Using patient surveys to measure the quality of outpatient care in Kraków, Poland.

OBJECTIVE: To test the feasibility of using patient reported information to create indicators of quality (access, patient experience--including satisfaction, and clinical quality) with the goal of providing Kraków city clinic managers (and potentially other audiences) with information about the quality of outpatient care in selected clinics. Setting and methods. Almost 2,000 patients from 19 outpatient clinics in Kraków, Poland were surveyed in November and December 1997 and January 1998. We prepared a self-completed questionnaire to capture data about the patient's experience with access to services, interactions with registration staff, communication with the doctor, information received from the doctor, and receipt of preventive services. RESULTS: Access varied across clinics. For example, 84% of patients waited less than 10 minutes at registration, whereas only 53% of patients waited less than 30 minutes to see the doctor. Among those who tried to register by telephone, only 72% were successful. Satisfaction was highest with the doctor visit (satisfaction=79, on a scale of 1-100) and lowest with telephone registration (satisfaction = 59). Preventive health care screening was generally disappointing, particularly for Papanicolaou smear and clinical breast examination, although frequent users of a clinic (with more opportunities for screening) generally had higher rates of screening. CONCLUSION: We demonstrated the feasibility of constructing indicators of multiple dimensions of the quality of outpatient care using patient-reported information. Quality dimensions captured by survey included access, patient experience and clinical quality. Results were successfully summarized in easy to read and understand formats for clinic managers and city health department officials.

A regionalized perinatal continuing education programme: successful adaptation to a foreign health care system and language.

Much of the decline in perinatal mortality over the past two decades in the United States has been attributed to regionalization of perinatal care. Outreach education from regional medical centres to community hospitals is an essential component of regionalization. The Perinatal Continuing Education Program (PCEP) has been successfully used for outreach education in more than 30 states since 1979. This project tested the efficacy of implementing the PCEP strategy in Poland. PCEP was adapted to Polish conditions, translated, and implemented in four phases. The scheme allowed gradual transfer of ownership to Polish leaders and use of the existing regional structure to disseminate information from regional centres to community hospitals. Evaluation included measures of programme use (participation and completion rates) and acceptance (participant evaluation forms), cognitive knowledge (pre- vs. post-tests), and patient care (chart reviews). Of 2093 doctors, nurses and midwives who began, 1615 (77%) completed the programme, with higher completion by regional centre than community hospital staff. All participant groups responded favourably to the materials and expressed moderate confidence in their mastery of the information and skills. Test scores improved significantly for all phases and for all disciplines, with baseline and final scores consistent with degrees of previous professional education. Large baseline and inter-hospital variations in chart review data restricted analysis of care practices. A comprehensive perinatal education programme can be successfully transferred to a foreign health care system. We believe the following to be particularly important: multidisciplinary instructors and students; a self-instructional format; content aimed at practice rather than theory; and an organized implementation strategy co-ordinated by local personnel.

Genetic analysis of cleft lip and cleft palate in southern Poland. I. Empiric and relative recurrence risks.

The study covered 1009 families with CL +/- P and 490 families with CP coming from the region of southern Poland wherein the incidence is 1.3/1000 for CL +/- P and 0.51/1000 for CP. The empiric recurrence risk of CL +/- P and CP was 1.6% +/- 0.66 and 0.93% +/- 0.75, respectively. It was found that the risk of CL +/- P recurrence was three times greater among the sibs of male probands in comparison to that of female index cases. The relative risk of malformation recurrence in a family with one of the offspring already affected was 14.57 for CL +/- P and 19.85 for CP. The heritability values, calculated according to Falconer's formula were found to be 54.77% +/- 5.07 for CL +/- P and 52.79% +/- 8.63 for CP and suggested the significant effect of environmental factors on the etiology of these anomalies.

Genetic analysis of cleft lip and cleft palate in southern Poland. II. Complex segregation analysis.

A complex segregation analysis based on the maximum likelihood method was applied on a sample of 329 families with CP and 687 families with CL +/- P. The results for CP malformations were equivocal, since the authors were unable to distinguish between the hypothesis of recessive inheritance with complete penetrance (chi 2 = 19.60) and that of multifactorial inheritance (chi 2 = 20.38). For CL +/- P lesions the most plausible hypothesis seemed to be that of dominant inheritance with low penetrance (t = 0.277) and relatively high frequency of phenocopies. For these hypotheses the values Q of theoretical recurrence risk were computed and presented.

The segregation-linkage analysis of genetically determined characters.

The model of combined segregation-linkage analysis is presented. The method offers the opportunity of simultaneous estimation of recombination fraction between the locus of genetic marker and that of a disease gene and the evaluation of its inheritance pattern. The computer programme MUBAS estimates combinations of parameters: dominance-d, penetrance-t and recombination fraction by the method of maximum likelihood using the distribution of the observed numbers of sib pairs: ill/proband and healthy/proband.

The maximum likelihood estimation of haplotype frequencies of HLA and HLA-like systems and addition loci of genes with the different modes of inheritance.

Conventional formula for the estimation of haplotype frequencies proposed by Yasuda was extended for the haplotypes constituting three HLA loci and two additional loci of genes with codominant alleles. The computer programme FREHAP estimates 32 haplotype frequencies rijkmn by the method of maximum likelihood, as well as it calculates the marginal frequencies rijk.. and r...mn, the matrix of expected numbers and the value of chi-square for the goodness of fit. The FREHAP has been programmed in FORTRAN IV for a CDC CYBER 72 computer.

Central nervous system malformations in the Kraków region. II. Case control studies on the human leukocyte antigen genotype and haplotype frequencies.

A case control study of human leukocyte antigen haplotypes was performed on a sample of 44 index families of children with central nervous system (CNS) malformation and 36 families of healthy newborn infants. HLA typing for antigens determined by loci A, B, and C was done on parents and offspring. The HLA genotypes were inferred from segregation in families and the HLA gene and haplotype frequencies were obtained by direct gene counting. Case-control comparison did not uncover significant differences at any HLA allele. The haploytype pattern in the group of index cases did not show association with CNS malformations. The HLA phenotype compatibility among the probands' and controls' parents was within the same range except for locus C where parents of children with neural tube defects (NTD) less frequently shared common HLA-C antigens. The segregation of paternal haploytypes showed significant deviation in the families of NTD infants.

The modification of Morton's complex segregation analysis.

Morton's model of a complex segregation analysis was modified by introducing the new meaning for penetrance. It was assumed that the parameter t specifies the penetrance of gene G instead of genotype GG. This approach leads to the construction of new theoretical risks of a disease which seem to us more reliable than those of Morton's.

Family studies in psoriasis. I. Complex segregation analysis.

The genetic background of psoriasis is unknown and its mode of inheritance is still controversial. Family studies in psoriasis were based on complex segregation analysis and a special computer programme was prepared. The results of the analysis in 244 families strongly suggest multifactorial inheritance of psoriasis vulgaris. Among the nine hypotheses of rank 1 and rank 2, the lowest value of chi-square, 72.847, was for recessive inheritance, but for the multifactorial model it was extremely low (chi-square = 35.980). The estimated heritability was 82%. It might be possible that at least two genetically distinct subpopulations of psoriasis vulgaris exist: one with multifactorial inheritance and a second with multigenic determination, if the disease were due to recessive genes and to one or more dominant factors. The theoretical recurrence risk of psoriasis for the multifactorial model was computed for families with normal parents and for families with one affected parent.