnosis of ACS throughout a period of 6 months were included in the study (n=606). Discriminatory capacity and calibration of the TIMI and GRACE risk scores for detection of in-hospital mortality and mortality within six months of index admission were assessed. RESULTS: The study showed that both TIMI and GRACE risk scores had high c statistics of 0.70 or higher. GRACE scores showed equal or higher c statistics than TIMI scores denoting better discriminatory capacity. TIMI risk score showed good calibration while GRACE risk score showed lower calibration capacity with certain patient categories. The GRACE risk score was used to calculate the standardized in-hospital mortality ratio which was higher than 1 for all participating hospitals indicating higher than expected mortality for ACS patients in these hospitals. CONCLUSIONS AND RECOMMENDATIONS: GRACE risk score showed good discriminatory capacity, suggesting that it is suitable for clinical use among ACS patients in Alexandria governorate. It was recommended to use GRACE risk score for risk adjustment in quality management activities.

Factors associated with hospitalization for type2 diabetic patients at a teaching hospital in saudi arabia.

UNLABELLED: Increasing prevalence of diabetes all over the world intensifies the demand for health care services, and particularly for inpatient care. The present study aims at identifying factors associated with hospitalization for patients with type 2 diabetes mellitus at a teaching hospital in Saudi Arabia. To achieve the objectives of the study, comparison was made between hospitalized and non-hospitalized type 2 diabetic patients using a retrospective case-control design. Four categories of factors namely, socio-demographic, outpatient clinic, clinical and quality indicators were investigated to elicit their relation with hospitalization among type 2 diabetes patients. Univariate analysis and stepwise multiple regression analysis were employed. Hospitalization was found to be independently associated with male gender, frequent visitors of outpatient clinics other than diabetes clinic, patients with nephropathy and patients with HbA1c >/= 7%. Limited number of cases and controls received the recommended ambulatory care for diabetes patients as evidenced by the marked low level of process of care indicators for diabetes patients. CONCLUSIONS AND RECOMMENDATIONS: Hospitalization was related to a limited number of factors many of which require better ambulatory care at outpatient clinics of the study hospital. It was recommended to continuously monitor the identified significant variables using the hospital electronic medical record system in order to target those patients at high risk for hospitalization.

Quality of diabetes care in family health facilities in one health district in alexandria.

BACKGROUND: The aim of the present study was to evaluate the quality of service provided to type 2 diabetes in family health facilities in one Health District in Alexandria governorate. Also, the study aimed at assessing the difference in the quality of diabetes care between family health units and family health centers. MATERIAL AND METHODS: Records of 384 diabetic patients in 6 family health units and 3 family health centers were reviewed to abstract variables used to compute process and outcome performance measures for diabetes care. RESULTS: The level of performing process of care measures varied between individual measures with microalbuminuria testing done for 1.3% of the sample while smoking cessation counseling was done for all smokers. All measures were performed in family health centers in higher or equal percentage to family health units. Out of 14 cases who performed glycated hemoglobin test, one case from a family health center had value below 7%. The last measured systolic blood pressure was below 140 mm/Hg for 64.6% of all patients while the last measured diastolic blood pressure was less than 90 mm/Hg for 58.1% of all patients. The total cholesterol level was equal or less than 193 mg/dl for 50.5% of tested 194 patients. Outcome measures showed better control of blood pressure and cholesterol level in patients attended family health units than patients attended family health centers. CONCLUSION AND RECOMMENDATIONS: Diabetes care provided by family health facilities in Al-Montazah health district, Alexandria, was not conforming to diabetes practice guidelines for family physicians. Patient's co-payment might play a role in the low performance of expensive diabetes preventive services. It was recommended to adjust fee for diabetes preventive services according to patients' willingness to pay and to conduct further studies to investigate the effect of financing methods on the quality of care provided under the Egyptian Health Sector Reform Program.

Missed appointments at a university hospital in eastern saudi arabia: magnitude and association factors.

UNLABELLED: Missed appointment is a common problem in ambulatory settings that has serious clinical and economic impacts. The present study aims at quantifying the burden of missed appointments and revealing the factors associated with it at a teaching hospital in Eastern Saudi Arabia. Two designs were used: a retrospective descriptive design to describe the magnitude of missed appointments during the year 2007, and a case-control design to identify factors associated with missed appointment. The association of socio-demographic, clinical, visit, and other factors with missed appointment was investigated through interviewing 150 cases and 150 controls. Univariate and stepwise multivariate logistic regression analyses were performed to determine the statistical significance of investigated factors. The rate of missed appointments at the study hospital in 2007 was 23.72%. Factors found to be associated with missed appointments were city of residence, duration from registration to appointment, reason of the visit and presence of pain at visit time. The main reasons given by patients for no-show were unavailability of transportation means (22.6%) and forgetting the appointment (17.3%). CONCLUSIONS AND RECOMMENDATIONS: The rate of missed appointment was high at the study hospital. Few factors were found to be significantly associated with missed appointments; many of them are not under the control of the hospital. Providing means of transportation and patient reminders can help reduce the problem.

Physicians' use of and attitudes toward electronic medical record system implemented at a teaching hospital in saudi arabia.

The present study aimed at investigating the usefulness of an electronic medical record (EMR) system implemented at a large teaching hospital in the Eastern province of Saudi Arabia. Demographic data, data about physician computer background and experience, level of use of core EMR system functions and physician satisfaction with EMR functions were collected from 142 physicians employed at the target hospital for more than one year (n=142). Results revealed that high percentage of physicians wasere dissatisfied with EMR system ability to add content, to send messages, to access reference materials and to get timely IT support. Over 75% of physicians indicated positive impact of EMR on work and quality of care. Varying percentages of physicians (0.0 - 54.9%) never used one or more of the 10 investigated core EMR functions. Multinomial logistic regression showed that satisfaction with the EMR system and experience with computers were significantly associated with the use of EMR. It was concluded that the benefits of the EMR are not fully achieved at the study hospital as many core functions are either unknown or never used by physicians. Improvement of the current EMR training and improvement of key identified aspects of the EMR system are likely to improve physicians' use of the system.

Bed utilization fluctuations at a university hospital in eastern saudi arabia and their impact on hospital cost.

As the demand for and complexity of inpatient care increases and hospital beds become more and more expensive and difficult to obtain, the appropriate use of hospital beds becomes increasingly important. The aim of the present study was to assess the actual hospital capacity and to study fluctuations in hospital occupancy rate during the year 2002 at a University Hospital in Eastern Saudi Arabia, and their impact on hospital cost. Results of the present study showed that 61 beds were not conforming to the standard definition of hospital beds; constituting 15.6 % of the actual hospital capacity. Wellborn nursery cribs and delivery beds accounted for the majority of these beds (82.0%). The present study revealed low average hospital occupancy rate in 2002 (62.0%) together with fluctuations in the average occupancy rates of all departments ranging between 30.9% and 77.0%; coefficient of variation ranges from 0.11 to 0.92. The observed low occupancy rate resulted in wasting of a large proportion of the hospital fixed costs amounting to 133, 591, 943 Saudi Riyals. Recommendations for improving the occupancy rate of the hospital and reducing its fluctuations are presented.