[Hospital capacity and waiting time for treatment--is there a connection?]. / Sykehuskapasitet og ventetid for behandling--er det noen sammenheng?

BACKGROUND: The association between hospital capacity and waiting time for treatment is uncertain. MATERIAL AND METHODS: Waiting times for patients on waiting lists for inpatient treatment in 1998 were analysed to disclose possible associations with the hospitals' treatment resources, i.e., general costs, number of beds, doctors or nurses in relation to the population of its catchment area, and the relation between acute and elective admissions. Waiting times were calculated from the National Patient Register, which collects information on hospital stays. Resource data and data on acute admissions were taken from the SAMDATA publications for 1998. RESULTS: Median waiting time varied from 50 to 300 days among the hospitals. Statistical regression models were, however, unable to explain the variation in waiting time on the basis of any variable related to hospital resources or acute admissions that may influence the capacity for elective admissions. INTERPRETATION: To avoid breaches of the guarantees for patients guaranteed a maximum of three months on the waiting list, the median waiting time should be below 12-15 days. This goal may, however, be much too ambitious in view of the fact that the median waiting time for patients with mammary or colon cancer is about 30 days.

[Criteria for waiting list guarantee. An attempt at precision]. / Kriterier for å få ventelistegaranti. Forsøk på presisering.

A scoring form has been developed, based upon the system of priorities used in Norway when deciding among patients waiting for investigation and treatment in hospital. This scoring form was used to evaluate 40 different case histories in gynaecological, orthopaedic, urologic and oto-rhino-laryngological departments. There was much disagreement when evaluating the different case histories. Using this scoring form did not result in greater agreement among the physicians using it than among another group of physicians who evaluated the same case histories without using the form.

[The waiting list guarantee. Variations in frequency of receiving the waiting list guarantee]. / Ventelistegarantiordningen. Variasjon i andel som får ventelistegaranti.

From 1987, patients waiting for treatment in Norwegian hospitals are given different degrees of priority, from zero to five. As from 1990, patients in priority group two are placed on a special list, and a report is made if they have not been treated within six months. There is a considerable variation in the frequency with which the patients are given this treatment guarantee in the different Norwegians counties. In the case of gynaecological patients the frequency varies from one to 94%, of urological patients from 43 to 100%, of orthopaedic patients from 21 to 89% and of otorhinolaryngological patients from 21 to 89%. The same variations are also seen within a single region of the country, and between departments. The reason for this discrepancy may be varying composition of the population, different extents of day surgery or different economic strategic thinking. Probably the main reason is that the criteria for giving a waiting list guarantee are not accepted as operational. This leads to different medical judgments when evaluating the applications for treatment in hospital.

[Waiting lists guarantee in health care. Some theoretical reflections]. / Ventelistegaranti og køer i helsevesenet. Noen teoretiske refleksjoner.

In 1990 a "waiting list guarantee" was introduced in the Norwegian health care system to secure treatment within six months for patients belonging to priority group II. (Priority group II are patients in need of treatment to avoid health hazards or serious long-term effects.) This guarantee has been difficult to honour and has caused considerable political unrest in the recent years. In an attempt to reform the guarantee, an analysis of our hospitals' capacity problems has been carried out, based on the general theory of queues. One result was that in order to fulfill the guarantee it is necessary to drastically reduce the queues and increase the capacity to deliver health services. This article presents the reasoning behind the analysis, in order to demonstrate the necessary foundation for a health policy that aims to reduce the time Norwegian patients have to wait for treatment in hospital.

[The waiting list guarantee and its violation. Characteristics of patients who have been waiting more than five months]. / Ventetidsgarantien og garantibrudd. Karakteristika ved pasienter som venter mer enn fem måneder.

In Norway as a whole, an average of six percent of all patients who had been guaranteed treatment within six months had not received treatment as promised. A survey of 917 orthopaedic "guarantee patients" who had waited longer than five months for treatment showed that 486 patients had waited longer than six months. 28% of the patients were suffering from hip or back problems, and the majority were suffering from problems in the extremities. In the case of 11% treatment was, in their own view, no longer relevant, and 2/3 were not interested in receiving treatment at another hospital, if this were to be offered. In the case of 33% of the patients the referring doctor thought it reasonable that the waiting time had exceeded six months.

Regurgitant volume in aortic regurgitation from a parameter estimation procedure.

The regurgitant volume and regurgitant orifice area as well as total peripheral resistance and arterial compliance were estimated in a cardiovascular hydromechanical simulator and in 10 patients with aortic regurgitation. A parameter estimation procedure based on a simple model of the cardiovascular system, Doppler measurements of the regurgitant jet, aortic systolic flow, and systolic and diastolic blood pressures was used. In the cardiovascular simulator the estimated regurgitant orifice area was compared with the size of a hole in the disk of a mechanical aortic valve. In the patients the regurgitant fraction was compared with semiquantitative grading from echocardiography routinely performed in our laboratory. In the hydromechanical simulator, the estimated regurgitant orifice area of 26.5 +/- 3.5 (SD) mm2 (n = 9) was not different from the true value of 24 mm2. In the patients there was a fair relationship between the estimated regurgitant fraction and the semiquantitative grading. The estimated regurgitant orifice areas varied between 1.6 and 31.2 mm2. The estimated mean values of total peripheral resistance and arterial compliance were 1.67 +/- 0.55 mmHg.s.ml-1 and 1.30 +/- 0.42 ml/mmHg, respectively.

Improving the quality of anti-emetic therapy.

