1
|
Slawomirski L, Hensher M, Campbell J, deGraaff B. Pay-for-performance and patient safety in acute care: A systematic review. Health Policy 2024; 143:105051. [PMID: 38547664 DOI: 10.1016/j.healthpol.2024.105051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/13/2024] [Accepted: 03/17/2024] [Indexed: 04/20/2024]
Abstract
Pay-for-performance (p4p) has been tried in all healthcare settings to address ongoing deficiencies in the quality and outcomes of care. The evidence for the effect of these policies has been inconclusive, especially in acute care. This systematic review focused on patient safety p4p in the hospital setting. Using the PRISMA guidelines, we searched five biomedical databases for quantitative studies using at least one outcome metric from database inception to March 2023, supplemented by reference tracking and internet searches. We identified 6,122 potential titles of which 53 were included: 39 original investigations, eight literature reviews and six grey literature reports. Only five system-wide p4p policies have been implemented, and the quality of evidence was low overall. Just over half of the studies (52 %) included failed to observe improvement in outcomes, with positive findings heavily skewed towards poor quality evaluations. The exception was the Fragility Hip Fracture Best Practice Tariff (BPT) in England, where sustained improvement was observed across various evaluations. All policies had a miniscule impact on total hospital revenue. Our findings underscore the importance of simple and transparent design, involvement of the clinical community, explicit links to other quality improvement initiatives, and gradual implementation of p4p initatives. We also propose a research agenda to lift the quality of evidence in this field.
Collapse
Affiliation(s)
- Luke Slawomirski
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St., Hobart 7000, Tasmania, Australia.
| | - Martin Hensher
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St., Hobart 7000, Tasmania, Australia
| | - Julie Campbell
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St., Hobart 7000, Tasmania, Australia
| | - Barbara deGraaff
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St., Hobart 7000, Tasmania, Australia
| |
Collapse
|
2
|
Brouwers J, Seys D, Claessens F, Van Wilder A, Bruyneel L, De Ridder D, Eeckloo K, Vanhaecht K. Effect on hospital incentive payments and quality performance of a hospital pay for performance (P4P) programme in Belgium. J Healthc Qual Res 2024; 39:147-154. [PMID: 38594161 DOI: 10.1016/j.jhqr.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/15/2024] [Accepted: 02/22/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Belgium initiated a hospital pay for performance (P4P) programme after a decade of fixed bonus budgets for "quality and safety contracts". This study examined the effect of P4P on hospital incentive payments, performance on quality measures, and the association between changes in quality performance and incentive payments over time. METHODS The Belgian government provided information on fixed bonus budgets in 2013-2017 and hospital incentive payments as well as hospital performance on quality measures for the P4P programmes in 2018-2020. Descriptive analyses were conducted to map the financial repercussion between the two systems. A difference-in-difference analysis evaluated the association between quality indicator performance and received incentive payments over time. RESULTS Data from 87 acute-care hospitals were analyzed. In the transition to a P4P programme, 29% of hospitals received lower incentive payments per bed. During the P4P years, quality performance scores increased yearly for 55% of hospitals and decreased yearly for 5% of hospitals. There was a significant larger drop in incentive payments for hospitals that scored above median with the start of the P4P programme. CONCLUSIONS The transition from fixed bonus budgets for quality efforts to a new incentive payment in a P4P programme has led to more hospitals being financially impacted, although the effect is marginal given the small P4P budget. Quality indicators seem to improve over the years, but this does not correlate with an increase in reward per bed for all hospitals due to the closed nature of the budget.
Collapse
Affiliation(s)
- J Brouwers
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Belgium; Department of Orthopaedics, University Hospitals Leuven, Belgium.
| | - D Seys
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Belgium
| | - F Claessens
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Belgium
| | - A Van Wilder
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Belgium
| | - L Bruyneel
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Belgium
| | - D De Ridder
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Belgium; Department of Quality Management, University Hospitals Leuven, Belgium
| | - K Eeckloo
- Department of Public Health and Primary Care, UGent & Strategic Policy Unit, Ghent University Hospital, Ghent, Belgium
| | - K Vanhaecht
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Belgium; Department of Quality Management, University Hospitals Leuven, Belgium
| |
Collapse
|
3
|
Saito Y, Inohara T, Kohsaka S, Wada H, Kumamaru H, Yamaji K, Ishii H, Amano T, Miyata H, Kobayashi Y, Kozuma K. Benchmarking System Monitoring on Quality Improvement in Percutaneous Coronary Intervention: A Nationwide Registry in Japan. JACC. ASIA 2024; 4:323-331. [PMID: 38660107 PMCID: PMC11035937 DOI: 10.1016/j.jacasi.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/11/2023] [Accepted: 12/11/2023] [Indexed: 04/26/2024]
Abstract
Background Quality indicators (QIs) have been developed to improve and standardize care quality in percutaneous coronary intervention (PCI). In Japan, consecutive PCI procedures are registered in a nationwide database (the Japanese Percutaneous Coronary Intervention registry), which introduces a benchmarking system for comparing individual institutional performance against the national average. Objectives The aim of this study was to assess the impact of the benchmarking system implementation on QI improvement at the hospital level. Methods A total of 734,264 PCIs were conducted at 1,194 institutions between January 2019 and December 2021. In January 2018, a web-based benchmarking system encompassing 7 QIs for PCI at the institutional level, including door-to-balloon time and rate of transradial intervention, was introduced. The process by which institutions tracked their QIs was centrally monitored. Results During the 3-year study period, the benchmarking system was reviewed at least once at 742 institutions (62.1%) (median 4 times; Q1-Q3: 2-7 times). The institutions that reviewed their records had higher PCI volumes. Among these institutions, although door-to-balloon time was not directly associated, the proportion of transradial intervention increased by 2.3% in the system review group during the initial year compared with 0.7% in their counterparts. However, in the subsequent year, the association between system reviews and QI improvement was attenuated. Conclusions The implementation of a benchmarking system, reviewed by participating institutions in Japan, was partially associated with improved QIs during the first year; however, this improvement was attenuated in the subsequent year, highlighting the need for further efforts to develop effective and sustainable interventions to enhance care quality in PCI.
Collapse
Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Taku Inohara
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hideki Wada
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kyohei Yamaji
- Department of Cardiology, Kyoto University, Kyoto, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Ken Kozuma
- Department of Cardiology, Teikyo University Hospital, Tokyo, Japan
| | - J-PCI Registry Investigators
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
- Department of Healthcare Quality Assessment, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
- Department of Cardiology, Kyoto University, Kyoto, Japan
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
- Department of Cardiology, Teikyo University Hospital, Tokyo, Japan
| |
Collapse
|
4
|
Ciemins EL, Mohl JT, Moreno CA, Colangelo F, Smith RA, Barton M. Development of a Follow-Up Measure to Ensure Complete Screening for Colorectal Cancer. JAMA Netw Open 2024; 7:e242693. [PMID: 38526494 DOI: 10.1001/jamanetworkopen.2024.2693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
Importance The current quality performance measure for colorectal cancer (CRC) screening is limited to initial screening. Despite low rates, there is no measure for appropriate follow-up with colonoscopy after receipt of an abnormal result of a stool-based screening test (SBT) for CRC. A quality performance measure is needed. Objective To develop and test a quality performance measure for follow-up colonoscopy within 6 months of an abnormal result of an SBT for CRC. Design, Setting, and Participants This retrospective quality improvement study examined data from January 1, 2016, to December 31, 2020, with 2018 plus 6 months of follow-up as the primary measurement period to verify performance rates, specify a potential measure, and test for validity, reliability, and feasibility. The Optum Labs Data Warehouse (OLDW), a deidentified database of health care claims and clinical data, was accessed. The OLDW contains longitudinal health information on enrollees and patients, representing a diverse mixture of ages and geographic regions across the US. For the database study, adults from 38 health care organizations (HCOs) aged 50 to 75 years who completed an initial CRC SBT with an abnormal result were observed to determine follow-up colonoscopy rates within 6 months. Rates were stratified by race, ethnicity, sex, insurance, and test modality. Three HCOs participated in the feasibility field testing. Data were analyzed from June 1, 2022, to May 31, 2023. Main Outcome and Measures The primary outcome consisted of follow-up colonoscopy rates following an abnormal SBT result for CRC. Reliability statistics were also calculated across HCOs, race, ethnicity, and measurement year. Results Among 20 581 adults (48.6% men and 51.4% women; 307 [1.5%] Asian, 492 [7.2%] Black, 644 [3.1%] Hispanic, and 17 705 [86.0%] White; mean [SD] age, 63.6 [7.1] years) in 38 health systems, 47.9% had a follow-up colonoscopy following an abnormal SBT result for CRC within 6 months. There was significant variation between HCOs. Notably, significantly fewer Black patients (37.1% [95% CI, 34.6%-39.5%]) and patients with Medicare (49.2% [95% CI, 47.7%-50.6%]) or Medicaid (39.2% [95% CI, 36.3%-42.1%]) insurance received a follow-up colonoscopy. A quality performance measure that tracks rates of follow-up within 6 months of an abnormal SBT result was observed to be feasible, valid, and reliable, with a median reliability statistic between HCOs of 94.5% (range, 74.3%-99.7%). Conclusions and Relevance The findings of this observational study of 20 581 adults suggest that a measure of follow-up colonoscopy within defined periods after an abnormal result of an SBT test for CRC is warranted based on low current performance rates and would be feasible to collect by health systems and produce valid, reliable results.
Collapse
Affiliation(s)
- Elizabeth L Ciemins
- Research and Analytics, American Medical Group Association, Alexandria, Virginia
| | - Jeff T Mohl
- Research and Analytics, American Medical Group Association, Alexandria, Virginia
| | - Carlos A Moreno
- Research and Analytics, American Medical Group Association, Alexandria, Virginia
- Now with Albany Medical College
| | | | - Robert A Smith
- Center for Cancer Screening, American Cancer Society, Atlanta, Georgia
| | - Mary Barton
- National Committee for Quality Assurance, Washington, DC
| |
Collapse
|
5
|
Harrington J, Rao VN, Leyva M, Oakes M, Mentz RJ, Bosworth HB, Pagidipati NJ. Improving Guideline-Directed Medical Therapy for Patients With Heart Failure With Reduced Ejection Fraction: A Review of Implementation Strategies. J Card Fail 2024; 30:376-390. [PMID: 38142886 DOI: 10.1016/j.cardfail.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/26/2023]
Abstract
Despite recent advances in the use of guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), achievement of target GDMT use and up-titration to goal dosages continue to be modest. In recent years, a number of interventional approaches to improve the usage of GDMT have been published, but many are limited by single-center experiences with small sample sizes. However, strategies including the use of multidisciplinary teams, dedicated GDMT titration algorithms and clinician audits with feedback have shown promise. There remains a critical need for large, rigorous trials to assess the utility of differing interventions to improve the use and titration of GDMT in HFrEF. Here, we review existing literature in GDMT implementation for those with HFrEF and discuss future directions and considerations in the field.
