Antibiotic use for inpatient newborn care with suspected infection: EN-BIRTH multi-country validation study

BACKGROUND

An estimated 30 million neonates require inpatient care annually, many with life-threatening infections. Appropriate antibiotic management is crucial, yet there is no routine measurement of coverage. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aimed to validate maternal and newborn indicators to inform measurement of coverage and quality of care. This paper reports validation of reported antibiotic coverage by exit survey of mothers for hospitalized newborns with clinically-defined infections, including sepsis, meningitis, and pneumonia.

METHODS

EN-BIRTH study was conducted in five hospitals in Bangladesh, Nepal, and Tanzania (July 2017-July 2018). Neonates were included based on case definitions to focus on term/near-term, clinically-defined infection syndromes (sepsis, meningitis, and pneumonia), excluding major congenital abnormalities. Clinical management was abstracted from hospital inpatient case notes (verification) which was considered as the gold standard against which to validate accuracy of women's report. Exit surveys were conducted using questions similar to The Demographic and Health Surveys (DHS) approach for coverage of childhood pneumonia treatment. We compared survey-report to case note verified, pooled across the five sites using random effects meta-analysis.

RESULTS

A total of 1015 inpatient neonates admitted in the five hospitals met inclusion criteria with clinically-defined infection syndromes. According to case note verification, 96.7% received an injectable antibiotic, although only 14.5% of them received the recommended course of at least 7 days. Among women surveyed (n = 910), 98.8% (95% CI: 97.8-99.5%) correctly reported their baby was admitted to a neonatal ward. Only 47.1% (30.1-64.5%) reported their baby's diagnosis in terms of sepsis, meningitis, or pneumonia. Around three-quarters of women reported their baby received an injection whilst in hospital, but 12.3% reported the correct antibiotic name. Only 10.6% of the babies had a blood culture and less than 1% had a lumbar puncture.

CONCLUSIONS

Women's report during exit survey consistently underestimated the denominator (reporting the baby had an infection), and even more so the numerator (reporting known injectable antibiotics). Admission to the neonatal ward was accurately reported and may have potential as a contact point indicator for use in household surveys, similar to institutional births. Strengthening capacity and use of laboratory diagnostics including blood culture are essential to promote appropriate use of antibiotics. To track quality of neonatal infection management, we recommend using inpatient records to measure specifics, requiring more research on standardised inpatient records.

A, Ruysen H, El Arifeen S, Mee P, Gladstone ME, Blencowe H, Lawn JE. Birthweight: EN-BIRTH multi-country validation study

BACKGROUND

Accurate birthweight is critical to inform clinical care at the individual level and tracking progress towards national/global targets at the population level. Low birthweight (LBW) < 2500 g affects over 20.5 million newborns annually. However, data are lacking and may be affected by heaping. This paper evaluates birthweight measurement within the Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study.

METHODS

The EN-BIRTH study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017-2018). Clinical observers collected time-stamped data (gold standard) for weighing at birth. We compared accuracy for two data sources: routine hospital registers and women's report at exit interview survey. We calculated absolute differences and individual-level validation metrics. We analysed birthweight coverage and quality gaps including timing and heaping. Qualitative data explored barriers and enablers for routine register data recording.

RESULTS

Among 23,471 observed births, 98.8% were weighed. Exit interview survey-reported weighing coverage was 94.3% (90.2-97.3%), sensitivity 95.0% (91.3-97.8%). Register-reported coverage was 96.6% (93.2-98.9%), sensitivity 97.1% (94.3-99%). Routine registers were complete (> 98% for four hospitals) and legible > 99.9%. Weighing of stillbirths varied by hospital, ranging from 12.5-89.0%. Observed LBW rate was 15.6%; survey-reported rate 14.3% (8.9-20.9%), sensitivity 82.9% (75.1-89.4%), specificity 96.1% (93.5-98.5%); register-recorded rate 14.9%, sensitivity 90.8% (85.9-94.8%), specificity 98.5% (98-99.0%). In surveys, "don't know" responses for birthweight measured were 4.7%, and 2.9% for knowing the actual weight. 95.9% of observed babies were weighed within 1 h of birth, only 14.7% with a digital scale. Weight heaping indices were around two-fold lower using digital scales compared to analogue. Observed heaping was almost 5% higher for births during the night than day. Survey-report further increased observed birthweight heaping, especially for LBW babies. Enablers to register birthweight measurement in qualitative interviews included digital scale availability and adequate staffing.

CONCLUSIONS

Hospital registers captured birthweight and LBW prevalence more accurately than women's survey report. Even in large hospitals, digital scales were not always available and stillborn babies not always weighed. Birthweight data are being captured in hospitals and investment is required to further improve data quality, researching of data flow in routine systems and use of data at every level.

Comparison of clinical outcomes between nurse practitioner and registrar-led medical emergency teams: a propensity-matched analysis

OBJECTIVE

Medical emergency teams (MET) are mostly led by physicians. Some hospitals are currently using nurse practitioners (NP) to lead MET calls. These are no studies comparing clinical outcomes between these two care models. To determine whether NP-led MET calls are associated with lower risk of acute patient deterioration, when compared to intensive care (ICU) registrar (ICUR)-led MET calls.