The outcome of anti-emetic therapy (AT) to women with gynaecological cancer receiving chemotherapy, in total 552 courses, was registered for a 1-year period. A quality improvement (QI) programme was established, based on three standardized AT regimens. Evaluation and documentation of AT effects were performed by the patients themselves, reporting the number of emetic episodes and degree of nausea for 5 days following the chemotherapeutic treatment. The results were visualized in monthly graphic displays. Various factors which might contribute to the achieved improvements are discussed. In conclusion, the continuous QI process seems to be a suitable method in guiding direct patient care.

[Bone density measurements in prevention of femoral neck fractures]. / Beintetthetsmålinger i forebygging av lårhalsbrudd.

With a view to preventing hip fractures, bone mineral density measurements have been suggested as a means of selecting individuals at risk. We suggest two focuses in a preventive strategy: selection and information. The overlap in mineral density distributions among women who experience hip fractures and those who do not leads to a high number of inconclusive measurements as regards placing individuals into two such groups. The measurements should therefore be used primarily to inform individuals about their risk. In order to evaluate this technology, prospective studies on bone mineral density measurements prior to oestrogen hormone replacement therapy are highly desirable.

Concerted action programme on quality assurance in hospitals in Norway.

Below are the results of the assessment phase of a research project conducted in Norway. This project dealt with various quality assurance strategies and their effect on improvement of care with respect to: prophylactic antibiotic use in surgery; preoperative assessment; keeping records and prevention and therapy of bedsores.

Segmental aortic wall stiffness from intravascular ultrasound at normal and subnormal aortic pressure in pigs.

Segmental aortic wall stiffness was calculated from intravascular ultrasound images and intravascular pressures in six pigs at normal and subnormal aortic pressures (21 sequences of pressures and areas before and after boli of intravenous nitroglycerin). The wall stiffness was expressed as the pressure-strain elastic modulus (Ep). The Ep was calculated from the formula: Ep = delta PR delta R-1 (P, pressure; R, radius) in two different ways. First from maximal and minimal values of pressure and area. Second as the slope of linear regression line of delta PR as a function of delta R from 29 simultaneous recorded pressures and images. The average Ep value for all sequences in the different segments was 0.58 +/- 0.55 10(5) Pa (Method 1) and 0.50 +/- 0.40 10(5) Pa (Method 2). Ep increased with the distance from the heart at normal aortic pressures. At subnormal aortic pressures after intravenous nitroglycerin this relationship was not so evident. At subnormal aortic pressures the calculated Ep values were significantly reduced in the lower half of the abdominal aorta. The phase lag, i.e. hysteresis, between pressure and diameter was demonstrated. Our study shows the applicability of intravascular ultrasound as a tool to evaluate arterial wall stiffness.

[Quality assurance in Norwegian somatic hospitals]. / Kvalitetssikring i norske somatiske sykehus.

In 1990, 70 Norwegian hospitals were mailed a questionnaire asking about quality assurance (QA) activities in the departments of internal medicine, surgery, gynaecology/obstetrics and pediatrics. Responses from 173 departments at 58 hospitals showed a marked interest in improving quality and quality assurance. However, few departments had implemented QA to any noticeable extent in their clinical practices. There were few differences between surgical and non-surgical departments. Only 30% of the respondents had established routines aimed at ensuring complete medical records. 47% had not established committees to record and evaluate accidents, or report hazards to patients, in spite of the fact that only 5% assumed QA was of little usefulness. In 1990, little time was spent on specific QA activities; the most common estimate was one hour per week. In our estimate, full QA in clinical department would require 2-5% of the total contribution of work.

Radiology in the Nordic Countries.

NEMT, Nordic Evaluation of Medical Technology, conducted a study in 1988-89 on the use and diffusion of diagnostic radiology technologies in Denmark, Finland, Iceland, Norway and Sweden, i.e. the Nordic Countries. The study analysed the responses to a questionnaire sent to all Nordic radiology departments. Our findings show a variation from about 500 to nearly 900 radiology examinations per 1000 inhabitants among the Nordic Countries. Some of the differences are explained by unique structural factors of the health care system in each country, even if they all provide comparable public health services. Other differences are explained by variations in medical practice, accessibility to new imaging modalities, and replacement policies. This paper summarizes the results of the study.

Haemodynamic effects of arterial compliance, total peripheral resistance, and glyceryl trinitrate on regurgitant volume in aortic regurgitation.

STUDY OBJECTIVE: Afterload reduction is known to reduce regurgitant flow in patients with aortic regurgitation. Both arterial compliance and total peripheral resistance are determinants of afterload. The aim of this study was to evaluate the influence of arterial compliance and total peripheral resistance on the regurgitant volume. DESIGN: The values of arterial compliance and total peripheral resistance were assessed during aortic regurgitation at different regurgitant orifice areas in eight pigs before and after a bolus of glyceryl trinitrate. In a computer model the importance of arterial compliance and total peripheral resistance on the regurgitant volume was assessed by keeping each of them constant while the other variable was changed. MEASUREMENTS AND MAIN RESULTS: In both the experimental and computer models a very strong correlation was found between decreased total peripheral resistance and decreased regurgitant volume. Arterial compliance was of hardly any importance. A bolus of glyceryl trinitrate reduced regurgitant volumes and regurgitant fractions significantly. CONCLUSIONS: Total peripheral resistance is an important factor in influencing the regurgitant volumes at a given regurgitant orifice area in aortic regurgitation, while arterial compliance is of less importance. Glyceryl trinitrate effectively reduces the regurgitant volumes by its effect on peripheral resistance.