The efficacy of a continuous quality improvement (CQI) method in a radiological department. Comparison with non-CQI control material.

OBJECTIVE: To study the efficacy of continuous quality improvement (CQI) compared to ordinary management in an on-duty radiology department. MATERIAL AND METHODS: Because of complaints regarding delivery of on-duty radiological services, an improvement was initiated simultaneously at two hospitals, at the HUCH (Helsinki University Central Hospital) utilising the CQI-method, and at the OUH (Oulu University Hospital) with a traditional management process. For the CQI project, a team was formed to evaluate the process with flow-charts, cause and effect diagrams, Pareto analysis and control charts. Interventions to improve the process were based on the results of these analyses. RESULTS: The team at the HUCH implemented the following changes: A radiologist was added to the evening shift between 15:00-22:00 and a radiographer was moved from the morning shift to 15:00-22:00. A clear improvement was achieved in the turn-around time, but in the follow-up some of the gains were lost. Only minimal changes were achieved at the OUH, where the intervention was based on traditional management processes. CONCLUSION: CQI was an effective method for improving the quality of performance of a radiology department compared with ordinary management methods, but some of this improvement may be subsequently lost without a continuous measurement system.

Activity-based costing in radiology. Application in a pediatric radiological unit.

PURPOSE: To get an informative and detailed picture of the resource utilization in a radiology department in order to support its pricing and management. MATERIAL AND METHODS: A system based mainly on the theoretical foundations of activity-based costing (ABC) was designed, tested and compared with conventional costing. The study was performed at the Pediatric Unit of the Department of Radiology, Oulu University Hospital. The material consisted of all the 7,452 radiological procedures done in the unit during the first half of 1994, when both methods of costing where in use. Detailed cost data were obtained from the hospital financial and personnel systems and then related to activity data captured in the radiology information system. RESULTS: The allocation of overhead costs was greatly reduced by the introduction of ABC compared to conventional costing. The overhead cost as a percentage of total costs dropped to one-fourth of total costs, from 57% to 16%. The change of unit costs of radiological procedures varied from -42% to +82%. CONCLUSION: Costing is much more detailed and precise, and the percentage of unspecified allocated overhead costs diminishes drastically when ABC is used. The new information enhances effective departmental management, as the whole process of radiological procedures is identifiable by single activities, amenable to corrective actions and process improvement.

Variation of growth in length and weight of children. I. Years 1 and 2.

As part of our work aiming at facilitation of growth screening, we analyzed the growth of 741 healthy infants from birth to 2 years of age. We 1) show that weight depends on length rather than age, 2) present new growth standards in a format which allows direct reading of relative length and relative weight, and 3) define the normal variation of changes over different periods in terms of relative length (SD score, SDS) and relative weight (deviation of weight from the median weight for length and sex, %DW). The group mean values for changes in length SDS and %DW were zero, but there were wide individual variations, which decreased with age and length. We present curves defining these variations for use in growth screening.

Variation of growth in height and weight of children. II. After infancy.

To provide for early detection of abnormal changes in growth, we propose the monitoring of all children for changes in relative height and relative weight as indirect indicators of growth velocity. To this end we analyzed the growth of 2,156 children, as recorded by the child health surveillance services at ages 2 to 19 years. From their data we constructed growth standards on charts of a novel type, which allow direct reading of relative height (SD score, SDS) and relative weight (percentage deviation of weight from median weight for height and sex, %DW). Variation in height explained most (mean 60%) of the variation in weight, and age did not contribute significantly. Hence, our weight charts are height-based. Next, we defined the variations of changes in (delta) SDS and %DW during the different periods of growth. The group means of changes in each period were zero. Variation in delta SDS is widest at the earliest ages, then decreases until year 9-10 (girls) and 10-11 (boys), and again increases. For delta %DW the picture is similar. We present these variations as diagrams for use in growth screening.

Growth evaluation: parent and child specific height standards.

