No ticking time bomb: hospital utilisation of 28,528 hip fracture patients in Stockholm during 1998-2007.

AIM: The objectives were to show how utilisation of hospital care among hip fracture patients has changed in Stockholm during 1998-2007 and to explore changes in some demographic and clinical characteristics as well as surgical treatment of the patients. METHODS: The Stockholm County Patient Care Register covers all public healthcare services in the region. All patients from 1998 to 2007 who had a hospital stay due to a hip fracture (ICD-10 codes S72.0, S72.1, S72.2) and had undergone hip surgery (NCSP codes NFB09-99 and NFJ39-99) were identified. Number of hospital stays, surgical procedures, deaths, and length of hospital stay were categorised according to age and sex, and presented as absolute and relative numbers year by year. Age- and sex-standardised annual incidence figures were calculated. RESULTS: A total of 28,528 patients (72.2% women, 27.8% men) were hospitalised due to a hip fracture. The annual numbers decreased during the study period in all age groups except men 85 years and older. The age- and sex-standardised hip fracture incidence fell with 16%. Mortality was slightly reduced. The acute care hospital length of stay fell with 1.4 days to 7.0 days, and the whole hospital episode increased by 1.4 days to 17.3 days. CONCLUSIONS: Despite a continued increase in the numbers of elderly during 1998-2007, the number of patients and their utilisation of hospital services remained constant and showed a marked decrease in women over 65 years of age. Comparisons with national statistics indicate that the results can be generalised to Sweden.

Analysis of 23 364 patient-generated, physician-reviewed malpractice claims from a non-tort, blame-free, national patient insurance system: lessons learned from Sweden.

CONTEXT: In Sweden, patient malpractice claims are handled administratively and compensated if an independent physician review confirms patient injury resulting from medical error. Full access to all malpractice claims and hospital discharge data for the country provided a unique opportunity to assess the validity of patient claims as indicators of medical error and patient injury. OBJECTIVE: To determine: (1) the percentage of patient malpractice claims validated by independent physician review, (2) actual malpractice claims rates (claims frequency / clinical volume) and (3) differences between Swedish and other national malpractice claims rates. DESIGN, SETTING AND MATERIAL: Swedish national malpractice claims and hospital discharge data were combined, and malpractice claims rates were determined by county, hospital, hospital department, surgical procedure, patient age and sex and compared with published studies on medical error and malpractice. RESULTS: From 1997 to 2004, there were 23 364 inpatient malpractice claims filed by Swedish patients treated at hospitals reporting 11 514 798 discharges. The overall claims rate, 0.20%, was stable over the period of study and was similar to that found in other tort and administrative compensation systems. Over this 8-year period, 49.5% (range 47.0-52.6%) of filed claims were judged valid and eligible for compensation. Claims rates varied significantly across hospitals; surgical specialties accounted for 46% of discharges, but 88% of claims. There were also large differences in claims rates for procedures. CONCLUSIONS: Patient-generated malpractice claims, as collected in the Swedish malpractice insurance system and adjusted for clinical volumes, have a high validity, as assessed by standardised physician review, and provide unique new information on malpractice risks, preventable medical errors and patient injuries. Systematic collection and analysis of patient-generated quality of care complaints should be encouraged, regardless of the malpractice compensation system in use.

Analysis of 23 364 patient-generated, physician-reviewed malpractice claims from a non-tort, blame-free, national patient insurance system: lessons learned from Sweden.