METHODS

The composite primary outcome included recurrence of MET call, occurrence of code blue or ICU admission within 24 h. Secondary outcomes were mortality within 24 h of MET call, length of hospital stay, hospital mortality and proportion of patients discharged home. Propensity score matching was used to reduce selection bias from confounding factors between the ICUR and NP group.

RESULTS

A total of 1343 MET calls were included (1070 NP, 273 ICUR led). On Univariable analysis, the incidence of the primary outcome was higher in ICUR-led MET calls (26.7% vs. 20.6%, p = 0.03). Of the secondary outcome measures, mortality within 24 h (3.4% vs. 7.7%, p = 0.002) and hospital mortality (12.7% vs. 20.5%, p = 0.001) were higher in ICUR-led MET calls. Propensity score-matched analysis of 263 pairs revealed the composite primary outcome was comparable between both groups, but NP-led group was associated with reduced risk of hospital mortality (OR 0.57, 95% CI 0.35-0.91, p = 0.02) and higher likelihood of discharge home (OR 1.55, 95% CI 1.09-2.2, p = 0.015).

CONCLUSION

Acute patient deterioration was comparable between ICUR- and NP-led MET calls. NP-led MET calls were associated with lower hospital mortality and higher likelihood of discharge home.

Association between 30-day readmission rates and health information technology capabilities in US hospitals

ABSTRACT

Health information technology (IT) is often proposed as a solution to fragmentation of care, and has been hypothesized to reduce readmission risk through better information flow. However, there are numerous distinct health IT capabilities, and it is unclear which, if any, are associated with lower readmission risk.To identify the specific health IT capabilities adopted by hospitals that are associated with hospital-level risk-standardized readmission rates (RSRRs) through path analyses using structural equation modeling.This STROBE-compliant retrospective cross-sectional study included non-federal U.S. acute care hospitals, based on their adoption of specific types of health IT capabilities self-reported in a 2013 American Hospital Association IT survey as independent variables. The outcome measure included the 2014 RSRRs reported on Hospital Compare website.A 54-indicator 7-factor structure of hospital health IT capabilities was identified by exploratory factor analysis, and corroborated by confirmatory factor analysis. Subsequent path analysis using Structural equation modeling revealed that a one-point increase in the hospital adoption of patient engagement capability latent scores (median path coefficient ß = -0.086; 95% Confidence Interval, -0.162 to -0.008), including functionalities like direct access to the electronic health records, would generally lead to a decrease in RSRRs by 0.086%. However, computerized hospital discharge and information exchange capabilities with other inpatient and outpatient providers were not associated with readmission rates.These findings suggest that improving patient access to and use of their electronic health records may be helpful in improving hospital performance on readmission; however, computerized hospital discharge and information exchange among clinicians did not seem as beneficial - perhaps because of the quality or timeliness of information transmitted. Future research should use more recent data to study, not just adoption of health IT capabilities, but also whether their usage is associated with lower readmission risk. Understanding which capabilities impact readmission risk can help policymakers and clinical stakeholders better focus their scarce resources as they invest in health IT to improve care delivery.

Pressure Injury Prevention in Patients with Prolonged ED Stays Prior to Admission

PURPOSE

The purpose of this project was to examine whether initiating a standardized pressure injury (PI) assessment and prevention protocol early in adult patients' ED stay reduces hospital-acquired PIs (HAPIs) in those patients admitted from the ED to acute care inpatient medical units.

METHODS

A nurse-led evidence-based practice team studied the problem of increasing HAPIs on four acute care inpatient units and found that, among patients who had been admitted to inpatient care from the ED, longer ED boarding times correlated with a higher rate of HAPIs. ED staff and acute care unit nurses collaborated to develop new protocols to prevent HAPIs in the ED, including staff education and standardized assessments and prevention care for at-risk patients. Data collection was performed at three time periods over approximately two and a half years: baseline, intervention, and postintervention.

RESULTS

The incidence rate for HAPIs decreased from 3.56 per 1,000 patient-days at baseline to 1.31 per 1,000 patient-days during the intervention period. This reduction was sustained over the next five months, during which the HAPI incidence rate was 1.53 per 1,000 patient-days.

IMPLICATIONS

At a time when ED length of stay is difficult to manage and continues to increase, the use of evidence-based interventions and protocols can reduce the rate of PIs in high-risk patients waiting for hospital admission, leading to a reduction in PI rates and overall hospital costs.

Funnel plots of patient-reported outcomes to evaluate health-care quality: Basic principles, pitfalls and considerations

A funnel plot is a graphical method to evaluate health-care quality by comparing hospital performances on certain outcomes. So far, in nephrology, this method has been applied to clinical outcomes like mortality and complications. However, patient-reported outcomes (PROs; eg, health-related quality of life [HRQOL]) are becoming increasingly important and should be incorporated into this quality assessment. Using funnel plots has several advantages, including clearly visualized precision, detection of volume-effects, discouragement of ranking hospitals and easy interpretation of results. However, without sufficient knowledge of underlying methods, it is easy to stumble into pitfalls, such as overinterpretation of standardized scores, incorrect direct comparisons of hospitals and assuming a hospital to be in-control (ie, to perform as expected) based on underpowered comparisons. Furthermore, application of funnel plots to PROs is accompanied by additional challenges related to the multidimensional nature of PROs and difficulties with measuring PROs. Before using funnel plots for PROs, high and consistent response rates, adequate case mix correction and high-quality PRO measures are required. In this article, we aim to provide insight into the use and interpretation of funnel plots by presenting an overview of the basic principles, pitfalls and considerations when applied to PROs, using examples from Dutch routine dialysis care.

