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Abstract
This editorial explores value in relation to plastic surgery and strategies that have been suggested to deliver value-based healthcare. We consider how value is measured, accounting for patient outcomes and experiences, costs and equity, and describe strategies that might improve value, such as outcome-based reimbursement, reporting transparency and high volume specialist centres.
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Akmaz B, Zipfel N, Bal RA, Rensing BJWM, Daeter EJ, van der Nat PB. Developing process measures in value-based healthcare: the case of aortic valve disease. BMJ Open Qual 2019; 8:e000716. [PMID: 31799447 PMCID: PMC6863668 DOI: 10.1136/bmjoq-2019-000716] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/09/2019] [Accepted: 10/20/2019] [Indexed: 11/15/2022] Open
Abstract
Background As process measures can be means to change practices, this article presents process measures that impact on outcome measures for surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) within value-based healthcare. Methods Desk research and observations of patient trajectories were performed to map the processes involved in TAVR and SAVR. Semistructured interviews were conducted with healthcare professionals (n=8) and patients (n=2) to explore which processes were most important in relation to a standard set of outcome measures that was already monitored. Additionally, open interviews (n=2) were held to prioritise results. A focus group was performed for validation of the formulated process measures. Numerical data for these measures was not collected. Results Process maps of the full cycle of care of TAVR and SAVR treatments in theory and in practice were developed. 28 processes were found important by interview participants due to their expected impact on patient-relevant outcomes. Seven processes were prioritised to be most important and were formulated into 12 process measures for both TAVR and SAVR: ‘Number of times that deficient information provision to SAVR patients causes negative outcomes’, ‘Type of TAVR/SAVR prosthesis’, ‘Brand of TAVR prosthesis’, ‘Number of times the frailty score of a TAVR/SAVR patient >75 years is measured’, ‘Time between TAVR/SAVR surgery indication and surgery’, ‘Number of times that anticoagulants are stopped within 3 days before surgery’, ‘Time in hours between TAVR/SAVR surgery and permanent pacemaker implantation’ and ‘Percentage of standardised pain measurements’. Conclusion This study proposes an addition of select process measures to standard sets of outcome measures to improve healthcare quality. It illustrates a clear method for identifying process measures with impact on health outcomes in the future.
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Affiliation(s)
- Berdel Akmaz
- Department of Value-Based Healthcare, Sint Antonius Hospital, Nieuwegein, The Netherlands.,Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Nina Zipfel
- Department of Value-Based Healthcare, Sint Antonius Hospital, Nieuwegein, The Netherlands.,Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Roland A Bal
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Benno J W M Rensing
- Department of Cardiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Edgar J Daeter
- Department of Cardiothoracic Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Paul B van der Nat
- Department of Value-Based Healthcare, Sint Antonius Hospital, Nieuwegein, The Netherlands.,Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Quality Measures in Foot and Ankle Care. J Am Acad Orthop Surg 2019; 27:e373-e380. [PMID: 30325881 DOI: 10.5435/jaaos-d-17-00733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Quality measures may be operationalized in payment models or quality reporting programs to assess foot and ankle surgeons, but if existing measures allow accurate representation of a foot and ankle surgeon's practice is unclear. METHODS National quality measures databases, clinical guidelines, and MEDLINE/PubMed were systematically reviewed for quality measures relevant to foot and ankle care. Measures meeting internal criteria were categorized by clinical diagnosis, National Quality Strategy priority, and Donabedian domain. RESULTS Of 12 quality measures and 16 candidate measures, National Quality Strategy priorities most commonly addressed "Effective Clinical Care" (n = 19) and "Communication and Coordination of Care" (n = 6). Donabedian classifications addressed were process (n = 25) and outcome (n = 3). Diabetic foot care was most commonly addressed (n = 18). CONCLUSIONS Available foot and ankle quality measures are limited in number and scope, which may hinder appropriate assessment of care, analysis of trends, and quality improvement. Additional measures are needed to support the transition to a value-based system. LEVEL OF EVIDENCE Level I.