Collapse
Affiliation(s)
- Josephine Harrington
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | - Vishal N Rao
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Monica Leyva
- Department of Population Health Sciences, Durham, NC
| | - Megan Oakes
- Department of Population Health Sciences, Durham, NC
| | - Robert J Mentz
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Hayden B Bosworth
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Department of Population Health Sciences, Durham, NC
| | - Neha J Pagidipati
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
| |
Collapse
|
6
|
Webb R, Ford E, Shakespeare J, Easter A, Alderdice F, Holly J, Coates R, Hogg S, Cheyne H, McMullen S, Gilbody S, Salmon D, Ayers S. Conceptual framework on barriers and facilitators to implementing perinatal mental health care and treatment for women: the MATRIx evidence synthesis. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-187. [PMID: 38317290 DOI: 10.3310/kqfe0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Background Perinatal mental health difficulties can occur during pregnancy or after birth and mental illness is a leading cause of maternal death. It is therefore important to identify the barriers and facilitators to implementing and accessing perinatal mental health care. Objectives Our research objective was to develop a conceptual framework of barriers and facilitators to perinatal mental health care (defined as identification, assessment, care and treatment) to inform perinatal mental health services. Methods Two systematic reviews were conducted to synthesise the evidence on: Review 1 barriers and facilitators to implementing perinatal mental health care; and Review 2 barriers to women accessing perinatal mental health care. Results were used to develop a conceptual framework which was then refined through consultations with stakeholders. Data sources Pre-planned searches were conducted on MEDLINE, EMBASE, PsychInfo and CINAHL. Review 2 also included Scopus and the Cochrane Database of Systematic Reviews. Review methods In Review 1, studies were included if they examined barriers or facilitators to implementing perinatal mental health care. In Review 2, systematic reviews were included if they examined barriers and facilitators to women seeking help, accessing help and engaging in perinatal mental health care; and they used systematic search strategies. Only qualitative papers were identified from the searches. Results were analysed using thematic synthesis and themes were mapped on to a theoretically informed multi-level model then grouped to reflect different stages of the care pathway. Results Review 1 included 46 studies. Most were carried out in higher income countries and evaluated as good quality with low risk of bias. Review 2 included 32 systematic reviews. Most were carried out in higher income countries and evaluated as having low confidence in the results. Barriers and facilitators to perinatal mental health care were identified at seven levels: Individual (e.g. beliefs about mental illness); Health professional (e.g. confidence addressing perinatal mental illness); Interpersonal (e.g. relationship between women and health professionals); Organisational (e.g. continuity of carer); Commissioner (e.g. referral pathways); Political (e.g. women's economic status); and Societal (e.g. stigma). These factors impacted on perinatal mental health care at different stages of the care pathway. Results from reviews were synthesised to develop two MATRIx conceptual frameworks of the (1) barriers and (2) facilitators to perinatal mental health care. These provide pictorial representations of 66 barriers and 39 facilitators that intersect across the care pathway and at different levels. Limitations In Review 1 only 10% of abstracts were double screened and 10% of included papers methodologically appraised by two reviewers. The majority of reviews included in Review 2 were evaluated as having low (n = 14) or critically low (n = 5) confidence in their results. Both reviews only included papers published in academic journals and written in English. Conclusions The MATRIx frameworks highlight the complex interplay of individual and system level factors across different stages of the care pathway that influence women accessing perinatal mental health care and effective implementation of perinatal mental health services. Recommendations for health policy and practice These include using the conceptual frameworks to inform comprehensive, strategic and evidence-based approaches to perinatal mental health care; ensuring care is easy to access and flexible; providing culturally sensitive care; adequate funding of services; and quality training for health professionals with protected time to do it. Future work Further research is needed to examine access to perinatal mental health care for specific groups, such as fathers, immigrants or those in lower income countries. Trial registration This trial is registered as PROSPERO: (R1) CRD42019142854; (R2) CRD42020193107. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR 128068) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.
Collapse
Affiliation(s)
- Rebecca Webb
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London, UK
| | - Elizabeth Ford
- Department of Primary Care and Public Health, Brighton & Sussex Medical School, Falmer, UK
| | | | - Abigail Easter
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
- Section of Women's Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Fiona Alderdice
- Oxford Population Health, National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Rose Coates
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London, UK
| | - Sally Hogg
- The Parent-Infant Foundation, London, UK
| | - Helen Cheyne
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK
| | | | - Simon Gilbody
- Mental Health and Addictions Research Group, University of York, York, UK
| | - Debra Salmon
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London, UK
| | - Susan Ayers
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London, UK
| |
Collapse
|
7
|
Speirs TP, Atkins E, Chowdhury MM, Hildebrand DR, Boyle JR. Adherence to vascular care guidelines for emergency revascularization of chronic limb-threatening ischemia. J Vasc Surg Cases Innov Tech 2023; 9:101299. [PMID: 38098680 PMCID: PMC10719409 DOI: 10.1016/j.jvscit.2023.101299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 05/08/2023] [Indexed: 12/17/2023] Open
Abstract
Objective In 2022, the National Health Service Commissioning for Quality and Innovation (CQUIN) indicator for vascular surgery, with its pay-for-performance incentive for timely (5-day) revascularization of chronic limb-threatening ischemia (CLTI), was introduced. We sought to assess its effects in terms of (1) changes in the care pathway process measures relating to timing and patient outcomes; and (2) adherence to the Peripheral Arterial Disease Quality Improvement Framework (PAD-QIF) guidelines for patients admitted with CLTI. Methods A retrospective before-and-after cohort study was performed from January to June 2022 of nonelective admissions for CLTI who underwent revascularization (open, endovascular, or hybrid) at Cambridge University Hospitals National Health Service Foundation Trust, a regional vascular "hub." The diagnostic and treatment pathway timing-related process measures recommended in the PAD-QIF were compared between two 3-month cohorts-before vs after introduction of the CQUIN. Results For the two cohorts (before vs after CQUIN), 17 of 223 and 17 of 219 total admissions met the inclusion criteria, respectively. After introduction of financial incentives, the percentage of patients meeting the 5-day targets for revascularization increased from 41.2% to 58.8% (P = .049). Improvements were also realized in the attainment of PAD-QIF targets for a referral-to-admission time of ≤2 days (from 82.4% to 88.8%; P = .525) and admission-to-specialist-review time of ≤14 hours (from 58.8% to 76.5%; P = .139). An increase also occurred in the percentage of patients receiving imaging studies within 2 days of referral (from 58.8% to 70.6%; P = .324). The reasons for delay included operating list pressures and unsuitability for intervention (eg, active COVID-19 [coronavirus disease 2019] infection). No statistically significant changes to patient outcomes were observed between the two cohorts in terms of complications (pre-CQUIN, 23.5%; post-CQUIN, 41.2%; P = .086), length of stay (pre-QUIN, 12.0 ± 12.0 days; post-QUIN, 15.0 ± 21.0 days; P = .178), and in-hospital mortality (pre-QUIN, 0%; post-QUIN, 5.9%). Other PAD-QIF targets relating to delivery of care were poorly documented for both cohorts. These included documented staging of limb threat severity with the WIfI (wound, ischemia, foot infection) score (2.9% of patients; target >80%), documented shared decision-making (47.1%; target >80%), documented issuance of written information to patient (5.9%; target 100%), and geriatric assessment (6.3%; target >80%). Conclusions The pay-for-performance incentive CQUIN indicators appear to have raised the profile for the need for early revascularization to treat CLTI, engaging senior hospital management, and reducing the time to revascularization in our cohort. Further data collection is required to detect any resultant changes in patient outcomes. Documentation of guideline targets for delivery of care was often poor and should be improved.
Collapse
Affiliation(s)
- Toby P. Speirs
- Department of Vascular Surgery, Cambridge University Hospitals, Queens' College, Cambridge, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Eleanor Atkins
- Department of Vascular Surgery, Cambridge University Hospitals, Queens' College, Cambridge, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Mohammed M. Chowdhury
- Department of Vascular Surgery, Cambridge University Hospitals, Queens' College, Cambridge, UK
- Department of Surgery, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Diane R. Hildebrand
- Department of Vascular Surgery, Cambridge University Hospitals, Queens' College, Cambridge, UK
| | - Jonathan R. Boyle
- Department of Vascular Surgery, Cambridge University Hospitals, Queens' College, Cambridge, UK
- Department of Surgery, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| |
Collapse
|
8
|
Nelson GE, Narayanan N, Onguti S, Stanley K, Newland JG, Doernberg SB. Principles and Practice of Antimicrobial Stewardship Program Resource Allocation. Infect Dis Clin North Am 2023; 37:683-714. [PMID: 37735012 DOI: 10.1016/j.idc.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Antimicrobial Stewardship Programs (ASP) improve individual patient outcomes and clinical care processes while reducing antimicrobial-associated adverse events, optimizing operational priorities, and providing institutional cost savings. ASP composition, resources required, and priority focuses are influenced by myriad factors. Despite robust evidence and broad national support, individual ASPs still face challenges in obtaining appropriate resources. Though understanding the current landscape of ASP resource allocation, factors influencing staffing needs, and strategies required to obtain desired resources is important, acceptance of recommended staffing levels and appropriate ASP resource allocation are much needed to facilitate ASP sustainability and growth across the complex and diverse health care continuum.
Collapse
Affiliation(s)
- George E Nelson
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, 1161 21st Avenue South, A2200 MCN, Nashville, TN 37232-2582, USA.
| | - Navaneeth Narayanan
- Department of Pharmacy Practice and Administration, Rutgers University Ernest Mario School of Pharmacy, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Sharon Onguti
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, 1161 21st Avenue South, A2200 MCN, Nashville, TN 37232-2582, USA
| | - Kim Stanley
- Department of Quality and Patient Safety, Division of Hospital Epidemiology and Infection Prevention, University of San Francisco, California, San Francisco, CA, USA
| | - Jason G Newland
- Department of Pediatrics, Division of Infectious Diseases, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Sarah B Doernberg
- Department of Medicine, Division of Infectious Diseases, University of San Francisco, California, 513 Parnassus Avenue, Box 0654, San Francisco, CA 94143, USA
| |
Collapse
|
9
|
Leao DLL, Cremers HP, van Veghel D, Pavlova M, Hafkamp FJ, Groot WNJ. Facilitating and Inhibiting Factors in the Design, Implementation, and Applicability of Value-Based Payment Models: A Systematic Literature Review. Med Care Res Rev 2023; 80:467-483. [PMID: 36951451 PMCID: PMC10469482 DOI: 10.1177/10775587231160920] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/08/2023] [Indexed: 03/24/2023]
Abstract
Evidence on the potential for value-based payment models to improve quality of care and ensure more efficient outcomes is limited and mixed. We aim to identify the factors that enhance or inhibit the design, implementation, and application of these models through a systematic literature review. We used the PRISMA guidelines. The facilitating and inhibiting factors were divided into subcategories according to a theoretical framework. We included 143 publications, each reporting multiple factors. Facilitators on objectives and strategies, such as realistic/achievable targets, are reported in 56 studies. Barriers regarding dedicated time and resources (e.g., an excessive amount of time for improvements to manifest) are reported in 25 studies. Consensus within the network regarding objectives and strategies, trust, and good coordination is essential. Health care staff needs to be kept motivated, well-informed, and actively involved. In addition, stakeholders should manage expectations regarding when results are expected to be achieved.
Collapse
|
10
|
Kim MJ. Unintended consequences of healthcare reform in South Korea: evidence from a regression discontinuity in time design. Health Res Policy Syst 2023; 21:60. [PMID: 37349727 DOI: 10.1186/s12961-023-00993-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 05/10/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND To address concerns over the financial stability of South Korea's National Health Insurance (NHI) programme, the government transitioned from an outpatient copayment system to a coinsurance system in 2007. This policy aimed to reduce healthcare overutilization by increasing patients' financial responsibility for outpatient services. METHODS Using comprehensive data on NHI beneficiaries, this study employs a regression discontinuity in time (RDiT) design to assess the policy's impact on outpatient healthcare utilization and expenditures. We focus on changes in overall outpatient visits, average healthcare cost per visit and total outpatient healthcare expenditures. RESULTS Our findings indicate that the transition from outpatient copayment to coinsurance led to a substantial increase in outpatient healthcare utilization (up to 90%) while decreasing medical expenditures per visit by 23%. The policy shift incentivized beneficiaries to seek more medical treatments during the grace period and enroll in supplemental private health insurance, which provided access to additional medical services at lower marginal costs. CONCLUSIONS The policy change and the emergence of supplemental private insurance contributed to moral hazard and adverse selection issues, culminating in South Korea becoming the country with the highest per capita utilization of outpatient health services worldwide since 2012. This study underscores the importance of carefully considering the unintended consequences of policy interventions in the healthcare sector.
Collapse
Affiliation(s)
- Moon Joon Kim
- Department of Economics, George Mason University Korea, Songdomunhwa-ro 119-4, Yeonsu-gu, Incheon, 21985, South Korea.
| |
Collapse
|
11
|
Lin PC, Lin CC, Li CI, Wang TC, Peng YH, Chang TT, Lin CY, Li TC, Hsieh CL. TCM as adjunctive therapy improves risks of respiratory hospitalizations in persons with type 2 diabetes: A retrospective cohort study. Medicine (Baltimore) 2023; 102:e33318. [PMID: 36961191 PMCID: PMC10036058 DOI: 10.1097/md.0000000000033318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/27/2023] [Indexed: 03/25/2023] Open
Abstract
Patients with type 2 diabetes are at a higher risk of chronic obstructive pulmonary disease (COPD) and asthma than the general population. In addition, emerging evidence suggests that traditional Chinese medicine (TCM) might be beneficial for patients with type 2 diabetes. We investigated whether TCM use was associated with a reduced risk of respiratory hospitalizations in patients with type 2 diabetes. Conducting a retrospective cohort study, we used data retrieved from the NDCMP database. Among 56,035 patients, 5226 were classified as TCM users; 50,809 were classified as TCM nonusers. Both groups were analyzed until the end of 2011 to examine the incidence of respiratory hospitalizations by using a Cox proportional hazards model to evaluate effects of TCM use on respiratory hospitalizations. During the 6-year study follow-up period, the incidence density rates of COPD- and asthma-related hospitalization were estimated to be 13.03 and 4.47 per 10,000 patient-years for TCM nonusers and 10.08 and 3.28 per 10,000 patient-years for TCM users, respectively. The HR of COPD-related hospitalization in TCM users was 0.88 (95% CI = 0.79-0.99); and the HR of asthma-related hospitalization in TCM users was 0.81 (95% CI = 0.66-1.00). Stratified analyses revealed that effects of TCM use were stronger among individuals who had diabetes for <3 years. As a part of Integrative Medicine, our study results demonstrate that TCM use was associated with a significant reduced risk of respiratory hospitalizations, especially in patients with diabetes for <3 years.