Key indicators for appraising adolescent sexual and reproductive health in South Asia: international expert consensus exercise using the Delphi technique

BACKGROUND

There is a need for an accurate assessment of the patterns and determinants of sexual and reproductive health in South Asia owing to high fertility rates and high incidence of unplanned pregnancy among adolescents. Health indicator sets, with a wide range of health dimensions, also support in formulating evidence-based policies. For attaining this, indicators should be developed and prioritized based on consensus and relevance.

OBJECTIVE

This study aimed to develop a comprehensive list of adolescent sexual and reproductive health (ASRH) key indicators for South Asia through systematic participatory expert consultation exercise using the Delphi technique.

METHODS

Experts were invited to two rounds of an indicator rating exercise and a third round to discuss the results in a broader regional perspective. A list of nine indicator categories, including 41 adolescent health indicators, was rated by the expert panel. Prioritization was based on mean Likert scores while consensus was established using Kendall's W.

RESULTS

24, 16 and six experts participated in the first, second and third round, respectively. Out of the nine indicator categories, demographics, reproductive health, violence, and nutrition were ranked high in relevance by the expert panel. Experts had a strong consensus on the relevance of parental control and connection, and behavioral indicators while there was moderate consensus on the relevance of nutrition, infectious disease, and mortality indicators.

CONCLUSION

As far as we know, this is the first study that employs the Delphi technique for prioritizing ASRH indicators for South Asia. Engaging a diverse group of experts, using an online platform, we developed a comprehensive list of key indicators for appraising ASRH relevant to South Asia based on expert panel consensus and recommendations. Our results also highlight that there is a need for developing a region-specific prioritized list of indicators which might assist in identifying regional health needs.

Assessing Nursing Homes Quality Indicators' Between-Provider Variability and Reliability: A Cross-Sectional Study Using ICCs and Rankability

Nursing home quality indicators are often used to publicly report the quality of nursing home care. In Switzerland, six national nursing home quality indicators covering four clinical domains (polypharmacy, pain, use of physical restraints and weight loss) were recently developed. To allow for meaningful comparisons, these indicators must reliably show differences in quality of care levels between nursing homes. This study’s objectives were to assess nursing home quality indicators’ between-provider variability and reliability using intraclass correlations and rankability. This approach has not yet been used in long-term care contexts but presents methodological advantages. This cross-sectional multicenter study uses data of 11,412 residents from a convenience sample of 152 Swiss nursing homes. After calculating intraclass correlation 1 (ICC1) and rankability, we describe between-provider variability for each quality indicator using empirical Bayes estimate-based caterpillar plots. To assess reliability, we used intraclass correlation 2 (ICC2). Overall, ICC1 values were high, ranging from 0.068 (95% confidence interval (CI) 0.047–0.086) for polypharmacy to 0.396 (95% CI 0.297–0.474) for physical restraints, with quality indicator caterpillar plots showing sufficient between-provider variability. However, testing for rankability produced mixed results, with low figures for two indicators (0.144 for polypharmacy; 0.471 for self-reported pain) and moderate to high figures for the four others (from 0.692 for observed pain to 0.976 for physical restraints). High ICC2 figures, ranging from 0.896 (95% CI 0.852–0.917) (self-reported pain) to 0.990 (95% CI 0.985–0.993) (physical restraints), indicated good reliability for all six quality indicators. Intraclass correlations and rankability can be used to assess nursing home quality indicators’ between-provider variability and reliability. The six selected quality indicators reliably distinguish care differences between nursing homes and can be recommended for use, although the variability of two—polypharmacy and self-reported pain—is substantially chance-driven, limiting their utility.

The association between the composite quality measure "textbook outcome" and long term survival in operated colon cancer

The aim of this study was to investigate the relationship between textbook outcome and survival in patients with surgically treated colon cancer. A total of 804 surgical cases were enrolled between June 1, 2010 and December 31, 2014. Textbook outcome was defined as patients who had colon cancer surgery and met the six healthcare parameters of surgery within 6 weeks, radical resection, lymph node (LN) yield ≥12, no ostomy, no adverse outcome and colonoscopy before/after surgery within 6 months. The effect of textbook outcome on 5-year disease-specific survival (DSS) was calculated using the Kaplan-Meier method. A Cox regression model was used to find significant independent variables and stratified analysis used to determine whether text-book outcome had a survival benefit. A textbook outcome was achieved in 59.5% of patients undergoing colon cancer surgery. Important obstacles to achieving textbook outcome were no stomy, no adverse outcome and LN yield ≥12. Patients with text-book outcome had statistically significant better 5-year DSS compared to those with-out (80.1% vs. 58.3%). Multivariate analyses indicated that colon cancer patients with textbook outcome had better 5-year DSS after adjusting for various confounders ([aHR], 0.44; 95% CI, 0.34-0.57). Thus, besides being an index of short-term quality of care, textbook outcomes could be used as a prognosticator of long-term outcomes, such as 5-year survival rates.

