Part 1: Quality of care--what is it?

Management by outcomes: efficiency and operational success in the ambulatory surgery center

Quality of care and service in health care can benefit from the use of algorithm-driven care (standard work) that integrates literature assessment and analysis of local outcome and process data to eliminate unnecessary variation that causes error and waste. Effective management of an ambulatory surgery center requires that leadership emphasize constant improvement in the processes of care to achieve maximum patient safety and satisfaction, delivered with highest efficiency. Process improvement may be achieved by simple measurement alone (the Hawthorne effect). However, as shown in this article, the authors have successfully used the implementation of regular measurement and open discussion of patients' clinical outcomes and other operational metrics to focus active systems improvement projects in ambulatory surgery centers, with excellent results.

COPD performance measures: missing opportunities for improving care

During the last decade, mounting evidence worldwide has heightened awareness that patients with diverse health conditions commonly do not receive recommended care despite the proliferation of clinical practice guidelines. This is a particular problem for patients with COPD, who only receive recommended care during 30% to 55% of encounters with providers. Considering that COPD is the fourth leading cause of death worldwide, failure to implement guideline-directed care represents a major concern for respiratory professional societies. For other health conditions, inadequacies of care have stimulated public and private agencies to increase provider accountability by linking the results of performance measures to various quality-improvement interventions. Despite limited evidence that these interventions improve care, widespread adoption of value-based reimbursement has occurred in the United States and United Kingdom, and the prominence of these strategies in health-care reform suggest future growth and the likely proliferation of the performance measures upon which they are based. Of note, relatively few performance measures exist for COPD as compared with other conditions that have less impact on global health. The lack of COPD measures diminishes public awareness of COPD, allows diversion of quality improvement resources toward other conditions with existing measures, and negatively impacts COPD care. Respiratory professional societies can play an important role in stimulating the development of valid COPD measures derived from COPD practice guidelines and coordinate future measures to avoid burdensome reporting requirements for physicians if COPD measures are developed by competing payers and agencies in a fragmented or non-patient-centered manner.

Developing and implementing a survey to determine employer satisfaction with care provided to injured workers

satisfaction surveys have become the primary means of evaluating perceptions of quality in the health care industry, including occupational health services. In occupational health, nurses need to know not only it injured workers are satisfied with their case, but also if injured workers' employers believe heath care provided to their workers was satisfactory. One problem is the lack of published surveys addressing issues relevant to occupational health services. the authors describe how a satisfaction was developed to understand employers' satisfaction with the case provided to injured workers. The theory of Self-Administered Questionnaire Design, a previously used survey, and in put from-multiple sources were used to develop the survey tool.

Associations between organizational characteristics and quality improvement activities of clinics participating in a quality improvement collaborative

BACKGROUND

Few studies have rigorously evaluated the associations between organizational characteristics and intervention activities of health care organizations participating in quality improvement collaboratives (QICs).

OBJECTIVE

To examine the relationship between clinic characteristics and intervention activities by primary care clinics that provide HIV care and that participated in a QIC.

DESIGN

Cross-sectional study of Ryan White CARE Act (now called Ryan White HIV/AIDS Treatment Modernization Act) funded clinics that participated in a QIC over 16 months in 2000 and 2001. The QIC was originally planned to be a more typical 12 months long, but was extended to increase the likelihood of success. Data were collected using surveys of clinicians and administrators in participating clinics and monthly reports of clinic improvement activities.

MEASURES

Number of interventions attempted, percent of interventions repeated, percent of interventions evaluated, and organizational characteristics.

RESULTS

Clinics varied significantly in their intervention choices. Organizations with a more open culture and a greater emphasis on quality improvement attempted more interventions (P < 0.01, P < 0.05) and interventions that were more comprehensive (P < 0.01, P < 0.10). Presence of multidisciplinary teams and measurement of progress toward quantifiable goals also were associated with comprehensiveness of interventions (P < 0.01, P < 0.05).

CONCLUSION

Clinic characteristics predicted intervention activities during a QIC. Further research is needed on how these organizational characteristics affect quality of care through their influence on intervention activities.

Defining high quality health care

Most health care quality improvement efforts target measures of health care structures, processes, and/or outcomes. Structural measures examine relatively fixed aspects of health care delivery such as physical plant and human resources. Process measures, the focus of the largest proportion of quality improvement efforts, assess specific transactions in clinical-patient encounters, such as use of appropriate surgical antibiotic prophylaxis, which are expected to improve outcomes. Outcome measures, which comprise quality of life endpoints as well as morbidity and mortality, are of greatest interest to clinicians and patients, but entail the greatest complexity, as the majority of variance in outcomes is attributable to patient and environmental factors that may not be readily modifiable. Selecting among structure, process, and outcome measures for quality improvement efforts generally will be dictated by the specific clinical situation for which improvement is desired. One aspect of health care quality that has received a great deal of attention in recent years is the relationship between surgical volume and health outcomes. Volume, an inherent characteristic of a health care facility or provider, is generally considered a structural measure of quality. Many studies have demonstrated a positive association between volume and outcomes, and policymakers in the private and public sectors have begun to consider volume in certification and reimbursement decisions. The volume-outcome association is not without controversy, however. Most studies in the field are limited by the nature of the administrative data on which they are based, and some studies have found that variation in quality within volume quantiles exceeds differences between quantiles. Moreover, regionalization driven by a focus on volume may exert adverse effects on access to care. The movement for health care quality improvement faces substantial methodological, clinical, financial, and political challenges. Despite these challenges, it is a movement that is gaining momentum, and the emphasis on quality in health care delivery is likely only to increase in the future. It is crucial, therefore, that physicians assume increasing leadership roles in efforts to define, measure, report, and improve quality of care.

