BackgroundSelf-management of asthma may improve asthma outcomes. The Internet has been suggested as a tool for the monitoring and self-management of asthma. However, in a recent study we found that a Web interface had some disadvantages and that users stopped using the application after a short while.ObjectiveThe primary objective of this study was to evaluate, from a user perspective, the feasibility of using short message service (SMS) for asthma diary data collection through mobile phones. The secondary objective was to investigate patient compliance with an SMS diary, as measured by response rates over time.MethodsThe study included quantitative response rate data, based on SMS collection, and qualitative data from a traditional focus group setting. In a period of 2 months, the participants received 4 SMS messages each day, including a medication reminder, a request to enter peak flow, data on sleep loss, and medication dosage. Participants were asked to reply to a minimum of 3 of the messages per day. Diary inputs were collected in a database and the response rate per patient was expressed as the number of diary inputs (SMS replies) divided by diary requests (product of number of days in the study and the number of diary questions per day) for each participant. After the study period, the participants were invited to a focus group interview addressing the participants' attitudes to their disease, their experience with the SMS asthma diary, and their future expectations from the SMS asthma diary.ResultsTwelve patients with asthma (6 males, 6 females) participated in the data collection study. The median age was 38.5 (range: 13 – 57) years. The median response rate per patient was 0.69 (range: 0.03 – 0.98), ie, half the participants reported more than about two thirds of the requested diary data. Furthermore, response rates were relatively steady during the study period with no signs of decreasing usage over time. From the subsequent focus group interview with 9 users we learned that, in general, the participants were enthusiastic about the SMS diary – it became an integrated part of their everyday life. However, the participants wished for a simpler diary with only one SMS message to respond to and a system with a Web interface for system customization and graphical display of diary data history.ConclusionThis study suggests that SMS collection of asthma diary data is feasible, and that SMS may be a tool for supporting the self-management of asthma (and possibly other chronic diseases) in motivated and self-efficacious patients because mobile phones are a part of people's everyday lives and enable active requests for data wherever the patient is. The combination of SMS data collection and a traditional Web page for data display and system customization may be a better and more usable tool for patients than the use of Web-based asthma diaries which suffer from high attrition rates.

A pear shaped non-electrostatic spacer, composed of steel with a volume of 250 ml and equipped with a facemask containing integrated inlet and outlet valves for inspiration and expiration, was compared with three plastic spacers. The plastic spacers were primed with repeated puffs from a budesonide pressurised metered dose inhaler (p-MDI) to minimise the electrostatic charge on the plastic. The procedure prolonged the half life (tm12) of the aerosol in the Nebuhaler from nine to 32 seconds. A normal cleaning procedure reduced the aerosol t/2 back to baseline.The t/ of the aerosol in the metal spacer was 27 seconds and independent of the use of p-MDI. In vitro the maximum dose of budesonide from a p-MDI, expressed as a percentage of the nominal dose, was 56% from the non-electrostatic spacer, 61% from the Nebuhaler, 450/0 from the Babyhaler, and 30% from the AeroChamber. In 124 children, age 6 months to 6 years, suspected to have asthma the non-electrostatic spacer delivered a mean total dose of budesonide aerosol of 39% of the nominal dose, which was significantly higher than the Babyhaler (28%), the Nebuhaler (21%), and the AeroChamber (19%). These differences were most pronounced in children younger than 4 years. The improved dose delivery from the small volume non-electrostatic spacer is probably related to the non-electrostatic spacer material and the valves which assured unidirectional airflow from the spacer without adding any dead space in the inspiratory channel. The non-electrostatic spacer should improve the cost effectiveness of aerosol treatment and, as the counteracting effects of priming and recharging ofthe plastic from cleaning are avoided, should deliver a more reliable dose. (Arch Dis Child 1995; 73: 226-230)

BackgroundA run chart is a line graph of a measure plotted over time with the median as a horizontal line. The main purpose of the run chart is to identify process improvement or degradation, which may be detected by statistical tests for non-random patterns in the data sequence.MethodsWe studied the sensitivity to shifts and linear drifts in simulated processes using the shift, crossings and trend rules for detecting non-random variation in run charts.ResultsThe shift and crossings rules are effective in detecting shifts and drifts in process centre over time while keeping the false signal rate constant around 5% and independent of the number of data points in the chart. The trend rule is virtually useless for detection of linear drift over time, the purpose it was intended for.

Background In May 2000, AstraZeneca launched a Web service for asthma patients and health-care providers called LinkMedica, which includes an asthma diary for monitoring and self-management. In the diary, the patient enters his or her peak flow, number of doses of rescue medication, and if there have been any asthma symptoms during the previous 24 hours. The patient receives an immediate response from LinkMedica, telling him or her if the asthma is under control and what to do if not, eg, increase the dose of inhaled steroid. Health-care providers have access to the patient diary.Objectives The primary objective of the study was to describe patients' and health-care providers' use of LinkMedica. Secondary objectives were to evaluate their perception of the system and how the users' interaction with the system is influenced by their everyday lives.Methods Site statistics regarding number of registered users and diary usage were analyzed. An online survey among users (85 respondents), a mailed questionnaire to health-care providers (131 respondents; response rate 26.8%), as well as in-depth interviews with 10 patients and 5 general practitioners, elicited further quantitative and qualitative data on users' perceptions.Results In February 2003, a total of 7653 users had registered. During 2002, the growth in registered users averaged 50 per month. In the same period, the number of unique diary users per month decreased from 307 to 138. Patients usually stopped using the diary after a short time; the doctors were reluctant to introduce the diary to patients because of time constraints. Several user subtypes were identified among patients and their relatives.Conclusion The self-selected survey responses and in-depth interviews indicated that LinkMedica is generally considered a trustworthy and reliable site by both patients and doctors. However, there was a contrast between users' positive perception of LinkMedica and their unwillingness to use the site for more than short periods. The primary reason for this was that LinkMedica did not fit into their everyday lives because of technical and psychological aspects. A number of recommendations to improve LinkMedica are suggested.