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Zitzman E, Berkley H, Jindal RM. Accountability in global surgery missions. BMJ Glob Health 2018; 3:e001025. [PMID: 30687523 PMCID: PMC6326286 DOI: 10.1136/bmjgh-2018-001025] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 11/07/2018] [Indexed: 12/27/2022] Open
Affiliation(s)
- Elena Zitzman
- USU-Walter Reed Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Holly Berkley
- Department of Obstetrics and Gynecology, Naval Medical Center San Diego, San Diego, California, USA
| | - Rahul M Jindal
- USU-Walter Reed Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Abstract
BACKGROUND Value-based healthcare models rely on quality measures to evaluate the efficacy of healthcare delivery and to identify areas for improvement. Quality measure research in other areas of health care has generally shown that there is a limited number of available quality measures and that those that exist disproportionately focus on processes as opposed to outcomes. The purpose of this study was to assess the current state of quality measures and candidate quality measures in spine surgery. QUESTIONS/PURPOSES (1) How many quality measures and candidate quality measures are currently available? (2) According to Donabedian domains and National Quality Strategy (NQS) priorities, what aspects or domains of care do the present quality measures and candidate quality measures represent? METHODS We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures relevant to spine surgery. A systematic search for candidate quality measures was also performed using MEDLINE/PubMed and Embase as well as publications from the American Academy of Orthopaedic Surgeons, Congress of Neurological Surgeons, and the North American Spine Society. Clinical practice guidelines were included as candidate quality measures if their development was in accordance with Institute of Medicine criteria for the development of clinical practice guidelines, they were based on consistent clinical evidence including at least one Level I study, and they carried the strongest possible recommendation by the developing body. Quality measures and candidate quality measures were then pooled for analysis and categorized by clinical focus, NQS priority, and Donabedian domain. Our initial search yielded a total of 3940 articles, clinical practice guidelines, and quality measures, 74 of which met criteria for inclusion in this study. RESULTS Of the 74 measures studied, 29 (39%) were quality measures and 45 (61%) were candidate quality measures. Fifty of 74 (68%) were specific to the care of the spine, and 24 of 74 (32%) were related to the general care of spine patients. The majority of the spine-specific measures were process measures (45 [90%]) and focused on the NQS priority of "Effective Clinical Care" (44 [88%]). The majority of the general care measures were also process measures (14 [58%]), the highest portion of which focused on the NQS priority of "Patient Safety" (10 [42%]). CONCLUSIONS Given the large number of pathologies treated by spine surgeons, the limited number of available quality measures and candidate quality measures in spine surgery is inadequate to support the transition to a value-based care model. Additionally, current measures disproportionately focus on certain aspects or domains of care, which may hinder the ability to appropriately judge an episode of care, extract usable data, and improve quality. Physicians can steward the creation of meaningful quality measures by participating in clinical practice guideline development, assisting with the creation and submission of formal quality measures, and conducting the high-quality research on which effective guidelines and quality measures depend.
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Affiliation(s)
- Chase Bennett
- Department of Orthopaedic Surgery, Stanford University Medical Center, Redwood City, CA, USA
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Abrams GD, Greenberg DR, Dragoo JL, Safran MR, Kamal RN. Quality Measures in Orthopaedic Sports Medicine: A Systematic Review. Arthroscopy 2017; 33:1896-1910. [PMID: 28655476 DOI: 10.1016/j.arthro.2017.04.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 03/18/2017] [Accepted: 04/03/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the current quality measures that are applicable to orthopaedic sports medicine physicians. METHODS Six databases were searched with a customized search term to identify quality measures relevant to orthopaedic sports medicine surgeons: MEDLINE/PubMed, EMBASE, the National Quality Forum (NQF) Quality Positioning System (QPS), the Agency for Healthcare Research and Quality (AHRQ) National Quality Measures Clearinghouse (NQMC), the Physician Quality Reporting System (PQRS) database, and the American Academy of Orthopaedic Surgeons (AAOS) website. Results were screened by 2 Board-certified orthopaedic surgeons with fellowship training in sports medicine and dichotomized based on sports medicine-specific or general orthopaedic (nonarthroplasty) categories. Hip and knee arthroplasty measures were excluded. Included quality measures were further categorized based on Donabedian's domains and the Center for Medicare and Medicaid (CMS) National Quality Strategy priorities. RESULTS A total of 1,292 quality measures were screened and 66 unique quality measures were included. A total of 47 were sports medicine-specific and 19 related to the general practice of orthopaedics for a fellowship-trained sports medicine specialist. Nineteen (29%) quality measures were collected within PQRS, with 5 of them relating to sports medicine and 14 relating to general orthopaedics. AAOS Clinical Practice Guidelines (CPGs) comprised 40 (60%) of the included measures and were all within sports medicine. Five (8%) additional measures were collected within AHRQ and 2 (3%) within NQF. Most quality measures consist of process rather than outcome or structural measures. No measures addressing concussions were identified. CONCLUSIONS There are many existing quality measures relating to the practice of orthopaedic sports medicine. Most quality measures are process measures described within PQRS or AAOS CPGs. CLINICAL RELEVANCE Knowledge of quality measures are important as they may be used to improve care, are increasingly being used to determine physician reimbursement, and can inform future quality measure development efforts.