Quality of health care in the United States: implications for pediatric inflammatory bowel disease

The Institute of Medicine's publications To Error is Human and Crossing the Quality Chasm publicized the widespread deficits in US health care quality. Emerging studies continue to reveal deficits in the quality of adult and pediatric care, including subspecialty care. In recent years, key stakeholders in the health care system including providers, purchasers, and the public have been applying various quality improvement methods to address these concerns. Lessons learned from these efforts in other pediatric conditions, including asthma, cystic fibrosis, neonatal intensive care, and liver transplantation may be applicable to the care of children with inflammatory bowel disease (IBD).This review is intended to be a primer on the quality of care movement in the United States, with a focus on pediatric IBD. In this article, we review the history, rationale, and methods of quality measurement and improvement, and we discuss the unique challenges in adapting these general strategies to pediatric IBD care.

How much do patients' preferences contribute to resource use?

Regional variation in health care use may stem, in part, from the fact that patients in high-utilization regions demand and receive more-intensive care. We examine the association between patients' care-seeking preferences and use of services, using a national survey of Medicare patients. Patients' preferences, in addition to health and sociodemographic characteristics, are associated with differences in individuals' use of office visits. However, we find that patients' preferences for seeking primary and specialty medical care do not play a significant role in explaining regional variation in health care use.

High quality care and ethical pay-for-performance: a Society of General Internal Medicine policy analysis

BACKGROUND

Pay-for-performance is proliferating, yet its impact on key stakeholders remains uncertain.

OBJECTIVE

The Society of General Internal Medicine systematically evaluated ethical issues raised by performance-based physician compensation.

RESULTS

We conclude that current arrangements are based on fundamentally acceptable ethical principles, but are guided by an incomplete understanding of health-care quality. Furthermore, their implementation without evidence of safety and efficacy is ethically precarious because of potential risks to stakeholders, especially vulnerable patients.

CONCLUSION

We propose four major strategies to transition from risky pay-for-performance systems to ethical performance-based physician compensation and high quality care. These include implementing safeguards within current pay-for-performance systems, reaching consensus regarding the obligations of key stakeholders in improving health-care quality, developing valid and comprehensive measures of health-care quality, and utilizing a cautious evaluative approach in creating the next generation of compensation systems that reward genuine quality.

Pain management within the palliative and end-of-life care experience in the ICU

In the ICU where critically ill patients receive aggressive life-sustaining interventions, suffering is common and death can be expected in up to 20% of patients. High-quality pain management is a part of optimal therapy and requires knowledge and skill in pharmacologic, behavioral, social, and communication strategies grounded in the holistic palliative care approach. This contemporary review article focuses on pain management within comprehensive palliative and end-of-life care. These key points emerge from the transdisciplinary review: (1) all ICU patients experience opportunities for discomfort and suffering regardless of prognosis or goals, thus palliative therapy is a requisite approach for every patient, of which pain management is a principal component; (2) for those dying in the ICU, an explicit shift in management to comfort-oriented care is often warranted and may be the most beneficial treatment the health-care team can offer; (3) communication and cultural sensitivity with the patient-family unit is a principal approach for optimizing palliative and pain management as part of comprehensive ICU care; (4) ethical and legal misconceptions about the escalation of opiates and other palliative therapies should not be barriers to appropriate care, provided the intention of treatment is alleviation of pain and suffering; (5) standardized instruments, performance measurement, and care delivery aids are effective strategies for decreasing variability and improving palliative care in the complex ICU setting; and (6) comprehensive palliative care should addresses family and caregiver stress associated with caring for critically ill patients and anticipated suffering and loss.

Clean intermittent self-catheterization after botulinum neurotoxin type A injections: short-term effect on quality of life

OBJECTIVE

To investigate the hypothesis that the need for clean intermittent self-catheterization after botulinum neurotoxin type A injections is outweighed by the efficacy of this treatment, so that clean intermittent self-catheterization is not a burden for patients with refractory idiopathic detrusor overactivity.

METHODS

Women undergoing intradetrusor injections of 200 units botulinum neurotoxin type A for refractory idiopathic detrusor overactivity were evaluated prospectively. Clean intermittent self-catheterization was discussed with all patients and its possible need after botulinum neurotoxin type A treatment. As indicator of quality of life, lower urinary tract symptom distress and effect on daily activities were assessed using the validated Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7) before and 4 weeks after receiving botulinum neurotoxin type A injections.

