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Prosedyrearbeid – meningsløst mangfold?
No full textNORSK: Bakgrunn\ud
Fagprosedyrer skal være en støtte for helsepersonell i det daglige arbeidet og bidra til god og forutsigbar kvalitet av tjenesten. Antall fagprosedyrer i norske helseforetak og måten de blir produsert på, er ukjent.\ud
\ud
Materiale og metode\ud
Vi gjennomførte en spørreundersøkelse med 25 spørsmål om omfang, kvalitet og koordinering av fagprosedyrer, sommeren 2009. 29 av 30 helseforetak svarte på spørsmålene.\ud
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Resultater\ud
Mer enn 4700 ansatte i norske helseforetak er involvert i utvikling og håndtering av fagprosedyrer. Det totale antallet fagprosedyrer er over 45 000. De fleste foretakene koordinerer ikke prosedyrearbeidet med andre helseforetak. To foretak formidler foretakets praksis over internett. 15 av de 29 foretakene oppgir at de systematisk kvalitetssikrer fagprosedyrene.\ud
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Fortolkning\ud
Det foregår trolig mye dobbeltarbeid knyttet til utvikling av fagprosedyrer ved norske foretak. Prosedyrene blir i regelen ikke delt med andre fagfolk og med befolkningen. Kvaliteten er ofte uviss, og bør undersøkes nærmere.ENGLISH: 1-page key messages\ud
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Background\ud
High-quality clinical procedures and guidelines should support health professionals and contribute to high quality care and reduce practice variation. Methods and quality, as well as coordination and transparency of work concerning electronic, clinical procedures in Norwegian Health Trusts, is questioned.\ud
\ud
Materials and methods\ud
We conducted a survey consisting of 25 questions about the extent, quality and coordination of clinical procedures among 30 Norwegian Health Trusts. \ud
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Results\ud
29 Health Trusts replied and the results showed that at least 4700 employees in the Trusts are involved in the development and maintenance of clinical procedures each year. The total number of clinical procedures is more than 45 000. Most health trusts do not collaborate or coordinate their work with others. Two Health Trusts publish their procedures on the internet and almost half do not systematically undertake a quality assessment of their procedures.\ud
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Discussion\ud
A lot of duplication of work is probably done in the development and updating of clinical procedures in Norwegian Health Trusts. The procedures are normally not shared among Trusts or among the general population. The quality is often undetermined, and warrants further examination. The extensive work concerning clinical procedures is in urgent need of direction, structure and transparency
Forslag til rammeverk for et nasjonalt kvalitetsindikatorsystem for helsetjenesten
No full textNORSK: Bakgrunn\ud
Kvalitetsindikatorer er målbare variabler som gir informasjon om kvaliteten innen et område som vanligvis ikke lett lar seg måle direkte. Bruk av kvalitetsindikatorer kan ha flere formål: De kan fungere som støtte til helsepolitisk styring, til virksomhetsstyring og intern kvalitetsforbedring, og de kan benyttes av pasienter og brukere for å sammenlikne tjenestenes standard ved valg av tjenesteyter eller tjenestested.\ud
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Datamessige og juridiske problemer har i vesentlig grad bidratt til å forhindre utviklingen av det norske kvalitetsindikatorsystemet.\ud
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Utvikling og bruk av denne typen systemer innebærer problemstillinger av stor samfunnsmessig interesse, og troverdigheten er helt avhengig av at utviklings- og implementeringsprosessene er preget av åpenhet og faglighet.\ud
\ud
Anbefalinger\ud
Prosjektet anbefaler at hovedperspektivet for systemet skal være helsepolitisk styring og læring. Prosjektet konkluderer med i alt 18 anbefalinger
Antibiotikabehandling i sykehus, peroral versus intravenøs behandling
No full textNORSK: Bakgrunn: Denne rapporten adresserer problemstillingen:\ud
Er det forskjell i effekt mellom peroral og intravenøs antibiotikabehandling av infeksjonssykdommer hos store og viktige pasientgrupper. Rapporten besvarer ikke spørsmålet om når (hvor tidlig) det kan skiftes fra intravenøs til peroral behandling.\ud
\ud
