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Kvalitetsindikatorer basert på data fra medisinske kvalitetsregistre
No full text1-PAGE KEY MESSAGES:\ud
Refining and expanding the national performance measurement system to include a set of core measures for public reporting, is one explicit goal of the Norwegian government. Calculation of many such measures may require access to patient-level data from e.g. administrative files, medical records or quality registries.\ud
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We performed a model-based evaluation to give advice on whether valid, reliable and evidence-based quality indicators may be developed with data from existing national quality registries. There are approximately 30 such registries in Norway, mainly covering hospital care and a range of clinical areas. Diabetes was chosen as a model for the evaluation. We designed the evaluation process in accordance with acknowledged international methods, in order to demonstrate how quality indicators can be developed and tested with a scientific approach and in a transparent manner. Process and outcome measures for diabetes, chosen in ongoing collaborative projects in which the Nordic countries participate (OECD, Nordic Council of Ministers, WHO), as well as the ones used for public reporting in Denmark and Sweden, formed the main basis for our model.\ud
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The indicators for diabetes currently in use in the evaluated measurement systems seem to be based on broad professional consensus, as expressed in evidence-based international guidelines and a systematic review prepared by the Danish indicator project. Norwegian clinical guidelines also give support to the validity of these indicators. The set of measures varied somewhat between the systems, probably due to variations in data availability, but also because of differences in purpose and scope of the reporting systems. We also found that the Norwegian quality registries for adult and childhood diabetes enter pertinent information necessary for calculation of all selected measures. However, data from these registers can not be further validated with regard to precision and minimum bias, until earliest in 2009, when both registers have been in operation for one year.\ud
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Partly due to legal requirements to obtain patients' permission, and voluntary cooperation from health personnel to enter data manually, we judge data quality in the registries to be suboptimal for indicator report retrieval, until the registries can supplemented and quality assured by linkage with hospital administrative files. Even a better option will be the development of a web-based information technology for interactive data entry from electronic medical records; however this technology will probably not be available in the near future.\ud
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In the meantime, we propose to base further development of existing and new indicators for diabetes, on an alternative dataset extracted for the period 2003-2007 from hospital administrative files, linked and matched with laboratory data and relevant public registries. This project will also have relevance for problems which have to be addressed if other quality registries are to be evaluated for indicator report retrieval
Atomtrusler
No full textThe likelihood for a severe nuclear or radiological incident to occur and have impact in Norway\ud
or to Norwegian interests is regarded to be small. But if such an incident was to occur, the\ud
consequences for Norwegian citizens, environment or society may be considerable. Some parts of\ud
the population, especially with connection to reindeer herding or outdoor use, are particularly\ud
vulnerable.Sannsynligheten for at en alvorlig atomhendelse skal inntreffe og ramme Norge eller norske\ud
interesser vurderes som liten. Men hvis en hendelse først inntreffer, kan det medføre svært store\ud
helsemessige, miljømessige eller andre samfunnsmessige konsekvenser. Enkelte grupper i\ud
befolkningen, særlig knyttet til reindrift eller utmarksbruk, er spesielt sårbare
Medikamentell vedlikeholdsbehandling av gravide med opioidavhengighet
No full textBACKGROUND: The Norwegian Directorate of Health commissioned the Norwegian Knowledge Centre for the Health Services (NOKC) to do a review about the effects of opioid agonist treatment for pregnant opioid dependent women. The review would help answer the question of whether and how opioid dependence in pregnant women should be managed with the opioid agonists methadone and buprenorphine. The issue to be addressed was what kind of treatment effects methadone and buprenorphine medication caused during pregnancy on mother and child, compared to other or no treatment. We examined four effect questions: (1) Different dose levels of methadone; (2) Standard methadone maintenance treatment (MMT) versus enhanced MMT; (3) MMT versus other opioid agonist treatment (buprenorphine, slow-release morphine, Natrexone implant treatment (NIT)); (4) MMT versus no medical maintenance treatment. We focused on the effects of such treatments on the opioid dependent women and their children.\ud
