The validity of indicators for assessing quality of care: a review of the European literature on hospital readmission rate

Background: Quality indicators are increasingly being implemented in Europe for policy and management purposes. Many of these indicators were initially developed and implemented in the USA. However, the suitability of directly adopting indicators that have been developed in a different health care system can be questioned. Therefore, we investigate the validity behind the readmission rate indicator in the European setting. Methods: A systematic literature study was conducted to identify the status of scientific research on the validity of this indicator (January 1999 and April 2010). Descriptive information as well as information on the data source, indicator definition, risk adjustment factors, and conclusions was assessed. Results: The majority of the 486 included studies focused on the actual use of the indicator as an outcome measure in European countries. Only 21 studies specifically addressed its validity, or important prerequisites of validity. There is little consensus over the time-frame used to calculate the indicator, the type of readmission that is included, and the case-mix adjustment applied. Conclusions: Despite the increase in Europe of the use of the readmission rate as a measure of quality of care, the amount of research performed on its validity is scarce. Those studies that report on validity replicate earlier, mainly US findings ( <1999) of methodological problems and express reservations on its large-scale use. The readmission rate as an indicator should be used with care. Users should address issues related to definition, time-frame and case-mix adjustment as part of the process to enhance validity in the European setting

Fingers crossed! An investigation of somatotopic representations using spatial directional judgements.

Processing of tactile stimuli requires both localising the stimuli on the body surface and combining this information with a representation of the current posture. When tactile stimuli are applied to crossed hands, the system first assumes a prototypical (e.g. uncrossed) positioning of the limbs. Remapping to include the crossed posture occurs within about 300 ms. Since fingers have been suggested to be represented in a mainly somatotopic reference frame we were interested in how the processing of tactile stimuli applied to the fingers would be affected by an unusual posture of the fingers. We asked participants to report the direction of movement of two tactile stimuli, applied successively to the crossed or uncrossed index and middle fingers of one hand at different inter-stimulus intervals (15 to 700 ms). Participants almost consistently reported perceiving the stimulus direction as opposite to what it was in the fingers crossed condition, even with SOAs of 700 ms, suggesting that on average they did not incorporate the unusual relative finger positions. Therefore our results are in agreement with the idea that, by default, the processing of tactile stimuli assumes a prototypical positioning of body parts. However, in contrast to what is generally found with tactile perception with crossed hands, performance did not improve with SOAs as long as 700 ms. This suggests that the localization of stimuli in a somatotopic reference and the integration of this representation with postural information are two separate processes that apply differently to the hands and fingers

The mean of median reaction times (ms) at different SOAs.

<p>Mean median reaction times in trials with fingers uncrossed (blue, open circles, dashed line) and crossed (red, filled circles, continuous line) are depicted at different SOAs. Reaction times are defined as the time between the second tap and the response. Negative SOAs again indicate trials in which the direction of stimuli was to the left in space. Error bars indicate 1 standard error of the mean.</p

RTs (ms) at different SOAs with respect to the first and second tap.

<p>Mean median reaction times (RTs) to the first and second tap at the different SOAs and 1 standard error of the mean. Reaction times to stimuli going leftwards and stimuli going rightwards are collapsed, since a finger position (2)×SOA (7)×stimulus direction (2) repeated measures analysis showed no main effect (or interaction) of stimulus direction.</p

The proportion of rightward directional judgements at the different SOAs.

<p>The average proportion of trials in which participants reported the direction of the stimuli to be to the right (in space) is depicted in the fingers uncrossed (blue, open circles) and crossed (red, filled circles) condition at different SOAs, together with the corresponding fitted logistic curves (red continuous line for crossed, blue dashed line for uncrossed condition). Negative SOAs indicate conditions in which the direction of stimuli was to the left in space. So, data points in the bottom left and top right quadrant represent conditions in which on average on more than 50% of the trials a correct response was given. Error bars indicate 1 standard error of the mean. A, B, C & D indicate the proportion of rightward directional judgements at the longest SOA (700 ms).</p

Frostbite of both first digits of the foot treated with delayed hyperbaric oxygen:a case report and review of literature

Frostbite is an uncommon event that can occur from exposure to temperatures below -4 degrees C and can lead to potential serious tissue damage and necrosis. This in turn can result in debilitating amputations in otherwise healthy people. The pathophysiological mechanisms of frostbite have marked similarities to those seen in thermal burns, ischemia/reperfusion injuries and crush injuries--i.e., non-healing wounds and inflammatory processes. These injuries are commonly treated with hyperbaric oxygen therapy. Evidence for treating frostbite with hyperbaric oxygen (HBO2) is scarce, and to date HBO2 is not a standard addition in the multidisciplinary care of freezing injuries. We aim to contribute to the available evidence with a case report and review the literature to reassess the multidisciplinary treatment of frostbite injuries. We present a case report of a woman with deep frostbite of the toes treated with hyperbaric oxygen therapy, after a delay of 21 days, with good results. No surgical intervention was needed. A literature search revealed 17 human case reports on frostbite and four animal studies in which hyperbaric oxygen was applied. All case reports showed positive effects, and in none of the cases was amputation necessary. In the animal studies, two showed significant positive results regarding tissue loss and reduction of inflammatory markers, whereas two did not. Based on our case report as well as the literature and the mechanisms of hyperbaric oxygen, we make the recommendation that this therapy be considered as an addition to the multidisciplinary treatment of frostbite, even after significant delay of treatmen

Behandeling van bevriezingsletsels

In Nederland zijn bevriezingsletsels in de gezonde populatie zeldzaam. Door een groeiend aantal winter- en buitensporters en reizigers naar hooggelegen gebieden, neemt het risico op bevriezingsletsel wel toe. Bevriezing is een koudegeïnduceerd letsel veroorzaakt door 2 processen: bevriezing en microvasculaire occlusie. Een goede eerste opvang, bestaande uit voorkoming van opnieuw bevriezen en van mechanisch letsel in combinatie met snel opwarmen en ibuprofen, is de belangrijkste factor die de uiteindelijke weefselschade kan beperken. Als een patiënt zich presenteert binnen 24 uur nadat het bevroren lichaamsdeel is ontdooid en de ernst van het letsel van dien aard is dat ernstige morbiditeit verwacht kan worden, is behandeling met iloprost en eventueel recombinant weefselplasminogeenactivator geïndiceerd. Als een patiënt zich later presenteert, is hyperbare-zuurstofbehandeling te overwegen; het bewijs hiervoor is echter beperkt