RESULTS

Mean age of the 65 women was 51 years, and all voided spontaneously before botulinum neurotoxin type A injections. After botulinum neurotoxin type A treatment, 28 (43%) required clean intermittent self-catheterization. Mean UDI-6 and IIQ-7 scores reduced from 61 to 33 (P<.001) and 62 to 30 (P<.001) in women performing clean intermittent self-catheterization and from 60 to 28 (P<.001) and 64 to 25 (P<.001) in those who did not, respectively. Comparison of quality of life in women performing clean intermittent self-catheterization and in those who did not revealed no significant differences before and after botulinum neurotoxin type A treatment.

CONCLUSION

Clean intermittent self-catheterization after botulinum neurotoxin type A intradetrusor injections did not impair quality of life in appropriately informed and selected women in the short term. All patients should be informed of the potential need for clean intermittent self-catheterization after botulinum neurotoxin type A injections, and a willingness to do so should be a prerequisite for this still unlicensed off-label treatment.

A conceptual framework for selecting the most appropriate variables for measuring hospital efficiency with a focus on Iranian public hospitals

Over the past few decades, there has been an increasing interest in the measurement of hospital efficiency in developing countries and in Iran. While the choice of measurement methods in hospital efficiency assessment has been widely argued in the literature, few authors have offered a framework to specify variables that reflect different hospital functions, the quality of the process of care and the effectiveness of hospital services. However, without the knowledge of hospital objectives and all relevant functions, efficiency studies run the risk of making biased comparisons, particularly against hospitals that provide higher quality services requiring the use of more resources. Undertaking an in-depth investigation regarding the multi-product nature of hospitals, various hospital functions and the values of various stakeholders (patient, staff and community) with a focus on the Iranian public hospitals, this study has proposed a conceptual framework to select the most appropriate variables for measuring hospital efficiency using frontier-based techniques. This paper contributes to hospital efficiency studies by proposing a conceptual framework and incorporating a broader set of variables in Iran. This can enhance the validity of hospital efficiency studies using frontier-based methods in developing countries.

Measuring quality of surgical care: is it attainable?

SUMMARY

Healthcare quality has emerged as an important discussion topic for the American people. With the continued lack of health insurance coverage for over 15 percent of Americans, questions are being posed regarding why the United States has spent $2.1 trillion per year in healthcare and is still unable to provide the highest quality of healthcare in the world. The World Health Organization's 2000 World Health Report ranked the United States at 24 out of 191 member countries in healthcare indices. Because of a looming reduction in the number of Americans covered through the Medicare and Medicaid programs due to budgetary constraints, many initiatives have been proposed to cut the cost of healthcare and at the same time improve the quality of the American system. In this article, the authors summarize the history of these quality initiatives and discuss current and future directions of programs to achieve better healthcare for the country. They also discuss how the American Society of Plastic Surgeons is engaging national organizations to be part of the solution for this crisis.

Measuring quality in health care and its implications for pay-for-performance initiatives

The quality of health care is important to American consumers, and discussion on quality will be a driving force toward improving the delivery of health care in America. Funding agencies are proposing a variety of quality measures, such as centers of excellence, pay-for-participation, and pay-for-performance initiatives, to overhaul the health care delivery system in this country. It is quite uncertain, however, whether these quality initiatives will succeed in curbing the unchecked growth in health care spending in this country, and physicians understandably are concerned about more intrusion into the practice of medicine. This article outlines the genesis of the quality movement and discusses its effect on the surgical community.

Unplanned extubation in a paediatric intensive care unit: impact of a quality improvement programme

Unplanned tracheal extubation is an important quality issue in current medical practice as it is a common occurrence in paediatric intensive care units. We have assessed the effectiveness of a continuous quality improvement programme in reducing the incidence of unplanned extubation over a 5-year period. After a 2-year baseline period, we developed action plans to address the issues identified. Following implementation of the programme, the overall incidence of unplanned extubation decreased from 2.9 unplanned extubations per 100 intubated patient days in the first year to 0.6 in the last year (p = 0.0001). This reduction was the result of a decrease in unplanned extubation in children younger than 2 years of age. Although mortality was similar to that of children who did not experience an unplanned extubation, those with an unplanned extubation had a significantly longer duration of mechanical ventilation, longer stay in the intensive care unit, and longer hospital stay. We found that the implementation of a continuous quality improvement programme is effective in reducing the overall incidence of unplanned extubations.

Patients' perspective in Chilean primary care: a questionnaire validation study

OBJECTIVE

The aim of this study was to adapt and validate an instrument for assessing quality of care from the patients' perspective in the context of Chilean primary care.

METHODS

The 'Health Centre Assessment Questionnaire' is made up of six multiple-item scales and two single-item scales addressing eight key areas of primary care activity. A further two single-item scales ask about the overall satisfaction and the way in which the centre deals with patients' health issues. The adaptation process was developed according to methods described in the specialized literature. The instrument was initially pre-tested in a sample of 100 primary care patients. The validation was carried out in 10 urban public primary healthcare centres where 2896 patients were invited to complete the questionnaire. The validity and reliability of the instrument was assessed using standard psychometric techniques.

RESULTS

Ninety nine per cent (2870) of those approached completed the questionnaire. It was acceptable to most of the patients as reflected by the high response rate, and a full range of possible scores in most of the scales. Reliability was good as reflected by high internal consistency and homogeneity. Validity was supported by the confirmation of scaling assumptions, the moderate correlations between multiple-item scales, and by the confirmation of our 'a priori' hypothesis.