Collapse
Affiliation(s)
- Pei-Chun Lin
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan, Republic of China
| | - Cheng-Chieh Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan, Republic of China
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Chia-Ing Li
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan, Republic of China
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Tang-Chuan Wang
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan, Republic of China
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan, Republic of China
- Department of Otolaryngology-Head and Neck Surgery, China Medical University Hsinchu Hospital, Hsinchu, Taiwan, Republic of China
| | - Yi-Hao Peng
- Department of Respiratory Therapy, Asia University Hospital, Asia University, Taichung, Taiwan, Republic of China
| | - Tung-Ti Chang
- School of Post-Baccalaureate Chinese Medicine, China Medical University, Taichung, Taiwan, Republic of China
- Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Chin-Yi Lin
- PhD Program for Aging, College of Medicine, China Medical University, Taichung, Taiwan, Republic of China
| | - Tsai-Chung Li
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan, Republic of China
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan, Republic of China
| | - Ching-Liang Hsieh
- Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan, Republic of China
- Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University, Taichung, Taiwan, Republic of China
- Chinese Medicine Research Center, China Medical University, Taichung, Taiwan, Republic of China
| |
Collapse
|
12
|
Buttenheim A, Castillo-Neyra R, Arevalo-Nieto C, Shinnick JE, Sheen JK, Volpp K, Paz-Soldan V, Behrman JR, Levy MZ. Do Incentives Crowd Out Motivation? A Feasibility Study of a Community Vector-Control Campaign in Peru. Behav Med 2023; 49:53-61. [PMID: 34847825 PMCID: PMC9869690 DOI: 10.1080/08964289.2021.1977603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 06/20/2021] [Accepted: 08/22/2021] [Indexed: 01/28/2023]
Abstract
Incentives are a useful tool in encouraging healthy behavior as part of public health initiatives. However, there remains concern about motivation crowd out-a decline in levels of motivation to undertake a behavior to below baseline levels after incentives have been removed-and few public health studies have assessed for motivation crowd out. Here, we assess the feasibility of identifying motivation crowd out following a lottery to promote participation in a Chagas disease vector control campaign. We look for evidence of crowd out in subsequent participation in the same behavior, a related behavior, and an unrelated behavior. We identified potential motivation crowd out for the same behavior, but not for related behavior or unrelated behaviors after lottery incentives are removed. Despite some limitations, we conclude that motivation crowd out is feasible to assess in large-scale trials of incentives.
Collapse
Affiliation(s)
- Alison Buttenheim
- Department of Family and Community Nursing, University of Pennsylvania, Philadelphia, USA
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, USA
| | - Ricardo Castillo-Neyra
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, Philadelphia, USA
- Department of Health Management, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Claudia Arevalo-Nieto
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, Philadelphia, USA
- Department of Health Management, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Julianna E. Shinnick
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, Philadelphia, USA
| | - Justin K. Sheen
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, Philadelphia, USA
| | - Kevin Volpp
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, USA
| | - Valerie Paz-Soldan
- Department of Health Management, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, USA
- Asociasión Benéfica PRISMA, Lima, Peru
| | - Jere R. Behrman
- Departments of Economics and Sociology, University of Pennsylvania, Philadelphia, USA
| | - Michael Z. Levy
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, Philadelphia, USA
- Department of Health Management, Universidad Peruana Cayetano Heredia, Lima, Peru
| |
Collapse
|
13
|
Han J, Jathavedam A, Perepelyuk M, Casale PN. Impact of a Clinician Incentive Program on Quality Measures Performance in a Medicare Shared Savings Accountable Care Organization. Am J Med Qual 2023; 38:29-36. [PMID: 36579962 DOI: 10.1097/jmq.0000000000000098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Financial incentives are often used to encourage and reward clinicians for achieving specific outcomes; however, there is limited data on their effectiveness. This study evaluates the impact of NewYork Quality Care's Clinician Incentive Program on improving quality measure performance over 4 years. Clinicians including primary care physicians and specialists actively opted-in to an incentive program where their quality performance was evaluated and rewarded biannually. Using Medicare Shared Savings Program data extracted for quality measures (2016-2019), this study analyzes quality measure performance between clinicians who opted-in to the program compared to those who did not. Additional analysis was performed comparing primary care clinician and specialist performance. The analysis revealed that clinicians in the incentive program significantly outperform (P < 0.05) clinicians who chose not to join the program in 6 of the 7 quality measures. In addition, the program helped facilitate discussions with clinicians more broadly in population health efforts.
Collapse
Affiliation(s)
- Jessica Han
- NewYork Quality Care, Accountable Care Organization of NewYork-Presbyterian, Weill Cornell Medicine, and Columbia Doctors, New York, NY
| | | | | | | |
Collapse
|
14
|
Liu J, Ma Z, Su J, Ge B. Optimal information disclosure strategy in the primary healthcare service market: From the perspective of signaling theory. Front Public Health 2022; 10:959032. [PMID: 36388347 PMCID: PMC9650283 DOI: 10.3389/fpubh.2022.959032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/06/2022] [Indexed: 01/24/2023] Open
Abstract
The promotion of general practitioner (GP) contract service is one of the key components of China's healthcare reform. We consider GPs providing primary health services with private competency information over two periods, where patients decide when to sign. Two types of GPs are considered: those with higher and lower competency. Under asymmetric information, to spur the patients' incentive to sign, the GPs can move to offer competency disclosure schemes to patients, for example, separating or pooling, through which true competency information is revealed, respectively. We investigate three scenarios, which are referred to as "separating-separating," "pooling-separating," and "pooling-pooling." The results of the three scenarios yield intriguing insights into the impact of the GP's competency disclosure decisions. Findings include that GPs prefer the "pooling-separating" strategy, but patients prefer "separating-separating." Besides, an extremely low cure rate may enable GPs to conceal some competency information. Furthermore, low-competency GPs may exaggerate their competency level for profit, but greater efforts in disclosing competency information may result in diminished benefits. Therefore, to promote the services of GPs, the core is always to improve GPs' competency.
Collapse
|
15
|
Wuebker A. Ways to Improve Hospital Quality - A Health System Perspective Comment on "Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review Into Integrated Hospital Strategies". Int J Health Policy Manag 2022; 12:7422. [PMID: 36300254 PMCID: PMC10125075 DOI: 10.34172/ijhpm.2022.7422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/07/2022] [Indexed: 11/07/2022] Open
Abstract
Wackers and colleagues' scoping review provides an informative and well-structured overview of hospital-based case studies focusing on integrated hospital strategies that seek to improve quality, while reducing or containing costs. Wackers et al take a hospital level perspective and evaluate facilitators and barriers to the successful implementation of those hospital strategies. I complement the hospital level perspective of Wackers et al with an analysis from a health system perspective. Regulations at the superordinate system level might influence decisions at the hospital level that are relevant for costs and quality of care. In this commentary, I discuss how interventions at the system level might affect hospital quality. The results suggest that especially competition between hospitals, pay for performance (PfP) initiatives in combination with publication of quality information, but also greater experience of hospital staff (as proxied by the volume outcome relationship) may provide impulses for improving quality of care.
Collapse
Affiliation(s)
- Ansgar Wuebker
- RWI – Leibniz-Institute for Economic Research, Essen, Germany
- Leibniz Science Campus Ruhr, Essen, Germany
- Hochschule Harz, Wernigerode, Germany
| |
Collapse
|
16
|
Davis R, Guo N, Bentley J, Sie L, Ansari J, Bateman B, Main E, Butwick AJ. Hospital-level variation in rates of postpartum hemorrhage in California. Transfusion 2022; 62:1743-1751. [PMID: 35920049 DOI: 10.1111/trf.17036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND To examine the extent of hospital-level variation in risk-adjusted rates of postpartum hemorrhage (PPH). STUDY DESIGN AND METHODS We performed a cross-sectional study examining live births in 257 California hospitals between 2011 and 2015 using linked birth certificate and maternal discharge data. PPH was measured using International Classification of Diseases Codes version 9. Mixed-effects logistic regression models were used to examine the presence and extent of hospital-level variation in PPH before and after adjustment for patient-level risk factors and select hospital characteristics (teaching status and annual delivery volume). Risk-adjusted rates of PPH were estimated for each hospital. The extent of hospital variation was evaluated using the median odds ratio (MOR) and intraclass correlation coefficient (ICC). RESULTS Our study cohort comprised 1,904,479 women who had a live birth delivery hospitalization at 247 hospitals. The median, lowest, and highest hospital-specific rates of PPH were 3.48%, 0.54%, and 12.0%, respectively. Similar rates were observed after adjustment for patient and hospital factors (3.44%, 0.60%, and 11.48%). After adjustment, the proportion of the total variation in PPH rates attributable to the hospital was low, with a MOR of 2.02 (95% confidence interval [CI]: 1.89-2.15) and ICC of 14.3% (95% CI: 11.9%-16.3%). DISCUSSION Wide variability exists in the rate of PPH across hospitals in California, not attributable to patient factors, hospital teaching status, and hospital annual delivery volume. Determining whether differences in hospital quality of care explain the unaccounted-for variation in hospital-level PPH rates should be a public health priority.
Collapse
Affiliation(s)
- Rudolph Davis
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Nan Guo
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jason Bentley
- Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Lillian Sie
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Jessica Ansari
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Brian Bateman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Elliot Main
- California Maternal Quality Care Collaborative, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
17
|
Milliren CE, Bailey G, Graham DA, Ozonoff A. Relationships Between Pediatric Safety Indicators Across a National Sample of Pediatric Hospitals: Dispelling the Myth of the "Safest" Hospital. J Patient Saf 2022; 18:e741-e746. [PMID: 35617599 PMCID: PMC9136151 DOI: 10.1097/pts.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE There are many measures of healthcare quality, but no obvious summary measures to simplify ranking of hospital performance. With public reporting and accountability for hospital performance, the validity of composite measures for performance rankings has increased importance. This study aimed to explore the covariance of pediatric hospital quality indicators and evaluate the use of a single composite score. METHODS We performed an observational study of pediatric hospital performance across 13 safety indicators extracted from the Pediatric Health Information System, a comparative database of children's hospitals in the United States. We included patients discharged from 36 hospitals from January 1, 2016, to December 31, 2019. Using principal components analysis, we investigate relationships among patient safety measures from the Agency for Healthcare Research and Quality pediatric quality indicators and Center for Medicare and Medicaid Services hospital-acquired conditions. We compare and summarize rankings based on individual safety indicators and calculate alternative composite scores. RESULTS We identified 5 orthogonal variance components accounting for 68% of variation in pediatric hospital quality indicators. Rankings demonstrated greater within-hospital variation compared with between-hospital variation. We observed discordant rankings across commonly used summary measures and conclude that these pediatric safety measures demonstrate at least 2 underlying variance components. CONCLUSIONS This study demonstrates the multifactorial nature of patient safety. This implies no unique ordering of hospitals based on these measures, and thus, no pediatric hospital can claim to be "the safest." This raises further questions about appropriate methods to rank hospitals by safety.