Data on the growth of 1063 children and their parents were analysed. Of the variation in height at prepuberty about 20%, and of the final height 30-46%, were explained by the variation in parental heights; the children's own height at the age of 1.0 year increased the proportion explained to half. Two equations were developed for increasing the accuracy of the evaluation of growth. One defines parent specific mean height standard deviation score, and the other includes the parents' heights and the child's height at the age of 1.0 year and defines expected standard deviation score for height. These equations are easy to use if they are converted to nomograms.

Femorotibial bypass grafting for lower limb ischaemia.

The results of 305 femorotibial bypass grafts performed in 246 patients are presented. Of these operations 246 were primary and 58 secondary or tertiary. A total of 66 diabetic patients were in the series. An autogenous saphenous vein graft was employed in 196 primary operations, the other grafts used being PTFE, human umbilical cord vein graft, venous allograft and knitted dacron velour graft. Hospital mortality was 8 patients (2.6%), while late mortality was 73 patients, 39 of them having had patent grafts. There were 89 (29.2%) immediate or early hospital failures. Two-hundred-sixteen grafts were followed for a mean observation time of 62.3 +/- 5.7 months. The cumulative patencies were analyzed using the life-table method. One, five, and ten year overall patencies for saphenous vein grafts as indicated by claudication were 73%, 53% and 35%, respectively. In rest pain, the patency rates were 62%, 46% and 40% at similar intervals. In impending gangrene the patencies were 43%, 35% and 20%, respectively. The patencies for arterial substitutes were generally poor, i.e., 35% and 15% at one and five years. None of the graft substitutes were followed for up to ten years. Diabetic patients had a significantly lower patency rate than nondiabetics (p = 0.002). The impact was remarkable if impending gangrene co-existed. In all these situations the early graft failure ensued. Both the run-off and inflow status affected the patency rates. This was significantly lower (p = 0.001) when only one distal branch was visualized in angiography.

Femoral-tibial bypass for limb salvage.

From 1967 to 1982, 305 femoral tibial bypasses were performed. Of these 180 (59%) were performed on limb salvage indication. A reversed autogenous saphenous vein was used in 134 instances, among 46 vein substitutes there were 15 vein allografts, 13 human umbilical cord vein grafts, 12 PTFE grafts and six dacron grafts. Hospital mortality was six patients. An additional 37 patients died during the follow-up period. The patency rates for saphenous vein bypass grafts were 62.5%, 48%, and 25% at one, five, and ten years, respectively, and 33% and 25% at one and five years, respectively, for the vascular substitutes. The mean +/- SD follow-up time was 62.27 +/- 5.7 months. During the early postoperative period 23 legs (12.7%) had to be amputated. During the follow-up period an additional 14 legs (7.8%) were lost giving a limb salvage rate of 79.5%.

Local management in primary breast cancer. Our experience of 331 cases.

The peroperative exploration of axillary content gave wrong result from the stage of axillary nodes in every fourth case compared with the final result of axillary evacuation. There were no locoregional recurrences in stage I-patients irradiated after mastectomy. In postoperatively irradiated stage II-patients there were locoregional recurrences in 2.5% of cases, which was 1/8 of recurrences of patients not irradiated postoperatively.

Fever, leucocytosis and C-reactive protein after open-heart surgery and their value in the diagnosis of postoperative infections.