CONCLUSIONS

The questionnaire could be a useful instrument for assessing a number of important dimensions in Chilean primary care. It is acceptable, reliable and valid. Further work is required to evaluate its validity against external criteria and its test-retest reliability.

[Accreditation of processes in hepatology]

The Spanish Association for the Study of the Liver decided in 2006 to develop a project to assess the quality of the professionals, processes and medical units dealing with the management of patients with liver diseases in Spain. The current article reports the criteria proposed to assess the quality and the accreditation of the processes in hepatology. The processes considered include most patients with liver diseases and the accreditation system designed is highly specific. This document, together with a previous one published in gastroenterología y hepatología concerning the accreditation of the professionals and a third document dealing with the accreditation of liver units that will be published soon, form the basis of the quality assessment of hepatology in our country.

Statistical methodology for classifying units on the basis of multiple-related measures

Both the private and public sectors have begun giving financial incentives to healthcare providers, such as hospitals, delivering superior 'quality of care'. Quality of care is assessed through a set of disease-specific measures that characterize the performance of healthcare providers. These measures are then combined into a unidimensional composite score. Most of the programs that reward superior performance use raw averages of the measures as the composite score. The scores based on raw averages fail to take into account typical characteristics of data used for performance evaluation, such as within-patient and within-hospital correlations, variable number of measures available in different hospitals, and missing data. In this paper, we contrast two different versions of composites based on raw average scores with a model-based score constructed using a latent variable model. We also present two methods to identify hospitals with superior performance. The methods are illustrated using national data collected to evaluate quality of care delivered by the U.S. acute care hospitals.

Assessing the quality of pharmacological treatments from administrative databases: the case of low-molecular-weight heparin after major orthopaedic surgery

RATIONALE, AIMS AND OBJECTIVES

'Real world data' are needed to assess the quality of pharmacological treatments in clinical practice. The aim of this study was to determine whether administrative databases can be used to assess the quality of prophylaxis with low-molecular-weight heparin after major orthopaedic surgery.

METHODS

The study was performed in a Belgian university hospital. Patients undergoing total hip replacement (THR), total knee replacement (TKR) or hip fracture surgery (HFS) were selected retrospectively from the hospital's 2002 and 2003 administrative databases. Readmissions during the same year as the procedure were also analysed. Three quality indicators were assessed: incidence of venous thromboembolism (VTE), major bleeding and death; adherence to guidelines; and the costs of care.

RESULTS

Although 70% of data were collected from administrative databases, patients' records also had to be examined. During the period studied, VTE and major bleeding events were rare. Patients undergoing HFS were at greater risk of having a pulmonary embolism [Exact odds ratio (OR)=3.78; 95% confidence interval (CI)=1.13-16.22; P=0.03] or of death from any cause (Exact OR=2.15; 95% CI=1.52-infinity; P<0.01) than patients undergoing THR or TKR. The hospital's prophylaxis protocol was not always followed. Half the patients received higher prophylaxis doses than recommended and 11% received lower doses but no impact on adverse events was demonstrated.

CONCLUSION

Results show that administrative databases contain enough information to measure the frequency of adverse events but complementary data on patient weight and on non-reimbursed drugs must be extracted from the patients' records to evaluate adherence to guidelines. Our findings stress the need for better integration of information systems.

Nativity status and patient perceptions of the patient-physician encounter: results from the Commonwealth Fund 2001 survey on disparities in quality of health care

BACKGROUND

Although racial and ethnic differences in healthcare have been extensively documented in the United States, little attention has been paid to the quality of health care for the foreign-born population in the United States.

OBJECTIVES

This study examines the association between patient perceptions of the patient-physician interaction and nativity status.

RESEARCH DESIGN

Cross-sectional telephone survey.

SUBJECTS

A total of 6674 individuals (US-born = 5156; foreign-born = 1518) 18 years of age and older.

MEASURES

Seven questions measuring the quality of patient-physician interactions.

RESULTS

Of the 7 outcome variables examined in the unadjusted logistic regression model, only 2 remained statistically significant in the fully adjusted model. For both the total sample and for Asians only, compared with US-born, foreign-born individuals were at greater odds [total sample, odds ratio (OR) = 1.43; 95% confidence interval (CI) = 1.01-2.04; Asians, OR = 3.25; 95% CI = 1.18-8.95] of reporting that their physician did not involve them in their care as much as they would have liked. Compared with US-born Asians, foreign-born Asians were at greater odds of reporting that their physician did not spend as much time with them as they would have liked (OR = 4.19; 95% CI = 1.68-10.46).

DISCUSSION

Findings from our study suggest that we should not only track disparities by race and ethnicity but also by nativity status.

Quality improvement designs are related to the degree of organisation of quality systems: An empirical study of hospital departments

Quality systems can help departments do the right things and do things right, but organisation and design need to be considered. The aim was to analyse whether quality systems that include certain quality improvement designs differ with regard to organisational factors and degrees of organisation. A questionnaire was developed and sent to a random sample of 600 hospital departments in Sweden (response rate=75%). A k-means cluster analysis was used to group departments into three degrees of organisation. Analyses of variance were done to study differences in organisational factors and quality improvement designs among the clusters. LISREL analyses were done to study the relationships between organisational factors and quality improvement designs. The results showed that quality systems that included certain quality improvement designs differed with regard to the organisational factors available resources, administration, culture, cooperation, and goal achievement. The results also showed that departments with quality systems of different organisational degrees used different quality improvement designs. Some quality improvement designs may require a quality system with a high degree of organisation to support a successful implementation. The appended questionnaire could be used to plan implementations and evaluate their results.