CONTEXT: In Sweden, patient malpractice claims are handled administratively and compensated if an independent physician review confirms patient injury resulting from medical error. Full access to all malpractice claims and hospital discharge data for the country provided a unique opportunity to assess the validity of patient claims as indicators of medical error and patient injury. OBJECTIVE: To determine: (1) the percentage of patient malpractice claims validated by independent physician review, (2) actual malpractice claims rates (claims frequency / clinical volume) and (3) differences between Swedish and other national malpractice claims rates. Design, setting and material: Swedish national malpractice claims and hospital discharge data were combined, and malpractice claims rates were determined by county, hospital, hospital department, surgical procedure, patient age and sex and compared with published studies on medical error and malpractice. RESULTS: From 1997 to 2004, there were 23 364 inpatient malpractice claims filed by Swedish patients treated at hospitals reporting 11 514 798 discharges. The overall claims rate, 0.20%, was stable over the period of study and was similar to that found in other tort and administrative compensation systems. Over this 8-year period, 49.5% (range 47.0-52.6%) of filed claims were judged valid and eligible for compensation. Claims rates varied significantly across hospitals; surgical specialties accounted for 46% of discharges, but 88% of claims. There were also large differences in claims rates for procedures. CONCLUSIONS: Patient-generated malpractice claims, as collected in the Swedish malpractice insurance system and adjusted for clinical volumes, have a high validity, as assessed by standardised physician review, and provide unique new information on malpractice risks, preventable medical errors and patient injuries. Systematic collection and analysis of patient-generated quality of care complaints should be encouraged, regardless of the malpractice compensation system in use.

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.

An automatic incision device for obtaining blood samples from the heels of preterm infants causes less damage than a conventional manual lancet.

OBJECTIVES: To evaluate in a randomised blind study the effect on puncture site lesions of two different incision devices used to obtain blood samples from preterm infants by repeated heel sticks. SETTING: The neonatal intensive care unit at the Hospital for Children and Adolescents and Laboratory, Helsinki University Central Hospital. PATIENTS: A total of 100 preterm infants (birth weight below 2500 g) not previously subjected to heel stick sampling. INTERVENTIONS: The infants were randomly allocated to blood sampling from the heel with either a conventional manual lancet or an automatic incision device. The same type of lancet was used for any given baby throughout the study (2-21 days). MAIN OUTCOME MEASURES: The damage caused by sampling was evaluated using four criteria: bruising of the heel, inflammation of the heel, bruising of either the ankle or the leg, and skin healing at the puncture site. The evaluation was based on photographs presenting typical categories of each outcome. RESULTS: To obtain a sufficient volume of blood, on average 2.6 times more punctures were needed when the conventional manual lancet was used than when the automatic incision device was used. Heels punctured with the lancet had more bruising (100% v 84%) and more signs of inflammation (79% v 53%), and there was more bruising of the ankle or leg (92% v 53%) than when the automatic incision device was used. Skin healed equally rapidly in the two groups. CONCLUSION: The use of an automatic incision device for collecting repeated skin puncture samples from preterm infants is less traumatic than the use of a conventional manual lancet.

Diagnosis of meningeoma. A comparison of costs before CT, during CT and after introduction of MR imaging.

OBJECTIVE: To assess whether the capital investment required by advances in radiological technology is offset by savings in the direct costs of diagnostic services. MATERIAL AND METHODS: Meningeoma was used as an indicator case. All meningeoma patients from three study periods were included: Twenty patients in 1976-77 before the introduction of CT, 22 patients in 1984-85 when CT was used and 16 patients in 1992 when MR imaging had replaced CT as the most informative imaging modality. Radiological and other diagnostic investigations, and the hospital stay were identified and cost analyzed. RESULTS: The costs of radiological examinations increased from 293 Euros in 1976-77 to 513 Euros in 1992. The average number of diagnostic examinations per patient decreased from 5.1 in 1976 77 to 2.4 in 1992. The length of hospital stay decreased from 11.5 to 2.7 days and the total costs of the diagnostic work-up decreased to one-third of the original, i.e. from 3423 Euros in 1976-77 to 1282 Euros in 1992. CONCLUSION: The costs of the radiological examinations rose, but the development of radiological technology simplified the diagnostic practice. The hospital stay drastically decreased. The total costs of diagnostic work-up per patient dropped to one-third of the baseline costs.

Cost-effectiveness of Percutaneous Transluminal Angioplasty (PTA) Versus Vascular Surgery in Limb-threatening Ischaemia.