The time course of body temperature (T), white blood cell count (WBC) and serum C-reactive protein (CRP) following uncomplicated open-heart surgery and the value of these three parameters in the diagnosis of postoperative infectious complications were analyzed in 153 patients. Preoperatively, all the patients had a normal T and the WBC level was under 10 X 10(9)/l. The CRP was elevated (over 20 mg/l) in five patients without having an influence on their postoperative courses. Postoperatively, T, WBC and CRP reached their maximum values during the first three days, decreasing gradually thereafter. Great individual variations in this average response to open-heart surgery were seen. Development of minor postoperative infections, mainly wound infection, (in 22 patients) were poorly reflected by these three parameters. However, a temperature exceeding 38 degrees C after the 6th postoperative day suggested presence of infection; less than 5% of patients without an infection had a temperature over this value. A secondary rise in CRP after the third postoperative day occurred in 20 patients and correlated well with postoperative complications; in 14 patients (70%) an infection became apparent, in three instances a probable infection was present, while two patients suffered from non-infectious complications. Only in one case (5%) did the cause for a secondary rise in CRP remain unknown. In major infections, i.e. mediastinitis, a CRP response occurred in all 12 patients, a temperature response in 11 patients (92%) and a WBC response in 10 patients (83%).

Risk factors and markers associated with proliferative retinopathy in patients with insulin-dependent diabetes.

To define risk factors and markers associated with proliferative retinopathy (PR), we compared 44 insulin-dependent diabetic patients with PR with 45 matched patients without advanced retinopathy (NR). Glycemic control assessed by HbA1 measurements from 5 yr preceding diagnosis of PR was significantly worse than in NR patients. The NR patients had more frequently been treated with multiple daily insulin injections than the PR patients. About half of the PR patients had Albustix-positive proteinuria, and these patients were further characterized by an abnormal lipid profile in plasma and increased frequency of cardiovascular disease. In contrast, PR patients without proteinuria did not differ from NR patients in these variables. Sensorimotor and autonomic neuropathy were twice as frequent in the PR than in the NR group. There was no correlation between anti-insulin antibody titer, immune complexes, and the presence of PR, but T-lymphocyte response to different stimuli was slightly reduced in the PR patients. The anti-insulin-antibody titer correlated with duration of diabetes in the NR but not the PR group. The frequency of HLA-DRw8 was slightly higher in the PR group than in the NR group (16 vs. 0%, NS), but we could not confirm the previously suggested association between HLA-DR4 and PR. Serum C4 levels were low in the diabetics but did not differ between PR patients without proteinuria and NR patients. In conclusion, poor glycemic control was clearly associated with PR in this study, and attempts to prevent this hazardous complication should include means to improve insulin therapy. We did not find support for the view that susceptibility to PR is associated with any known HLA antigen(s).(ABSTRACT TRUNCATED AT 250 WORDS)

The usefulness of micro- and macrochromatographic determinations of glycohemoglobin in diabetic patients with nephropathy.

Determination of glycohemoglobin in blood (HbA1) represents an established measure of glycemic control in diabetic patients. In patients with uremia, however, the determination can be subject to pitfalls which may limit its reliability. In order to evaluate the clinical usefulness of HbA1 determinations in diabetic patients with nephropathy, concentrations of HbA1 and its subfractions HbA1c and HbA1a+b were measured by micro- and macrocolumn chromatography in 58 diabetic and 80 non-diabetic patients with impaired renal function. Fifteen diabetic patients without nephropathy and 15 healthy subjects served as controls. The concentrations of HbA1 and its subfractions were significantly higher in non-diabetic patients with nephropathy than in healthy controls. A positive correlation was seen between HbA1 and plasma glucose concentrations in all subjects, and between HbA1 and serum urea and creatinine concentrations in the non-diabetic subjects. When measured repeatedly in the same patient there was a positive correlation between HbA1 and plasma glucose concentrations in diabetic patients with azotemia. There was no change in HbA1 concentrations measured immediately before and after hemo- or peritoneal dialysis. The increase of chromatographically determined HbA1 concentrations in azotemic patients is most likely due to the joint action of carbamylation of hemoglobin with urea derived cyanate and deterioration of glycemic control induced by azotemia. Despite these problems, chromatographically determined HbA1 is still a clinically useful measure of glycemic control in diabetic patients with nephropathy. This presumes repeated measurements in the same patient and the use of appropriate reference levels which consider the degree of renal impairment.

Total gastrectomy with esophagojejunostomy. Analysis of 100 consecutive patients.