Collapse
Affiliation(s)
- Carly E. Milliren
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA, United States
| | | | - Dionne A. Graham
- Program for Patient Safety and Quality, Boston Children’s Hospital, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Al Ozonoff
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, MA, United States
| |
Collapse
|
18
|
de Geus SW, Papageorge MV, Woods AP, Wilson S, Ng SC, Merrill A, Cassidy M, McAneny D, Tseng JF, Sachs TE. A Rising Tide Lifts All Boats: Impact of Combined Volume of Complex Cancer Operations on Surgical Outcomes in a Low-Volume Setting. J Am Coll Surg 2022; 234:981-988. [PMID: 35703786 PMCID: PMC9204842 DOI: 10.1097/xcs.0000000000000228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Centralization for complex cancer surgery may not always be feasible owing to socioeconomic disparities, geographic constraints, or patient preference. The present study investigates how the combined volume of complex cancer operations impacts postoperative outcomes at hospitals that are low-volume for a specific high-risk cancer operation. STUDY DESIGN Patients who underwent pneumonectomy, esophagectomy, gastrectomy, hepatectomy, pancreatectomy, or proctectomy were identified from the National Cancer Database (2004-2017). For every operation, 3 separate cohorts were created: low-volume hospitals (LVH) for both the individual cancer operation and the total number of those complex operations, mixed-volume hospital (MVH) with low volume for the individual cancer operation but high volume for total number of complex operations, and high-volume hospitals (HVH) for each specific operation. RESULTS LVH was significantly (all p ≤ 0.01) predictive for 30-day mortality compared with HVH across all operations: pneumonectomy (9.5% vs 7.9%), esophagectomy (5.6% vs 3.2%), gastrectomy (6.8% vs 3.6%), hepatectomy (5.9% vs 3.2%), pancreatectomy (4.7% vs 2.3%), and proctectomy (2.4% vs 1.3%). Patients who underwent surgery at MVH and HVH demonstrated similar 30-day mortality: esophagectomy (3.2 vs 3.2%; p = 0.993), gastrectomy (3.2% vs 3.6%; p = 0.637), hepatectomy (3.8% vs 3.2%; p = 0.233), pancreatectomy (2.8% vs 2.3%; p = 0.293), and proctectomy (1.2% vs 1.3%; p = 0.843). Patients who underwent pneumonectomy at MVH demonstrated lower 30-day mortality compared with HVH (5.4% vs 7.9%; p = 0.045). CONCLUSION Patients who underwent complex operations at MVH had similar postoperative outcomes to those at HVH. MVH provide a model for the centralization of complex cancer surgery for patients who do not receive their care at HVH.
Collapse
Affiliation(s)
- Susanna Wl de Geus
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Marianna V Papageorge
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Alison P Woods
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Woods)
| | - Spencer Wilson
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Sing Chau Ng
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Andrea Merrill
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Michael Cassidy
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - David McAneny
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Jennifer F Tseng
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Teviah E Sachs
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| |
Collapse
|
19
|
Kara P, Valentin JB, Mainz J, Johnsen SP. Composite measures of quality of health care: Evidence mapping of methodology and reporting. PLoS One 2022; 17:e0268320. [PMID: 35552561 PMCID: PMC9098058 DOI: 10.1371/journal.pone.0268320] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/27/2022] [Indexed: 11/19/2022] Open
Abstract
Background Quality indicators are used to quantify the quality of care. A large number of quality indicators makes assessment of overall quality difficult, time consuming and impractical. There is consequently an increasing interest for composite measures based on a combination of multiple indicators. Objective To examine the use of different approaches to construct composite measures of quality of care and to assess the use of methodological considerations and justifications. Methods We conducted a literature search on PubMed and EMBASE databases (latest update 1 December 2020). For each publication, we extracted information on the weighting and aggregation methodology that had been used to construct composite indicator(s). Results A total of 2711 publications were identified of which 145 were included after a screening process. Opportunity scoring with equal weights was the most used approach (86/145, 59%) followed by all-or-none scoring (48/145, 33%). Other approaches regarding aggregation or weighting of individual indicators were used in 32 publications (22%). The rationale for selecting a specific type of composite measure was reported in 36 publications (25%), whereas 22 papers (15%) addressed limitations regarding the composite measure. Conclusion Opportunity scoring and all-or-none scoring are the most frequently used approaches when constructing composite measures of quality of care. The attention towards the rationale and limitations of the composite measures appears low. Discussion Considering the widespread use and the potential implications for decision-making of composite measures, a high level of transparency regarding the construction process of the composite and the functionality of the measures is crucial.
Collapse
Affiliation(s)
- Pinar Kara
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Psychiatry, Aalborg University Hospital, Aalborg, Denmark
- * E-mail:
| | - Jan Brink Valentin
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jan Mainz
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Psychiatry, Aalborg University Hospital, Aalborg, Denmark
- Department for Community Mental Health, University of Haifa, Haifa, Israel
- Department of Health Economics, University of Southern Denmark, Odense, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
20
|
Petrella F, Casiraghi M, Radice D, Bardoni C, Cara A, Mohamed S, Sances D, Spaggiari L. Unplanned Return to the Operating Room after Elective Oncologic Thoracic Surgery: A Further Quality Indicator in Surgical Oncology. Cancers (Basel) 2022; 14:cancers14092064. [PMID: 35565193 PMCID: PMC9104285 DOI: 10.3390/cancers14092064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/13/2022] [Accepted: 04/18/2022] [Indexed: 01/25/2023] Open
Abstract
Background: An unplanned return to the operating room (UROR) is defined as a readmission to the operating room because of a complication or an untoward outcome related to the initial surgery. The aim of the present report is to evaluate the role of URORs after elective oncologic thoracic surgery. Methods: In the study, 4012 consecutive patients were enrolled; among them, 71 patients (1.76%) had an unplanned return to the operating room. Age, sex, Charlson comorbidity index, induction treatments, type of the first operation, indication to readmission to the operating room and type of second operation, length of stay, complication after reoperation and outcomes were collected. Results: The mean age was 63.3 (SD: 13.0); there were 53 male patients (74.6%); the type of the first procedure was: lower lobectomy (11.3%), middle lobectomy (1.4%), upper lobectomy (22.5%), metastasectomy (5.6%), extrapleural pneumonectomy (4.2%), pneumonectomy (40.9%), pleural biopsy (5.6%) and other procedures (8.5%). Patients presenting complications after UROR had undergone a significantly longer first procedure (p < 0.02), had a longer length of stay (p < 0.001) and had higher post-operative mortality (p < 0.001). Conclusions: The patients experiencing UROR after elective oncologic thoracic surgery have significantly higher morbidity and mortality rates when compared to standard thoracic surgery. Bronchopleural fistula remains the most lethal complication in patients undergoing UROR.
Collapse
Affiliation(s)
- Francesco Petrella
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy; (M.C.); (C.B.); (A.C.); (S.M.); (L.S.)
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, 20122 Milan, Italy
- Correspondence: or ; Tel.: +39-0257489362; Fax: +39-0294379218
| | - Monica Casiraghi
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy; (M.C.); (C.B.); (A.C.); (S.M.); (L.S.)
| | - Davide Radice
- Division of Epidemiology and Biostatistics, IRCCS European Institute of Oncology, 20141 Milan, Italy;
| | - Claudia Bardoni
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy; (M.C.); (C.B.); (A.C.); (S.M.); (L.S.)
| | - Andrea Cara
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy; (M.C.); (C.B.); (A.C.); (S.M.); (L.S.)
| | - Shehab Mohamed
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy; (M.C.); (C.B.); (A.C.); (S.M.); (L.S.)
| | - Daniele Sances
- Division of Anesthesiology, IRCCS European Institute of Oncology, 20141 Milan, Italy;
| | - Lorenzo Spaggiari
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy; (M.C.); (C.B.); (A.C.); (S.M.); (L.S.)
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, 20122 Milan, Italy
| |
Collapse
|
21
|
Sagheb E, Wi CI, Yoon J, Seol HY, Shrestha P, Ryu E, Park M, Yawn B, Liu H, Homme J, Juhn Y, Sohn S. Artificial Intelligence Assesses Clinicians' Adherence to Asthma Guidelines Using Electronic Health Records. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1047-1056.e1. [PMID: 34800704 PMCID: PMC9007821 DOI: 10.1016/j.jaip.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 10/20/2021] [Accepted: 11/07/2021] [Indexed: 05/25/2023]
Abstract
BACKGROUND Clinicians' asthma guideline adherence in asthma care is suboptimal. The effort to improve adherence can be enhanced by assessing and monitoring clinicians' adherence to guidelines reflected in electronic health records (EHRs), which require costly manual chart review because many care elements cannot be identified by structured data. OBJECTIVE This study was designed to demonstrate the feasibility of an artificial intelligence tool using natural language processing (NLP) leveraging the free text EHRs of pediatric patients to extract key components of the 2007 National Asthma Education and Prevention Program guidelines. METHODS This is a retrospective cross-sectional study using a birth cohort with a diagnosis of asthma at Mayo Clinic between 2003 and 2016. We used 1,039 clinical notes with an asthma diagnosis from a random sample of 300 patients. Rule-based NLP algorithms were developed to identify asthma guideline-congruent elements by examining care description in EHR free text. RESULTS Natural language processing algorithms demonstrated a sensitivity (0.82-1.0), specificity (0.95-1.0), positive predictive value (0.86-1.0), and negative predictive value (0.92-1.0) against manual chart review for asthma guideline-congruent elements. Assessing medication compliance and inhaler technique assessment were the most challenging elements to assess because of the complexity and wide variety of descriptions. CONCLUSIONS Natural language processing technologies may enable the automated assessment of clinicians' documentation in EHRs regarding adherence to asthma guidelines and can be a useful population management and research tool to assess and monitor asthma care quality. Multisite studies with a larger sample size are needed to assess the generalizability of these NLP algorithms.
Collapse
Affiliation(s)
- Elham Sagheb
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minn
| | - Chung-Il Wi
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn
| | - Jungwon Yoon
- Department of Pediatrics, Myongji Hospital, Goyang, South Korea
| | - Hee Yun Seol
- Pusan National University, Yangsan Hospital, Yangsan, South Korea
| | - Pragya Shrestha
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn
| | - Euijung Ryu
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Barbara Yawn
- Department of Family and Community Health, University of Minnesota, Minneapolis, Minn
| | - Hongfang Liu
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minn
| | - Jason Homme
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn
| | - Young Juhn
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn.
| | - Sunghwan Sohn
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minn.
| |
Collapse
|
22
|
Tayfun Şahiner İ, Esen E, Deniz Uçar A, Serdar Karaca A, Çınar Yastı A. Pay for performance system in Turkey and the world; a global overview. Turk J Surg 2022; 38:46-54. [DOI: 10.47717/turkjsurg.2022.5439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/08/2021] [Indexed: 11/23/2022]
Abstract
Objective: This study aimed to compare the pay for performance system applied nationally in Turkey and in other countries around the world and to reveal the effects of the system applied in our country on the general surgery.
Material and Methods: Current literature and countries’ programs on the implementation of the pay for performance system were recorded. The results of the Turkish Surgical Association’s performance and Healthcare Implementation Communique (HIC) commission studies were evaluated in light of the literature.
Results: Many countries have implemented performance systems on a limited scale to improve quality, speed up the diagnosis, treatment, and control of certain diseases, and they have generally applied it as a financial promotion by receiving the support of health insurance companies and nongovernmental organizations. It turns out that surgeons in our country feel that they are being wronged because of the injustice in the current system because the property of their works is not appreciated and they cannot get the reward for the work they do. This is also the reason for the reluctance of medical school graduates to choose general surgery.
Conclusion: Authorities should pay attention to the opinions of associations and experts in the related field when creating lists of interventional procedures related to surgery. Equal pay should be given to equal work nationally, and surgeons should be encouraged by incentives to perform detailed, qualified surgeries. There is a possibility that the staff positions opened for general surgery, as well as, all surgical branches will remain empty in the near future.
