The involvement of medical doctors in hospital governance and implications for quality management: a quick scan in 19 and an in depth study in 7 OECD countries.

BACKGROUND: Hospital governance is broadening its orientation from cost and production controls towards 'improving performance on clinical outcomes'. Given this new focus one might assume that doctors are drawn into hospital management across OECD countries. Hospital performance in terms of patient health, quality of care and efficiency outcomes is supposed to benefit from their involvement. However, international comparative evidence supporting this idea is limited. Just a few studies indicate that there may be a positive relationship between medical doctors being part of hospital boards, and overall hospital performance. More importantly, the assumed relationship between these so-called doctor managers and hospital performance has remained a 'black-box' thus far. However, there is an increasing literature on the implementation of quality management systems in hospitals and their relation with improved performance. It seems therefore fair to assume that the relation between the involvement of doctors in hospital management and improved hospital performance is partly mediated via quality management systems. The threefold aim of this paper is to 1) perform a quick scan of the current situation with regard to doctor managers in hospital management in 19 OECD countries, 2) explore the phenomenon of doctor managers in depth in 7 OECD countries, and 3) investigate whether doctor involvement in hospital management is associated with more advanced implementation of quality management systems. METHODS: This study draws both on a quick scan amongst country coordinators in OECD's Health Care Quality Indicator program, and on the DUQuE project which focused on the implementation of quality management systems in European hospitals. RESULTS: This paper reports two main findings. First, medical doctors fulfil a broad scope of managerial roles at departmental and hospital level but only partly accompanied by formal decision making responsibilities. Second, doctor managers having more formal decision making responsibilities in strategic hospital management areas is positively associated with the level of implementation of quality management systems. CONCLUSIONS: Our findings suggest that doctors are increasingly involved in hospital management in OECD countries, and that this may lead to better implemented quality management systems, when doctors take up managerial roles and are involved in strategic management decision making

An improvement of the Berry--Esseen inequality with applications to Poisson and mixed Poisson random sums

By a modification of the method that was applied in (Korolev and Shevtsova, 2009), here the inequalities $$\rho(F_n,\Phi)\le\frac{0.335789(\beta^3+0.425)}{\sqrt{n}}$$ and $$\rho(F_n,\Phi)\le \frac{0.3051(\beta^3+1)}{\sqrt{n}}$$ are proved for the uniform distance $\rho(F_n,\Phi)$ between the standard normal distribution function $\Phi$ and the distribution function $F_n$ of the normalized sum of an arbitrary number $n\ge1$ of independent identically distributed random variables with zero mean, unit variance and finite third absolute moment $\beta^3$. The first of these inequalities sharpens the best known version of the classical Berry--Esseen inequality since $0.335789(\beta^3+0.425)\le0.335789(1+0.425)\beta^3<0.4785\beta^3$ by virtue of the condition $\beta^3\ge1$, and 0.4785 is the best known upper estimate of the absolute constant in the classical Berry--Esseen inequality. The second inequality is applied to lowering the upper estimate of the absolute constant in the analog of the Berry--Esseen inequality for Poisson random sums to 0.3051 which is strictly less than the least possible value of the absolute constant in the classical Berry--Esseen inequality. As a corollary, the estimates of the rate of convergence in limit theorems for compound mixed Poisson distributions are refined.Comment: 33 page

Мультимодальна покрокова тактика хірургічного лікування хворих з гострим некротичним панкреатитом

Мета. Оцінити ефективність розробленої тактики мультимодального покрокового хірургічного лікування гострого некротичного панкреатиту (ГНП). Матеріали і методи. Проаналізовано результати лікування 317 хворих з ГНП, яким протягом 2013-2017 рр. застосовували запропоновану тактику виконання хірургічних втручань. Для оцінки ефективності лікування вивчали вперше виявлену органну недостатність (ОН) після операції, тривалість інтенсивної терапії, післяопераційні ускладнення та летальність. Результати. Застосування запропонованої тактики забезпечило зменшення частоти виконання широкої лапаротомної некрсеквестректомії до 14,5% та відтермінування його на строк після 4-го тижня від початку захворювання у 82,6% оперованих пацієнтів. У післяопераційному періоді ускладнення спостерігали у 28,3% пацієнтів, загальна летальність становила 3,5%, після виконання широких лапаротомних некрсеквестректомій - 6,5%. Висновки. Використання мультимодальної покрокової тактики хірургічного лікування хворих з ГНП забезпечує зменшення частоти виконання широкої лапаротомної некрсеквестректомії та частоти виникнення післяопераційних ускладнень