One hundred consecutive patients treated for gastric cancer by total gastrectomy from 1977 to 1982 at the second department of surgery of the Helsinki University Central Hospital were analyzed. The mean age of the patients was 61.5 years. Gastroscopy proved to be diagnostically superior to roentgenographic examination, particularly in cases of proximally located cancer. The mean length of postoperative hospital stay was 19.7 days, and the hospital mortality was 8 percent. Respiratory complications accounted for nearly half of the complications, and postoperative intraabdominal complications were recorded in 15 patients. Reoperation was performed on eight patients during the initial hospital stay due to complications. The results suggest that total gastrectomy is a safe procedure with an acceptable mortality rate, and it can be recommended both as a curative and a palliative operation in patients with gastric cancer.

Pulmonary vein diameter in normal children.

A total of 24 normal children's hearts with their great vessels were examined at autopsy and the diameters of the pulmonary veins measured. The values so obtained were plotted against patient height, body-surface area, weight, and age and were subjected to multi-variate regression analysis. Height gave the best correlation with pulmonary venous diameter. For practical purposes, the normal diameter of each pulmonary vein (in millimeters) = 0.07 X height (in centimeters).

Factors influencing 5-year survival in gastric malignancies after total gastrectomy.

One hundred consecutive patients were analysed who had been treated with total gastrectomy in the Second Department of Surgery, Helsinki University Central Hospital, for malignancies of the stomach from 1977 to 1982. Hospital mortality was 8%. The 5-year survival rate in this selected group of patients was 43% and 34% for patients with gastric cancer. Patients with metastases died within 42 months, more than half of them within one year. However, palliative total gastrectomy is recommended in proximally located obstructing tumours. Radical operations on patients with tumour growth to adjacent tissue and organs had no effect on the 5-year survival rates compared to those on patients with metastases. Surgical removal of the primary tumour is recommended in these cases as well. Patients without lymph node metastases had a survival rate of 67% but the prognosis was even better in cases with intact serosa (96%).

Changes in the treatment and prognosis of breast cancer.

The data of 331 women with breast cancer treated in the Second Department of Surgery, Helsinki University, during the period 1976-1980 (patient material, treatment, prognostic factors) is evaluated and compared with an equally large patient material treated during the period 1951-1961 in the same hospital. A breast lump was the main symptom in 94% and the tumour was found by the patient in most cases. Only two patients were younger than 30 years. The median delays to the first medical contact and to operative treatment were 30 and 20 days respectively. The delay had no influence on the prognosis. Also, the age of the patients and the localization of the tumour had no significant effect on the prognosis. Simple mastectomy with axillary lymph node excision was the main operative treatment in the present material whereas Halsted's radical mastectomy was frequently performed in the previous study. Operative radicality was the same in both studies. The prognosis has improved in all clinical stages. The present relative five year survivals in stages I-IV were 95, 83, 53 and 18%, whereas in the previous study they were 75, 58, 41 and 0%, respectively. The improvement in stage II-IV breast cancers is probably due to advances in radio- and chemotherapy. However, the improvement in the prognosis of stage I and to a lesser extent of stage II breast cancers cannot be explained on this basis alone. Neither do the shorter delays in treatment fully explain the differences in the prognosis. The most frequent sites of metastasis were bone and lung/pleura where almost half of the total metastasis occurring during the follow-up were found.

Post-operative outcome in rhegmatogenous retinal detachment.

Anatomic and visual results of retinal detachment surgery were analyzed in 352 consecutive eyes operated on for rhegmatogenous type of retinal detachment in 1978-1981 at the University Eye Hospital in Helsinki. From 1978-79 to 1980-81, both the re-attachment rate and the visual results improved significantly (P less than 0.05). In the latter period, the retina was re-attached in 87% and partially re-attached in 2%. In the same period, a good visual acuity (VA greater than or equal to 0.5) was achieved in 39%, reasonable (VA 0.4-0.15) in 28%, and an ambulatory vision (VA 0.1-CF2m) in 16%, whereas 18% of the eyes became blind (VA CF1m or worse). A favourable outcome was related to good pre-operative visual acuity, short duration and limited extent of detachment as well as sparing of the macula. Among factors which predicted an unfavourable outcome were aphakia, failure to detect retinal breaks, signs of proliferative vitreoretinopathy, multiple operations and old age. Poor outcome was more common after encircling as compared with localized procedures, but the success rate of the various types of operations was not comparable because encircling procedures were selected for more severe cases.

