Aslak Aslaksen

Ultrasound measurement of the luminal diameter of the abdominal aorta and iliac arteries in patients without vascular disease

PURPOSE The purpose of this study was to establish ultrasonographic criteria for the normal size of the abdominal aorta and iliac arteries in patients without vascular disease. METHODS The luminal diameters of the proximal and distal abdominal aorta and the common iliac arteries were measured by ultrasonography in 160 patients (15 to 89 years) who were without known vascular disease. RESULTS In patients above 50 years of age the distal aorta, which most often is involved in aneurysmatic dilations, measured 16.8 +/- 2.9 mm in men and 14.6 +/- 1.9 mm in women (p < 0.001). The diameter of the iliac artery in these patients was 10.1 +/- 2.0 mm in men and 9.2 +/- 1.3 mm in women (p < 0.001). The usually present gradual narrowing of the aorta toward the bifurcation was replaced by a slight increase (1 to 2 mm) in 5% of the men and 6% of the women. Focal areas of aortic enlargement, however, were not observed. In multivariate analysis, including age, height, body weight, and sex, the distal aortic diameter was significantly correlated only to age (r = 0.46; p < 0.001) and sex (r = -0.29; p < 0.001). With aging the mean of the proximal and distal aortic diameters increased by 0.08 and 0.05 mm/yr, respectively. Also correlated with age was a linear reduction in systolic expansion (r = -0.73; p < 0.001). CONCLUSIONS Enlargement of the distal aorta and common iliac artery should be considered when (1) the luminal diameters in men exceed 23 and 14 mm, respectively, and in women 19 and 12 mm, respectively, (2) the ratio of the proximal and distal aortic diameter exceeds 1.1, and (3) there is demonstration of focal enlargement.

Sustainability of healthcare improvement: what can we learn from learning theory?

BackgroundChanges that improve the quality of health care should be sustained. Falling back to old, unsatisfactory ways of working is a waste of resources and can in the worst case increase resistance to later initiatives to improve care. Quality improvement relies on changing the clinical system yet factors that influence the sustainability of quality improvements are poorly understood. Theoretical frameworks can guide further research on the sustainability of quality improvements. Theories of organizational learning have contributed to a better understanding of organizational change in other contexts. To identify factors contributing to sustainability of improvements, we use learning theory to explore a case that had displayed sustained improvement.MethodsFørde Hospital redesigned the pathway for elective surgery and achieved sustained reduction of cancellation rates. We used a qualitative case study design informed by theory to explore factors that contributed to sustain the improvements at Førde Hospital. The model Evidence in the Learning Organization describes how organizational learning contributes to change in healthcare institutions. This model constituted the framework for data collection and analysis. We interviewed a strategic sample of 20 employees. The in-depth interviews covered themes identified through our theoretical framework. Through a process of coding and condensing, we identified common themes that were interpreted in relation to our theoretical framework.ResultsClinicians and leaders shared information about their everyday work and related this knowledge to how the entire clinical pathway could be improved. In this way they developed a revised and deeper understanding of their clinical system and its interdependencies. They became increasingly aware of how different elements needed to interact to enhance the performance and how their own efforts could contribute.ConclusionsThe improved understanding of the clinical system represented a change in mental models of employees that influenced how the organization changed its performance. By applying the framework of organizational learning, we learned that changes originating from a new mental model represent double-loop learning. In double-loop learning, deeper system properties are changed, and consequently changes are more likely to be sustained.

Impaired accommodation of the proximal stomach in children with recurrent abdominal pain

BACKGROUND A new ultrasonographic method was applied in children with recurrent abdominal pain, to study accommodation of the proximal stomach to a meal. METHODS After an overnight fast, 20 patients with recurrent abdominal pain (age, 7-14 years) and 23 healthy control subjects (age, 7-13 years), were scanned by a 5-MHz transducer positioned in the epigastrium, to monitor the size of the proximal stomach before and after a test meal of meat soup. RESULTS Children with recurrent abdominal pain had a significantly smaller sagittal area of the proximal stomach at 10 and 20 minutes after the meal than in healthy control subjects (P = 0.01 for both) and significantly higher emptying fraction of the proximal stomach at 10 minutes after the meal than in healthy control subjects (P = 0.02). There was no significant difference in emptying of the distal stomach between the patients and healthy control subjects. Children with recurrent abdominal pain experienced more symptoms (pain, bloating) in response to the test meal than did healthy control subjects. CONCLUSION The results support the view that recurrent abdominal pain in children may be a motility disorder that can be detected in the proximal stomach as an impairment of adaptive relaxation in response to a meal. This new ultrasonographic method may become a valuable diagnostic tool in patients with recurrent abdominal pain.