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Affiliation(s)
- Geoffrey D Abrams
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California, U.S.A.; Veterans Administration, Palo Alto, California, U.S.A..
| | - Daniel R Greenberg
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Jason L Dragoo
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Marc R Safran
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Robin N Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
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Schumann S, Bühligen U, Neumuth T. Outcome quality assessment by surgical process compliance measures in laparoscopic surgery. Artif Intell Med 2015; 63:85-90. [PMID: 25739791 DOI: 10.1016/j.artmed.2014.10.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 09/05/2014] [Accepted: 10/26/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The effective and efficient assessment, management, and evolution of surgical processes are intrinsic to excellent patient care. Hence, in addition to economic interests, the quality of the outcome is of great importance. Process benchmarking examines the compliance of an intraoperative surgical process to another process that is considered as best practice. The objective of this work is to assess the relationship between the course and the outcome of surgical processes of the study. MATERIALS AND METHODS By assessing 450 skill practices on rapid prototyping models in minimally invasive surgery training, we extracted descriptions of surgical processes and examined the hypothesis that a significant relationship exists between the course of a surgical process and the quality of its outcome. RESULTS The results showed a significant correlation with Person correlation coefficients >0.05 between the quality of process outcome and process compliance for simple and complex suturing tasks in the study. CONCLUSIONS We conclude that high process compliance supports good quality outcomes and, therefore, excellent patient care. We also showed that a deviation from best training processes led to a decreased outcome quality. This is relevant for identifying requirements for surgical processes, for generating feedback for the surgeon with regard to human factors and for inducing changes in the workflow in order to improve the outcome quality.
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Affiliation(s)
- Sandra Schumann
- Innovation Center Computer Assisted Surgery, Universität Leipzig, Semmelweisstr. 14, D-04103 Leipzig, Germany
| | - Ulf Bühligen
- Department of Pediatric Surgery, University Medical Center, Liebigstr. 20a, D-04103 Leipzig, Germany
| | - Thomas Neumuth
- Innovation Center Computer Assisted Surgery, Universität Leipzig, Semmelweisstr. 14, D-04103 Leipzig, Germany.
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Morimoto T. Investigating the Quality of Care in Cardiovascular Medicine. Circ J 2015; 79:966-8. [DOI: 10.1253/circj.cj-15-0371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Shin MH, Sullivan JL, Rosen AK, Solomon JL, Dunn EJ, Shimada SL, Hayes J, Rivard PE. Examining the validity of AHRQ's patient safety indicators (PSIs): is variation in PSI composite score related to hospital organizational factors? Med Care Res Rev 2014; 71:599-618. [PMID: 25380608 DOI: 10.1177/1077558714556894] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Increasing use of Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) for hospital performance measurement intensifies the need to critically assess their validity. Our study examined the extent to which variation in PSI composite score is related to differences in hospital organizational structures or processes (i.e., criterion validity). In site visits to three Veterans Health Administration hospitals with high and three with low PSI composite scores ("low performers" and "high performers," respectively), we interviewed a cross-section of hospital staff. We then coded interview transcripts for evidence in 13 safety-related domains and assessed variation across high and low performers. Evidence of leadership and coordination of work/communication (organizational process domains) was predominantly favorable for high performers only. Evidence in the other domains was either mixed, or there were insufficient data to rate the domains. While we found some evidence of criterion validity, the extent to which variation in PSI rates is related to differences in hospitals' organizational structures/processes needs further study.