Family and Friend Perceptions of Quality of End-of-Life Care in Medicare Advantage vs Traditional Medicare

IMPORTANCE

Medicare Advantage (MA) insures an increasing proportion of Medicare beneficiaries, but evidence is lacking on patient or family perceptions of the quality of end-of-life care in MA vs traditional Medicare.

OBJECTIVE

To determine if there is a difference in quality of care reported by family and friends of individuals who died while insured by MA vs traditional Medicare at the end of life.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used the 2011 to 2017 Medicare-linked National Health and Aging Trends Study to conduct population-based survey research representing 8 668 829 Medicare enrollees. Included individuals were 2119 enrollees who died when aged 65 years or older, with quality of care reported by a family member or close friend familiar with the individual's last month of life. Analysis was conducted in July 2020.

EXPOSURES

MA enrollment at the time of death or before hospice enrollment.

MAIN OUTCOMES AND MEASURES

Perception of end-of-life care was measured with 9 validated items, with the primary outcome variable being overall care rated not excellent. We conducted a propensity score-weighted multivariable model to examine the association of each item with MA vs traditional Medicare enrollment. The propensity score and multivariable model included covariates capturing demographic and socioeconomic factors, function and health, and relationship of the respondent to the individual who died. The sample was then stratified by hospice enrollment and setting of care in the last month.

RESULTS

Of 2119 people in the sample, 670 individuals were enrolled in MA at the time of death or prior to hospice (32.7%) and 1449 were enrolled in traditional Medicare (67.3%). In survey-weighted percentages, 53.6% (95% CI, 51.0% to 56.1%) were women and 43.4% (95% CI, 41.5% to 45.3%) were older than 85 years at the time of death. In the adjusted model, family and friends of individuals in MA were more likely to report that care was not excellent (odds ratio, 1.28; 95% CI, 1.01 to 1.61; P = .04) and that they were not kept informed (odds ratio, 1.48; 95% CI, 1.06 to 2.05; P = .02). For those in nursing homes, there was an estimated probability of 57.2% of respondents reporting that care was not excellent for individuals with traditional Medicare, compared with 77.9% of respondents for individuals with MA (marginal increase for those in MA, 0.21; 95% CI, 0.08 to 0.32; P = .001).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of people who died while enrolled in Medicare, friends and family of those in MA reported lower-quality end-of-life care compared with friends and family of those enrolled in traditional Medicare. These findings suggest that, given the rapid growth of MA, Medicare should take steps to ensure that MA plans are held accountable for quality of care at the end of life.

Factors That Influence Data Use to Improve Health Service Delivery in Low- and Middle-Income Countries

BACKGROUND

Health service delivery indicators are designed to reveal how well health services meet a community's needs. Effective use of the data can enable targeted improvements in health service delivery. We conducted a systematic review to identify the factors that influence the use of health service delivery indicators to improve delivery of primary health care services in low- and middle-income settings.

METHODS

We reviewed empirical studies published in 2005 or later that provided evidence on the use of health service delivery data at the primary care level in low- and middle-income countries. We searched Scopus, Medline, the Cochrane Library, and citations of included studies. We also searched the gray literature, using a separate strategy. We extracted information on study design, setting, study population, study objective, key findings, and any identified lessons learned.

RESULTS

Twelve studies met the inclusion criteria. This small number of studies suggests there is insufficient evidence to draw reliable conclusions. However, a content analysis identified the following potentially influential factors, which we classified into 3 categories: governance (leadership, participatory monitoring, regular review of data); production of information (presentation of findings, data quality, qualitative data); and health information system resources (electronic health management information systems, organizational structure, training). Contextual factors and performance-based financing were also each found to have a role; however, discussing these as mediating factors may not be practical in terms of promoting data use.

CONCLUSION

Scant evidence exists regarding factors that influence the use of health service delivery indicators to improve delivery of primary health care services in low- and middle-income countries. However, the existing evidence highlights some factors that may have a role in improving data use. Further research may benefit from comparing data use factors across different types of program indicators or using our classification as a framework for field experiments.

Monitoring and evaluation of breast cancer screening programmes: selecting candidate performance indicators

BACKGROUND

In the scope of the European Commission Initiative on Breast Cancer (ECIBC) the Monitoring and Evaluation (M&E) subgroup was tasked to identify breast cancer screening programme (BCSP) performance indicators, including their acceptable and desirable levels, which are associated with breast cancer (BC) mortality. This paper documents the methodology used for the indicator selection.

METHODS

The indicators were identified through a multi-stage process. First, a scoping review was conducted to identify existing performance indicators. Second, building on existing frameworks for making well-informed health care choices, a specific conceptual framework was developed to guide the indicator selection. Third, two group exercises including a rating and ranking survey were conducted for indicator selection using pre-determined criteria, such as: relevance, measurability, accurateness, ethics and understandability. The selected indicators were mapped onto a BC screening pathway developed by the M&E subgroup to illustrate the steps of BC screening common to all EU countries.

RESULTS

A total of 96 indicators were identified from an initial list of 1325 indicators. After removing redundant and irrelevant indicators and adding those missing, 39 candidate indicators underwent the rating and ranking exercise. Based on the results, the M&E subgroup selected 13 indicators: screening coverage, participation rate, recall rate, breast cancer detection rate, invasive breast cancer detection rate, cancers > 20 mm, cancers ≤10 mm, lymph node status, interval cancer rate, episode sensitivity, time interval between screening and first treatment, benign open surgical biopsy rate, and mastectomy rate.