The purpose of this study was to analyze the cost and cost-effectiveness of femoropopliteal PTA compared to femoropopliteal bypass surgery in chronic critical ischaemia of the lower limb. A total of 772 patients were treated either by femoropopliteal PTA or vascular reconstruction in two of the three largest vascular centers in Finland 1991-1992. A subset of 124 cases with chronic critical leg ischaemia, which according to a retrospective independent analysis by a vascular surgeon and a radiologist could have been treated with either modality, were included in the study. Eighty-six of those were treated with PTA and 38 with surgery. The patients were followed up for to three years after treatment. Clinical outcomes were measured as change in the ABI (ankle-brachial pressure index) and avoidance of reoperation and amputation. The hospital costs covering all events from preoperative examinations to the three-year follow-up visit were identified by using hospital discharge register and accounting data. Cost-effectiveness was calculated as cost per reoperation-free year and year of leg saved. Surgery cases were found to have a more severe disease as indicated by lower distal pressures and longer occlusions and they also showed a slightly better clinical outcome, although the differences were not statistically significant. PTA costs were half of those of vascular surgery. The cost-effectiveness rates were significantly better for the PTA patients. PTA is a feasible and cost-effective procedure in chronic critical ischaemia of the lower limb and should be the treatment of choice in the subset of patients where both procedures are possible.

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.

Changes in the work and motivation of staff delivering home care services in Finland.

This article describes how the policy to emphasize noninstitutional care is reflected in home care service strategies and work characteristics as well as the work motivation of home care staff in Finland. The data were gathered through a questionnaire answered by 312 employees in home care services and 22 social welfare and primary health care administrators. The methods of analysis used were cross-tabulations, one-way analysis of variance, and regression analysis. According to the results, institutional care had been reduced too fast and home care services had not been developed sufficiently. Most of the staff reported that their work had changed considerably. Although their work had become more interesting and more independent, over one third of the employees felt that the pressure of work had become unbearable and their responsibility was too heavy. The views of the home care staff differed from those of the administrators regarding the change strategies that had been carried out. The majority of the staff were moderately or highly motivated. Thirty-four percent of the variance of work motivation was explained mainly by work characteristics. More attention should be paid to the development of home care services before institutional care is reduced. Training the staff and informing them about the planned reform should not be neglected.

Sliced down to the moral backbone? Ethical issues of structural reforms in healthcare organizations.

Throughout the 1990s we have experienced a wave of healthcare reforms. This article assesses central issues in policy and systems as well as structural changes in the provision of services against the ethical principles of non-maleficence, beneficence, autonomy and justice. The lack of universal coverage is a serious threat to a just and equitable healthcare system. Doubts have recently been expressed concerning the benefits of competition, even within a regulated internal market. Service reorganization raises fewer ethical concerns. Cost-cutting has followed in the aftermath of the financial crises of the early 1990s, and when carried out by restricting access, it may be in conflict with principles of justice and autonomy. Mere cost-cutting does not, however, establish a viable political agenda. It is argued that changes in healthcare need to be implemented in a way that does not lead to conflict with professional values.

Mortality in ruptured abdominal aortic aneurysms. The Finnvasc Study Group.

OBJECTIVE: To assess mortality related to rupture of abdominal aortic aneurysm (RAAA). DESIGN: A 4-year cross-sectional study based on a nationwide vascular registry Finnvasc and national cause-of-death registry (Statistics Finland). MATERIALS AND METHODS: A total of 454 operations for RAAA among 11,747 surgical vascular reconstructions recorded in the Finnvasc registry and 1004 deaths due to RAAA during the same period based on Statistics Finland. RESULTS: The operative mortality rate was 49% based on the Finnvasc registry and 54% based on Statistics Finland. With all RAAA deaths at hospitals included, total hospital mortality was 68%. No association existed between hospital volume of RAAA operations and surgical mortality, although an inverse association did exist between hospital volume of RAAA operations and all RAAA deaths in the hospital (p = 0.01). The case fatality for RAAA in Finland was 80%. CONCLUSIONS: RAAA surgical mortality calculations for RAAA, based on a vascular registry, underestimate the true rate because some cases with fatal outcome tend to escape registration. Because surgical mortality rates may also be skewed by patient selection, total hospital RAAA mortality thus represents the results of RAAA treatment more accurately.

Costs of plain-film radiography in a partially digitized radiology department. An activity-based cost analysis.