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Affiliation(s)
| | - Jennifer L Sullivan
- VA Boston Healthcare System, Boston, MA, USA Boston University School of Public Health, Boston, MA, USA
| | - Amy K Rosen
- VA Boston Healthcare System, Boston, MA, USA Boston University School of Medicine, Boston, MA, USA
| | | | | | - Stephanie L Shimada
- Boston University School of Public Health, Boston, MA, USA Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA, USA VA eHealth Quality Enhancement Research Initiative, Bedford, MA, USA University of Massachusetts Medical School, Worcester, MA, USA
| | - Jennifer Hayes
- VA Boston Healthcare System, Boston, MA, USA VA Office of Academic Affiliations, Evaluation & Analytics, San Francisco, CA, USA
| | - Peter E Rivard
- VA Boston Healthcare System, Boston, MA, USA Suffolk University, Sawyer Business School, Boston, MA, USA
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Lee L, Li C, Robert N, Latimer E, Carli F, Mulder DS, Fried GM, Ferri LE, Feldman LS. Economic impact of an enhanced recovery pathway for oesophagectomy. Br J Surg 2013; 100:1326-34. [PMID: 23939844 DOI: 10.1002/bjs.9224] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Data are lacking to support the cost-effectiveness of enhanced recovery pathways (ERP) for oesophagectomy. The aim of this study was to investigate the impact of an ERP on medical costs for oesophagectomy. METHODS This study investigated all patients undergoing elective oesophagectomy between June 2009 and December 2011 at a single high-volume university hospital. From June 2010, all patients were enrolled in an ERP. Clinical outcomes were recorded for up to 30 days. Deviation-based cost modelling was used to compare costs between the traditional care and ERP groups. RESULTS A total of 106 patients were included (47 traditional care, 59 ERP). There were no differences in patient, pathological and operative characteristics between the groups. Median length of hospital stay (LOS) was lower in the ERP group (8 (interquartile range 7-18) days versus 10 (9-18) days with traditional care; P = 0·019). There was no difference in 30-day complication rates (59 per cent with ERP versus 62 per cent with traditional care; P = 0·803), and the 30-day or in-hospital mortality rate was low (3·8 per cent, 4 of 106). Costs in the on-course and minor-deviation groups were significantly lower after implementation of the ERP. The pathway-dependent cost saving per patient was €1055 and the overall cost saving per patient was €2013. One-way sensitivity analysis demonstrated that the ERP was cost-neutral or more costly only at extreme values of ward, operating and intensive care costs. CONCLUSION A multidisciplinary ERP for oesophagectomy was associated with cost savings, with no increase in morbidity or mortality.
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Affiliation(s)
- L Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
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Affiliation(s)
- Carol Parker
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
| | - Lee H. Schwamm
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
| | - Gregg C. Fonarow
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
| | - Eric E. Smith
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
| | - Mathew J. Reeves
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
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Lagoe RJ, Westert GP, Czyz AM, Johnson PE. Reducing potentially preventable complications at the multi hospital level. BMC Res Notes 2011; 4:271. [PMID: 21801385 PMCID: PMC3160398 DOI: 10.1186/1756-0500-4-271] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 07/29/2011] [Indexed: 11/10/2022] Open
Abstract
Background This study describes the continuation of a program to constrain health care costs by limiting inpatient hospital programs among the hospitals of Syracuse, New York. Through a community demonstration project, it identified components of individual hospital programs for reduction of complications and their impact on the frequency and rates of these outcomes. Findings This study involved the implementation of interventions by three hospitals using the Potentially Preventable Complications System developed by 3M™ Health Information Systems. The program is noteworthy because it included competing hospitals in the same community working together to reduce adverse patient outcomes and related costs. The study data identified statistically significant reductions in the frequency of high and low volume complications during the three year period at two of the hospitals. At both of these hospitals, aggregate complication rates also declined. At these hospitals, the differences between actual complication rates and severity adjusted complication rates were also reduced. At the third hospital, specific and aggregate complication rates remained the same or increased slightly. Differences between these rates and those of severity adjusted comparison population also remained the same or increased. Conclusions Results of the study suggested that, in one community health care system, the progress of reducing complications involved different experiences. At two hospitals with relatively higher rates at the beginning of the study, management by administrative and clinical staff outside quality assurance produced significant reductions in complication rates, while at a hospital with lower rates, management by quality assurance staff had little effect on reducing the rate of PPCs.