A new pathway for elective surgery to reduce cancellation rates

BackgroundThe cancellation of planned surgeries causes prolonged wait times, harm to patients, and is a waste of scarce resources. To reduce high cancellation rates in a Norwegian general hospital, the pathway for elective surgery was redesigned. The changes included earlier clinical assessment of patients, better planning and documentation systems, and increased involvement of patients in the scheduling of surgeries. This study evaluated the outcomes of this new pathway for elective surgery and explored which factors affected the outcomes.MethodsWe collected the number of planned operations, performed operations, and cancellations per month from the hospital’s patient administrative system. We then used Students t-test to analyze differences in cancellation rates (CRs) before and after interventions and a u-chart to analyze whether the improvements were sustained. We also conducted semi-structured interviews with employees of the hospital to explore the changes in the surgical pathway and the factors that facilitated these changes.ResultsThe mean CR was reduced from 8.5% to 4.9% (95% CI for mean reduction 2.6-4.5, p < 0.001). The reduction in the CR was sustained over a period of 26 months after the interventions. The median number of operations performed per month increased by 17% (p = 0.04). A clear improvement strategy, involvement of frontline clinicians, introduction of an electronic scheduling system, and engagement of middle managers were important factors for the success of the interventions.ConclusionThe redesign of the old clinical pathway contributed to a sustained reduction in cancellations and an increased number of performed operations.

Patient experiences with interventions to reduce surgery cancellations: a qualitative study

BackgroundThe cancellation of planned surgery harms patients, increases waiting times and wastes scarce health resources. Previous studies have evaluated interventions to reduce cancellations from medical and management perspectives; these have focused on cost, length of stay, improved efficiency, and reduced post-operative complications. In our case a hospital had experienced high cancellation rates and therefore redesigned their pathway for elective surgery to reduce cancelations. We studied how patients experienced interventions to reduce cancellations.MethodsWe conducted a comparative, qualitative case study by interviewing 8 patients who had experienced the redesigned pathway, and 8 patients who had experienced the original pathway. We performed a content analysis of the interviews using a theory-based coding scheme. Through a process of coding and condensing, we identified themes of patient experience.ResultsWe identified three common themes summarizing patients’ positive experiences with the effects of the interventions: the importance of being involved in scheduling time for surgery, individualized preparation before the hospital admission, and relationships with few clinicians during their hospital stay.ConclusionsPatients appreciated the effects of interventions to reduce cancellations, because they increased their autonomy. Unanticipated consequences were that the telephone reminder created a personalized dialogue and centralization of surgical preparation and discharge processes improved continuity of care. Thus apart from improving surgical logistics, the pathway became more patient-centered.

Recommended content of referral letters from general practitioners to specialised mental health care: a qualitative multi-perspective study

BackgroundIn most Western countries, the referral letter forms the basis for establishing the priority of patients for specialised health care and for the coordination of care between the services. To be able to define the quality of referral letters, the potential impact of the quality on the organisation of care, and to improve the quality of the letters, we need a multidimensional definition of the ideal content. The study’s aim was to explore what information is seen as most important and should be included in referral letters from primary care to specialised mental health care to facilitate prioritisation and planning of treatment and follow-up of the patients.MethodsBased on purposive sampling, four mixed discussion groups, which included general practitioners, mental health nurses from primary health care, psychiatrists and psychologists from specialised mental health care, managers and patient representatives, were formed; they were asked to identify the information they considered important in a mental health referral letter. In line with the Delphi technique, the importance of the themes was later individually rated by the participants. The study was conducted within The Western Norway Regional Health Authority.ResultsThe four groups identified 174 information themes. After excluding themes that were assessed as duplicates, replaceable or less important, 40 themes were suggested, organised in seven units. A set of check-off points of essential information is recommended as an introduction in the referral letter.ConclusionCompared with general guidelines and guidelines for somatic care, the results of this study suggest that the referral letter to specialised mental health care should have a larger emphasis on the overall treatment plan, on the specific role of specialised health care in the continuum of care, and on patient involvement. Further research should evaluate the validity of these findings for other patient groups in need of integrated care and investigate how the quality of referral letters affects patient-related and organisational outcomes.Trial RegistrationTrial Registration number: NCT01374035

Quality indicators for the referral process from primary to specialised mental health care: an explorative study in accordance with the RAND appropriateness method.