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METHODS: In June 2007, we searched systematically for relevant literature in international scientific databases, selected studies according to pre-set criteria, appraised the methodological quality using checklists, and summarised the results in tables and in meta-analyses. We analysed the studies according to the four above mentioned foci.\ud
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RESULTS: We included and summarised results from a total of 30 studies; four randomised controlled trials, one non-randomised clinical control trial and 25 non-randomised effect evaluations. Most studies were of medium or low quality and GRADE showed that the quality of the evidence was very low or low for all outcomes. With respect to dose level, there were too few studies and they were too heterogenous for us to perform any meta-analysis. This was true also for the question of standard versus enhanced MMT. With respect to the question of effect differences between MMT and buprenorphine, the meta-analysis showed that treatment with buprenorphine resulted in more mothers keeping custody of their children. However, GRADE documented very low quality for this outcome. According to our meta-analysis, methadone resulted in significantly fewer incidences of Neonatal Abstinence Syndrome (NAS) compared to slow-release morphine, but GRADE showed very low quality for this outcome. Lastly, with respect to effect differences between MMT and no medical maintenance treatment the meta-analyses showed that there were more cases of NAS among newborns of mothers receiving MMT compared to newborns of mothers receiving no treatment, and a longer treatment period was needed for these babies. However, women receiving MMT reported more prenatal visits, gave birth to babies with higher birth weight and gestation age, and these women were more likely to keep custody of their child compared to women receiving no treatment. GRADE showed very low quality for these outcomes.\ud
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CONCLUSION: The evidence base in this review was of very low quality and several questions could not be adequately answered. The current evidence base is insufficient to draw conclusions regarding the differential effects of various methadone dosages and standard versus enhanced MMT. Our meta-analyses suggested that there is an increased risk of NAS among newborns of mothers receiving MMT, and a longer treatment period is required. On the other hand, MMT led to some positive outcomes such as higher birth weight and parental custody. The evidence base included in this review was of low quality and the results are therefore tentative. There is an urgent need for more studies of high quality on the effects of medical maintenance treatment for opioid dependent pregnant women
Sikkerhet og klinisk effekt av hudgjennomtrengende fokusert ultralyd som metode for varig fjerning av uønsket kroppsfett
No full textBruk av hudgjennomtrengende fokusert ultralyd (Ultrashape, LipoSonix) markedsføres som en sikker ikke-kirurgisk metode for varig fjerning av uønsket kroppsfett. Vi har på oppdrag fra Forbrukerombudet utformet en sammenfatning av forskningsgrunnlaget for om metoden er sikker og om den virker (klinisk effekt).\ud
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Vi fant at forskningsgrunnlaget er begrenset til to små studier av henholdsvis 137 og 30 friske og normalvektige personer med inntil 12 ukers oppfølging etter behandling. Den største studien sammenlikner effektmålene for de 137 behandlete med en gruppe av 27 ubehandlete.\ud
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* I studiene ble ingen alvorlige tidlige komplikasjoner rapportert, men henholdsvis 5 og 7 prosent av personene som ble behandlet, fikk lette bivirkninger.\ud
* Begge studiene rapporterte reduksjon av tykkelsen på fettlaget og omfanget av behandlet kroppsdel. Vi fant at studiene ikke er egnet til å utelukke placeboeffekter, påvirkning fra operatør eller forekomst av sjeldne eller langsiktige komplikasjoner. Studiene gir heller ikke informasjon om varighet av en eventuell effekt utover 12 uker.\ud
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Vi konkluderer med at det er usikkert om fokusert ultralyd er en sikker og virksom metode for varig fjerning av uønsket kroppsfett
Peripheral pulmonary nodules: relationship between multi-slice spiral CT perfusion imaging and tumor angiogenesis and VEGF expression.