CONCLUSION

This systematic approach led to the identification of 13 BCSP candidate performance indicators to be further evaluated for their association with BC mortality.

High Frequency of Non-Compliance with Quality Indicators of Enteral and Parenteral Nutritional Therapy in Hospitalized Patients

Quality indicators in nutritional therapy (QINT) are measures of the effectiveness and quality of nutrition support. The purpose of this study was to evaluate the frequency of the QINT adequacy of Enteral Nutritional Therapy (EN) and/or Parenteral (PN) in hospitalized patients and identify the best indicators according to health professionals. A prospective study was performed, including data from patients aged 18 years or over admitted to clinical or surgical wards. The patients who had received EN and/or PN were followed from the first day of nutritional prescription until discharge. Twelve indicators were calculated, as recommended by the literature. Regarding professional opinion, the QINT adequacy was evaluated by observing its utility, simplicity, objectivity, and cost. Of the 727 hospitalized patients, 101 were on EN and/or PN. Regarding the 12 QINT evaluated, only 25% (3) achieved the goals: involuntary withdrawal of enteral feeding tube (0.01%); feeding tube occlusion or withdrawal per occlusion (0%); the measurement of energy and protein requirements (92%). A high frequency of non-compliance (75% of QINT) was observed in clinical and surgical patients on EN and/or PN. With knowledge of the six best indicators chosen by health professionals in this service, it will be possible to elaborate protocols according to the real-life situation in the institution.

Towards an integrated perinatal care pathway for vulnerable women: The development and validation of quality indicators

OBJECTIVE

Development and validation of a set of quality indicators for vulnerable women during the perinatal period.

DESIGN

A three-phase method was used. Phase 1 consisted of a literature review to identify publications for the development of care domains and potential QIs, as well as a quality assessment by the research team. In phase 2 an expert panel assessed the set of concept QIs in a modified three-round Delphi survey. Finally, semi-structured interviews with vulnerable women were conducted as a final quality assessment of a set of indicators (phase 3). Ethical approval was obtained from the ethics committee of the University Hospital Brussels and from the Ethics Committees of all the participating hospitals.

SETTING

The Flemish Region and the Brussels Capital Region in Belgium.

PARTICIPANTS

Healthcare and social care professionals (n = 40) with expertise in the field of perinatal care provision for vulnerable families. Vulnerable women (n = 11) who gave birth in one of the participating hospitals.

FINDINGS

The literature review resulted in a set of 49 potential quality indicators in five care domains: access to healthcare, assessment and screening, informal support, formal support and continuity of care. After assessment by the expert panel and vulnerable women, a final set of 21 quality indicators in five care domains was identified. First of all, organisation of care must involve an integrated multidisciplinary approach taking account of financial, administrative and social barriers (care domain 1: access to healthcare). Second, qualitative care includes the timely initiation of care, a general screening of the various aspects of vulnerability (biological, psychological, social and cognitive) and a risk assessment for all women (care domain 2: assessment and screening). Vulnerable women benefit from intensive formal and informal support taking account of individual needs and strengths (care domain 3: formal support; care domain 4: informal support). Finally, continuity of care needs to be guaranteed in line with vulnerable woman's individual needs (care domain 5: continuity of care).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Implementing quality indicators in existing and new care pathways offers an evidence-based approach facilitating an integrated view promoting a healthy start for woman and child. These quality indicators can assist healthcare providers, organisations and governmental agencies to improve the quality of perinatal care for vulnerable women.

Association of Do-Not-Resuscitate Patient Case Mix With Publicly Reported Risk-Standardized Hospital Mortality and Readmission Rates

IMPORTANCE

The Centers for Medicare and Medicaid Services's (CMS's) 30-day risk-standardized mortality rate (RSMR) and risk-standardized readmission rate (RSRR) models do not adjust for do-not-resuscitate (DNR) status of hospitalized patients and may bias Hospital Readmissions Reduction Program (HRRP) financial penalties and Overall Hospital Quality Star Ratings.

OBJECTIVE

To identify the association between hospital-level DNR prevalence and condition-specific 30-day RSMR and RSRR and the implications of this association for HRRP financial penalty.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study obtained patient-level data from the Medicare Limited Data Set Inpatient Standard Analytical File and hospital-level data from the CMS Hospital Compare website for all consecutive Medicare inpatient encounters from July 1, 2015, to June 30, 2018, in 4484 US hospitals. Hospitalized patients had a principal diagnosis of acute myocardial infarction (AMI), heart failure (HF), stroke, pneumonia, or chronic obstructive pulmonary disease (COPD). Incoming acute care transfers, discharges against medical advice, and patients coming from or discharged to hospice were among those excluded from the analysis.

EXPOSURES

Present-on-admission (POA) DNR status was defined as an International Classification of Diseases, Ninth Revision diagnosis code of V49.86 (before October 1, 2015) or as an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of Z66 (beginning October 1, 2015). Hospital-level prevalence of POA DNR status was calculated for each of the 5 conditions.