Mortality from ischaemic heart disease among patients using anticonvulsive drugs: a case-control study.

Patients who use phenytoin and some other anticonvulsive drugs have been shown to have raised concentrations of plasma high density lipoprotein. As this lipoprotein is known to be inversely associated with the incidence of ischaemic heart disease the causes of death of all patients with epilepsy known to be taking anticonvulsive drugs who died during 1978-80 were studied. Of 1399 deaths of anticonvulsant users, 258 (18.4%) were caused by ischaemic heart disease. This was significantly less (p less than 0.001) than the 382 deaths from ischaemic heart disease (27.3%) observed among paired controls matched for sex, age, and date of death. The total cardiovascular mortality was also lower among patients with epilepsy than among controls (p less than 0.02) despite there being more deaths due to cerebrovascular disease among patients. The difference in mortality from ischaemic heart disease was significant for both sexes and was not accounted for by excess deaths due to any other single cause. Users of phenytoin, carbamazepine, and barbiturates (alone or in combination) showed 29% less mortality due to ischaemic heart disease than respective controls (p less than 0.001).

Significance of estrogen and progesterone receptors, disease-free interval, and site of first metastasis on survival of breast cancer patients.

Estrogen and progesterone receptors (ER/PR) were measured in primary tumors and metastases of 397 breast cancer patients. Survival following mastectomy was significantly longer in patients with ER and PR positive tumors, as was survival after first recurrence. The prognostic value of ER and PR was compared with such clinical factors as disease-free interval (DFI) and the dominant site of first metastasis by Cox's regression analysis. With all the different therapy modalities long DFI was the best prognostic indicator. However, in the patient group treated with endocrine therapy, ER and PR positivity was the best prognostic indicator, suggesting that longer survival in receptor positive patients was related to the response to endocrine treatment.

Characteristics of rhegmatogenous retinal detachment.

Characteristics of rhegmatogenous retinal detachment and its predisposing factors were studied in a consecutive series of 342 patients operated on for retinal detachment (RD) at the University Eye Hospital in Helsinki in 1978-1981. On these, 234 were pre-operatively examined and operated on by the senior author. The mean age of the patients was 52.8 +/- 1.0 (range 5.7 to 83.0) years, 49.1% were males, 50.9% females. Bilateral RD occurred in 9.9%, and another 4.7% had been treated for retinal breaks in the fellow eye. Of the main predisposing factors, myopia (greater than or equal to -1.0 D) was found in 50.6% of the phakic eyes, 23.0% of the eyes were aphakic, and lattice degeneration was found in 15.1% and trauma in 11.9% of the whole series. In the nontraumatic phakic group, lattice degeneration was present in 31.3%. In the aphakic group, 25.9% had underlying myopia and 8.1% showed lattice degeneration. The relative importance of these factors varied with age. Total RD was found in 60 eyes (17.0%), most commonly in aphakic eyes (32.1%). Macula was detached in 56.5%. Two or more retinal breaks were found in 40.9%. The type of breaks varied with age and refraction. Oral dialysis was common before the age of 20 in non-myopic phakic eyes. Between 20 and 39 years, tears and holes were equally common, and after 40 years of age tears predominated. Tears outnumbered holes both in nonmyopic and myopic eyes, most round holes were found in myopic eyes. In 11.6% of the eyes no sure retinal breaks were detected. Relation of retinal breaks to peripheral retinal degenerations was studied.