No full textBACKGROUND: The aim of this study is to investigate the relationship between 16-slice spiral CT perfusion imaging and tumor angiogenesis and VEGF (vascular endothelial growth factor) expression in patients with benign and malignant pulmonary nodules, and differential diagnosis between benign and malignant pulmonary nodules. METHODS: Sixty-four patients with benign and malignant pulmonary nodules underwent 16-slice spiral CT perfusion imaging. The CT perfusion imaging was analyzed for TDC (time density curve), perfusion parametric maps, and the respective perfusion parameters. Immunohistochemical findings of MVD (microvessel density) measurement and VEGF expression was evaluated. RESULTS: The shape of the TDC of peripheral lung cancer was similar to those of inflammatory nodule. PH (peak height), PHpm/PHa (peak height ratio of pulmonary nodule to aorta), BF (blood flow), BV (blood volume) value of peripheral lung cancer and inflammatory nodule were not statistically significant (all P > 0.05). Both showed significantly higher PH, PHpm/PHa, BF, BV value than those of benign nodule (all P < 0.05). Peripheral lung cancer showed significantly higher PS (permeability surface) value than that of inflammatory nodule and benign nodule (all P < 0.05). BV, BF, PS, MTT, PH, PHpm/PHa, and MVD among three groups of peripheral lung cancers were not significantly (all P > 0.05). In the case of adenocarcinoma, BV, BF, PS, PHpm/PHa, and MVD between poorly and well differentiation and between poorly and moderately differentiation were statistically significant (all P < 0.05). The peripheral lung cancers with VEGF positive expression showed significantly higher PH, PHpm/PHa, BF, BV, PS, and MVD value than those of the peripheral lung cancer with VEGF negative expression, and than those of benign nodule with VEGF positive expression (all P < 0.05). When investigating VEGF negative expression, it is found that PH, PHpm/PHa, and MVD of inflammatory nodule were significantly higher than those of peripheral lung cancer, PS of inflammatory nodule were significantly lower than that of peripheral lung cancer (all P < 0.05). PH, PHpm/PHa, BF, and BV of benign nodule were significantly lower than those of inflammatory nodule (all P < 0.05), rather than PS and MTT (mean transit time) (all P > 0.05). PH, PHpm/PHa, BV, and PS of benign nodule were significantly lower than those of peripheral lung cancer (all P < 0.05). In the case of VEGF positive expression, MVD was positively correlated with PH, PHpm/PHa, BF, BV, and PS of peripheral lung cancer and PS of benign nodule (all P < 0.05). CONCLUSION: Multi-slice spiral CT perfusion imaging closely correlated with tumor angiogenesis and reflected MVD measurement and VEGF expression. It provided not only a non-invasive method of quantitative assessment for blood flow patterns of peripheral pulmonary nodules but also an applicable diagnostic method for peripheral pulmonary nodules
The key to reducing duration of untreated first psychosis: information campaigns.
No full textThe TIPS early intervention program reduced the duration of untreated psychosis (DUP) in first-episode schizophrenia from 16 to 5 weeks in a health care sector using a combination of easy access detection teams (DTs) and a massive information campaign (IC) about the signs and symptoms of psychosis. This study reports what happens to DUP and presenting schizophrenia in the same health care sector when the IC is stopped. METHODS: Using an historical control design, we compare 2 cohorts of patients with first-episode Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, non-affective psychosis at admission to treatment. The first cohort (N = 108) was recruited from January 1997 to December 2000, using an IC to raise awareness about recognizing psychosis to the public, the schools, and to general practitioners. The second cohort (N = 75) was recruited from January 2002 to June 2004 with no-IC. Easy access DTs were available to both cohorts. RESULTS: In the no-IC period, DUP increased back up to 15 weeks (median) and fewer patients came to clinical attention through the DTs. No-IC patients were diagnosed less frequently with schizophreniform disorder, more Positive and Negative Syndrome Scale positive and total symptoms, and poorer Global Assessment of Functioning (symptom) Scale scores. CONCLUSIONS: Intensive education campaigns toward the general public, the schools, and the primary health care services appear to be an important and necessary part of an early detection program. When such a campaign was stopped, there was a clear regressive change in help-seeking behavior with an increase in DUP and baseline symptoms
Pre-hospital advanced airway management by anaesthesiologists: Is there still room for improvement?
