Development of a dementia assessment quality database.

OBJECTIVE: Increased focus on the quality of health care requires tools and information to address and improve quality. One tool to evaluate and report the quality of clinical health services is quality indicators based on a clinical database. METHOD: The Capital Region of Denmark runs a quality database for dementia evaluation in the secondary health system. One volume and seven process quality indicators on dementia evaluations are monitored. Indicators include frequency of demented patients, percentage of patients evaluated within three months, whether the work-up included blood tests, Mini Mental State Examination (MMSE), brain scan and activities of daily living and percentage of patients treated with anti-dementia drugs. Indicators can be followed over time in an individual clinic. Up to 20 variables are entered to calculate the indicators and to provide risk factor variables for the data analyses. RESULTS: The database was constructed in 2005 and covers 30% of the Danish population. Data from all consecutive cases evaluated for dementia in the secondary health system in the Capital Region of Denmark are entered. The database has shown that the basic diagnostic work-up programme with MMSE, and a brain scan is performed in almost all patients. Differences in the prevalence of etiological diagnoses indicate differences in the application of the diagnostic criteria. This has initiated a process to harmonize the use of diagnostic criteria and the MMSE including administration guide. CONCLUSION: Clinical quality indicators based on all patients evaluated for dementia can be used to standardize and harmonize the evaluation process and improve clinical health services.

[Analysis of quality data based on national clinical databases]. / Analyse af kvalitetsdata baseret på landsdaekkende kliniske databaser.

There is little agreement on the philosophy of measuring clinical quality in health care. How data should be analyzed and transformed to healthcare information is an ongoing discussion. To accept a difference in quality between health departments as a real difference, one should consider to which extent the selection of patients, random variation, confounding and inconsistency may have influenced results. The aim of this article is to summarize aspects of clinical healthcare data analyses provided from the national clinical quality databases and to show how data may be presented in a way which is understandable to readers without specialised knowledge of statistics.

[Publication of healthcare quality data to citizens--status and perspectives]. / Offentliggørelse af kvalitetsoplysninger om sundhedsvaesenet til borgerne--status og perspektiver.

Public quality reports are intended to stimulate active consumer participation by enabling consumers to make informed choices about their healthcare providers. Despite all efforts, public reporting has been shown not to be effective in stimulating consumers to choose their healthcare provider based on performance information in Denmark and other countries. Numerous barriers are identified. In an effort to move towards an effective public reporting system in Denmark, the present article discusses how quality information can be made accessible and meaningful to wider groups of consumers.

Timing of heparin prophylaxis and bleeding complications in hysterectomy a nationwide prospective cohort study of 9,949 Danish women.

OBJECTIVE: To examine bleeding complications and thromboembolic events in relation to timing of heparin prophylaxis after hysterectomy. DESIGN: Nationwide prospective cohort study with 30 days post-operative follow-up within the Danish Hysterectomy Database (DHD). SETTING: All gynecological departments in Denmark (n=31). SAMPLE: 9,949 women who had an elective hysterectomy for benign indication between October 2003 and May 2006 and were reported to DHD (national response rate: 88-99% throughout 2004-2005). MAIN OUTCOME MEASURES: Odds ratios (OR) of peri-operative bleeding complications (> or =1,000 ml bleeding during surgery or post-operative wound/vaginal-vault/intraabdominal bleeding or hematoma) and number of events of venous thromboembolism. Logistic regression analysis adjusting for: age, body mass index, alcohol, smoking, meno-/metrorrhagia, uterine weight, department volume, surgeon's experience, route and type of hysterectomy and additional surgery, and stratification on assistant's experience, peri-operative pain prophylaxis with NSAID and daily use of Acetyl Salicylic Acid (ASA)/NSAID. RESULTS: 9,051 women (92%) received thromboprophylaxis with heparin, initiated pre-operatively in 48% and post-operatively in 52%. At least one bleeding complication was noted in 881 women (10%). Post-operative heparin administration was associated with a reduced risk of bleeding complications; OR=0.85 (95% confidence interval 0.73-0.99) compared to pre-operative administration. Excluding cases with potential impaired hemostasis at baseline, the OR was 0.78 (0.64-0.94). There was no fatal embolism. Three of seven pulmonary embolisms and one of three symptomatic deep venous thromboses occurred with the post-operative heparin administration. CONCLUSION: Post-operative rather than pre-operative administration of heparin prophylaxis may reduce the risk of bleeding complications after hysterectomy without apparent risk of increased thromboembolic events.