BackgroundCommunication between involved parties is essential to ensure coordinated and safe health care delivery. However, existing literature reveals that the information relayed in the referral process is seen as insufficient by the receivers. It is unknown how this insufficiency affects the quality of care, and valid performance measures to explore it are lacking. The aim of the present study was to develop quality indicators to detect the impact that the quality of referral letters from primary care to specialised mental health care has on the quality of mental health services.MethodsUsing a modified version of the RAND/UCLA appropriateness method, a systematic literature review and focus group interviews were conducted to define quality indicators for mental health care expected to be affected by the quality of referral information. Focus group participants included psychiatrists, psychologists, general practitioners, patient representatives and managers. The existing evidence and suggested indicators were presented to expert panels, who assessed the indicators by their validity, reliability, sensitivity and feasibility.ResultsSixteen preliminary indicators emerged during the focus group interviews and literature review. The expert panels recommended four of the 16 indicators. The recommended indicators measure a) timely access, b) delay in the process of assessing the referral, c) delay in the onset of care and d) the appropriateness of the referral. Adjustment was necessary for five other indicators, and seven indicators were rejected because of expected confounding factors reducing their validity and sensitivity.ConclusionsThe quality of information relayed in the referral process from primary care to specialised mental health care is expected to affect a wide range of dimensions defining high quality care. The expected importance of the referral process for ensuring ‘timely access’-one of the six aims of high-quality health care defined by the Institute of Medicine-is highlighted. Exploring the underlying mechanisms for the potential impact of referral information on patient outcomes is recommended to enhance quality of care.Trial registrationClinicalTrials.gov: NCT01374035 (28 April 2011).

Development and testing of an instrument in Western Norway to measure the quality of referral information from primary care to specialised mental health care

Introduction Several studies have indicated that medical referral letters do not convey the necessary information to ensure sufficient coordination of care. However, there is no definition of the core set of information items that should be communicated in a referral process, and no valid measurements to assess, and thus improve, the quality of such information. The present study aimed to develop and test an instrument to measure the quality of referral information provided by general practitioners to specialised mental health care services for adults. Methods Based on a recommendation taking the users’ standpoint into account, a minimum set of items for referral communication seen as essential by experienced specialists (N = 42) was developed. An instrument to assess the quality of referral information for specialised mental health care for adults was then examined based on its psychometric properties. The examination was conducted within the region of Western Norway Regional Health Authority (www.helse-vest.no), representing the public specialised mental health care for approximately 1 million citizens. Results Nineteen items were recommended, and the instrument was found valid and reliable. The inter-rater correlation varied, and the test–retest was found to be substantial or almost perfect for a majority of the raters. Discussion This study embeds an exploration of improvement potential, impact of quality improvement efforts and sustainability of such efforts for facilitating effective communication in the interface between the two main health services for people with mental health problems. Further exploration on the instruments generalisability to other contexts and to the inter-rater correlation are recommended.

Ultrasonography Versus Urography as Preoperative Investigation Prior to Hysterectomy

Ultrasonography (US) has been compared with urography (IVU) as a preoperative investigation prior to hysterectomy in 62 patients. In 38 patients the urinary tract was deemed normal by both US and IVU. US and IVU coincided in varying degrees of hydronephrosis in 8 patients and disagreed in one. Of 5 double ureters, US missed 2. IVU showed expansile lesions in 5 kidneys where US showed benign cysts. No severe contrast media reactions were observed. We recommend that preoperative urography should be replaced by preoperative ultrasonography when a screening examination of the upper urinary tract morphology is deemed necessary prior to hysterectomy.

Radiological screening of the upper urinary tract prior to pelvic surgery

Intravenous urography has been a standard preoperative procedure prior to gynecologic operations in some parts of the world, to screen for occult renal disease and to prevent ureteral injury. There is a lack of evidence for any value of preoperative screening for these reasons. In staging cervical cancer, urography has been considered necessary to depict the degree of obstruction, as hydronephrosis is considered a sign of pelvic infiltration and thereby a higher tumor stage. There is good correlation between ultrasonography and urography in detecting hydronephrosis, and we recommend that the preoperative urogram be replaced by a preoperative ultrasonogram when a preoperative investigation is deemed necessary.