No full textABSTRACT: BACKGROUND: Endotracheal intubation is an important part of pre-hospital advanced life support that requires training and experience, and should only be performed by specially trained personnel. In Norway, anaesthesiologists serve as Helicopter Emergency Medical Service HEMS physicians. However, little is known about how they themselves evaluate the quality and safety of pre-hospital advanced airway management. METHOD: Using a semi-structured questionnaire, we interviewed anaesthesiologists working in the three HEMS programs covering Western Norway. We compared answers from specialists and non-specialists as well as full- and part-time HEMS physicians. RESULTS: Of the 17 available respondents, most (88%) felt that their continuous exposure to intubations was not sufficient. Additional training was mainly acquired through other clinical practice and mannequin- or cadaver-based skills training. Of the respondents, 77% and 35% reported having experienced difficult and failed intubations, respectively. Further, 59% reported knowledge of airway management-related deaths in their HEMS program. Significantly more full- than part-time HEMS physicians had experienced these problems. All respondents had airway back-up equipment in their service, but 29% were not familiar with all the equipment. CONCLUSION: The majority of anaesthesiologists working as HEMS physicians view pre-hospital advanced airway management as a high-risk procedure. Relevant airway management competencies for HEMS physicians in Norway seem to be insufficiently trained and maintained. A better-defined level of competence with better training methods and systems seems warranted
Range of shoulder motion in patients with adhesive capsulitis; intra-tester reproducibility is acceptable for group comparisons.
No full textBACKGROUND: Measurements of range of motion play a key role in shoulder research. The purpose of this study is to investigate intra-observer reproducibility of measurements of active and passive range of motion in patients with adhesive capsulitis. METHODS: The study was carried out in a population consisting of 32 patients with clinical signs of adhesive capsulitis. A specified measurement protocol was used, and range of motion in affected and non-affected shoulders was measured twice for each patient with a one-week interval. RESULTS: For most of the investigated individual movements, test-retest differences in range of motion score of more than approximately 15 degrees are not likely to occur as a result of measurement error only. Point-estimates for the intraclass correlation coefficient ranged from 0.61 to 0.93. CONCLUSION: Range of motion of patients with adhesive capsulitis can be measured with acceptable reproducibility in settings where groups are compared. Scores for individual patients should be interpreted with caution
A systematic review of delay in the diagnosis and treatment of tuberculosis.