Collapse
|
23
|
Zogg CK, Metcalfe D, Judge A, Perry DC, Costa ML, Gabbe BJ, Schoenfeld AJ, Davis KA, Cooper Z, Lichtman JH. Learning From England's Best Practice Tariff: Process Measure Pay-for-Performance Can Improve Hip Fracture Outcomes. Ann Surg 2022; 275:506-514. [PMID: 33491982 PMCID: PMC9233527 DOI: 10.1097/sla.0000000000004305] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate England's Best Practice Tariff (BPT) and consider potential implications for Medicare patients should the US adopt a similar plan. SUMMARY BACKGROUND DATA Since the beginning of the Affordable Care Act, Medicare has renewed efforts to improve the outcomes of older adults through introduction of an expanding set of alternative-payment models. Among trauma patients, recommended arrangements met with mixed success given concerns about the heterogeneous nature of trauma patients and resulting outcome variation. A novel approach taken for hip fractures in England could offer a viable alternative. METHODS Linear regression, interrupted time-series, difference-in-difference, and counterfactual models of 2000 to 2016 Medicare (US), HES-APC (England) death certificate-linked claims (≥65 years) were used to: track US hip fracture trends, look at changes in English hip fracture trends before-and-after BPT implementation, compare changes in US-versus-English mortality, and estimate total/theoretical lives saved. RESULTS A total of 806,036 English and 3,221,109 US hospitalizations were included. After BPT implementation, England's 30-day mortality decreased by 2.6 percentage-points (95%CI: 1.7-3.5) from a baseline of 9.9% (relative reduction 26.3%). 90- and 365-day mortality decreased by 5.6 and 5.4 percentage-points. 30/90/365-day readmissions also declined with a concurrent shortening of hospital length-of-stay. From 2000 to 2016, US outcomes were stagnant (P > 0.05), resulting in an inversion of the countries' mortality and >38,000 potential annual US lives saved. CONCLUSIONS Process measure pay-for-performance led to significant improvements in English hip fracture outcomes. As efforts to improve US older adult health continue to increase, there are important lessons to be learned from a successful initiative like the BPT.
Collapse
Affiliation(s)
- Cheryl K. Zogg
- Yale School of Medicine, New Haven, Connecticut
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Yale School of Public Health, New Haven, Connecticut
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Daniel C. Perry
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Matthew L. Costa
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Belinda J. Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew J. Schoenfeld
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Orthopaedic Surgery, Brigham & Women’s Hospital, Boston, Massachusetts
| | | | - Zara Cooper
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | |
Collapse
|
24
|
Frenkel Rutenberg T, Aizer A, Levi A, Naftali N, Zeituni S, Velkes S, Aka Zohar A. Antibiotic prophylaxis as a quality of care indicator: does it help in the fight against surgical site infections following fragility hip fractures? Arch Orthop Trauma Surg 2022; 142:239-245. [PMID: 33216182 DOI: 10.1007/s00402-020-03682-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 11/04/2020] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Fragility hip fractures are associated with increased morbidity, mortality, and costs. To improve patient care, quality indicator programs were introduced. Yet, the efficacy of these programs and specific quality indicators are questioned. We aimed to determine whether defining prophylactic pre-surgical antibiotic treatment as a quality indicator affected hip fracture outcomes. MATERIALS AND METHODS A retrospective study comparing consecutive patients, 65 years and older, who were operated for fragility hip fractures between 01/01/2011 and 30/06/2016, before and after the prophylactic pre-surgical antibiotic treatment quality indicator, which was introduced in 01/2014. Primary outcomes were 1-year surgical site infections (SSI). Secondary outcomes were meeting the quality index and mortality rates, either within a hospital or during the first post-operative year. RESULTS 904 patients, ages 82.5 ± 7.2 years were operated for fragility hip fractures. 403 patients presented before the antibiotic prophylaxis quality indicator, and 501 following its administration. Patients demographics were comparable. In the pre-quality indicator period, documentation of prophylactic antibiotic treatment was lacking. Only 19.6% had a record for antibiotic administration in their surgical records and for merely 10.4% the type of antibiotic was stated. However, in the post-quality indicator period, 97.0% of patients had a registered prophylactic antibiotic regimen in the hour preceding the surgical incision (p < 0.001). Post-operative SSI rates were equivalent, and as were in-hospital infections, mortality and recurrent hospitalizations CONCLUSIONS: The introduction of the pre-operative antibiotic treatment quality indicator increased the documentation of antibiotic administration yet failed to influence the incidence of post-operative orthopaedic and medical infections in fragility hip fracture patients.
Collapse
Affiliation(s)
- Tal Frenkel Rutenberg
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, affiliated to the Sackler Faculty of Medicine, Aviv University, Tel Aviv, Israel.
| | - Anat Aizer
- Department of Management, Bar Ilan University, Public Health MHA Program, Ramat Gan, Israel
| | - Avraham Levi
- Department of Management, Bar Ilan University, Public Health MHA Program, Ramat Gan, Israel
| | - Noa Naftali
- Department of Management, Bar Ilan University, Public Health MHA Program, Ramat Gan, Israel
| | - Shelly Zeituni
- Department of Management, Bar Ilan University, Public Health MHA Program, Ramat Gan, Israel
| | - Steven Velkes
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, affiliated to the Sackler Faculty of Medicine, Aviv University, Tel Aviv, Israel
| | - Anat Aka Zohar
- Department of Management, Bar Ilan University, Public Health MHA Program, Ramat Gan, Israel
| |
Collapse
|
25
|
Zuber A, Kumpf O, Spies C, Höft M, Deffland M, Ahlborn R, Kruppa J, Jochem R, Balzer F. Does adherence to a quality indicator regarding early weaning from invasive ventilation improve economic outcome? A single-centre retrospective study. BMJ Open 2022; 12:e045327. [PMID: 34992097 PMCID: PMC8739420 DOI: 10.1136/bmjopen-2020-045327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To measure and assess the economic impact of adherence to a single quality indicator (QI) regarding weaning from invasive ventilation. DESIGN Retrospective observational single-centre study, based on electronic medical and administrative records. SETTING Intensive care unit (ICU) of a German university hospital, reference centre for acute respiratory distress syndrome. PARTICIPANTS Records of 3063 consecutive mechanically ventilated patients admitted to the ICU between 2012 and 2017 were extracted, of whom 583 were eligible adults for further analysis. Patients' weaning protocols were evaluated for daily adherence to quality standards until ICU discharge. Patients with <65% compliance were assigned to the low adherence group (LAG), patients with ≥65% to the high adherence group (HAG). PRIMARY AND SECONDARY OUTCOME MEASURES Economic healthcare costs, clinical outcomes and patients' characteristics. RESULTS The LAG consisted of 378 patients with a median negative economic results of -€3969, HAG of 205 (-€1030), respectively (p<0.001). Median duration of ventilation was 476 (248; 769) hours in the LAG and 389 (247; 608) hours in the HAG (p<0.001). Length of stay (LOS) in the LAG on ICU was 21 (12; 35) days and 16 (11; 25) days in the HAG (p<0.001). LOS in the hospital was 36 (22; 61) days in the LAG, and within the HAG, respectively, 26 (18; 48) days (p=0.001). CONCLUSIONS High adherence to this single QI is associated with better clinical outcome and improved economic returns. Therefore, the results support the adherence to QI. However, the examined QI does not influence economic outcome as the decisive factor.
Collapse
Affiliation(s)
- Alexander Zuber
- Institute of Medical Informatics, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Kumpf
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Moritz Höft
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Marc Deffland
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Ahlborn
- IT Department, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen Kruppa
- Institute of Medical Informatics, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Roland Jochem
- Departments of Machine Tools and Factory Management, TU Berlin, Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
26
|
Arntson E, Dimick JB, Nuliyalu U, Errickson J, Engler TA, Ryan AM. Changes in Hospital-acquired Conditions and Mortality Associated With the Hospital-acquired Condition Reduction Program. Ann Surg 2021; 274:e301-e307. [PMID: 34506324 DOI: 10.1097/sla.0000000000003641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE To improve patient safety, the Centers for Medicare and Medicaid Services announced the Hospital-Acquired Condition Reduction Program (HACRP) in August 2013. The program reduces Medicare payments by 1% for hospitals in the lowest performance quartile related to hospital-acquired conditions. Performance measures are focused on perioperative care. OBJECTIVE To evaluate changes in HACs and 30-day mortality after the announcement of the HACRP. DESIGN Interrupted time-series design using Medicare Provider and Analysis Review (MEDPAR) claims data. We estimated models with linear splines to test for changes in HACs and 30-day mortality before the Affordable Care Act (ACA), after the ACA, and after the HACRP. SETTING Fee-for-service Medicare 2009-2015. PARTICIPANTS Medicare beneficiaries undergoing surgery and discharged from an acute care hospital between January 2009 and August 2015 (N = 8,857,877). MAIN OUTCOME AND MEASURE Changes in HACs and 30-day mortality after the announcement of the HACRP. RESULTS Patients experienced HACs at a rate of 13.39 per 1000 discharges [95% confidence interval (CI), 13.10 to 13.68] in the pre-ACA period. This declined after the ACA was passed and declined further after the HACRP announcement [adjusted difference in annual slope, -1.34 (95% CI, -1.64 to -1.04)]. Adjusted 30-day mortality was 3.69 (95% CI, 3.64 to 3.74) in the pre-ACA period among patients receiving surgery. Thirty-day mortality continued to decline after the ACA [adjusted annual slope -0.04 (95% CI, -0.05 to -0.02)] but was flat after the HACRP [adjusted annual slope -0.01 (95% CI, -0.04 to 0.02)]. CONCLUSIONS AND RELEVANCE Although hospital-acquired conditions targeted under the HACRP declined at a greater rate after the program was announced, 30-day mortality was unchanged.
Collapse
Affiliation(s)
- Emily Arntson
- University of Michigan Medical School, Ann Arbor, Michigan
- University of Michigan School of Public Health, Ann Arbor, Michigan
- Center for Evaluating Health Reform, Ann Arbor, Michigan
| | - Justin B Dimick
- University of Michigan Medical School, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
| | - Ushapoorna Nuliyalu
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
- Center for Evaluating Health Reform, Ann Arbor, Michigan
| | - Josh Errickson
- University of Michigan Consulting for Statistics, Computing and Analytics Research, Ann Arbor, Michigan
| | - Tedi A Engler
- University of Michigan School of Public Health, Ann Arbor, Michigan
- Center for Evaluating Health Reform, Ann Arbor, Michigan
| | - Andrew M Ryan
- University of Michigan School of Public Health, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
- Center for Evaluating Health Reform, Ann Arbor, Michigan
| |
Collapse
|
27
|
A decade of commitment to hospital quality of care: overview of and perceptions on multicomponent quality improvement policies involving accreditation, public reporting, inspection and pay-for-performance. BMC Health Serv Res 2021; 21:990. [PMID: 34544408 PMCID: PMC8450175 DOI: 10.1186/s12913-021-07007-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 09/07/2021] [Indexed: 01/02/2023] Open
Abstract
Background Quality improvement (QI) initiatives such as accreditation, public reporting, inspection and pay-for-performance are increasingly being implemented globally. In Flanders, Belgium, a government policy for acute-care hospitals incorporates aforementioned initiatives. Currently, questions are raised on the sustainability of the present policy. Objective First, to summarise the various initiatives hospitals have adopted under government encouragement between 2008 and 2019. Second, to study the perspectives of healthcare stakeholders on current government policy. Methods In this multi-method study, we collected data on QI initiative implementation from governmental and institutional sources and through an online survey among hospital quality managers. We compiled an overview of QI initiative implementation for all Flemish acute-care hospitals between 2008 (n = 62) and 2019 (n = 53 after hospital mergers). Stakeholder perspectives were assessed via a second survey available to all healthcare employees and a focus group with healthcare policy experts was consulted. Variation between professions was assessed. Results QI initiatives have been increasingly implemented, especially from 2016 onwards, with the majority (87%) of hospitals having obtained a first accreditation label and all hospitals publicly reporting performance indicators, receiving regular inspections and having entered the pay-for-performance initiative. On the topic of external international accreditation, overall attitudes within the survey were predominantly neutral (36.2%), while 34.5% expressed positive and 29.3% negative views towards accreditation. In examining specific professional groups in-depth, we learned 58% of doctors regarded accreditation negatively, while doctors were judged to be the largest contributors to quality according to the majority of respondents. Conclusions Hospitals have demonstrated increased efforts into QI, especially since 2016, while perceptions on currently implemented QI initiatives among healthcare stakeholders are heterogeneous. To assure quality of care remains a top-priority for acute-care hospitals, we recommend a revision of the current multicomponent quality policy where the adoption of all initiatives is streamlined and co-created bottom-up. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07007-w.
Collapse
|
28
|
Abstract
Supplemental Digital Content is available in the text. New York state implemented the first state-level sepsis regulations in 2013. These regulations were associated with improved mortality, leading other states to consider similar steps. Our objective was to provide insight into New York state’s sepsis policy making process, creating a roadmap for policymakers in other states considering similar regulations.
