Quality. A tightrope for the '90s.

How accurately can you measure quality of care in health care? Recently, HMOs and other types of managed care organizations have been in the process of defining quality in quantitative terms. Physicians who utilize fewer resources and who care for more patients per-unit-of-time are valued as providing better care than colleagues who may work at a slower (more expensive?) pace. The pressure to evaluate or treat greater numbers of patients in shorter periods of time can produce adverse consequences. And numbers do not necessarily take into account the quality of the care delivered. There is clearly a middle road. Physicians must take care of a sufficient number of patients with a given problem to gain and maintain expertise and mastery. But they must also guard against the insidious pressure for the procedure to become the end in itself.

7 Gryzmish: toward an understanding of collaboration.

Nurses and physicians have a long history of conflicted relationships. The conflict is multifaceted and deeply rooted in a mesh of social, economic, and professional issues. This legacy makes collaboration very difficult, but not impossible, to achieve. The barriers imposed by history must be dismantled for nurses and physicians to forge a new relationship. This new relationship will not just happen. It requires a vision, an unswerving commitment, and a leap of faith that collaboration will dramatically improve patient care and provider satisfaction. Collaborative relationships, although positive and progressive, are not easily forged. People must examine and work on their inner feelings. Physicians and nurses need to communicate openly and address conflict directly. Role realignment causes anxiety, uncertainty, and frustration. Often it may seem easier to revert to former patterns of behavior. Dysfunctional as those may be, they offer role familiarity. Collaboration is a conscious, learned behavior that must be constantly nurtured, reinforced, and reflected on, for it holds great promise for both patients and providers.

Recurrent cholangitis after biliary surgery.

After a biliary-enteric anastomosis, the development of cholangitis is usually assumed to be due to obstruction of the stoma. Six patients in whom this was not the case are described. Achlorhydria, duodenal diverticula, and foreign bodies are important predisposing factors. When bacterial contamination is severe in an abnormal intrahepatic biliary tree, especially that which follows long-standing intermittent common duct obstruction, symptomatic biliary infection may occur in the absence of extra-hepatic biliary obstruction.

The long-term outcome of restorative operation in Crohn's disease: influence of location, prognostic factors and surgical guidelines.

The course of all 113 patients with Crohn's disease whose initial procedure involved an anastomosis operated upon from 1942 to 1972 was followed through 1980. The calculated cumulative 30-year total mortality was 23.4%, 16.7% disease-related. The cumulative recurrence rate was 29% at five years, 52% at ten years, 64% at 15 years and 84% at 25 years, with no important differences between disease locations and types of operation. Sex, age, duration, granulomas, enteral or perirectal fistulas and length of the resection, the disease, and the proximal resection margin had no significant influence on the rates of development of recurrent disease or on functional outcome. By far the most common site of recurrence was the neo-terminal ileum, but in ileocolitis compared with ileitis, recurrence was 5.2 times more likely (p = 0.0001) to involve the adjacent or remote colon as well. Moreover, only 1/63 ileitis patients eventually required ileostomy, whereas 15/47 patients with ileocolitis or colitis ultimately required this procedure (p less than 0.001). The current status of the patients was excellent or good in 64% and unwell or dead related in 24%. Urolithiasis developed in 19%.