Purulent-septic complications of acute necrotizing pancreatitis: prognosis of development and early diagnosis

Aim. To determine frequency and causes of purulent-septic complications of acute necrotizing pancreatitis, to elaborate and introduce into clinical practice prognostic and early diagnostic criteria for infection of pathological foci in the pancreas. Material and methods. Prospective cohort study of 70 patients with severe acute necrotizing pancreatitis was performed in one intensive care department during the years 2015-2019. Clinical, bacteriological and instrumental examinations were carried out. Serum concentration of sCD14 receptors and presepsin were determined. Results. Overall mortality rate reached 18.8 %, but it was twice as high in patients with purulent-septic complications (P < 0.05). Primary infection of pancreatic necrotic tissues was diagnosed in 21 (55.7 %) patients. Secondary infection of pathological foci was identified in 22 (57.9 %) patients who had been operated before the 4th week and in 6 (18.6 %) – at latter periods of the disease onset. It was found that the serum content of sCD14 receptors above 1670 ng/ml at admission had been served as an independent prognostic criterion for the development of purulent-septic complications (sensitivity – 87 %, specificity – 81 %). The level of presepsin was three-four times higher in the patients with infectious complications than that in the individuals with sterile pancreatic necrosis (P < 0.01). The study showed strong correlation between presepsin concentration and infectious complications: presepsin level increased to 677 ± 30 pg/ml in patients with local purulent processes, to 988 ± 47 pg/ml – with sepsis, and to 2668 ± 583 pg/ml – with septic shock. Presepsin was the biomarker with high performance for all types of infected complications in acute necrotizing pancreatitis (ROC AUC 0.956 ± 0.007 (Р < 0.0001)). Conclusions. High level of sCD14 at admission is associated with the development of infected acute necrotizing pancreatitis. Presepsin concentration is early and highly sensitive and specific marker of purulent-septic complications in acute pancreatitis

Antibiotic resistance peculiarities of S. aureus isolates, obtained from nasal and throat mucosa of outpatients, Chernivtsi city

The purpose of this study was to determine the specificity of sensitivity to antibiotics of S. aureus strains isolated from nasal mucous membranes and tonsils, as well as to identify the factors of antibiotic resistance. Materials and methods. The pure culture method was used to study smears of the palatine tonsils, the nose and the secret of the external auditory canal of 561, 56 and 15 cultures, respectively. Identification of isolated cultures was carried out according to morphological, tinctorial, physiological and biochemical characteristics. The sensitivity of S. aureus strains to antibiotics was studied and analyzed, 211 of which were isolated from the mucous of the palatine tonsils and 18 - from the nasal mucous. All the isolated strains of S. aureus were determined for the presence of antibiotic resistance factors (FA) -ß-lactamases (BL) and penicillin-binding protein (PВPs). Results. High percentage of strains resistant to ß-lactam antibiotics and macrolides was found in both groups of studied cultures. However, the number of resistant forms to these antibiotics was higher among nasal strains. At the same time, none of the resistant strain to aminoglycosides, fluoroquinolones, lincosamides, tetracyclines, and vancomycin was detected among them. 9.57 % of the strains isolated from the tonsillar mucosa were resistant to the last one. BL and PВPs antibiotic resistance factors of isolated S. aureus strains were more frequent among nasal isolates (BL – 83.3 %, PВPs – 66.7 %) than in strains isolated from the palatine tonsils (BL – 66.3 %, PВPs – 38.6 %), P < 0.05. Sensitivity to antibiotics of S. aureus strains having both FA simultaneously (30 strains) and strains having none of them (26 strains) turned out to be different. Among the strains having both FA, 100 % were resistant to penicillin, 93.3 % to oxacillin, and 36.7 % to vancomycin. Whereas there were 3.9 %, 0.0 %, and 7.7 % strains without FA resistant to these antibiotics, respectively. Resistance to azithromycin was greater in the group of strains with FA: 26.7 % versus 7.7 % in the group without FA. The strains of both groups were highly sensitive with an insignificant difference to other studied antibiotics (aminoglycosides, fluoroquinolones, macrolides, lincosamides and tetracyclines). Conclusions. S. aureus strains isolated from the mucous membranes of the nose and tonsils differ in sensitivity to antibiotics and the presence of FA. The nasal strains of S. aureus are more likely to be resistant to ß-lactam antibiotics and macrolides. Vancomycin resistant strains of S. aureus are significantly more common among strains with FA