Establishment of a national Danish hysterectomy database: preliminary report on the first 13,425 hysterectomies.

OBJECTIVE: To describe the concept and early results from the Danish Hysterectomy Database (DHD). DESIGN: Nationwide prospective cohort. SETTING: Denmark. POPULATION: All women who had undergone an elective hysterectomy for benign indication carried out in 2004-2006. METHODS: Structured data are registered prospectively by the surgeons involved in the treatment. Data is reported using the Danish National Patient Registry (LPR) and feedback is provided as clinical indicators with well-defined goals. The DHD concept includes annual plenary meetings, elaboration of national clinical guidelines and parallel causal studies. MAIN OUTCOME MEASURES: Completeness, data validation and department-identifiable clinical indicators (surgical volume, method of hysterectomy, use of antibiotic and thromboembolic prophylaxis, postoperative hospitalization and bleeding complications, surgical infections, reoperations, readmissions and death within 30 days postoperatively). RESULTS: A total of 13,425 hysterectomies were performed in Denmark from 2004 to 2006. In 2005, all gynecological departments in Denmark (n=31) were included in the database collaboration and the national response rate was 99%. Data validity was good in general (82-100% agreement and kappa=0.40-1.00) and data completeness was high (92-100% in 2006). From 2004 to 2006, two clinical guidelines were implemented, the postoperative hospitalization was stable at median 2 days, the rate of postoperative surgical infections was reduced from 4 to 2%, the rate of bleeding complications from 8 to 6%, the reoperation rate from 5 to 4%, and the readmission rate from 7 to 5%. CONCLUSIONS: Clinical performance indicators, audit meetings and nationwide collaboration are useful in monitoring and improving outcome after hysterectomy on a national level. In addition, the DHD offers scope for causal studies about perioperative management.

[The Danish Hysterectomy Database seen from a public health-economic perspective]. / Dansk Hysterektomi Database set i et sundhedsøkonomisk perspektiv.

INTRODUCTION: National clinical databases are a tool for quality improvement in clinical divisions. Furthermore, they can be used to make the quality of health care contributions visible to the population, as part of the free choice of hospital. Using data from one of the Danish nationwide databases, this article is the first to illustrate the potential economic resource gains from the use of these databases. MATERIALS AND METHODS: The calculations performed are based on the Danish Hysterectomy Database. This database has selected quality indicators and measures for quality improvements for a three years period and include reduction of complications to one in three (from 18% to 6%), reduction of admission to one in two (from 4 to 2 days) and reduction of rehospitalisation and reoperation to one in two (from 6% to 3%). RESULTS: Provided the proposed improvements are achieved, the expected resource gain will be approximately Dkr. 22 million (depending on the method of calculation). In-bed per day charges and "hotel charges" may vary considerably among hospitals. DISCUSSION: Every year, Dkr. 15 million are allocated to the national clinical databases, and in 2003, 34 different databases received financial support. The maximum amount that each database can receive is Dkr. 500,000. The amount currently allocated to quality monitoring is small compared to the potential resource gains from these databases and the annual expenditures by the Danish health care sector, which amount to a total of Dkr. 48 billion.

[Will publication of quality indicators in the health service improve the quality? International experiences and Danish perspectives]. / Fører offentliggørelse af kvalitetsmålinger i sundhedsvaesenet til bedre kvalitet? Internationale erfaringer og danske perspektiver.

It is well known that publication of hospital quality indicators may lead to improving of treatments. But the publication can also have some negative side effects: Focus may shift to the evaluated areas at the expense of non-evaluated areas. The most ill patients may be sorted out and high risk patients may be transferred to other hospitals or discharged in order to avoid their dying during hospitalisation and improve statistics. Overestimation of patient risk in order to improve relative treatment outcome. Increasing flow of patients to hospitals with high scores on quality indicators may cause imbalance between activities and budgets and hence longer waiting times and reduced quality of treatment. Negative publicity due to low scores on quality indicators may lead to under-utilisation of hospital capacity, patient and staff insecurity and staff wastage. Thus, publication of quality indicators may improve quality within the health sector, but it is very important to recognise potential pitfalls and negative side effects.

