Continuous quality improvement in public health in Ghana: CQI as a model for primary health care management and delivery.

This article describes the context and examines factors influencing the quality of primary health care delivery and management in Ghana, West Africa. It describes the potential of continuous quality improvement as a management philosophy and tool to improve the quality of primary health care delivery and management in Ghana. It compares the Ghanaian context in which the use of continuous quality improvement in health care is new and untried with the developed country context (mainly the U.S.), where continuous quality improvement has a relatively long history of use in health care and is a requirement for the accreditation of health institutions. Finally, the article discusses the steps that have to be taken to translate continuous quality improvement from a theoretical management concept to improve quality of care to an actual managerial intervention in Ghana. In conclusion, continuous quality improvement is shown to be a potential viable approach to improving quality of care in the Ghanaian context and merits further investigation.

Continuous quality improvement in contract research organizations--managing improvement processes.

The challenge of quality improvement extends beyond traditional service delivery organizations. This article, the second in a two-part series (see QMHC 7:3, Spring 1999, 7-21 for the first part) focuses on training and empowerment, leadership and statistical process control, and the contribution of these factors to the success of CROs in the pharmaceutical and biotechnology industry. The importance of each is presented along with specific illustrations from operating CROs.

Continuous quality improvement in contract research organizations--the customer focus.

The challenge of quality improvement extends beyond traditional service delivery organizations. This is the first of a two-part series on the application of continuous quality improvement (CQI) to contract research organizations associated with the pharmaceutical and biotechnology industry. The challenges and processes of clinical trials research, and the role of CQI within that process, are presented. The importance of customer focus, which is a key element of CQI, is described here as the foundation of the CQI process among contract research organizations (CROs) and as a major contributing factor to their success in recent years.

Electrotrichogenesis: further evidence of efficacy and safety on extended use.

These data represent a subset of data from the original 36-week study conducted by Maddin et al., which was in itself a preliminary study of a pulsed electrical stimulation device in male subjects alone. The extension phase of this study, which is summarized here, was undertaken to gather data on longer-term efficacy and safety and to study clinical effects in control subjects who were then switched to active treatment. Thirteen subjects had active treatment for 70 weeks, and 14 subjects were included in the crossover group, which had sham treatment for 36 weeks followed by active treatment for 30 additional weeks. On average, terminal hair counts increased from 82 to 276 in the active treatment group. Among those in the crossover group, a mild increase, from 124 to 160, was observed during the sham treatment period and a more notable increase, from 160 to 249, occurred during the subsequent active treatment period. The results presented here provide evidence of the efficacy and safety of this device during extended use; however, the generalizability of these findings is limited by the small subset of subjects for whom complete data are available.

Multicenter clinical trial of ibuprofen and acetaminophen in the treatment of postoperative dental pain.

Pharmacological management of pain for acute and chronic conditions has been guided by a scientific understanding of peripheral and central acting mechanisms for the control of inflammation as well as pain. Oral surgery pain is a reliable model to reference the effectiveness of commonly used analgesics such as ibuprofen and acetaminophen. A total of 706 patients who were experiencing moderate to severe pain received a single dose of ibuprofen, acetaminophen, or placebo. After 6 hours, the degree of pain relief and tolerance was assessed. Ibuprofen has important implications for postoperative pain in clinical practice.

The assessment of health policy changes using the time-reversed crossover design.

The time-reversed crossover design is a quasi-experimental design which can be applied to evaluate the impact of a change in health policy on a large population. This design makes use of separate sampling and analysis strategies to improve the validity of conclusions drawn from such an evaluation. The properties of the time-reversed crossover design are presented including the use of stratification on outcome in the sampling stage, which is intended to improve external validity. It is demonstrated that, although this feature of the design introduces internal validity threats due to regression toward the mean in extreme-outcome strata, these effects can be measured and eliminated from the test of significance of treatment effects. Methods for within- and across-stratum estimation and hypothesis-testing are presented which are similar to those which have been developed for the traditional two-period crossover design widely used in clinical trials. The procedures are illustrated using data derived from a study conducted by the United Mine Workers of America Health and Retirement Funds to measure the impact of cost-sharing on health care utilization among members of its health plan.

Statistical considerations in the design, analysis, and interpretation of comparative clinical studies.

Comparative clinical studies are extensively used as a basis of support for the potential approval of treatments by the Food and Drug Administration and also for other general health policy decisions. The purpose of this paper is to review statistical principles that are relevant to the design, analysis, and interpretation of comparative clinical studies. Three general criteria are emphasized: clarity, comparability, and generalizability. These criteria are discussed in terms of their implications to such considerations as scope of patient population, sample size, randomization, and covariance analysis. Also, an extensive reference list further addressing these topics is presented.

A need-based model to project national dental expenditures.

A national model on need for dental treatment, as measured by the HANES survey of the National Center for Health Statistics, is described and applied to determine expenditures required to provide necessary dental services under third-party funding of a national dental program. Services have been divided into five components by type of service and age of the population and expenditures are projected for each year, 1980-84. Total expenditures are projected to increase from 18.98 billion dollars in 1980 to 26.42 billion in 1984. Separate projections are also provided for each component and each service. Expenditures derived from this model are compared to direct projections of trends taking place in the current dental care system. Only minor discrepancies in total expenditures are noted but there are large differences for individual services, notably in the areas of prevention and periodontal diseases. Separate comparisons with demand-based projections derived from the experience of the California Dental Service are also presented. Again, the major differences relate to expenditures for individual services, particularly crowns, for which demand expenditures outstripped need by a three-fold margin.