Comparison of external evaluation policies and regulations for quality improvement and safety of health services in Norway and the United States

Purpose The authors compare perspectives on external evaluation of health service provision between Norway and the USA. External inspection and accreditation are examples of internationally wide-spread external evaluation methods used to assess the quality of care given to patients. Different countries have different national policy strategies and arrangements set up to do these evaluations. Although there is growing attention to the impact and effects on quality and safety from external evaluation, there is still a gap in knowledge to how structures and processes influence these outcomes. Accordingly, the purpose of this article is to describe the structures and processes in external evaluation designed to promote quality improvement in Norway and the USA with attention to comparison of enablers and barriers in external evaluation systems. Design/methodology/approach Data collection consisted of documentary evidence retrieved from governmental policies, and reviews of the Joint Commission (the US), international guidelines, recommendations and reports from the International Society for Quality in Health Care, and the World Health Organization, and policies and regulations related to Norwegian governmental bodies such as the Ministry of Health and Care Services, the Norwegian Directorate of Health, and the Norwegian Board of Health Supervision . Data were analyzed inspired by a deductive, direct content analytical framework. Findings The authors found that both accreditation and inspection are strategies put in place to ensure that healthcare providers have adequate quality systems as well as contributing to the wider risk and safety enhancing management and implementation processes in the organizations subjected to evaluation. The US and the Norwegian external regulatory landscapes are complex and include several policymaking and governing institutions. The Norwegian regulatory framework for inspection has replaced an individual blame logic with a model which “blames” the system for inadequate quality and patient harm. This contrasts with the US accreditation system, which focuses on accreditation visits. Although findings indicate an ongoing turning point in accreditation, findings also demonstrate that involving patients and next of kin directly in adverse event inspections is a bigger part of a change in external inspection culture and methods than in processes of accreditation. Research limitations/implications The message of this paper is important for policymakers, and bodies of inspection and accreditation because knowledge retrieved from the comparative document study may contribute to better understanding of the implications from the different system designs and in turn contribute to improving external evaluations. Originality/value Although there is a growing attention to the impact and effects on quality and safety from external evaluation, the implications of different regulatory strategies and arrangements for evaluation on quality and safety remain unclear.acceptedVersio

Gain-of-Function Mutations in the K_ATP Channel (KCNJ11) Impair Coordinated Hand-Eye Tracking

Background: Gain-of-function mutations in the ATP-sensitive potassium channel can cause permanent neonatal diabetes mellitus (PNDM) or neonatal diabetes accompanied by a constellation of neurological symptoms (iDEND syndrome). Studies of a mouse model of iDEND syndrome revealed that cerebellar Purkinje cell electrical activity was impaired and that the mice exhibited poor motor coordination. In this study, we probed the hand-eye coordination of PNDM and iDEND patients using visual tracking tasks to see if poor motor coordination is also a feature of the human disease.Methods: Control participants (n = 14), patients with iDEND syndrome (n = 6 or 7), and patients with PNDM (n = 7) completed three computer-based tasks in which a moving target was tracked with a joystick-controlled cursor. Patients with PNDM and iDEND were being treated with sulphonylurea drugs at the time of testing.Results: No differences were seen between PNDM patients and controls. Patients with iDEND syndrome were significantly less accurate than controls in two of the three tasks. The greatest differences were seen when iDEND patients tracked blanked targets, i.e. when predictive tracking was required. In this task, iDEND patients incurred more discrepancy errors (p = 0.009) and more velocity errors (p  = 0.009) than controls.Conclusions: These results identify impaired hand-eye coordination as a new clinical feature of iDEND. The aetiology of this feature is likely to involve cerebellar dysfunction. The data further suggest that sulphonylurea doses that control the diabetes of these patients may be insufficient to fully correct their neurological symptoms.</p

Failure to increase insulin secretory capacity during pregnancy-induced insulin resistance is associated with ethnicity and gestational diabetes

Objective To assess changes in insulin resistance and β-cell function in a multiethnic cohort of women in Oslo, Norway, from early to 28 weeks' gestation and 3 months post partum and relate the findings to gestational diabetes mellitus (GDM). Method Population-based cohort study of 695 healthy pregnant women from Western Europe (41%), South Asia (25%), Middle East (15%), East Asia (6%) and elsewhere (13%). Blood samples and demographics were recorded at mean 15 (V1) and 28 (V2) weeks' gestation and 3 months post partum (V3). Universal screening was by 75 g oral glucose tolerance test at V2, GDM with modified IADPSG criteria (no 1-h measurement): fasting plasma glucose (PG) ≥5.1 or 2-h PG ≥8.5 mmol/l. Homeostatic model assessment (HOMA)-β (β-cell function) and HOMA-IR (insulin resistance) were calculated from fasting glucose and C-peptide. Result Characteristics were comparable across ethnic groups, except age (South Asians: younger, P<0.001) and prepregnant BMI (East Asians: lower, P=0.040). East and South Asians were more insulin resistant than Western Europeans at V1. From V1 to V2, the increase in insulin resistance was similar across the ethnic groups, but the increase in β-cell function was significantly lower for the East and South Asians compared with Western Europeans. GDM women compared with non-GDM women were more insulin resistant at V1; from V1 to V2, their β-cell function increased significantly less and the percentage increase in β-cell function did not match the change in insulin resistance. Conclusion Pregnant women from East Asia and South Asia were more insulin resistant and showed poorer HOMA-β-cell function than Western Europeans