PURPOSE: The aim of the study was to analyse the costs of computed radiography (CR) as part of a small picture archiving and communication system (mini-PACS), and to compare these costs with those of conventional analogue radiography using activity-based accounting (ABC). MATERIAL AND METHODS: The study was conducted at the Central Hospital of Vaasa where in 1993 the Radiology Department acquired a mini-PACS with a CR reader, a chest CR unit, and a CT unit as digital image processing modalities. Of altogether 34140 plain-film examinations, 3/4 were made with CR and stored mostly on film, and 1/4 were made with conventional analogue radiography. The costs and activities of these two modes were analysed by means of the ABC method which identifies and allocates indirect costs in radiological procedures. RESULTS: The costs of CR imaging were 9% higher than those of conventional radiography. The costs of the chest CR unit were equal to those of conventional radiography. The difference was due to higher investment costs in digital image processing. The time gained from a reduction in the number of retakes did not shorten the time spent by patients in the examination room, and its effect on film costs was minimal. CONCLUSION: In planning the step-by-step transition of conventional film-based analogue radiography to fully digitized radiography, it should be noted that films are still used in the transition period and that this is associated with higher costs than in the previous system of conventional analogue plain-film imaging.

The validity of hospital discharge register data on coronary heart disease in Finland.

We studied the validity of the Finnish hospital discharge register data on coronary heart disease (CHD) for the purposes of epidemiologic studies and health services research. The Finnish nationwide hospital discharge register (HDR) was linked with the FINMONICA acute myocardial infarction (AMI) register for the years 1983-1990. The frequency of errors in the HDR was assessed separately. Between 8% and 13% of hospitalized AMI events registered in the AMI Register were not found in the HDR with an ICD code for CHD. Problems with the register linkage and the use of some ICD code other than one of the codes for CHD explained these missing events. The frequency of errors in the personal identification number was about 5% in the early 1980s. After 1986 errors were found only occasionally. The diagnosis recorded in the HDR was the same as that in the discharge sheet in about 95% of hospitalizations. The positive predictive value of the ICD code 410 (AMI), compared with the FINMONICA definite+possible AMI category, was very high and stable, about 90% in all areas and all hospitals, but the sensitivity varied from 50% at local hospitals to 80% at central hospitals. In summary, data on CHD obtained from the Finnish hospital discharge register give, on average, a correct picture on changes in the occurrence of AMI in Finland and can, with necessary caution, be used in epidemiological studies and health services research. However, the classification of individual cases is not standardized in the HDR, but varies over time, between geographical areas and the levels of care. Therefore, these data should not be used without confirmation in studies where correct classification of individual outcomes is of crucial importance, such as follow-up studies and case-control studies.

Local heroes beat national champions: quality improvement in Finnish health care.

UNLABELLED: FINNISH HEALTH CARE: Although health care services in Finland are organized uniformly throughout the country, they, along with the application of total quality management (TQM)/continuous quality improvement (CQI), are the responsibility of municipalities. CASE 1: At the Helsinki City Health Organization, top management launched an organizationwide quality improvement (QI) initiative in 1993, entailing 150 CQI projects. Yet top and middle managers were not sufficiently dedicated to the initiative to provide adequate support to many of the quality projects. Only "islands of activity" were spotted. CASE 2: A physician in the pediatrics department of a hospital helped initiate CQI projects--for improvements in administration of x-rays for patients with antebrachium fractures, transport of samples to the microbiology laboratory, and admissions of patients with acute infectious disease. Successes led senior management in the hospital federation to issue a quality policy based on CQI management, showing the power of the good example. CASE 3: The first launch of CQI at the Helsinki University Central hospital was part of a management development project that did not have the full support of senior management and that, consequently, failed. A second initiative undertaken a year later, the quality council, was more successful. CASE 4: At a local center for social services and primary care, quality projects have strengthened the organization's team and network structures across two professional cultures. DISCUSSION: The four cases provide insight into the diffusion of TQM/QI and implementation strategies on the local level.

Health care reform in The Netherlands, Sweden, and the United Kingdom.

The experiences of three European countries that are actively engaged in reforming their health care systems--the Netherlands, Sweden, and the United Kingdom--point to a degree of convergence in the types of reforms being pursued. European experiences also offer a number of lessons for the United States. These include the importance of government intervention in the health care market to ensure universal coverage, the key role of primary care in ensuring access to basic health services and in containing costs, and the need to create a strong purchasing or insurance function to hold providers accountable on behalf of patients. The pace and scope of reform are affected significantly by the political process in each country.