MAIN OUTCOMES AND MEASURES

Hospital-level 30-day RSMRs and RSRRs for 5 condition-specific cohorts (mortality cohorts: AMI, HF, stroke, pneumonia, and COPD; readmission cohorts: AMI, HF, pneumonia, and COPD) and HRRP financial penalty status (yes or no).

RESULTS

Included in the study were 4 884 237 inpatient encounters across condition-specific 30-day mortality cohorts (patient mean [SD] age, 78.8 [8.5] years; 2 608 182 women [53.4%]) and 4 450 378 inpatient encounters across condition-specific 30-day readmission cohorts (patient mean [SD] age, 78.6 [8.5] years; 2 349 799 women [52.8%]). Hospital-level median (interquartile range [IQR]) prevalence of POA DNR status in the mortality cohorts varied: 11% (7%-16%) for AMI, 13% (7%-23%) for HF, 14% (9%-22%) for stroke, 17% (9%-26%) for pneumonia, and 10% (5%-18%) for COPD. For the readmission cohorts, the hospital-level median (IQR) POA DNR prevalence was 9% (6%-15%) for AMI, 12% (6%-22%) for HF, 16% (8%-24%) for pneumonia, and 9% (4%-17%) for COPD. The 30-day RSMRs were significantly higher for hospitals in the highest quintiles vs the lowest quintiles of DNR prevalence (eg, AMI: 12.9 [95% CI, 12.8-13.1] vs 12.5 [95% CI, 12.4-12.7]; P < .001). The inverse was true among the readmission cohorts, with the highest quintiles of DNR prevalence exhibiting the lowest RSRRs (eg, AMI: 15.3 [95% CI, 15.1-15.5] vs 15.9 [95% CI, 15.7-16.0]; P < .001). A 1% absolute increase in risk-adjusted hospital-level DNR prevalence was associated with greater odds of avoiding HRRP financial penalty (odds ratio, 1.06; 95% CI, 1.04-1.08; P < .001).

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that the lack of adjustment in CMS 30-day RSMR and RSRR models for POA DNR status of hospitalized patients may be associated with biased readmission penalization and hospital-level performance.

Trends in measles cases in Bayelsa state, Nigeria: a five-year review of case-based surveillance data (2014-2018)

BACKGROUND

Measles is a vaccine preventable, highly transmissible viral infection that affects mostly children under five years. It has been ear marked for elimination and Nigeria adopted the measles elimination strategies of the World Health Organization (WHO) African region to reduce cases and deaths. This study was done to determine trends in measles cases in Bayelsa state, to describe cases in terms of person and place, identify gaps in the case-based surveillance data collection system and identify risk factors for measles infection.

METHODS

We carried out a secondary data analysis of measles case-based surveillance data for the period of January 2014 to December 2018 obtained in Microsoft Excel from the State Ministry of Health. Cases were defined according to WHO standard case definitions. We calculated frequencies, proportions, estimated odds ratios (OR), 95% confidence intervals (CI) and multivariate analysis.

RESULTS

A total of 449 cases of measles were reported. There were 245(54.6%) males and the most affected age group was 1-4 years with 288(64.1%) cases. Of all cases, 289(9.35%) were confirmed and 70 (48.27%) had received at least one dose of measles vaccine. There was an all-year transmission with increased cases in the 4th quarter of the year. Yenegoa local government area had the highest number of cases. Timeliness of specimen reaching the laboratory and the proportion of specimens received at the laboratory with results sent to the national level timely were below WHO recommended 80% respectively. Predictors of measles infection were, age less than 5 years (AOR: 0.57, 95% CI: 0.36-0.91) and residing in an urban area (AOR: 1.55, 95% CI:1.02-2.34).

CONCLUSIONS

Measles infection occurred all-year round, with children less than 5 years being more affected. Measles case-based surveillance system showed high levels of case investigation with poor data quality and poor but improving indicators. Being less than 5 years was protective of measles while living in urban areas increased risk for infection. We recommended to the state government to prioritize immunization activities in the urban centers, start campaigns by the 4th quarter and continue to support measles surveillance activities and the federal government to strengthen regional laboratory capacities.

Determinants of Insufficient Optimal Medical Therapy after Acute Myocardial Infarction

Objective Although the importance of evidence-based optimal medical therapy (OMT) after acute myocardial infarction (AMI) has been recognized, the prescription rate of OMT is not sufficiently high in real-word clinical settings. The purpose of this study was to identify the clinical characteristics of AMI patients who did not receive OMT. Methods The present study was a retrospective study. OMT was defined as the combination of antiplatelet therapy, angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta-blockers, and statins at the time of hospital discharge. Non-OMT was defined as the lack of either antiplatelet therapy, ACE inhibitors/ARBs, beta-blockers, or statins. Results A total of 457 AMI patients were included as the final study population, and 98 patients (22.4%) lacked at least 1 OMT medication. The prescription rates of antiplatelet therapy, ACE inhibitors/ARBs, beta-blockers, and statins were 98.7%, 87.5%, 90.4%, and 96.7%, respectively. In the multivariate logistic regression analysis, age [per 1-year increase: odds ratio (OR) 1.033, 95% confidence interval (CI) 1.007-1.059, p=0.014], hemodialysis (vs. no hemodialysis: OR 2.707, 95% CI 1.082-6.774, p=0.033), estimated glomerular filtration rate <30 mL/min/1.73 m² without hemodialysis (OR 4.585, 95% CI 1.975-10.644, p<0.001), AMI caused by vasospastic angina (VSA) (vs. no VSA: OR 13.198, 95% CI 1.809-96.260, p=0.011), and asthma (vs. no asthma: OR 7.241, 95% CI 1.716-30.559, p=0.007) were significantly associated with non-OMT, whereas heart rate on admission (per 1-bpm increase: 0.987, 95% CI 0.975-0.999, p=0.033), any PCI (vs. no PCI: OR 0.156, 95% CI 0.066-0.373, p<0.001), and ST-elevation myocardial infarction (STEMI) (vs. NSTEMI: OR 0.384, 95% CI 0.218-0.675, p=0.001) were inversely associated with non-OMT. Conclusion An advanced age, VSA, bradycardia, asthma, impaired renal function, non-PCI revascularization, and non-ST-elevation myocardial infarction were significantly associated with non-OMT.