Transferring critically ill patients out of hospital improves the standardized mortality ratio: a simulation study

BACKGROUND

Transferring critically ill patients to other acute care hospitals may artificially impact benchmarking measures. We sought to quantify the effect of out-of-hospital transfers on the standardized mortality ratio (SMR), an outcome-based measure of ICU performance.

METHODS

We performed a cohort study and Monte Carlo simulation using data from 85 ICUs participating in the acute physiology and chronic health evaluation (APACHE) clinical information system from 2002 to 2003. The SMR (observed divided by expected hospital mortality) was calculated for each ICU using APACHE IV risk adjustment. A set number of patients was randomly assigned to be transferred out alive rather than experience their original outcome. The SMR was recalculated, and the mean simulated SMR was compared to the original.

RESULTS

The mean (+/- SD) baseline SMR was 1.06 +/- 0.19. In the simulation, increasing the number of transfers by 2% and 6% over baseline decreased the SMR by 0.10 +/- 0.03 and 0.14 +/- 0.03, respectively. At a 2% increase, 27 ICUs had a decrease in SMR of > 0.10, and two ICUs had a decrease in SMR of > 0.20. Transferring only one additional patient per month was enough to create a bias of > 0.1 in 27 ICUs.

CONCLUSIONS

Increasing the number of acute care transfers by a small amount can significantly bias the SMR, leading to incorrect inference about ICU quality. Sensitivity to the variation in hospital discharge practices greatly limits the use of the SMR as a quality measure.

Conceptualizing a quality plan for healthcare. A philosophical reflection on the relevance of the health profession to society

Today, health systems around the world are under pressure to create greater value for patients and society; increasing access, improving client orientation and responsiveness, reducing medical errors and safety, restraining utilization via managed care, and implementing priority allocation of resources for high-burden health problems are examples of strategies towards this end. The quality paradigm by virtue of its strategic consumer focus and its methods for achieving operational excellence has proved an effective approach for creating higher value in many sectors. If applied in a deliberate and holistic manner, the quality paradigm can bring about a more cost-effective organization of the health systems. In this article, we apply quality concepts to healthcare in a conceptual format; we characterize the health system's customers and outputs with their quality dimensions. The product of this effort is a blueprint for a customer-driven health system which identifies six types of customers, nine types of outputs and the associated operations. As a preliminary step, a new analysis and definition of health and disease is provided. Rethinking the structure of health system in this manner and the related conceptual model can guide medical research, health sciences education, and health services policy, and help the practitioner to integrate all modern trends in healthcare delivery.

The structure of quality systems is important to the process and outcome, an empirical study of 386 hospital departments in Sweden

BACKGROUND

Clinicians, nurses, and managers in hospitals are continuously confronted by new technologies and methods that require changes to working practice. Quality systems can help to manage change while maintaining a high quality of care. A new model of quality systems inspired by the works of Donabedian has three factors: structure (resources and administration), process (culture and professional co-operation), and outcome (competence development and goal achievement). The objectives of this study were to analyse whether structure, process, and outcome can be used to describe quality systems, to analyse whether these components are related, and to discuss implications.

METHODS

A questionnaire was developed and sent to a random sample of 600 hospital departments in Sweden. The adjusted response rate was 75%. The data were analysed with confirmatory factor analysis and structural equation modeling in LISREL. This is to our knowledge the first large quantitative study that applies Donabedian's model to quality systems.

RESULTS

The model with relationships between structure, process, and outcome was found to be a reasonable representation of quality systems at hospital departments (p = 0.095, indicating no significant differences between the model and the data set). Structure correlated strongly with process (0.72) and outcome (0.60). Given structure, process also correlated with outcome (0.20).

CONCLUSION

The model could be used to describe and evaluate single quality systems or to compare different quality systems. It could also be an aid to implement a systematic and evidence-based system for working with quality improvements in hospital departments.

Pay-for-performance: considerations in application to the management of spinal disorders

STUDY DESIGN

Descriptive review.

OBJECTIVES

To describe the role of pay-for-performance as a health care policy that has a significant influence on the management of spinal disorders, and to consider parameters of quality measure that are likely to optimize the efficacy of a pay-for-performance system as applied to spine care.

SUMMARY OF BACKGROUND DATA

Pay-for-performance arrangements have been adopted in many areas of medicine with limited evidence for improvement in quality of care. There is an important role for a system that will improve quality of care in the management of spinal disorders. The absence of accepted evidence-based approaches to the management of spinal disorders makes the choice of parameters to measure for quality difficult.

RESULTS

Performance parameters to consider include a continuum of measures from process variables that focus on a discrete component of the health care experience, to outcome variables that encompass the end result of care. There are advantages and limitations to each parameter discussed.

CONCLUSION

A pay-for-performance system in the management of spinal disorders should include both process variables that measure safety and outcome variables that reflect the end result of care.