Dynamics of methicillin-resistant staphylococcus aureus prevalence among patients of the Chernivtsi region

The aim of this study was to analyze the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) during 2018–2020 among patients with purulent-inflammatory diseases of different localization in the Chernivtsi region. Materials and methods. A total of 804 strains of S. aureus were studied. Isolates were identified by morphological, tinctorial, physiological and biochemical characteristics, and their sensitivity to antibiotics was tested. Preparation and the susceptibility testing were performed in accordance with the recommendations of the Clinical & Laboratory Standards Institute (2017), as well as quality control of each batch of antibiotic discs (Oxoid, UK). Determination of methicillin resistance was performed by a surrogate test using a disk of 30 μg cefoxitin. Results. The significant increasing in the frequency of MRSA were found in 2020 as compared to previous years – a total of 1.6–2.0 times compared to 2018 and 2019. The difference between 2019 and 2020 was statistically significant: tφ = 2.49 (P ˂ 0.05). There was also a clear upward tendency in the isolation frequency of poly-resistant strains during the observation period. Conclusions. Significant changes in the frequency of isolation of Staphylococcus aureus strains from foci of purulent-inflammatory processes of different localization were not detected over the years of observations. There was an increase in the isolation frequency of the MRSA strains from patients with purulent-inflammatory diseases in the Chernivtsi region in 2020 mainly due to isolation of such strains from the mucous membranes of the oral cavity and tonsils. The proportion of MRSA poly-resistant strains increased significantly (almost twice) during the observation period suggesting that their spread should be monitored

Хірургічна тактика лікування гострого некротичного панкреатиту

The aim of the work: to estimate efficacy of proposed tactic of surgical treatment of acute necrotizing pancreatitis. Materials and Methods. We analyzed results of treatment of 317 patients with acute necrotizing pancreatitis in whom proposed tactic of surgical interventions was used during 2013–2019. New onset of organ failure after operation, duration of intensive care treatment, postoperative complications and mortality rates were studied. Results and Discussion. We used the step-up approach of surgical treatment which started from either diapeutic transcutaneous ultrasound-guided procedures in 48.2 % and endoscopic ultrasound-guided – in 46.2 % observations. Transcutaneous procedures were followed by less complication rate in acute necrotic collections cases whereas endoscopic interventions – in walled-off pancreatic necrosis patients. Wide laparotomic necrosectomies was applied in 14.5 % of patients after 4th week from onset. Overall mortality rate was 3.5&nbsp;%, after interventional treatment – 6.5 %. Application of step-up tactic of surgical&nbsp; treatment in patients with ANP decreases necessary in wide laparotomic necrosectomies and reduces level of postoperative complications.Цель работы: оценить эффективность разработанной хирургической тактики лечения острого некротического панкреатита. Материалы и методы. Проведенный анализ результатов лечения 317 больных острым некротическим панкреатитом, у которых в течение 2013-2019 годов использовали предложенную тактику проведения хирургических вмешательств. Для оценки эффективности лечения изучали впервые обнаруженную органную недостаточность после операции, продолжительность интенсивной терапии, послеоперационные осложнения и летальность. Результаты исследований и их обсуждение. Применяли пошаговую тактику хирургического лечения, которая начиналась с диапевтических транскутанных вмешательств у 48,2 % и эндоскопических – в 46,2 % наблюдений. Транскутанные вмешательства сопровождались меньшей частотой осложнений у больных с острыми некротическими скоплениями, а эндоскопические – у пациентов с ограниченными очагами панкреатического некроза. Широкие лапаротомные некрсеквестрэктомии выполнялись у 14,5 % наблюдений после 4 недели от начала заболевания. Общая летальность составила 3,5 %, послеоперационная – 6,5 %. Использование пошаговой хирургической тактики лечения больных острым некротическим панкреатитом уменьшает потребность в широких лапаротомных некрсеквестрэктомиях и способствует снижению уровня послеоперационных осложнений.Мета роботи: оцінити ефективність розробленої хірургічної тактики лікування гострого некротичного панкреатиту. Матеріали і методи. Проведений аналіз результатів лікування 317 хворих на гострий некротичний панкреатит, в яких протягом 2013–2019 рр. використовували запропоновану тактику проведення хірургічних втручань. Для оцінки ефективності лікування вивчали вперше виявлену органну недостатність після операції, тривалість інтенсивної терапії, післяопераційні ускладнення та летальність. Результати досліджень та їх обговорення. Застосовували покрокову тактику хірургічного лікування, яка розпочиналася з діапевтичних транскутанних втручань у 48,2 % та ендоскопічних – у 46,2 % спостережень. Транскутанні втручання супроводжувалися меншою частотою ускладень у хворих із гострими некротичними скупченнями, а ендоскопічні – у пацієнтів із відмежованими вогнищами панкреатичного некрозу. Широкі лапаротомні некрсеквестректомії виконані в 14,5 % спостережень після 4 тижня від початку захворювання. Загальна летальність становила 3,5 %, післяопераційна – 6,5 %. Використання покрокової хірургічної тактики лікування хворих на гострий некротичний панкреатит зменшує потребу в широких лапаротомних некрсеквестректоміях та сприяє зниженню рівня післяопераційних ускладнень