[Esophageal resections in Denmark 1997-2000]. / Esophagusresektioner i Danmark 1997-2000.

INTRODUCTION: We evaluated the changes in Denmark since the 1980s in the incidence, management and outcome of oesophageal resections. MATERIAL AND METHODS: The national patient hospital register and discharge information from the hospitals were examined for the number of oesophageal resections performed, the length of the postoperative stay, readmission, postoperative complications, and hospital mortality in the period 1/1-1997 to 30/6-2000. RESULTS: Twenty-six departments in 18 hospitals performed 476 resections. Five hospitals accounted for 92% of all the resections performed. In three hospitals, the resections were carried out in three different departments and 18 departments performed fewer than four resections per year. The postoperative stay was 19.2 days. The frequency of surgical complications was 19% and hospital mortality was 10.7%. DISCUSSION: The small number of oesophageal resections performed in many departments in Denmark is not in accordance with international recommendations, which say that the operation should be performed in high volume centres by experienced oesophageal surgeons, including thoracic surgeons, surgical gastroenterologists, and thoracic anaesthesiologists. On these results, it is recommended that the operation is performed in few centres and by few surgeons in multidisciplinary teams.

[Hysterectomy in Denmark. An analysis of postoperative hospitalization, morbidity and readmission]. / Hysterektomi i Danmark. En analyse af postoperativ hospitalisering, morbiditet og genindlaeggelse.

INTRODUCTION: The aim of this study was to demonstrate the incidence of "standard" hysterectomy in Denmark, including surgical route, postoperative hospitalisation, morbidity, mortality, and readmission rate within 30 days. MATERIAL AND METHODS: We analysed data from the Danish National Patient Register over a two-year period (1998-2000) on hysterectomies for benign indications, carcinoma in situ cervicis uteri, and cancer corporis uteri stage 1. A stratified sample of 821 discharge résumés was reviewed for detection of complications. RESULTS: Over the two-year period, 10,171 women had "standard" hysterectomies followed by a median postoperative hospitalisation of four days. In departments performing more than 100 operations per year, the median hospital stay varied from three to 5.5 days. Eighty per cent of the hysterectomies were abdominal, 6% laparoscopically assisted, and 14% vaginal with marked regional variation in the choice of surgical approach. The number of vaginal hysterectomies varied from 0 to 67% in departments with a surgical activity of more than 100 per year. Eight per cent were readmitted within 30 days of the operation and the mortality rate was 0.6@1000. Extrapolation from the random sample to the entire population gives an estimated complication rate of a minimum of 18%. DISCUSSION: "Standard" hysterectomy in Denmark is associated with considerable morbidity and marked regional variation in the choice of surgical approach. The present study emphasises the need for a national hysterectomy database with the possibility of evaluating surgical activity, reducing morbidity rates, and developing homogeneous guidelines.

Hysterectomy in Denmark. An analysis of postoperative hospitalisation, morbidity and readmission.

INTRODUCTION: The aim of this study was to describe the incidence of "standard" hysterectomy in Denmark, including surgical procedure, postoperative hospitalisation, morbidity, mortality and readmission rate within 30 days. MATERIAL AND METHODS: Analysis of data from the Danish National Patient Register for a two-year period (1998-2000) concerning hysterectomies for benign indications, carcinoma in situ cervicis uteri and endometrial carcinoma stage I. A stratified sample of 821 discharge resumés was reviewed for detection of complications. RESULTS: During the two years 10,171 women underwent "standard" hysterectomy followed by a median postoperative hospitalisation of 4 days. In departments performing more than 100 operations per year, the median hospital stay varied from 3 to 5.5 days. Eighty per cent were performed by laparotomy, 6% laparoscopically assisted and 14% by the vaginal route with marked regional variation in the choice of surgical approach. The number of vaginal hysterectomies varied from 0-67% in departments with a surgical activity of more than 100 per year. The mortality rate was 0.06% and 8% were readmitted within 30 days after the operation. If allowing extrapolation from the random sample to the entire population the complication rate was estimated to a minimum of 18%. CONCLUSION: "Standard" hysterectomy in Denmark is associated with considerable morbidity and marked regional variation in choice of surgical approach. The present study emphasizes the need for a national hysterectomy database with the possibility of evaluating surgical activity, reducing morbidity rates and developing homogeneous guidelines.