Quality in radiation oncology

A modern approach to quality was developed in the United States at Bell Telephone Laboratories during the first part of the 20th century. Over the years, those quality techniques have been adopted and extended by almost every industry. Medicine in general and radiation oncology in particular have been slow to adopt modern quality techniques. This work contains a brief description of the history of research on quality that led to the development of organization-wide quality programs such as Six Sigma. The aim is to discuss the current approach to quality in radiation oncology as well as where quality should be in the future. A strategy is suggested with the goal to provide a threshold improvement in quality over the next 10 years.

Factors affecting inpatient satisfaction: structural equation modeling

OBJECTIVE

Our study aimed to identify factors affecting patient satisfaction.

DATA

The study was conducted at a training hospital in Turkey. The final sample consisted of 302 inpatients. In this study, patient satisfaction was examined using a survey questionnaire with 22 questions collected under five dimensions.

METHOD

Factor analysis was used to group 22 questions measuring patients' satisfaction questions into certain dimensions. Then, structural equation model (SEM) was performed to determine the influence of patient characteristics on patient satisfaction.

RESULTS

Our analysis showed the questionnaire has an appropriate reliability and validity. The structural equation model (SEM) was used to determine those factors which could affect patient satisfaction. The results of SEM analysis showed that 15% of the total variance in patients' satisfaction was explained by the model. The SEM analysis found that variables of education and type of clinic (surgical vs. non-surgical) were significant on patient satisfaction. Persons with a higher level of education were less satisfied when compared to those with a lower level of education. Surgical patients are more satisfied with the care they received when compared to non-surgical patients.

CONCLUSION

The education level of patients and the type of clinics had a significant influence on patient satisfaction.

Proposed quality measures for palliative care in the critically ill: a consensus from the Robert Wood Johnson Foundation Critical Care Workgroup

For critically ill patients and their loved ones, high-quality health care includes the provision of excellent palliative care. To achieve this goal, the healthcare system needs to identify, measure, and report specific targets for quality palliative care for critically ill or injured patients. Our objective was to use a consensus process to develop a preliminary set of quality measures to assess palliative care in the critically ill. We built on earlier and ongoing efforts of the Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup to propose specific measures of the structure and process of palliative care. We used an informal iterative consensus process to identify and refine a set of candidate quality measures. These candidate measures were developed by reviewing previous literature reviews, supplementing the evidence base with recently published systematic reviews and consensus statements, identifying existing indicators and measures, and adapting indicators from related fields for our objective. Among our primary sources, we identified existing measures from the Voluntary Hospital Association's Transformation of the ICU program and a government-sponsored systematic review performed by RAND Health to identify palliative care quality measures for cancer care. Our consensus group proposes 18 quality measures to assess the quality of palliative care for the critically ill and injured. A total of 14 of the proposed measures assess processes of care at the patient level, and four measures explore structural aspects of critical care delivery. Future research is needed to assess the relationship of these measures to desired health outcomes. Subsequent measure sets should also attempt to include outcome measures, such as patient or surrogate satisfaction, as the field develops the means to rigorously measure such outcomes. The proposed measures are intended to stimulate further discussion, testing, and refinement for quality of care measurement and enhancement.

Defining and measuring quality palliative and end-of-life care in the intensive care unit

Quality of health care is primarily concerned with the provision of health services that intend to lead to valued health outcomes and are based and driven by evidence. Among other desired health outcomes are patient-and-family-centered values consistent with proficient palliative and end-of-life care in the intensive care unit. The research in palliative and end-of-life care has elucidated important domains for quality care-in general, major targets for improvement are known. However, assessment of quality at local and national levels remains relevant as innovators select where to begin quality improvement efforts and the healthcare system evaluates the efficacy and potential harm from care delivery transformations. In this article, I endeavor to impart a practical framework for quality of end-of-life care assessment with the goal of guiding the selection of initiatives and evaluating cycles of innovation. I will ground this quality evaluation by reviewing palliative and end-of-life care and the known domains for quality palliative care. Although the field has identified candidate indicators for evaluating palliative and end-of-life care in the intensive care unit, future work is needed to operationalize assessment for important aspects of care with valid, reliable, acceptable, efficient, and responsive measures.

Certificate of Need Regulation and Cardiac Catheterization Appropriateness After Acute Myocardial Infarction

BACKGROUND

Certificate of need (CON) regulation was introduced to control healthcare costs and improve quality of care in part by limiting the number of facilities providing complex medical care. Our objective was to examine whether rates of appropriate cardiac catheterization after admission for acute myocardial infarction varied between states with and without CON regulation of cardiac catheterization.