ObjectivesTo describe experiences with the implementation of global trigger tool (GTT) reviews in five Danish hospitals and to suggest ways to improve the performance of GTT review teams.DesignRetrospective observational study.SettingThe measurement and monitoring of harms are crucial to campaigns to improve the safety of patients. Increasingly, teams use the GTT to review patient records and measure harms in English and non-English-speaking countries. Meanwhile, it is not clear as to how the method performs in such diverse settings.ParticipantsReview teams from five Danish pilot hospitals of the national Danish Safer Hospital Programme.Primary and secondary outcome measuresWe collected harm rates, background and anecdotal information and reported patient safety incidents (PSIs) from five pilot hospitals currently participating in the Danish Safer Hospital Programme. Experienced reviewers categorised harms by type. We plotted harm rates as run-charts and applied rules for the detection of patterns of non-random variation.ResultsThe hospitals differed in size but had similar patient populations and activity. PSIs varied between 3 and 12 per 1000 patient-days. The average harm rate for all hospitals was 60 per 1000 patient-days ranging from 34 to 84. The percentage of harmed patients was 25 and ranged from 18 to 33. Overall, 96% of harms were temporary. Infections, pressure ulcers procedure-related and gastrointestinal problems were common. Teams reported differences in training and review procedures such as the role of the secondary reviewer.ConclusionsWe found substantial variation in harm rates. Differences in training, review procedures and documentation in patient records probably contributed to these variations. Training reviewers as teams, specifying the roles of the different reviewers, training records and a database for findings of reviews may improve the application of the GTT.

Run charts are widely used in healthcare improvement, but there is little consensus on how to interpret them. The primary aim of this study was to evaluate and compare the diagnostic properties of different sets of run chart rules. A run chart is a line graph of a quality measure over time. The main purpose of the run chart is to detect process improvement or process degradation, which will turn up as non-random patterns in the distribution of data points around the median. Non-random variation may be identified by simple statistical tests including the presence of unusually long runs of data points on one side of the median or if the graph crosses the median unusually few times. However, there is no general agreement on what defines “unusually long” or “unusually few”. Other tests of questionable value are frequently used as well. Three sets of run chart rules (Anhoej, Perla, and Carey rules) have been published in peer reviewed healthcare journals, but these sets differ significantly in their sensitivity and specificity to non-random variation. In this study I investigate the diagnostic values expressed by likelihood ratios of three sets of run chart rules for detection of shifts in process performance using random data series. The study concludes that the Anhoej rules have good diagnostic properties and are superior to the Perla and the Carey rules.

BackgroundLinkMedica-Heart is a novel Internet based program intended to support people who seek to improve their life style by means of changes in diet and physical activity. The program is currently under evaluation in a clinical study and the present study is a feasibility test of the LinkMedica-Heart Internet based program.ObjectiveThe aim of this study was to evaluate LinkMedica-Heart, an Internet based program we designed for support and maintenance of patient-led life style changes.MethodsThe feasibility study of LinkMedica-Heart presented here is a qualitative study. Nine general practitioners were invited to participate. Each practitioner was asked to introduce LinkMedica-Heart to not less than two patients, with a maximum of five patients per practitioner. Patients and general practitioners were both asked to participate in testing the program for a period of 6 months. At the end of 6 months, evaluation meetings were held with the general practitioners, and separate interviews took place with some of the participating patients who were selected by the GPs.ResultsFive general practitioners and 25 patients participated in the study. The general practitioners and the patients were enthusiastic about the prospect of an Internet based life style change program. However, the program was not able to sustain patient loyalty over an extended period. The doctors found that the program was much too complicated to navigate and that the results from the program could not be trusted. The patients in contrast had fewer complaints about the program design, but found that the advice given by the program was too elaborate and detailed and, in general, did not add to the patient's knowledge on life style change.ConclusionOur study confirms that there is a need for, and a receptive attitude toward a Web-based program that supports people who want to improve their life style and health. LinkMedica-Heart in its present form does not satisfy these needs. We suggest a number of design changes and improvements to the program.

Background Community-acquired pneumonia (CAP) is one of the leading causes of healthcare utilisation and death worldwide. Treatment according to evidence-based clinical guidelines can reduce mortality, antibiotic exposure and length of hospital stay related to CAP. Local problem Several studies, including a pilot study from one of our sites, indicate that physicians show a low grade of guideline adherence when managing patients with CAP. Methods To improve the guideline-based treatment of patients with CAP admitted to hospital, we designed a quality improvement study. Four process indicators were combined in a CAP care bundle: chest X-ray, CURB-65 severity score, lower respiratory tract samples and antibiotics within 8 hours from admission. After a 4-month baseline period, we applied multiple interventions at three hospitals during 8 months. Progression in our process indicators was measured continuously and compared with a control site without interventions. After the 8month intervention period, we continued with a 4-month follow-up period to assess the sustainability of the improvements.