Metode: Vi baserte kunnskapsoppsummeringen på et litteratursøk etter systematiske oversikter i relevante bibliografiske databaser. For sykdommene lungebetennelse og urinveisinfeksjoner søkte vi også etter randomiserte kontrollerte studier. Vi sammenfattet og vurderte den samlede dokumentasjonen fra studier som oppfylte de forhåndsdefinerte inklusjonskriteriene. Vi oppsummerte resultater for seks hovedendepunkt: Totaldødelighet, helbredelsesrate, mislykket behandling, reinnleggelser, liggetid og alvorlige bivirkninger.\ud
\ud
Resultater: Vi inkluderte seks systematiske oversikter som har vurdert effekten av peroral versus intravenøs administrasjon av antibiotika for sykdommene lungebetennelse, urinveisinfeksjon, osteomyelitt, spontan bakteriell peritonitt og febril neutropeni hos kreftpasienter. I tillegg inkluderte vi 10 randomiserte kontrollerte studier. For de ulike endepunktene finner vi stort sett ikke signifikante forskjeller mellom peroral og intravenøs administrasjon av antibiotika. Kvaliteten på denne dokumentasjonen er lav og estimatene er dermed usikre. \ud
\ud
Konklusjon: Dokumentasjonen gir ikke grunnlag for å avgjøre om det er forskjell i effekt og sikkerhet for peroral versus intravenøs administrasjon av antibiotika. Dette betyr ikke at det ikke er forskjeller i administrasjonsmåte, men at resultatene er for usikre til at vi kan trekke konklusjoner om dette.ENGLISH: 1-page key messages\ud
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Background: This report addresses the following question: Is there a difference in efficacy between oral and intravenous antibiotic treatment of infectious diseases for large and important groups of patients. The report does not answer the question of when (how soon) you can change from intravenous to oral treatment.\ud
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Methods: We based this systematic review of a search for other systematic reviews in relevant bibliographic databases. For pneumonia and urinary tract infections, we also searched for randomized controlled trials. We compiled, analysed and graded the quality of the documentation. We summarized the results for six main outcomes: Total mortality, cure rates, treatment failure, re-admissions, length of stay in hospital and serious side effects.\ud
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Results: We included six systematic reviews which evaluated the effect of oral versus intravenous administration of antibiotics for pneumonia, urinary tract infection, osteomyelitis, spontaneous bacterial peritonitis, and febrile neutropenia in cancer patients. In addition, we included 10 randomized controlled trials. On the whole, we did not find significant differences between oral and intravenous administration of antibiotics. The quality of this documentation is low and the estimates are therefore uncertain.\ud
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Conclusion: The documentation provides no basis for determining whether there is difference in efficacy and side effects of oral versus intravenous administration of antibiotics. This does not mean that there are no differences in the administration route, but the results are too uncertain for us to draw conclusions about this
Intravenøs trombolytisk behandling av hjerneinfarkt i akuttfasen og sekundær blodproppforebyggende behandling (platehemmende behandling og antikoagulasjonsbehandling) etter hjerneslag
No full textBakgrunn\ud
Hjerneslag er den tredje hyppigste dødsårsaken og den vanligste årsaken til\ud
alvorlig nevrologisk funksjonshemning i Norge. Hjerneslag har store helsemessige\ud
og økonomiske konsekvenser både for pasienter, pårørende, helsevesenet\ud
og samfunnet forøvrig. Hvilket legemiddel som bør velges ved behandling\ud
av hjerneslag er avhengig av flere faktorer, som blant annet effektivitet og\ud
pris.\ud
Kunnskapssenteret ble bedt om å gjøre en helseøkonomisk evaluering av alternative\ud
behandlingsmetoder ved hjerneslag.\ud
Hovedfunn\ud
Intravenøs trombolytisk behandling gitt innen tre timer etter akutt hjerneslag\ud
gir både høyere helsegevinst og lavere kostnader sammenlignet\ud
med ingen trombolytisk behandling.\ud
Trombolytisk behandling gitt mellom tre og fem timer etter hjerneslag er\ud
kostnadseffektivt i Kunnskapssenterets analyser, men bør vurderes nøye\ud
i et etisk perspektiv fordi slik behandling ser ut til å medføre både kortere\ud
forventet levetid og lavere livskvalitet sammenlignet med ingen trombolytisk\ud