Mathematical Model of Oxygen, Nutrient, and Drug Transport in Tuberculosis Granulomas

Physiological abnormalities in pulmonary granulomas–pathological hallmarks of tuberculosis (TB)–compromise the transport of oxygen, nutrients, and drugs. In prior studies, we demonstrated mathematically and experimentally that hypoxia and necrosis emerge in the granuloma microenvironment (GME) as a direct result of limited oxygen availability. Building on our initial model of avascular oxygen diffusion, here we explore additional aspects of oxy- gen transport, including the roles of granuloma vasculature, transcapillary transport, plasma dilution, and interstitial convection, followed by cellular metabolism. Approximate analytical solutions are provided for oxygen and glucose concentration, interstitial fluid velocity, interstitial fluid pressure, and the thickness of the convective zone. These predictions are in agreement with prior experimental results from rabbit TB granulomas and from rat carcinoma models, which share similar transport limitations. Additional drug delivery predictions for anti-TB-agents (rifampicin and clofazimine) strikingly match recent spatially-resolved experimental results from a mouse model of TB. Finally, an approach to improve molecular transport in granulomas by modulating interstitial hydraulic conductivity is tested in silico

The Multidimensional Prognostic Index in general practice: One-year follow-up study.

BACKGROUND Older patients' health problems in general practice (GP) can often not be assigned to a specific disease, requiring a paradigm shift to goal-oriented, personalised care for clinical decision making. PURPOSE To investigate the predictive value of the comprehensive geriatric assessment (CGA)-based Multidimensional Prognostic Index (MPI) in a GP setting with respect to the main healthcare indicators during the 12 months following initial evaluation. METHODS One hundred twenty-five consecutive patients aged 70 years and older were enrolled in a GP and followed up to one year. All patients underwent a CGA based on which the MPI was calculated and subdivided into three risk groups (MPI-1, 0-0.33 = low risk, MPI-2, 0.34-0.66 = moderate risk and MPI-3, 0.67-1, severe risk). Grade of Care (GC), hospitalization rate, mortality, nursing home admission, use of home care services, falls, number of general practitioner contacts (GPC), of geriatric resources (GR) and geriatric syndromes (GS) during the 12 months following initial evaluation were collected. RESULTS The MPI was significantly associated with number of GS (P < .001), GR (P < .001), GC (P < .001) as well as with the average number of GPC per year (mean 10.4, P = .046). Interestingly, the clinical judgement of the general practitioner, in this case knowing his patients for 16 years on average, was associated with adverse outcomes to a similar extent than the prediction offered by the MPI (GP/adverse outcomes and MPI/adverse outcomes P < .001). CONCLUSION The MPI is strongly associated with adverse outcomes in older GP patients and strongly predicts the number of GPC up to one year after initial evaluation. Considering the feasibility and the strong clinimetric properties of the MPI, its collection should be encouraged as early as possible to disclose risk conditions, implement tailored preventive strategies and improve cost-effectiveness of healthcare resources use

Excellence initiatives in Nordic research policies. Policy issues - tensions and options

This report presents results from a research project (PEAC) studying the impact of funding schemes for Centres of Excellence (CoE) in the Nordic countries

Is fatness or fitness key for survival in older adults with intellectual disabilities?

Background: Overweight/obesity and poor physical fitness are two prevalent lifestyle-related problems in older adults with intellectual disabilities, which each require a different approach. To improve healthy ageing, we assessed whether fatness or fitness is more important for survival in older adults with intellectual disabilities. Methods: In the HA-ID study, we measured obesity and fitness of 874 older adults with intellectual disabilities (61.4 ± 7.8 years). Alsl-cause mortality was assessed over a 5-year follow-up period. Results: Fitness, but not obesity, was significantly related to survival (HR range of 0.17–0.22). People who were unfit were 3.58 (95% CI = 1.72–7.46) to 4.59 (95% CI = 1.97–10.68) times more likely to die within the follow-up period than people who were fit, regardless of obesity. Conclusion: This was the first study to show that being fit is more important for survival than fatness in older adults with intellectual disabilities. The emphasis should, therefore, shift from weight reduction to improving physical fitness

Age-related differences in left ventricular structure and function between healthy men and women

Full Article Figures & data References Supplemental Citations Metrics Reprints & Permissions Get access Abstract Objectives: Cardiovascular function generally decreases with age, but whether this decrease differs between men and women is unclear. Our aims were twofold: (1) to investigate age-related sex differences in left ventricular (LV) structure, function and mechanics, and (2) to compare these measures between pre- and postmenopausal women in the middle-aged group. Methods: Resting echocardiography was performed in a cross-sectional sample of 82 healthy adults (14 young men, 19 middle-aged men, 15 young women, 34 middle-aged women: 15 premenopausal and 19 postmenopausal). Two-way ANOVAs were used to examine sex × age interactions, and t-tests to compare pre- and postmenopausal women (α < 0.1). Results: Normalized LV mass, stroke volume and end-diastolic volume were significantly lower in middle-aged than young men, but this difference was smaller between middle-aged and young women. Peak systolic apical mechanics were significantly greater in middle-aged men than in middle-aged women, but not between young men and women. Postmenopausal women had significantly lower LV relaxation and mechanics (torsion, twisting velocity and apical circumferential strain rates) compared with middle-aged premenopausal women. Conclusion: Our cross-sectional findings suggest that the hearts of men and women may age differently, with men displaying greater differences in LV volumes accompanied by differences in apical mechanics