METHODS AND RESULTS

We performed a retrospective analysis of chart-abstracted data for 137,279 Medicare patients admitted for acute myocardial infarction between 1994 and 1996 at 4179 US acute-care hospitals. Using 3-level hierarchical generalized linear modeling adjusted for patient sociodemographic and clinical characteristics and physician and hospital characteristics, we compared catheterization rates within 60 days of admission for states (and the District of Columbia) with (n=32) and without (n=19) CON regulation in the full cohort and stratified by catheterization appropriateness. Appropriateness was categorized as strongly, equivocally, or weakly indicated. We found CON regulation was associated with a borderline-significant lower rate of catheterization overall (45.8% versus 46.5%; adjusted risk ratio [RR] 0.91, 95% confidence interval 0.82 to 1.00, P=0.06). After stratification by appropriateness, CON regulation was not associated with a significantly lower rate of catheterization among 63,823 patients with strong indications (49.9% versus 50.3%; adjusted RR 0.94, 95% confidence interval 0.86 to 1.02, P=0.17). However, CON regulation was associated with significantly lower rates of catheterization among 65,077 patients with equivocal indication (45.0% versus 46.0%; adjusted RR 0.88, 95% confidence interval 0.78 to 1.00, P=0.05) and among 8379 patients with weak indications (19.8% versus 21.8%; adjusted RR 0.84, 95% confidence interval 0.71 to 0.98, P=0.04). Associations were weakened substantially after adjustment for hospital coronary artery bypass graft surgery or cardiac catheterization capability.

CONCLUSIONS

CON regulation was associated with modestly lower rates of equivocally and weakly indicated cardiac catheterization after admission for acute myocardial infarction, but no significant differences existed in rates of strongly indicated catheterization.

Comparison of single and multiple agency clients in substance abuse treatment services

BACKGROUND

Frequent and multiple service utilization among substance abusers is a well-known problem. However, little statistical evidence exists about overlapping agency populations.

METHODS

This phenomenon was studied in a clear-cut region in Belgium, based on intake information concerning all clients who addressed a drug treatment center within a 6-month period (n=1,139).

RESULTS

Multiple service utilization was rather common but not omnipresent during this particular registration period. Almost 15% of the clients were registered in more than one substance abuse treatment agency. Compared to single agency attendees, multiple agency clients appeared to be more often poly-substance abusers with a longer previous treatment history and greater problem severity.

CONCLUSION

A continuous care perspective, interagency collaboration and a common tracking and documentation system are recommended to better address the needs of this specific subgroup of substance abusers. More research is needed to clarify whether these multiple service utilization patterns are caused by client-related, agency-related or other factors.

Towards using administrative databases to measure population-based indicators of quality of end-of-life care: testing the methodology

This study is concerned with methods to measure population-based indicators of quality end-of-life care. Using a retrospective cohort approach, we assessed the feasibility, validity and reliability of using administrative databases to measure quality indicators of end-of-life care in two Canadian provinces. The study sample consisted of all females who died of breast cancer between 1 January 1998 and 31 December 2002, in Nova Scotia or Ontario, Canada. From an initial list of 19 quality indicators selected from the literature, seven were determined to be fully measurable in both provinces. An additional seven indicators in one province and three in the other province were partially measurable. Tests comparing administrative and chart data show a high level of agreement with inter-rater reliability, confirming consistency in the chart abstraction process. Using administrative data is an efficient, population-based method to monitor quality of care which can compliment other methods, such as qualitative and purposefully collected clinical data.

[ICU performance: results of a French study involving 80,000 ICU stays]

OBJECTIVE

The Standard Mortality Ratio (SMR), comparing the observed in-hospital mortality to the predicted, may measure the intensive care units (ICU) performance.

STUDY DESIGN

Multicentric retrospective national study.

METHODS

A probability model using a severity score such SAPS II calculated the predicted mortality rate. A national French study has been undertaken to compare the SMR of ICUs and looked for explanation.

RESULTS

One hundred six units, 34 were medical (32%), 18 surgical (17%) and 57 medical/surgical (51%) participated to the study. Forty-six ICUs (43%) were located in teaching hospitals. The SMR of the 87,099 stays was 0.84 (0.82-0.85). The SMR of ICUs varied from 0.41 to 1.55. Ten units had a SMR>0.85, which suggested a low performance. They had more stays for cardiovascular failures, as compared with others. The best units (SMR<0.82) had more stays for drug overdose. The SMR increased with the number of organ failures, from 0.47 with zero failure to 1.11 with 4 or more organ failures. The stays with cardiovascular failure, either unique or associated, had a higher SMR. The 7935 stays with a drug overdose had a SMR of 0.12 (0.10-0.14), which suggested a bad calibration of the model in theses cases.

CONCLUSION

The case mix must be taken in account when comparing the ICUs performance by the mean of SMR, particularly when the units admitted a lot of drug overdoses.

Complementary and Conventional Medicine in Switzerland: Comparing Characteristics of General Practitioners

OBJECTIVES

Do structural characteristics of general practitioners (GPs) who practice complementary medicine (CAM) differ from those GPs who do not? Assessed characteristics included experience and professional integration of general practitioners (GPs), workload, medical activities, and personal and technical resources of practices. The investigated CAM disciplines were anthroposophic medicine, homoeopathy, traditional Chinese medicine, neural therapy and herbal medicine.

MATERIAL AND METHODS

We designed a cross-sectional study with convenience and stratified samples of GPs providing conventional (COM) and/or complementary primary care in Switzerland. The samples were taken from the database of the Swiss medical association (FMH) and from CAM societies. Data were collected using a postal questionnaire.