behandling.\ud
Som sekundærforebygging etter hjerneslag, gir kombinasjonsbehandling\ud
med acetylsalisylsyre og dipyridamol større helsegevinst og reduserte\ud
livstidskostnader sammenlignet med acetylsalisylsyre alene. Sammenlignet\ud
med klopidogrel gir kombinasjonsbehandling med acetylsalisylsyre\ud
og dipyridamol også noe helsegevinst og reduserte livstidskostnader.\ud
For pasienter med hjerneslag som også har atrieflimmer, var antikoagulasjonsbehandling\ud
med warfarin dominant strategi (lavere kostnader og\ud
mer effektivt) som sekundærprofylakse sammenlignet med acetylsalisylsyre.\ud
Intravenøs trombolytisk behandling\ud
av hjerneinfarkt i\ud
akuttfasen og sekundær blodproppforebyggende\ud
behandling\ud
(platehemmende behandling\ud
og antikoagulasjonsbehandling)\ud
etter hjerneslag\ud
--------------------------------\ud
Hva slags rapport\ud
er dette?\ud
Medisinsk metodevurdering\ud
En medisinsk metodevurdering\ud
er resultatet av en systematisk\ud
oppsummering av\ud
forskningsbasert kunnskap\ud
med minst ett av følgende\ud
tillegg: vurdering av etiske,\ud
juridiske og/eller organisatoriske\ud
og sosiale konsekvenser\ud
---------------------------------Background\ud
Stroke is the third most common cause of death, a major cause of severe disability\ud
and accounts for considerable consumption of healthcare resources.\ud
Which medication should be chosen for the treatment of stroke depends on several\ud
factors, including efficiency and price.\ud
Task requirement\ud
The Norwegian Directorate of Health’s development groups for the preparation\ud
of national clinical guideline for stroke have commissioned the Norwegian\ud
Knowledge Centre for the Health Services to conduct economic evaluations of\ud
some central recommendations in the stroke guideline. We evaluated the clinical\ud
efficacy and conducted health economic evaluation of:\ud
1. Intravenous thrombolytic treatment of patients with acute stroke (within 3\ud
hours and between 3 to 5 hours after symptom onset) in addition to standard\ud
treatment compared to treatment without thrombolysis\ud
2. Pharmacological secondary prevention of stroke\ud
Antiplatelet therapy: acetylsalicylic acid (ASA) combined with\ud
slow-release dipyridamole compared with ASA monotherapy\ud
Antiplatelet therapy: ASA combined with slow-release dipyridamole\ud
compared with clopidogrel monotherapy\ud
Anticoagulation therapy with warfarin compared with ASA for\ud
prophylaxis of stroke in patients with atrial fibrillation\ud
Main Results\ud
Thrombolytic treatment within 3 hours after stoke reduces lifetime costs\ud
and adds quality-adjusted life years (QALYs) compared with standard\ud
treatment without thrombolysis for selected stroke patients.\ud
Thrombolysis given between 3 and 5 hours after stroke is cost-effective\ud
compared to no thrombolytic treatment. However, the choice of thrombolysis\ud
in this time interval should also be carefully considered from an\ud
ethical perspective, because it leads to shorter life expectancy relative to\ud
no thrombolytic treatment.\ud
The combination of ASA and extended-release dipyridamole increases\ud
QALYs and reduces lifetime costs compared with ASA monotherapy in\ud
secondary prevention of stroke.\ud
Intravenous thrombolytic\ud
treatment after acute stroke\ud
and secondary antithrombotic\ud
prevention treatment\ud
(antiplatelet and anticoagulant\ud
treatment) after stroke\ud
-------------------------------\ud
What kind of\ud
report is this?\ud
Health technology assessment\ud
-------------------------------\ud
Who produced\ud
it?\ud
-The Norwegian Knowledge\ud
Centre for the Health Services\ud
on behalf of the Norwegian\ud
Directorate of Healt
Vurdering av elementer som kan inngå i et nasjonalt kvalitetssystem for primærhelsetjenesten
No full textThe Norwegian Knowledge Center for the Health Services was commissioned by The\ud
Department of Health and the Directorate of Health, to survey and recommend\ud
elements to be included in a national quality system for the primary health services.\ud
These are the main recommendations from the present report:\ud
The goals for a national quality system for the primary health care should be\ud
documentation and visibility of quality, learning and quality improvement in a\ud
coordinated way, in all four levels of services; the health care worker /patient\ud
level, the health organizational level, the municipality level and the national\ud