Collapse
|
29
|
Effect of Time of Daily Data Collection on the Calculation of Catheter-associated Urinary Tract Infection Rates. Pediatr Qual Saf 2021; 6:e466. [PMID: 34476317 PMCID: PMC8389923 DOI: 10.1097/pq9.0000000000000466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/15/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction According to the National Healthcare Safety Network (NHSN) definitions for Catheter-associated urinary tract infections (CAUTI) rates, determination of the number of urinary catheter days must occur by calculating the number of catheters in place "for each day of the month, at the same time of day" but does not define at what time of day this occurs. The purpose of this review was to determine if a data collection time of 11 am would yield a greater collection of urinary catheter days than that done at midnight. Methods During a 20-month period, the number of urinary catheter days was calculated using once-a-day electronic measurements to identify a urinary catheter presence. We used data collected at 11 am and collected at midnight (our historic default) in comparing the calculated urinary catheter days and resultant CAUTI rates. Results There were 7,548 patients who had a urinary tract catheter. The number of urinary catheter days captured using the 11 am collection time was 15,425, and using the midnight collection time was 10,234, resulting in a 50.7% increase. The CAUTI rate per 1,000 urinary catheter days calculated using the 11 am collection method was 0.58, and using the midnight collection method was 0.88, a reduced CAUTI rate of 33.6%. Conclusion The data collection time can significantly impact the calculation of urinary catheter days and on calculated CAUTI rates. Variations in how healthcare systems define their denominator per current National Healthcare Safety Network policy may result in significant differences in reported rates.
Collapse
|
30
|
Holmgren AJ, Bates DW. Association of Hospital Public Quality Reporting With Electronic Health Record Medication Safety Performance. JAMA Netw Open 2021; 4:e2125173. [PMID: 34546374 PMCID: PMC8456388 DOI: 10.1001/jamanetworkopen.2021.25173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
IMPORTANCE Despite billions spent in public investment, electronic health records (EHRs) have not delivered on the promise of large quality and safety improvement. Simultaneously, there is debate on whether public quality reporting is a useful tool to incentivize quality improvement. OBJECTIVE To evaluate whether publicly reported feedback was associated with hospital improvement in an evaluation of medication-related clinical decision support (CDS) safety performance. DESIGN, SETTINGS, AND PARTICIPANTS This nonrandomized controlled trial included US hospitals that participated in the Computerized Provider Order Entry (CPOE) Evaluation Tool in the Leapfrog Hospital Survey, a national quality reporting program that evaluates safety performance of hospital CDS using simulated orders and patients, in 2017 to 2018. A sharp regression discontinuity design was used to identify the association of receiving negative feedback with hospital performance improvement in the subsequent year. Data were analyzed from January through September 2020. EXPOSURES Publicly reported quality feedback. MAIN OUTCOMES AND MEASURES The main outcome was improvement from 2017 to 2018 on the Leapfrog CPOE Evaluation Tool, using regression discontinuity model estimates of the association of receiving negative publicly reported feedback with quality improvement. RESULTS A total of 1183 hospitals were included, with a mean (SD) CPOE score of 59.3% (16.3%) at baseline. Hospitals receiving negative feedback improved 8.44 (95% CI, 0.09 to 16.80) percentage points more in the subsequent year compared with hospitals that received positive feedback on the same evaluation. This change was driven by differences in improvement in basic CDS capabilities (β = 8.71 [95%CI, 1.67 to 18.73]) rather than advanced CDS (β = 6.15 [95% CI, -9.11 to 26.83]). CONCLUSIONS AND RELEVANCE In this nonrandomized controlled trial, publicly reported feedback was associated with quality improvement, suggesting targeted measurement and reporting of process quality may be an effective policy lever to encourage improvement in specific areas. Clinical decision support represents an important tool in ensuring patient safety and decreasing adverse drug events, especially for complex patients and those with multiple chronic conditions who often receive several different drugs during an episode of care.
Collapse
Affiliation(s)
| | - David W. Bates
- Brigham & Women’s Hospital, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
31
|
Barbash IJ, Davis BS, Yabes JG, Seymour CW, Angus DC, Kahn JM. Treatment Patterns and Clinical Outcomes After the Introduction of the Medicare Sepsis Performance Measure (SEP-1). Ann Intern Med 2021; 174:927-935. [PMID: 33872042 PMCID: PMC8844885 DOI: 10.7326/m20-5043] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Medicare requires that hospitals report on their adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). OBJECTIVE To evaluate the effect of SEP-1 on treatment patterns and patient outcomes. DESIGN Longitudinal study of hospitals using repeated cross-sectional cohorts of patients. SETTING 11 hospitals within an integrated health system. PATIENTS 54 225 encounters between January 2013 and December 2017 for adults with sepsis who were hospitalized through the emergency department. INTERVENTION Onset of the SEP-1 reporting requirement in October 2015. MEASUREMENTS Changes in SEP-1-targeted processes, including antibiotic administration, lactate measurement, and fluid administration at 3 hours from sepsis onset; repeated lactate and vasopressor administration for hypotension within 6 hours of sepsis onset; and sepsis outcomes, including risk-adjusted intensive care unit (ICU) admission, in-hospital mortality, and home discharge among survivors. RESULTS Two years after its implementation, SEP-1 was associated with variable changes in process measures, with the greatest effect being an increase in lactate measurement within 3 hours of sepsis onset (absolute increase, 23.7 percentage points [95% CI, 20.7 to 26.7 percentage points]; P < 0.001). There were small increases in antibiotic administration (absolute increase, 4.7 percentage points [CI, 1.9 to 7.6 percentage points]; P = 0.001) and fluid administration of 30 mL/kg of body weight within 3 hours of sepsis onset (absolute increase, 3.4 percentage points [CI, 1.5 to 5.2 percentage points]; P < 0.001). There was no change in vasopressor administration. There was a small increase in ICU admissions (absolute increase, 2.0 percentage points [CI, 0 to 4.0 percentage points]; P = 0.055) and no changes in mortality (absolute change, 0.1 percentage points [CI, -0.9 to 1.1 percentage points]; P = 0.87) or discharge to home. LIMITATION Data are from a single health system. CONCLUSION Implementation of the SEP-1 mandatory reporting program was associated with variable changes in process measures, without improvements in clinical outcomes. Revising the measure may optimize its future effect. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
Collapse
Affiliation(s)
- Ian J Barbash
- University of Pittsburgh School of Medicine and UPMC Health System, Pittsburgh, Pennsylvania (I.J.B., C.W.S.)
| | - Billie S Davis
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (B.S.D., J.G.Y.)
| | - Jonathan G Yabes
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (B.S.D., J.G.Y.)
| | - Chris W Seymour
- University of Pittsburgh School of Medicine and UPMC Health System, Pittsburgh, Pennsylvania (I.J.B., C.W.S.)
| | - Derek C Angus
- University of Pittsburgh School of Medicine, University of Pittsburgh Graduate School of Public Health, and UPMC Health System, Pittsburgh, Pennsylvania (D.C.A., J.M.K.)
| | - Jeremy M Kahn
- University of Pittsburgh School of Medicine, University of Pittsburgh Graduate School of Public Health, and UPMC Health System, Pittsburgh, Pennsylvania (D.C.A., J.M.K.)
| |
Collapse
|
32
|
Salaheldin MH, Hassanain MA, Hamida MB, Ibrahim AM. Performance assessment of the built environment in healthcare facilities. JOURNAL OF FACILITIES MANAGEMENT 2021. [DOI: 10.1108/jfm-08-2020-0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
This study presents findings of post-occupancy evaluation (POE), through a performance assessment, on a polyclinic, as a health-care facility, in Saudi Arabia.
Design/methodology/approach
Review of the literature is conducted to identify the recent publications, on conducting POE, and performance indicators (PIs) assessing performance of health-care facilities. This research uses a triangulated approach by adopting several qualitative and quantitative methods, on a case study. The approach comprised conducting investigative walkthrough to assess the case study facility, interviews with group of occupants to assess its satisfaction levels. The findings were presented to a focus group, where a plan of recommendations was raised to improve the performance of the case study facility.
Findings
A total of 24 PIs were identified, and clustered, mainly under: “Thermal comfort”, “Natural lighting”, “Artificial lighting” and others. The case study has proven a satisfactory performance to the evaluated indicators. However, observations of performance snags were identified that formulated conclusions, related to: “Improvements to air temperature performance in summer season”, “Need of control on natural lighting due to glare”, “Accommodating an over demand for car parking spaces”, Need for development of systems dedicated for collection of occupants satisfaction” and “Enhancing circulation”.
Originality/value
There is a gap identified, through the literature review on availability of systematic conduct of POE, especially in health-care facilities. This paper contributes to the body of knowledge and professional practice, as a guiding systematic scheme, for the conduct of POE, which can be followed and expanded upon by future research.
Collapse
|
33
|
Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
34
|
Webb R, Uddin N, Ford E, Easter A, Shakespeare J, Roberts N, Alderdice F, Coates R, Hogg S, Cheyne H, Ayers S. Barriers and facilitators to implementing perinatal mental health care in health and social care settings: a systematic review. Lancet Psychiatry 2021; 8:521-534. [PMID: 33838118 DOI: 10.1016/s2215-0366(20)30467-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 02/06/2023]
Abstract
The improvement of perinatal mental health formed part of WHO's Millennium Development Goals. Research suggests that the implementation of perinatal mental health care is variable. To ensure successful implementation, barriers and facilitators to implementing perinatal mental health services need to be identified. Therefore, we aimed to identify the barriers and facilitators to implementing assessment, care, referral, and treatment for perinatal mental health into health and social care services. In this systematic review, we searched CINAHL, Embase, MEDLINE, and PsycINFO with no language restrictions for primary research articles published between database inception and Dec 11, 2019. Forward and backward searches of included studies were completed by March 31, 2020. Studies were eligible if they made statements about factors that either facilitated or impeded the implementation of perinatal mental health assessment, care, referral, or treatment. Partial (10%) dual screening was done. Data were extracted with EPPI-Reviewer 4 and analysed by use of a thematic synthesis. The protocol is registered on PROSPERO, CRD42019142854. Database searching identified 21 535 citations, of which 46 studies were included. Implementation occurred in a wide range of settings and was affected by individual (eg, an inability to attend treatment), health-care professional (eg, training), interpersonal (eg, trusting relationships), organisational (eg, clear referral pathways), political (eg, funding), and societal factors (eg, stigma and culture). A complex range of barriers and facilitators affect the implementation of perinatal mental health policy and practice. Perinatal mental health services should be flexible and women-centred, and delivered by well trained health-care professionals working within a structure that facilitates continuity of carer. Strategies that can be used to improve implementation include, but are not limited to, co-production of services, implementation team meetings, funding, and coalition building. Future research should focus on implementation barriers and facilitators dependent on illness severity, the health-care setting, and inpatient care.
Collapse
Affiliation(s)
- Rebecca Webb
- Centre for Maternal and Child Health, City, University of London, London, UK.
| | - Nazihah Uddin
- Centre for Maternal and Child Health, City, University of London, London, UK
| | - Elizabeth Ford
- Department of Primary Care and Public Health, Brighton & Sussex Medical School, Falmer, UK
| | - Abigail Easter
- Section of Women's Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | - Nia Roberts
- Nuffield Department of Population Health, Bodleian Health Care Libraries, Oxford, UK
| | - Fiona Alderdice
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Rose Coates
- Centre for Maternal and Child Health, City, University of London, London, UK
| | | | - Helen Cheyne
- NMAHP Research Unit, Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Susan Ayers
- Centre for Maternal and Child Health, City, University of London, London, UK
| | | |
Collapse
|
35
|
Do NTT, Li R, Dinh HTT, Nguyen HTL, Dao MQ, Nghiem TNM, Nadjm B, Luong KN, Cao TH, Le DTK, Cluzeau F, Ngo CQ, Chu HT, Vu DQ, van Doorn HR, Roberts CM. Improving antibiotic prescribing for community-acquired pneumonia in a provincial hospital in Northern Vietnam. JAC Antimicrob Resist 2021; 3:dlab040. [PMID: 34046595 PMCID: PMC8127081 DOI: 10.1093/jacamr/dlab040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 03/05/2021] [Indexed: 01/13/2023] Open
Abstract
Objectives To test the effectiveness of a quality improvement programme to promote adherence to national quality standards (QS) for patients hospitalized with community-acquired pneumonia (CAP), exploring the factors that hindered improvements in clinical practice. Methods An improvement bundle aligned to the QS was deployed using plan-do-study-act methodology in a 600 bed hospital in northern Vietnam from July 2018 to April 2019. Proposed care improvements included CURB65 score guided hospitalization, timely diagnosis and inpatient antibiotic treatment review to limit the spectrum and duration of IV antibiotic use. Interviews with medical staff were conducted to better understand the barriers for QS implementation. Results The study found that improvements were made in CURB65 score documentation and radiology results available within 4 h (P < 0.05). There were no significant changes in the other elements of the QS studied. We documented institutional barriers relating to the health reimbursement mechanism and staff cultural barriers relating to acceptance and belief as significant impediments to implementation of the standards. Conclusions Interventions led to some process changes, but these were not utilized by clinicians to improve patient management. Institutional and behavioural barriers documented may inhibit wider national uptake of the QS. National system changes with longer term support and investment to address local behavioural barriers are likely to be crucial for future improvements in the management of CAP, and potentially other hospitalized conditions, in Vietnam.