May Measurement Month 2017 in Russia: hypertension treatment and control-Europe

Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. May Measurement Month (MMM) is a global initiative by the International Society of Hypertension aimed at raising awareness of high BP and to act as a temporary solution to the lack of screening programs worldwide. The most recent publication compared data from three surveys performed in Russian population aged 25-64 showed that the prevalence of hypertension increased by approximately 20% from 2003 to 2013. This study presents screening data collected in 2017 though the MMM17 initiative in Russia. An opportunistic cross-sectional survey of volunteers aged ≥18 was carried out in May 2017 in 19 Russian cities. Blood pressure measurement, the definition of hypertension, and statistical analysis followed the standard MMM protocol. The recruitment of MMM17 participants in Russia occurred in shopping malls, colleges and universities, supermarkets, business centres, parks, and squares. Russian young cardiologists as an official section of Russian Society of Cardiology was actively involved. A total of 5660 individuals were screened. After multiple imputation, 2709 (47.9%) had hypertension. Of individuals not receiving antihypertensive medication, 753 (20.3%) were hypertensive. Of individuals receiving antihypertensive medication, 1094 (55.9%) had uncontrolled BP. Comparing with the worldwide results of MMM17 screening, Russian participants had a higher proportion of hypertension, comparable antihypertensive prescription rate, and worse hypertension control. Thus, the MMM17 project appears to be an important step in evaluating hypertension burden in Russia and emphasizes the further need to improve hypertension awareness, treatment, and control

Prevalence and relationship between metabolic syndrome and risk of cardiovascular disease: Evidence from two population-based studies

Background and aim: The metabolic syndrome (MetS) has become one of the most important clinical issues in the cardiovascular field for this decade because of the marked increase in cardiovascular (CV) risk associated with a clustering of risk factors. The aim of the current study was to evaluate the relationship between MetS and its components and cardiovascular disease (CVD). Methods: This population-based cross-sectional study was based on data from two studies carried out in Russia (ESSE-RF) and Italy (PLIC). One sample from each cohort was selected, matching individuals by sex and age. A comparison between samples of MetS components distribution and CV risk, according to SCORE chart, has been conducted. Results: A total of 609 individuals (mean [SD] age 55 [8] years, about 39% males) for each cohort were selected. Almost half of PLIC cohort participants belonged to the moderate CV risk group (47% vs 27%), while in ESSE-RF cohort a relatively higher prevalence of individuals classified in the high and very high risk group was observed (19% vs 11%, 21% vs 6%, respectively). Overall, 43% of ESSE-RF participants were diagnosed with MetS, compared with the 27% of PLIC members (the difference in prevalence becomes 37% vs 21%, considering a more conservative cut-off for waist circumference). Both cohorts showed a trend towards the increase of MetS components moving from the lowest to the highest CV risk class, with a high prevalence of patients with four or five MetS determinants allocated in the high/very high CV risk group. Conclusions: Developing effective public health strategies for the prevention, detection and treatment of MetS should be an urgent priority to reduce the burden of CVD, not only in subjects at high/very high CV risk, but also in those characterized by a lower risk, as even rare CV events that come from low risk group bring a tangible burden to healthcare systems