Clinical pathways – the Bulgarian approach

Background: Over the past 20 years, the use of clinical pathways has increased rapidly in many countries. The implementation of clinical pathways, i.e., using evidence-based gold standards in diagnostic and treatment algorithms, is aimed at optimising patient care, improving the intermediate and discharge outcomes, as well as reducing the inpatient length of stay and the overall costs. Bulgaria introduced CPs in 2000, but failed to achieve the goals it had initially set. To analyse the potential reasons for this failure, our study aims to describe the approaches used in Bulgaria to develop CPs and the actual application of CPs in Bulgaria. Methods: We analysed Bulgarian literature and official government publications and utilised the author’s first-hand experience, working as a consultant to various governmental organisations. To evaluate the Bulgarian CPs we compared the Bulgarian approach with internationally acknowledged methods to devise CPs. Results: In Bulgaria, the requirements for understanding the procedures covered by CPs, for defining the rules of treatment, for monitoring deviations, for refining the rules and ultimately for modifying practice behaviour have not been complied with while developing the clinical pathways. Bulgaria uses CPs as an instrument for resource allocation to inpatient health-care providers rather than as a tool for improving health-care quality. Conclusions: Despite the broad scope of discussion in Bulgaria and the experience and knowledge gained in the past 5 years, the utilisation of clinical pathways for improving the quality of medical care is still unsatisfactory. Bulgarian health decision-makers merely used the title of a tool with proven qualities in managed care and efficient resource utilisation without implementing it according to international standards

Satisfaction of inpatients with acute coronary syndrome in Bulgaria

© 2008 Ganova-Iolovska et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens

Hospital quality reports in Germany: patient and physician opinion of the reported quality indicators

<p>Abstract</p> <p>Background</p> <p>Starting in 2005, Germany's health law required hospital quality reports to be published every two years by all acute care hospitals. The reports were intended to help patients and physicians make informed choices of hospitals. However, while establishing the quality indicators that form the content of the reports, the information needs of the target groups were not explicitly taken into account. Therefore, the aim of our study was to determine patient and physician opinion of the relevance of the reported quality indicators for choosing or referring to a hospital.</p> <p>Methods</p> <p>Convenience samples of 50 patients and 50 physicians were asked to rate the understandability (patients), suitability (physicians) and relevance (both groups) of a set of 29 quality indicators. The set was drawn from the reports (24 indicators) and supplemented by five indicators commonly used in hospital quality reports. We analysed the differences in patient and physician ratings of relevance of all indicators by applying descriptive statistics, t-tests and Wilcoxon tests.</p> <p>Results</p> <p>Only three indicators were considered not understandable by the interviewed patients and unsuitable by the interviewed physicians. The patients rated 19 indicators as highly or very relevant, whereas the physicians chose 15 indicators. The most relevant indicator for the patients was "qualification of doctors", and for the physicians "volume of specified surgical procedures". Patient and physician rankings of individual indicators differed for 25 indicators. However, three groups of indicators could be differentiated, in which the relevance ratings of patients and physicians differed only within the groups. Four of the five indicators that were added to the existing set of reported indicators ranked in the first or second group ("kindness of staff", "patient satisfaction", "recommendation", and "distance to place of living").</p> <p>Conclusion</p> <p>Most of the content of Germany's hospital quality reports seems to be useful for patients and physicians and influence their choice of hospitals. However, the target groups revealed that approximately one third of the indicators (mostly hospital structural characteristics), were not useful and hence could have been omitted from the reports. To enhance the usefulness of the reports, indicators on patient experiences should be added.</p

Five years "Healthy Lower Rhine ... Against Stroke": implementation of a regional, intersectoral and sustainable public health program