Collapse
Affiliation(s)
- Nga T T Do
- Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Ryan Li
- Global Health and Development Group, Imperial College London, London, UK
| | | | | | | | | | - Behzad Nadjm
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,University College London Hospitals NHS Foundation Trust, London, UK.,Clinical Services Department, MRC Unit The Gambia at The London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Khue N Luong
- Medical Services Administration, Ministry of Health, Hanoi, Vietnam
| | - Thai H Cao
- Medical Services Administration, Ministry of Health, Hanoi, Vietnam
| | - Dung T K Le
- Medical Services Administration, Ministry of Health, Hanoi, Vietnam
| | - Francoise Cluzeau
- Global Health and Development Group, Imperial College London, London, UK
| | | | | | - Dat Q Vu
- Hanoi Medical University, Hanoi, Vietnam.,National Hospital of Tropical Diseases, Hanoi, Vietnam
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - C Michael Roberts
- Essex Partnership University NHS Trust, Wickford, UK.,UCL Partners, London, UK.,Royal College of Physicians, London, UK
| |
Collapse
|
36
|
The hospital management practices in Chinese county hospitals and its association with quality of care, efficiency and finance. BMC Health Serv Res 2021; 21:449. [PMID: 33975605 PMCID: PMC8111980 DOI: 10.1186/s12913-021-06472-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/30/2021] [Indexed: 11/21/2022] Open
Abstract
Background County hospitals as the backbone of the China’s healthcare system are providing services for over 70% of the total population. However, the hospital management practice (HMP) and its links with quality of care, efficiency and finance in these hospitals are unknown. Methods We did two cross-sectional surveys of HMP in 2013 and 2015 among 101 county hospitals across rural China. Three managing roles (hospital director, director of medical affairs office and director of cardiology) and a cardiologist were invited to the surveys. A novel HMP rating scale, with 100 as full score, was used to measure the HMP in 17 indicators under four dimensions (target, operation, performance, and talent management) for each hospital. We analyzed the association of HMP score with variables on quality of care, efficiency and finance using linear mixed models with and without adjustment for potential confounders. Findings A total of 95 hospitals participated in at least one survey and were included in the analysis. The overall mean HMP score varied dramatically across the hospitals and 84% of them scored less than 60. The dimension mean HMP score was 38.6 (target), 56.4 (operation), 53.2 (performance) and 55.7 (talent), respectively. The pattern of indicator mean HMP score, however, was almost identical between hospitals with high and low overall HMP score, showing the same ‘strength’ (staff satisfaction, staff performance appraisal, ‘hard wares’, patient-centered services, etc.) and ‘weakness’ (target balance, target setting, continuous quality improvement, penalties on staff with dissatisfied performance, etc.). The associations of overall mean HMP score with quality of care and efficiency variables and cost per hospitalization was not statistically significant. The statistical significance in the association with hospital annual total income disappeared after adjusting for region, teaching status, number of competitors, number of staff and number of beds in use. Conclusion The HMP in Chinese county hospitals scores low in general and was not significantly associated with hospital care quality, efficiency and finance. The current healthcare reform in China should address the micro level issues in hospital management practices. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06472-7.
Collapse
|
37
|
Baumgartner H, De Backer J, Babu-Narayan SV, Budts W, Chessa M, Diller GP, Iung B, Kluin J, Lang IM, Meijboom F, Moons P, Mulder BJ, Oechslin E, Roos-Hesselink JW, Schwerzmann M, Sondergaard L, Zeppenfeld K, Ernst S, Ladouceur M, Aboyans V, Alexander D, Christodorescu R, Corrado D, D’Alto M, de Groot N, Delgado V, Di Salvo G, Dos Subira L, Eicken A, Fitzsimons D, Frogoudaki AA, Gatzoulis M, Heymans S, Hörer J, Houyel L, Jondeau G, Katus HA, Landmesser U, Lewis BS, Lyon A, Mueller CE, Mylotte D, Petersen SE, Petronio AS, Roffi M, Rosenhek R, Shlyakhto E, Simpson IA, Sousa-Uva M, Torp-Pedersen CT, Touyz RM, Van De Bruaene A. Guía ESC 2020 para el tratamiento de las cardiopatías congénitas del adulto. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
38
|
Abstract
IMPORTANCE Safety-net hospitals (SNHs) operate under limited financial resources and have had challenges providing high-quality care. Medicaid expansion under the Affordable Care Act led to improvements in hospital finances, but whether this was associated with better hospital quality, particularly among SNHs given their baseline financial constraints, remains unknown. OBJECTIVE To compare changes in quality from 2012 to 2018 between SNHs in states that expanded Medicaid vs those in states that did not. DESIGN, SETTING, AND PARTICIPANTS Using a difference-in-differences analysis in a cohort study, performance on quality measures was compared between SNHs, defined as those in the highest quartile of uncompensated care in the pre-Medicaid expansion period, in expansion vs nonexpansion states, before and after the implementation of Medicaid expansion. A total of 811 SNHs were included in the analysis, with 316 in nonexpansion states and 495 in expansion states. The study was conducted from January to November 2020. EXPOSURES Time-varying indicators for Medicaid expansion status. MAIN OUTCOMES AND MEASURES The primary outcome was hospital quality measured by patient-reported experience (Hospital Consumer Assessment of Healthcare Providers and Systems Survey), health care-associated infections (central line-associated bloodstream infections, catheter-associated urinary tract infections, and surgical site infections following colon surgery) and patient outcomes (30-day mortality and readmission rates for acute myocardial infarction, heart failure, and pneumonia). Secondary outcomes included hospital financial measures (uncompensated care and operating margins), adoption of electronic health records, provision of safety-net services (enabling, linguistic/translation, and transportation services), or safety-net service lines (trauma, burn, obstetrics, neonatal intensive, and psychiatric care). RESULTS In this difference-in-differences analysis of a cohort of 811 SNHs, no differential changes in patient-reported experience, health care-associated infections, readmissions, or mortality were noted, regardless of Medicaid expansion status after the Affordable Care Act. There were modest differential increases between 2012 and 2016 in the adoption of electronic health records (mean [SD]: nonexpansion states, 99.4 [7.4] vs 99.9 [3.8]; expansion states, 94.6 [22.6] vs 100.0 [2.2]; 1.7 percentage points; P = .02) and between 2012 and 2018 in the number of inpatient psychiatric beds (mean [SD]: nonexpansion states, 24.7 [36.0] vs 23.6 [39.0]; expansion states: 29.3 [42.8] vs 31.4 [44.3]; 1.4 beds; P = .02) among SNHs in expansion states, although they were not statistically significant at a threshold adjusted for multiple comparisons. In subgroup analyses comparing SNHs with higher vs lower baseline operating margins, an isolated differential improvement was noted in heart failure readmissions among SNHs with lower baseline operating margins in expansion states (mean [SD], 22.8 [2.1]; -0.53 percentage points; P = .001). CONCLUSIONS AND RELEVANCE This difference-in-differences cohort study found that despite reductions in uncompensated care and improvements in operating margins, there appears to be little evidence of quality improvement among SNHs in states that expanded Medicaid compared with those in states that did not.
Collapse
Affiliation(s)
- Paula Chatterjee
- Perelman School of Medicine, Division of General Internal Medicine, University of Pennsylvania, Philadelphia.,The Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia.,Department of Medicine, Penn Presbyterian Hospital, Philadelphia
| | - Mingyu Qi
- Perelman School of Medicine, Division of General Internal Medicine, University of Pennsylvania, Philadelphia
| | - Rachel M Werner
- Perelman School of Medicine, Division of General Internal Medicine, University of Pennsylvania, Philadelphia.,The Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia.,The Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| |
Collapse
|
39
|
Bouda Abdulai AS, Mukhtar F, Ehrlich M. United States' Performance on Emergency Department Throughput, 2006 to 2016. Ann Emerg Med 2021; 78:174-190. [PMID: 33865616 DOI: 10.1016/j.annemergmed.2021.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 10/30/2020] [Accepted: 01/07/2021] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE Studies of early data found that US emergency departments (EDs) were characterized by prolonged patient waiting, long visit times, frequent and prolonged boarding (ie, patients kept waiting in ED hallways or other space outside the ED on admission to the hospital), and patients leaving without receiving or completing treatment. We sought to assess recent trends in ED throughput nationally. METHODS This was a retrospective cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey from 2006 to 2016. We used survey-weighted generalized linear models to assess changes over time. The primary outcome variables were the number of visits, wait time to consult a physician, length of visit (time from arrival to leaving for home or hospital ward), boarding time, the proportion of patients leaving without being seen, the proportion treated within recommended waiting times, and the proportion dispositioned within 4, 6, and 8 hours. RESULTS Between 2006 and 2016, the number of ED visits increased from 119.2 million to 145.6 million. During this period, annual median wait time decreased from 31 minutes (interquartile range 14 to 67) to 17 minutes (interquartile range 6 to 45). The proportion of patients who left without being seen declined from 2.0% (95% confidence interval [CI] 1.7% to 2.4%) to 1.1% (95% CI 0.8% to 1.4%). The proportion treated by a qualified practitioner within recommended waiting times increased from 75.5% (95% CI 72.7% to 78.3%) to 80.8% (95% CI 77.2% to 84.4%). Overall, there was no statistically significant change in median length of visit. However, over time, decreased proportions of the sickest patients were discharged within 4, 6, and 8 hours, whereas increased proportions of low-acuity patients were discharged within 4 hours. The distribution of patient boarding time remained fairly unchanged from 2009 to 2015, with a median of approximately 75 minutes. CONCLUSION Overall, there was improvement in ED timeliness from 2006 to 2016. However, we observed a decrease in the proportion of the sickest patients discharged within 8 hours of arrival, although this may be due to increased ancillary testing or specially consultation over time.
Collapse
Affiliation(s)
- Abubakar Sadiq Bouda Abdulai
- Martin Tuchman School of Management, New Jersey Institute of Technology, Newark, NJ; New Jersey Innovation Institute Healthcare Delivery Systems iLab, Newark, NJ.
| | - Fahad Mukhtar
- Department of Behavioral Health, St. Elizabeths Hospital, Washington, DC
| | - Michael Ehrlich
- Martin Tuchman School of Management, New Jersey Institute of Technology, Newark, NJ
| |
Collapse
|
40
|
Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2583] [Impact Index Per Article: 861.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
41
|
Aghajani MH, Manavi S, Maher A, Rafiei S, Ayoubian A, Shahrami A, Ronasiyan R, Maziar P. Pay for performance in hospital management: A case study. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2021. [DOI: 10.1080/20479700.2019.1664029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
| | - Saeed Manavi
- Ministry of Health and Medical Education, Tehran, Iran
| | - Ali Maher
- Department of Health Policy, School of Management and Medical Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sima Rafiei
- Social Determinants of Health Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Ali Ayoubian
- Department of Health Services Management, College of Management and Social Science, North Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Ali Shahrami
- Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Pooneh Maziar
- Ministry of Health and Medical Education, Tehran, Iran
| |
Collapse
|
42
|
Salehi AS, Blanchet K, Vassall A, Borghi J. Political economy analysis of the performance-based financing programme in Afghanistan. Glob Health Res Policy 2021; 6:9. [PMID: 33750468 PMCID: PMC7945625 DOI: 10.1186/s41256-021-00191-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 02/10/2021] [Indexed: 11/10/2022] Open
Abstract
Background Performance-based financing (PBF) has attracted considerable attention in recent years in low and middle-income countries. Afghanistan’s Ministry of Public Health (MoPH) implemented a PBF programme between 2010 and 2015 to strengthen the utilisation of maternal and child health services in primary health facilities. This study aimed to examine the political economy factors influencing the adoption, design and implementation of the PBF programme in Afghanistan. Methods Retrospective qualitative research methods were employed using semi structured interviews as well as a desk review of programme and policy documents. Key informants were selected purposively from the national level (n = 9), from the province level (n = 6) and the facility level (n = 15). Data analysis was inductive as well as deductive and guided by a political economy analysis framework to explore the factors that influenced the adoption and design of the PBF programme. Thematic content analysis was used to analyse the data. Results The global policy context, and implementation experience in other LMIC, shaped PBF and its introduction in Afghanistan. The MoPH saw PBF as a promise of additional resources needed to rebuild the country’s health system after a period of conflict. The MoPH support for PBF was also linked to their past positive experience of performance-based contracting. Power dynamics and interactions between PBF programme actors also shaped the policy process. The PBF programme established a centralised management structure which strengthened MoPH and donor ability to manage the programme, but overlooked key stakeholders, such as provincial health offices and non-state providers. However, MoPH had limited input in policy design, resulting in a design which was not well tailored to the national setting. Conclusions This study shows that PBF programmes need to be designed and adapted according to the local context, involving all relevant actors in the policy cycle. Future studies should focus on conducting empirical research to not only understand the multiple effects of PBF programmes on the performance of health systems but also the main political economy dynamics that influence the PBF programmes in different stages of the policy process.