RESULTS

Of the 650 practitioners who were included in the study, 191 were COM, 167 noncertified CAM and 292 certified CAM physicians. The proportion of females was higher in the population of CAM physicians. Gender-adjusted age did not differ between CAM and COM physicians. Nearly twice as many CAM physicians work part-time. Differences were also seen for the majority of structural characteristics such as qualification of physicians, type of practice, type of staff, and presence of technical equipment.

CONCLUSION

The study results show that structural characteristics of primary health care do differ between CAM and COM practitioners. We assumed that the activities of GPs are defined essentially by analyzed structures. The results are to be considered for evaluations in primary health care, particularly when quality of health care is assessed.

The Seattle Pediatric Palliative Care Project: Effects on Family Satisfaction and Health-Related Quality of Life

PURPOSE

This paper presents the components of a pediatric palliative care demonstration program implemented in Seattle during the period 1999-2001. It reports findings from the evaluation of quality of life and family satisfaction among enrolled participants. The program was designed to enhance patient-provider communication using the Decision-making Tool (DMT) and experimented with co-management by clinicians and insurers to support decision making in advanced serious pediatric illness.

DESIGN

The project design consisted of ethical decision-making, provider education, and flexible administration of health benefits through co-case management between insurers and care providers. The evaluation study design is a non-experimental pretest, posttest design comparison of pediatric quality of life and family satisfaction at program entry with repeated measures at 3 months post-program entry. Quality of life was measured with parent proxy reports of health-related quality of life using the PedsQL() Version 4.0, and family satisfaction was measured with a 31-item self-administered questionnaire designed by project staff.

RESULTS

Forty-one patients ranging in age from infancy to 22 years old were enrolled in the program over a 2-year period. Parents consented to participate in the evaluation study. Thirty one specific diagnoses were represented in the patient population; 34% were some form of cancer. Improvements in health-related quality of life over baseline were observed for 21 matched pairs available for analysis in each domain of health-related quality of life; positive changes in reports of emotional well-being were statistically significant. Improvements over baseline in 14 of 31 family satisfaction items were statistically significant.

CONCLUSIONS

Pediatric palliative care services that focus on effective communication, decision support, and co-case management with insurers can improve aspects of quality of life and family satisfaction.

Development and preliminary validation of Brace Questionnaire (BrQ): a new instrument for measuring quality of life of brace treated scoliotics

BACKGROUND

The quality of life among children with idiopathic scoliosis during their adolescence has been reported to be affected by the brace itself. However, a controversy exists whether brace treated scoliotics experience a poor quality of life, thus there is a need for the development of a brace-oriented instrument, as the now-existing questionnaires that are commonly used, such as the SRS -22, take into consideration the effects of both the conservative and the surgical treatment on quality of life of scoliotic children. The aim of the present study is to assess the validity and reliability of Brace Questionnaire (BrQ), a new instrument for measuring quality of life of scoliotic adolescents who are treated conservatively with a brace.

MATERIAL-METHOD

Methodology of development involved literature review, patient and health care professionals' in-depth interviews and content validity analysis on patients. A validation study was performed on 28 brace treated scoliotic children aged between 9 and 18 years old. BrQ was assessed for the following psychometric properties: item convergent validity, floor and ceiling effects, internal consistency reliability, clinical validity and responsiveness to change.

RESULTS

BrQ is self administrated and developmentally appropriate for ages 9 to 18 years old and is consisted of 34 Likert-scale items associated with eight domains: general health perception, physical functioning, emotional functioning, self esteem and aesthetics, vitality, school activity, bodily pain and social functioning of scoliotic children treated conservatively with a brace. The subscales of these eight dimensions can be combined to produce a total score. Higher scores mean a better quality of life. An item convergent validity >/= 0.40 was satisfied by all items in the present study. A satisfactory internal consistency reliability for the BrQ was recorded (Cronbach's alpha coefficient was 0.82). There were no floor or ceiling effects. The correlation between BrQ overall scores and mild and moderate scoliosis was statistically significant (p < 0.001), revealing high clinical validity. An increase in effect sizes for the patient with improved scoliotic curves indicates that the BrQ is responsive to change in health status.

CONCLUSION

BrQ is reliable, valid and responsive to change in adolescents with IS who are treated conservatively with a brace.

Different types and aspects of quality systems and their implications

Policy makers and managers face a difficult challenge in keeping up with the changing organisations and methods of health care. Organised systematic quality work, that is, quality systems, can make this task easier. The aim here was to study different quality systems, identify common characteristics, find types of quality systems and discuss the practical implications of the results. The study was designed as a qualitative study of seven clinics with quality systems at a large university hospital in Sweden. Purposefully selected, 19 managers or quality co-ordinators were interviewed. The interviews were audio taped, transcribed verbatim and analysed thematically. Six organisational aspects were present in the interviews: resources, administration, culture, co-operation, goal achievement and development of competence. The aspects were used to categorise the clinics' systems into three types: local, centralised and integrated systems. The responses indicated that local systems had a decentralised organisation, allowing for a high degree of adaptability. Centralised systems were reported to be more top-down orientated, allowing for a highly predictable output. Integrated systems were reported to have a management style that emphasized co-operation, allowing for both good adaptability and predictability. Policy makers and managers could use the described aspects and types of quality systems to help decide what type of quality system to implement in a specific setting, as a base line for evaluation, or as a framework for developing existing quality systems.