No full textBACKGROUND: Early diagnosis and immediate initiation of treatment are essential for an effective tuberculosis (TB) control program. Delay in diagnosis is significant to both disease prognosis at the individual level and transmission within the community. Most transmissions occur between the onset of cough and initiation of treatment. METHODS: A systematic review of 58 studies addressing delay in diagnosis and treatment of TB was performed. We found different definitions of, for example, debut of symptoms, first appropriate health care provider, time to diagnosis, and start of treatment. Rather than excluding studies that failed to meet strict scientific criteria (like in a meta-analysis), we tried to extract the "solid findings" from all of them to arrive on a more global understanding of diagnostic delay in TB. RESULTS: The main factors associated with diagnostic delay included human immunodeficiency virus; coexistence of chronic cough and/or other lung diseases; negative sputum smear; extrapulmonary TB; rural residence; low access (geographical or sociopsychological barriers); initial visitation of a government low-level healthcare facility, private practitioner, or traditional healer; old age; poverty; female sex; alcoholism and substance abuse; history of immigration; low educational level; low awareness of TB; incomprehensive beliefs; self-treatment; and stigma. CONCLUSION: The core problem in delay of diagnosis and treatment seemed to be a vicious cycle of repeated visits at the same healthcare level, resulting in nonspecific antibiotic treatment and failure to access specialized TB services. Once generation of a specific diagnosis was in reach, TB treatment was initiated within a reasonable period of time
Rutinemessig ultralydundersøkelse i svangerskapet
No full textKEY MESSAGES\ud
Routine ultrasound in pregnancy\ud
The Norwegian Knowledge Centre for the Health Services was asked to evaluate the\ud
clinical effect and the diagnostic value of routine ultrasound in the first, second and\ud
third trimester of pregnancy. Today all women are offered an ultrasound in the 17th to\ud
19th week of pregnancy. This routine ultrasound offer information on estimation of term,\ud
number of foetuses, detection of placenta praevia and detection of structural\ud
abnormalities and foetal develpoment. Based on the research literature we found no\ud
additional evidence in favour of introducing additional routine ultrasound in the first\ud
trimester (week 11 to 14) or in the third trimester (week 32 til 34) of pregnancy. However,\ud
an effect of introducing an early ultrasound is the information it gives if investigating\ud
foetuses for increased risk for chromosome abnormalities. If this is the aim, the early\ud
ultralsound combined with serum markers is the most effective test. Combined\ud
ultrasound and serum markers early in pregnancy give better indication for finding\ud
foetous at increased risk for chromosome abnormalitites (and therefore fewer\ud
miscarriages due to amniosenteces) than testing based on mothers’ age.\ud
Based on our review of the included literature, there does not seem to be any important\ud
differences between ultrasound in the first or second trimester with respect to term\ud
estimation. When it comes to twin pregnancies, ultrasound in the first trimester will\ud
provide added information about mono- or dichorionic placentas. Ultrasound with\ud
measurement of nuchal translucency (NT) in week 11+0 to 13+6 supplied with maternal\ud
blood tests (CUB), is effective in terms of finding foetuses at increased risk of Down’s\ud
syndrome and is associated with a higher sensitivity than ultrasound in second trimester\ud
or risk assessment based on maternal age. Severe structural abnormalities (with normal\ud
chromosomes) are more effectively detected in the second trimester. There does not\ud
seem to be any evidence in favour of routine ultrasound in the third trimester of\ud
11 Rutinemessig ultralydundersøkelse i svangerskapet | Hele rapporten i pdf format: www.kunnskapssenteret.no\ud
pregnancy as an addition to ultrasound in the first and/or second trimester on health\ud
outcomes.\ud
Ultrasound is offered to all pregnant women in weeks 17 to 19 of pregnancy and has a\ud
high uptake which indicates that women are in favour of it. Based on the literature\ud
included, it does not seem to be the case that screening programmes in the first or\ud
second trimester increase levels of anxiety or worries. For women who experience\ud
positive findings (increased risk for abnormalities) the level of anxiety increases.\ud
Although further investigations or diagnostic tests indicate that the finding was ”false\ud
positive”, these women will continue to suffer from a higher level of anxiety than other\ud
pregnant women throughout the pregnancy. Newer studies indicate that women are well\ud
informed about routine ultrasound in pregnancy, but there are challenges when\ud
informing about nuchal translucency (NT) and serum markers.\ud
Ultrasound is part of routine antenatal care in Norway and is offered from the 17th to\ud
the 19th week of pregnancy. Norwegian clinicians do not define the routine ultrasound\ud
as a screening test (Consensus report of 1995), however, in international literature it is\ud
often defined as such. The offer of routine ultrasound is based on womens’ choice. When\ud
clinicians and health authorities discuss the option of introducing more routine\ud
ultrasound scans in routine practice, they might consider the extension programme in\ud
view of requirements that are important in population screening programmes. These\ud
include documentation of diagnostic precision, effect of interventions, as well as\ud
information about the screening test and how findings are handled