Musculoskeletal injury quality outcome indicators for the emergency department

High standards of care for musculoskeletal injuries presenting to emergency departments (ED) must be maintained despite financial constraints, the model of care in place, or the pressure to reach time-based performance measures. Outcome quality indicators (QIs) provide a tangible way of assessing and improving the outcomes of health-care delivery. This study aimed to develop a set of outcome QIs for musculoskeletal injuries in the ED that are meaningful, valid, feasible to collect, simple to use for clinical quality improvement and chosen by experts in the field. The study used a multi-phase mixed methods design, commencing with a systematic review of available outcome QIs. An expert panel then developed a set of preliminary QIs based on the available scientific evidence. Prospective observational data collection was undertaken across eight EDs with subsequent retrospective chart audits, follow-up phone calls and audit of administrative databases. After statistical analysis, validated results were presented to the expert panel who discussed, refined and formally voted on a final outcome QI set. A total of 41 preliminary outcome QIs were field tested in EDs, with data collected on 633 patients. Using the field study results, the expert panel voted 11 outcome QIs into the final set. These covered effectiveness of pain management, timeliness to discharge, re-presentations to the ED and unplanned visits to health professionals in the community, missed injuries, opioids side effects and the patient experience. An evidence-based set of outcome quality indicators is now available to support clinical quality improvement of musculoskeletal injury care in the ED setting.

Vaccination Status and Adherence to Quality Measures for Acute Respiratory Tract Illnesses

OBJECTIVES

To assess the relationship between vaccination status and clinician adherence to quality measures for children with acute respiratory tract illnesses.

METHODS

We conducted a multicenter prospective cohort study of children aged 0 to 16 years who presented with 1 of 4 acute respiratory tract illness diagnoses (community-acquired pneumonia, croup, asthma, and bronchiolitis) between July 2014 and June 2016. The predictor variable was provider-documented up-to-date (UTD) vaccination status. Our primary outcome was clinician adherence to quality measures by using the validated Pediatric Respiratory Illness Measurement System (PRIMES). Across all conditions, we examined overall PRIMES composite scores and overuse (including indicators for care that should not be provided, eg, C-reactive protein testing in community-acquired pneumonia) and underuse (including indicators for care that should be provided, eg, dexamethasone in croup) composite subscores. We examined differences in length of stay, costs, and readmissions by vaccination status using adjusted linear and logistic regression models.

RESULTS

Of the 2302 participants included in the analysis, 92% were documented as UTD. The adjusted mean difference in overall PRIMES scores by UTD status was not significant (adjusted mean difference -0.3; 95% confidence interval: -1.9 to 1.3), whereas the adjusted mean difference was significant for both overuse (-4.6; 95% confidence interval: -7.5 to -1.6) and underuse (2.8; 95% confidence interval: 0.9 to 4.8) composite subscores. There were no significant adjusted differences in mean length of stay, cost, and readmissions by vaccination status.

CONCLUSIONS

We identified lower adherence to overuse quality indicators and higher adherence to underuse quality indicators for children not UTD, which suggests that clinicians "do more" for hospitalized children who are not UTD.

Physician characteristics correlate with hospital readmission rates

Hospital readmission rates are used as a metric to measure quality patient care. While several tools predict readmissions based on patient-specific characteristics, this study assesses if physician characteristics correlate with hospital readmission rates.In a 5-year retrospective electronic record review at a single institution, 31 internal medicine attending physicians' discharges were tracked for a total of 70 physician years, and 15,933 hospital discharges. Each physician's yearly 7-day, 8 to 30-day, and 30-day readmission rates were compared. Each rate was also correlated with years of post-graduate clinical experience, discharge volume, physician sex, and fiscal year.Individual physicians had significantly different 7-day, 8 to 30-day, and 30-day readmission rates from each other. The rates were not related to sex, years after post-graduate training, or fiscal year. However, physician patient volume correlated with 7-day readmission rates. Physicians who discharged ≤100 patients per year had a higher 7-day readmission rate than physicians who discharged >100 patients per year. This correlation with patient volume did not hold for the 8 to 30-day and 30-day readmission rates.Individual physicians differ in their patient readmission rates in 7-day, 8 to 30-day, and 30-day categories. A critical level of a physician's hospital activity, as reflected by the number of patient discharges per year (>100), results in lower 7-day readmission rates. Sex, post-graduate years of clinical experience, and fiscal year did not play a role. The lack of correlation between each physicians' 7-day and 8 to 30-day readmission rates suggests that different physician factors are involved in these 2 rates.

