[Benchmarken is 'work in progress']. / Benchmarken is 'werk-in-uitvoering'

BACKGROUND: In the March edition of this journal a group of professors criticised the methods adopted by the SBG (Benchmark foundation of the Dutch Mental Health Services). The critical comments relate to the alleged objectives ('pay-for-performance' in the Dutch Mental Health Services) and the methods involving confounding, bias and the use of insufficiently sensitive instruments. AIM: To provide more detailed information about the SBG and the role of the scientific council (WR) and about the social context within which rom and benchmarking are developing, and to give our views on the methodological criticisms. METHOD: We elucidate the methods of the SBG and the role of the WR and we clarify the ways in which ROM and benchmarking are currently being used. RESULTS: We recognise that there are methodological problems. The wr too warns against jumping to conclusions on the basis of data whose validity is still under discussion. The Dutch Mental Health Services have practically no experience of rom and benchmarking. The Dutch Mental Health Services need to gain more experience in this field. On the other hand, it is true that rom data and comparisons between institutions can lead to improvements in the standard of care, provided these procedures are carried out carefully. In the SGB methods the aforementioned problems have been removed, at least partially. The SBG is concerned not only with symptom reduction but also with the functioning of the individual and with his or her quality of life. CONCLUSION: The WR believes that the Dutch Mental Health Services should operate a scientifically validated benchmark system. Sofar, there has been hardly any research into whether benchmark data really say anything about quality and/or whether comparisons between institutions are valid. A national ROM-system is needed. Current initiatives are creating ways in which these matters can be investigated, preferably in conjunction with scientists and professionals.

Consultation-Liaison psychiatric service delivery: results from a European study.

The reported findings of the European Consultation-Liaison Workgroup (ECLW) Collaborative Study describe consultation-liaison service delivery by 56 services from 11 European countries aggregated on a C-L service level. During the period of 1 year (1991), the participants applied a standardized, reliability tested method of patient data collection, and data were collected describing pertinent characteristics of the hospital, the C-L service, and the participating consultants. The consultation rate of 1% (median; 1.4% mean) underscores the discrepancy between epidemiology and the services delivered. The core function of C-L services in general hospitals is a quick, comprehensive emergency psychiatric function. Reasons to see patients were the following. deliberate self-harm (17%), substance abuse (7.2%), current psychiatric symptoms (38.6%), and unexplained physical complaints (18.6%) (all means). A significant number of patients are old and seriously ill. Mood disorders and organic mental disorders are most predominant (17.7%). Somatoform and dissociative disorders together constitute 7.5%. C-L services in European countries are mainly emergency psychiatric services and perform an important bridge function between primary, general health, and mental health care.

Care complexity in the general hospital: results from a European study.

There is increasing pressure to effectively treat patients with complex care needs from the moment of admission to the general hospital. In this study, the authors developed a measurement strategy for hospital-based care complexity. The authors' four-factor model describes the interrelations between complexity indicators, highlighting differences between length of stay (LOS), objective complexity (such as medications or consultations), complexity ratings by the nurse, and complexity ratings by the doctor. Their findings illustrate limitations in the use of LOS as a sole indicator for care complexity. The authors show how objective and subjective complexity indicators can be used for early and valid detection of patients needing interdisciplinary care.

Mercapturic acids, protein adducts, and DNA adducts as biomarkers of electrophilic chemicals.

The possibilities and limitations of using mercapturic acids and protein and DNA adducts for the assessment of internal and effective doses of electrophilic chemicals are reviewed. Electrophilic chemicals may be considered as potential mutagens and/or carcinogens. Mercapturic acids and protein and DNA adducts are considered as selective biomarkers because they reflect the chemical structure of the parent compounds or the reactive electrophilic metabolites formed during biotransformation. In general, mercapturic acids are used for the assessment of recent exposure, whereas protein and DNA adducts are used for the assessment of semichronic or chronic exposure. 2-Hydroxyethyl mercapturic acid has been shown to be the urinary excretion product of five different reactive electrophilic intermediates. Classification of these electrophiles according to their acid-base properties might provide a tool to predict their preference to conjugate with either glutathione and proteins or with DNA. Constant relationships appear to exist in the cases of 1,2-dibromoethane and ethylene oxide between urinary mercapturic acid excretion and DNA and protein adduct concentrations. This suggests that mercapturic acids in some cases may also play a role as a biomarker of effective dose. It is concluded that simultaneous determination of mercapturic acids, protein and DNA adducts, and other metabolites can greatly increase our knowledge of the specific roles these biomarkers play in internal and effective dose assessment. If the relationship between exposure and effect is known, similar to protein and DNA adducts, mercapturic acids might also be helpful in (individual) health risk assessment.

Role of ethylene and cytokinins in the initiation of lateral shoot growth in bromeliads.

Aechmea victoriana var discolor L. B. Foster and Aechmea dactylina Bal. are commercially propagated in vitro through lateral shoot growth. A modified Murashige and Skoog medium is used which contains both BA and IAA. These growth substances were shown in the present study to synergistically stimulate the production of ethylene by the cultured plants. The stimulation of ethylene production is correlated with the outgrowth of the lateral buds. The rise in ethylene production was concluded to induce lateral shoot growth, because: (a) outgrowth of the shoots was blocked by preventing an increase in ethylene production, (b) 1-aminocyclopropane-1-carboxylic acid (ACC), the natural precursor of ethylene biosynthesis, substituted for IAA in the promotion of ethylene production and lateral bud outgrowth. Although ACC could substitute for IAA, it could not substitute for BA; therefore, cytokinins are concluded to be essential for lateral bud outgrowth in vitro in Aechmea. These results suggest that cytokinins and ethylene both play roles in natural lateral bud initiation and that the cytokinin function involves two stages of the process.