Collapse
Affiliation(s)
- Ahmad Shah Salehi
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, Department of Global Health and Development, London, UK.
| | - Karl Blanchet
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, Department of Global Health and Development, London, UK.,CERAH, University of Geneva, Geneva, Switzerland
| | - Anna Vassall
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, Department of Global Health and Development, London, UK
| | - Josephine Borghi
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, Department of Global Health and Development, London, UK
| |
Collapse
|
43
|
Prang KH, Maritz R, Sabanovic H, Dunt D, Kelaher M. Mechanisms and impact of public reporting on physicians and hospitals' performance: A systematic review (2000-2020). PLoS One 2021; 16:e0247297. [PMID: 33626055 PMCID: PMC7904172 DOI: 10.1371/journal.pone.0247297] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 02/04/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Public performance reporting (PPR) of physician and hospital data aims to improve health outcomes by promoting quality improvement and informing consumer choice. However, previous studies have demonstrated inconsistent effects of PPR, potentially due to the various PPR characteristics examined. The aim of this study was to undertake a systematic review of the impact and mechanisms (selection and change), by which PPR exerts its influence. METHODS Studies published between 2000 and 2020 were retrieved from five databases and eight reviews. Data extraction, quality assessment and synthesis were conducted. Studies were categorised into: user and provider responses to PPR and impact of PPR on quality of care. RESULTS Forty-five studies were identified: 24 on user and provider responses to PPR, 14 on impact of PPR on quality of care, and seven on both. Most of the studies reported positive effects of PPR on the selection of providers by patients, purchasers and providers, quality improvement activities in primary care clinics and hospitals, clinical outcomes and patient experiences. CONCLUSIONS The findings provide moderate level of evidence to support the role of PPR in stimulating quality improvement activities, informing consumer choice and improving clinical outcomes. There was some evidence to demonstrate a relationship between PPR and patient experience. The effects of PPR varied across clinical areas which may be related to the type of indicators, level of data reported and the mode of dissemination. It is important to ensure that the design and implementation of PPR considered the perspectives of different users and the health system in which PPR operates in. There is a need to account for factors such as the structural characteristics and culture of the hospitals that could influence the uptake of PPR.
Collapse
Affiliation(s)
- Khic-Houy Prang
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
| | - Roxanne Maritz
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
- Rehabilitation Services and Care Unit, Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland
| | - Hana Sabanovic
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
| | - David Dunt
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
| | - Margaret Kelaher
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
| |
Collapse
|
44
|
Baumgartner H, De Backer J, Babu-Narayan SV, Budts W, Chessa M, Diller GP, Lung B, Kluin J, Lang IM, Meijboom F, Moons P, Mulder BJM, Oechslin E, Roos-Hesselink JW, Schwerzmann M, Sondergaard L, Zeppenfeld K. 2020 ESC Guidelines for the management of adult congenital heart disease. Eur Heart J 2021; 42:563-645. [PMID: 32860028 DOI: 10.1093/eurheartj/ehaa554] [Citation(s) in RCA: 798] [Impact Index Per Article: 266.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
|
45
|
Farrag A, Harris Y. A discussion of the United States’ and Egypt’s health care quality improvement efforts. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2021. [DOI: 10.1080/20479700.2019.1620454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Amel Farrag
- Technical Office, General Directorate of Quality, Ministry of Health and Population, Cairo, Egypt
| | - Yael Harris
- Health Research and Evaluation, American Institutes of Research, Washington, DC, USA
| |
Collapse
|
46
|
Estimating Aspirin Overuse for Primary Prevention of Atherosclerotic Cardiovascular Disease (from a Nationwide Healthcare System). Am J Cardiol 2020; 137:25-30. [PMID: 32991852 DOI: 10.1016/j.amjcard.2020.09.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/17/2020] [Accepted: 09/21/2020] [Indexed: 01/16/2023]
Abstract
The American College of Cardiology and American Heart Association recently published guidelines narrowing the indications for low-dose aspirin use. The suitability of the electronic health record (EHR) to identify patients for low-dose aspirin deprescribing is unknown. To apply the 3 low-dose aspirin guidelines to EHR data, the guidelines were deconstructed into components from their narrative text and assigned computer-interpretable definitions based on electronic data interchange standards. These definitions were used to search EHR data to identify patients for aspirin deprescribing. To verify EHR records for low-dose aspirin, we then compared the records with a survey of patients' self-reported use of low-dose aspirin. Of the 3 aspirin guidelines, only 1 had a definition suitable for EHR implementation. The other 2 contained difficult-to-implement phrases (e.g., "higher ASCVD risk", "increased bleeding risk"). An EHR search with the single implementable guideline identified 86,555 people for possible aspirin deprescribing (2% of 5,598,604). Only 676 of 1,135 (60%) patients who self-reported taking low-dose aspirin had an active EHR record for low-dose aspirin at that time. Limitations exist when using EHR data to identify patients for possible low-dose aspirin deprescribing such as incomplete EHR capture of and the interpretation of non-specific terminology when translating guidelines into an electronic equivalent. In conclusion, data show many people unnecessarily take low-dose aspirin.
Collapse
|
47
|
Khalife J, Ammar W, Emmelin M, El-Jardali F, Ekman B. Hospital performance and payment: impact of integrating pay-for-performance on healthcare effectiveness in Lebanon. Wellcome Open Res 2020; 5:95. [PMID: 33437874 PMCID: PMC7780336 DOI: 10.12688/wellcomeopenres.15810.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2020] [Indexed: 11/25/2022] Open
Abstract
Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures. Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found. Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data.
Collapse
Affiliation(s)
- Jade Khalife
- Faculty of Medicine at Lund University, Lund, Sweden
- Ministry of Public Health, Beirut, Lebanon
| | - Walid Ammar
- Ministry of Public Health, Beirut, Lebanon
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Maria Emmelin
- Faculty of Medicine at Lund University, Lund, Sweden
| | - Fadi El-Jardali
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Bjorn Ekman
- Faculty of Medicine at Lund University, Lund, Sweden
| |
Collapse
|
48
|
Gallani S, Kajiwara T, Krishnan R. Value of new performance information in healthcare: evidence from Japan. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2020; 20:319-357. [PMID: 32808057 DOI: 10.1007/s10754-020-09283-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 08/07/2020] [Indexed: 06/11/2023]
Abstract
Mandatory measurement and disclosure of outcome measures are commonly used policy tools in healthcare. The effectiveness of such disclosures relies on the extent to which the new information produced by the mandatory system is internalized by the healthcare organization and influences its operations and decision-making processes. We use panel data from the Japanese National Hospital Organization to analyze performance improvements following regulation mandating standardized measurement and peer disclosure of patient satisfaction performance. Drawing on value of information theory, we document the absolute value and the benchmarking value of new information for future performance. Controlling for ceiling effects in the opportunities for improvement, we find that the new patient satisfaction measurement system introduced positive, significant, and persistent mean shifts in performance (absolute value of information) with larger improvements for poorly performing hospitals (benchmarking value of information). Our setting allows us to explore these effects in the absence of confounding factors such as incentive compensation or demand pressures. The largest positive effects occur in the initial period, and improvements diminish over time, especially for hospitals with poorer baseline performance. Our study provides empirical evidence that disclosure of patient satisfaction performance information has value to hospital decision makers.
Collapse
Affiliation(s)
- Susanna Gallani
- Harvard Business School, 369 Morgan Hall, 15 Harvard Way, Boston, MA, 02163, USA.
| | - Takehisa Kajiwara
- Graduate School of Business Administration, Kobe University, 2-1 Rokkodai, Nada-ku, Kobe, 657-8501, Japan
| | - Ranjani Krishnan
- The Eli Broad College of Business, Michigan State University, N207 North Business College Complex, 632 Bogue St, East Lansing, MI, 48824, USA
| |
Collapse
|
49
|
Lam MB, Raphael K, Mehtsun WT, Phelan J, Orav EJ, Jha AK, Figueroa JF. Changes in Racial Disparities in Mortality After Cancer Surgery in the US, 2007-2016. JAMA Netw Open 2020; 3:e2027415. [PMID: 33270126 PMCID: PMC7716190 DOI: 10.1001/jamanetworkopen.2020.27415] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Racial disparities are well documented in cancer care. Overall, in the US, Black patients historically have higher rates of mortality after surgery than White patients. However, it is unknown whether racial disparities in mortality after cancer surgery have changed over time. OBJECTIVE To examine whether and how disparities in mortality after cancer surgery have changed over 10 years for Black and White patients overall and for 9 specific cancers. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, national Medicare data were used to examine the 10-year (January 1, 2007, to November 30, 2016) changes in postoperative mortality rates in Black and White patients. Data analysis was performed from August 6 to December 31, 2019. Participants included fee-for-service beneficiaries enrolled in Medicare Part A who had a major surgical resection for 9 common types of cancer surgery: colorectal, bladder, esophageal, kidney, liver, ovarian, pancreatic, lung, or prostate cancer. EXPOSURES Cancer surgery among Black and White patients. MAIN OUTCOMES AND MEASURES Risk-adjusted 30-day, all-cause, postoperative mortality overall and for 9 specific types of cancer surgery. RESULTS A total of 870 929 cancer operations were performed during the 10-year study period. In the baseline year, a total of 103 446 patients had cancer operations (96 210 White patients and 7236 Black patients). Black patients were slightly younger (mean [SD] age, 73.0 [6.4] vs 74.5 [6.8] years), and there were fewer Black vs White men (3986 [55.1%] vs 55 527 [57.7%]). Overall national mortality rates following cancer surgery were lower for both Black (-0.12%; 95% CI, -0.17% to -0.06% per year) and White (-0.14%; 95% CI, -0.16% to -0.13% per year) patients. These reductions were predominantly attributable to within-hospital mortality improvements (Black patients: 0.10% annually; 95% CI, -0.15% to -0.05%; P < .001; White patients: 0.13%; 95% CI, -0.14% to -0.11%; P < .001) vs between-hospital mortality improvements. Across the 9 different cancer surgery procedures, there was no significant difference in mortality changes between Black and White patients during the period under study (eg, prostate cancer: 0.35; 95% CI, 0.02-0.68; lung cancer: 0.61; 95% CI, -0.21 to 1.44). CONCLUSIONS AND RELEVANCE These findings offer mixed news for policy makers regarding possible reductions in racial disparities following cancer surgery. Although postoperative cancer surgery mortality rates improved for both Black and White patients, there did not appear to be any narrowing of the mortality gap between Black and White patients overall or across individual cancer surgery procedures.
Collapse
Affiliation(s)
- Miranda B. Lam
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Radiation Oncology, Brigham and Women’s Hospital/Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Katherine Raphael
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Winta T. Mehtsun
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital/Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Jessica Phelan
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - E. John Orav
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Ashish K. Jha
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
50
|
Trends, Predictors, and Outcomes Associated With 30-Day Hospital Readmissions After Percutaneous Coronary Intervention in a High-Volume Center Predominantly Using Radial Vascular Access. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1525-1531. [DOI: 10.1016/j.carrev.2020.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/18/2020] [Indexed: 11/22/2022]
|