level.\ud
In order to efficiently contribute to quality improvement, a partnership model\ud
for development and implementation should be adopted, with involvement of\ud
patients and users, and all stakeholders in the process.\ud
Patients and users need available and understandable information about quality\ud
of the services, and should to a larger extent than today be given the\ud
opportunity to query information on quality and safety, and contribute in the\ud
development of quality of the services.\ud
The quality of the services should be measured and visualized in a way that is\ud
useful for patients and health workers own quality improvement work.\ud
The development of quality indicators for all services in primary health care is\ud
an essential element of a national quality system. These should be developed\ud
according to the principles outlined in the report: Conceptual Framework for a\ud
National Healthcare Quality Indicator System in Norway - Recommendations\ud
(8).\ud
The lack of IKT programmes, equipment, coordination and functions in relation\ud
to possible retrieval, processing, and analysing data is a major obstacle for\ud
documentation of the quality of the services.\ud
In order to compare measures for quality through benchmarking, structured\ud
and goal oriented processes need to be in place in each of the services. This can\ud
be done in relation to local challenges, or by regional or national processes.\ud
Leaders on the national and municipality levels, and the leaders of the\ud
individual services, should to a larger extent than today query about quality of\ud
the services and make sure documentation of quality is in place. Annual quality\ud
reports from the individual services and the municipalities. In addition there is\ud
9 Key messages\ud
a need for more focus on patient safety, and a system for registering unwanted\ud
incidents may be established, as it is in the specialized health care services. The\ud
focus for such a registry should be on understanding the mechanisms and\ud
learning.\ud
To have the right competence in place is important to ensure and develop\ud
quality in the primary health care services. Both professional knowledge and\ud
quality improvement knowledge is important to ensure and develop quality of\ud
the services. Knowledge and skills in both evidence based practice and quality\ud
improvement is should to a larger extent than today be included in the basic\ud
education of health care workers, as well as in their postgraduate further\ud
education.\ud
More research is needed about quality improvement in the primary care sector.\ud
Improvement projects should be followed by evaluation, as should the\ud
implementation of a national quality system in the primary care services.\ud
To give push, pull and direction in the quality documentation, visualization and\ud
improvement work, we propose establishing a unit with particular responsibility\ud
to develop and implement at national quality system for the primary health\ud
services. Such a unit needs to coordinate and further develop the work already\ud
in place today, and establish technical and process support for the locally based\ud
quality improvement work. The main focus of the work should be learning and\ud
quality improvement, and user involvement is understood.\ud
Anchoring the work in the health laws would be a tremendous help in getting\ud
increased focus and resources for an increased and coordinated effort towards\ud
better quality
The prevalence of alcohol and drugs in sampled oral fluid is related to sample volume.
No full textAbout 22,000 samples of oral fluid have been collected in five population studies in Norway using either the Intercept or Statsure oral fluid sampling devices. The prevalence of alcohol and drugs was found to be higher in oral fluid samples with small volumes than in those with large volumes for both sampling devices; the largest differences were observed for tetrahydrocannabinol, alcohol, amphetamines, and cocaine/benzoylecgonine when using the Statsure device. Our recommendation is that samples of oral fluid with smaller volume than required by the analytical methods should not be discarded, but instead be analyzed using a smaller sample volume, if necessary, after dilution. If not analyzed, positive drug cases will be missed, and the total prevalence of alcohol and drugs in the population being studied will be underestimated
