Prioritizing quality indicator development across the healthcare system: identifying what to measure.

Measuring healthcare quality has become an increasingly important task for regulating bodies and healthcare institutions. Strategically chosen quality indicators provide a means of understanding the quality and safety of the healthcare system. Current frameworks developed to determine aspects of care to be measured do not provide the level of precision required to ensure that indicators are best selected to enable focused action to improve health. We propose a clearly structured process for selecting indicators at a national and local level based on six steps: (i) identify the problem for which measurement is needed, (ii) identify the perspective from which to measure, (iii) focus measurement on transition points through the health system, (iv) identify the type of probe required, (v) apply evaluation criteria to prioritize indicator selection and action and (vi) test the indicator in the clinical setting to which it will be applied. These steps should form the basis of a framework to drive quality indicator development.

Patterns of analgesic and anti-inflammatory medicine use by Australian veterans.

BACKGROUND: We examined analgesic and anti-inflammatory medicine use by Australian veterans before and after the introduction of selective Cox-2 inhibitors. METHODS: We studied cohorts of Gold Card-holding veterans using prescription data held by the Department of Veterans' Affairs for the period 1 July 1998 to 30 June 2004. Outcomes were volume dispensed, average daily quantity and cumulative incidence of use of paracetamol-containing and aspirin-containing medicines, non-selective and Cox-2-selective non-steroidal anti-inflammatory drugs (NSAIDs), tramadol and dextropropoxyphene. RESULTS: Overall, we found high levels of use of analgesic and anti-inflammatory medicines, which increased by 43% over the study period. Use of paracetamol-containing medicines was overtaken by NSAIDs in 1999/2000, corresponding to the introduction of the Cox-2-selective agents. Between 12 and 17% of Cox-2-selective medicine recipients were supplied amounts indicative of continuous use in relatively high doses and 51% of veterans received at least one relatively Cox-2-selective medicine (celecoxib, rofecoxib, meloxicam, diclofenac) by the end of the study period. Dextropropoxyphene use declined during the study and tramadol use increased 10-fold. CONCLUSION: This study shows very high levels of Cox-2 inhibitor use during the 6-year period. Cox-2-selective agents were more likely to be taken continuously and at higher doses than non-selective NSAIDs. This is relevant in view of the cardiovascular toxicity of this group of medicines. The study shows the value of using unit record dispensing data to assess drug use patterns. Linking dispensing records to hospital separation and mortality data will further enhance our ability to monitor drug safety.

Information sources used by New South Wales cancer clinicians: a qualitative study.

BACKGROUND: This study identified (i) information sources used by cancer clinicians to guide pharmacological treatments, (ii) utilization of, and opinions about, online information sources and (iii) clinicians' ability to access a specific cancer treatment protocol (escalated bleomycin, etiposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone (BEACOPP) for Hodgkin's Lymphoma). The work was carried out before activation of the Cancer Institute New South Wales Standard Cancer Treatment (CI-SCaT) programme. METHODS: We conducted semistructured interviews with a purposeful sample of senior and junior doctors, nurses and pharmacists treating adult cancer patients (n = 32) in eight New South Wales public hospitals. RESULTS: Information seeking processes are context specific and vary from clinician to clinician and ward to ward. Clinicians use human, electronic and printed information sources at, or close to, the point of patient care; however, experienced colleagues are preferred where information is needed quickly or in unfamiliar clinical situations. Barriers to using online cancer information are environmental (hardware, connection speeds, time), personal (poor computer literacy and lack of awareness of appropriate sites) and economic (costs of journal subscriptions). Just over half of participants were able to locate a specific cancer protocol and none of these protocols was fully consistent with CI-SCaT recommendations. CONCLUSION: There is no standardized approach to the pharmacological treatment of cancer patients in this sample of New South Wales clinicians. CI-SCaT will fill a gap with respect to standardizing oncology treatment. However, to ensure maximal CI-SCaT uptake, implementation plans should harness positive behavioural influences and attempt to modify the negative forces that act on hospital clinicians in their day-to-day work.