Developing a framework for performance assessment of the public long-term care system in Korea: methodological and policy lessons

BACKGROUND

Limited evidence exists on how to assess long-term care system performance. This study aims to report on the process and results of developing a performance assessment framework to evaluate the long-term care system financed by the public long-term care insurance in South Korea.

METHODS

The framework was developed through a six-step approach, including setting the goals and scope of performance assessment in the given policy context, reviewing existing performance frameworks, developing a framework with a wide range of potential indicators, refining the framework through a series of Delphi surveys and expert meetings, examining the feasibility of generated indicators through a pilot test, receiving the comments of stakeholders, and finalising the performance framework.

RESULTS

The finalised framework has 4 domains - coverage, quality of care, quality of life and system sustainability - and 28 indicators, including 10 core indicators to monitor long-term care system performance. Usability and feasibility along with policy relevance were important criteria in selecting these indicators. The proposed framework can be used to assess the performance of the long-term care system in Korea, and the framework and its methodological approach can be benchmarks for other countries developing their own framework.

CONCLUSIONS

It is critical to reconcile and prioritise various stakeholders' views and information needs as well as to balance methodological rigor with practical usefulness and feasibility in the development and implementation of a long-term care performance monitoring system.

Identifying optimal indicators and purposes of population segmentation through engagement of key stakeholders: a qualitative study

BACKGROUND

Various population segmentation tools have been developed to inform the design of interventions that improve population health. However, there has been little consensus on the core indicators and purposes of population segmentation. The existing frameworks were further limited by their applicability in different practice settings involving stakeholders at all levels. The aim of this study was to generate a comprehensive set of indicators and purposes of population segmentation based on the experience and perspectives of key stakeholders involved in population health.

METHODS

We conducted in-depth semi-structured interviews using purposive sampling with key stakeholders (e.g. government officials, healthcare professionals, social service providers, researchers) involved in population health at three distinct levels (micro, meso, macro) in Singapore. The interviews were audio-recorded and transcribed verbatim. Thematic content analysis was undertaken using NVivo 12.

RESULTS

A total of 25 interviews were conducted. Eight core indicators (demographic characteristics, economic characteristics, behavioural characteristics, disease state, functional status, organisation of care, psychosocial factors and service needs of patients) and 21 sub-indicators were identified. Age and financial status were commonly stated as important indicators that could potentially be used for population segmentation across three levels of participants. Six intended purposes for population segmentation included improving health outcomes, planning for resource allocation, optimising healthcare utilisation, enhancing psychosocial and behavioural outcomes, strengthening preventive efforts and driving policy changes. There was consensus that planning for resource allocation and improving health outcomes were considered two of the most important purposes for population segmentation.

CONCLUSIONS

Our findings shed light on the need for a more person-centric population segmentation framework that incorporates upstream and holistic indicators to be able to measure population health outcomes and to plan for appropriate resource allocation. Core elements of the framework may apply to other healthcare settings and systems responsible for improving population health.

TRIAL REGISTRATION

The study was approved by the SingHealth Institutional Review Board (CIRB Reference number: 2017/2597).

Benefits of implementing a rapid access clinic in a high-volume inflammatory bowel disease center: Access, resource utilization and outcomes

BACKGROUND

Emergency situations in inflammatory bowel diseases (IBD) put significant burden on both the patient and the healthcare system.

AIM

To prospectively measure Quality-of-Care indicators and resource utilization after the implementation of the new rapid access clinic service (RAC) at a tertiary IBD center.

METHODS

Patient access, resource utilization and outcome parameters were collected from consecutive patients contacting the RAC between July 2017 and March 2019 in this observational study. For comparing resource utilization and healthcare costs, emergency department (ED) visits of IBD patients with no access to RAC services were evaluated between January 2018 and January 2019. Time to appointment, diagnostic methods, change in medical therapy, unplanned ED visits, hospitalizations and surgical admissions were calculated and compared.

RESULTS

488 patients (Crohn’s disease: 68.4%/ulcerative colitis: 31.6%) contacted the RAC with a valid medical reason. Median time to visit with an IBD specialist following the index contact was 2 d. Patients had objective clinical and laboratory assessment (C-reactive protein and fecal calprotectin in 91% and 73%). Fast-track colonoscopy/sigmoidoscopy was performed in 24.6% of the patients, while computed tomography/magnetic resonance imaging in only 8.1%. Medical therapy was changed in 54.4%. ED visits within 30 d following the RAC visit occurred in 8.8% (unplanned ED visit rate: 5.9%). Diagnostic procedures and resource utilization at the ED (n = 135 patients) were substantially different compared to RAC users: Abdominal computed tomography was more frequent (65.7%, P < 0.001), coupled with multiple specialist consults, more frequent hospital admission (P < 0.001), higher steroid initiation (P < 0.001). Average medical cost estimates of diagnostic procedures and services per patient was $403 CAD vs $1885 CAD comparing all RAC and ED visits.

CONCLUSION

Implementation of a RAC improved patient care by facilitating easier access to IBD specific medical care, optimized resource utilization and helped avoiding ED visits and subsequent hospitalizations.