Aim: Stroke is one of the leading causes of death worldwide. Optimizing health care according to the "time is brain" concept is recommended by the Local Health Conferences (KGK) in North Rhine-Westphalia. In 2001, KGK managers from six neighboring districts and municipalities founded the "Healthy Lower Rhine Network." In 2003 the network launched the program "Healthy Lower Rhine ... Against Stroke." This initiative aims primarily at reducing pre-hospital time, i.e., delays from onset of symptoms to hospital presentation in order to optimize modern acute health care. Improving community knowledge of stroke is crucial in this context as well as training in the professional sector. Methods: The conceptual framework comprised three elements: (1) needs assessment, using local expert panels, surveys into community knowledge and clinic data samples of health care quality; (2) intervention plan containing a social marketing concept with two-level organization and standards, training and education in health care; (3) formative and summative evaluation. Central elements of the intervention plan are: local health targets, collaboration and networking, intersectorality, continuity and sustainability (5-year runtime), corporate design, target groups and settings. Results: The central elements of the concepts were implemented. Community surveys revealed similar deficits in public knowledge on stroke in the city of Düsseldorf (2000 and 2004) and in the Wesel district (2002 and 2008). Knowledge of proper action (phone 112 in case of a stroke) significantly improved in Düsseldorf's community with 32.5% correct statements in 2000 versus 50.6% correct answers in 2004 and, finally, 69% correct answers in 2008 in the Wesel district. Clinics in the Wesel district collected 3-month samples of data on pre-hospital times in 2003 before the start of the initiative and in 2005. There was no significant change, with a constant portion of 28% of patients being hospitalized within a 3-h window after onset of stroke symptoms. Conclusion: Due to medical progress and demographic changes, stroke remains a paramount issue in Public Health in Germany. The "Healthy Lower Rhine Network" uses its program "Healthy Lower Rhine ... Against Stroke" to present a strategy to launch and implement a complex, sustainable and intersectoral Public Health intervention, in spite of a growing shortage of resources in public health services

Evaluation of quality of life and description of the sociodemographic state in adolescent and young adult patients with phenylketonuria (PKU)

BACKGROUND: Normal intellectual and personal development can be expected in early-diagnosed and treated PKU patients. Aim of the study was to analyse quality of life and social status, which are important parameters for an overall estimation of success of treatment apart from intellectual outcome in adult PKU patients. METHODS: 67 patients completed a questionnaire on quality of life and social status. Data was compared to the German census on an age matched control collective. RESULTS: Quality of life measured with the Profile of Quality of Life in the Chronically Ill (PLC) revealed mean values for capacity of performance in the patient group in the same range as in the control collective. The analysis of the social state of PKU patients revealed a tendency towards lower or delayed autonomy, and a low rate of forming normal adult relationships in which to have children. Schooling and professional career corresponded approximately to the control collective. CONCLUSION: Though every chronic disorder must be regarded as restraining, it shows that PKU does not preclude healthy emotional adjustment when the disease is diagnosed early and treated well

Evaluating compulsory minimum volume standards in Germany: how many hospitals were compliant in 2004?

<p>Abstract</p> <p>Background</p> <p>Minimum hospital procedure volumes are discussed as an instrument for quality assurance. In 2004 Germany introduced such annual minimum volumes nationwide on five surgical procedures: kidney, liver, stem cell transplantation, complex oesophageal, and pancreatic interventions. The present investigation is the first part of a study evaluating the effects of these minimum volumes on health care provision. Research questions address how many hospitals and cases were affected by minimum volume regulations in 2004, how affected hospitals were distributed according to minimum volumes, and how many hospitals within the 16 German states complied with the standards set for 2004.</p> <p>Methods</p> <p>The evaluation is based on the mandatory hospital quality reports for 2004. In the reports, all hospitals are statutorily obliged to state the number of procedures performed for each minimum volume. The data were analyzed descriptively.</p> <p>Results</p> <p>In 2004, 485 out of 1710 German hospitals providing acute care and approximately 0.14% of all hospital cases were affected by minimum volume regulations. Liver, kidney, and stem cell transplantation affected from 23 to hospitals; complex oesophageal and pancreatic interventions affected from 297 to 455 hospitals. The inter-state comparison of the average hospital care area demonstrates large differences between city states and large area states and the eastern and western German states ranging from a minimum 51 km²up to a maximum 23.200 km², varying according to each procedure. A range of 9% – 16% of the transplantation hospitals did not comply with the standards affecting 1% – 2% of the patients whereas 29% and 18% of the hospitals treating complex oesophageal and pancreatic interventions failed the standards affecting 2% – 5% of the prevailing cases.</p> <p>Conclusion</p> <p>In 2004, the newly introduced minimum volume regulations affected only up to a quarter of German acute care hospitals and few cases. However, excluding the hospitals not meeting the minimum volume standards from providing the respective procedures deserves considering two aspects: the hospital health care provision concepts by the German states as being responsible and from a patient perspective the geographically equal access to hospital care.</p