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Finney JW, Humphreys K, Kivlahan DR, Harris AHS. Why health care process performance measures can have different relationships to outcomes for patients and hospitals: understanding the ecological fallacy. Am J Public Health 2011; 101:1635-42. [PMID: 21778493 DOI: 10.2105/ajph.2011.300153] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Relationships between health care process performance measures (PPMs) and outcomes can differ in magnitude and even direction for patients versus higher level units (e.g., health care facilities). Such discrepancies can arise because facility-level relationships ignore PPM-outcome relationships for patients within facilities, may have different confounders than patient-level PPM-outcome relationships, and may reflect facility effect modification of patient PPM-outcome relationships. If a patient-level PPM is related to better patient outcomes, that care process should be encouraged. However, the finding in a multilevel analysis that the proportion of patients receiving PPM care across facilities nevertheless is linked to poor hospital outcomes would suggest that interventions targeting the health care facility also are needed.
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Affiliation(s)
- John W Finney
- Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park, CA 94025, USA.
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Abstract
TITLE Variations in nursing care quality across hospitals. AIMS The aim of the study was to describe Registered Nurses' reports of unmet nursing care needs and examine the variation of nursing care quality across hospitals. BACKGROUND Large proportions of Registered Nurses have reported leaving necessary care activities undone because they lacked the time to complete the activities. Nursing care left undone can be expected to adversely affect the quality of care. However, little is known about the degree of variation in the quality of nursing care across hospitals. METHODS In 2008, a secondary analysis of a 1999 survey of Registered Nurses (n = 10,184) was conducted using descriptive and comparative statistics. Data were derived from inpatient staff nurses working in acute care hospital settings (n = 168). A hospital-level measure (i.e. unmet nursing care needs) of the quality of nursing care was developed from care needs left undone among all nurses. RESULTS Across hospitals there was a wide range in the proportion of Registered Nurses who reported leaving each nursing care need undone. They reported leaving two of seven necessary nursing care activities undone during their last shift. After controlling for nurses' demographic information, we found statistically significant variations in the quality of nursing care across hospitals. CONCLUSION Differences in nursing care quality across hospitals appear to be closely associated with variations in the quality of care environments. Understanding the determinants of unmet nursing care needs can support policy decisions on systems and human resources management to enhance nurses' awareness of their care practices and the care environment.
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Affiliation(s)
- Robert J Lucero
- Center for Evidence-Based Practice in the Underserved, Columbia University, New York, USA.
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Triano JJ. What constitutes evidence for best practice? J Manipulative Physiol Ther 2009; 31:637-43. [PMID: 19028247 DOI: 10.1016/j.jmpt.2008.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 06/17/2008] [Accepted: 09/08/2008] [Indexed: 11/30/2022]
Abstract
The guiding principles, methods, and common factors that serve as the foundation for the Commission of the Council on Chiropractic Guidelines and Practice Parameters best practices initiative are discussed in the context of the chiropractic practice environment.
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Lyrer PA. Acute stroke units and teams. HANDBOOK OF CLINICAL NEUROLOGY 2009; 94:1195-1203. [PMID: 18793895 DOI: 10.1016/s0072-9752(08)94058-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Yano EM. The role of organizational research in implementing evidence-based practice: QUERI Series. Implement Sci 2008; 3:29. [PMID: 18510749 PMCID: PMC2481253 DOI: 10.1186/1748-5908-3-29] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2006] [Accepted: 05/29/2008] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Health care organizations exert significant influence on the manner in which clinicians practice and the processes and outcomes of care that patients experience. A greater understanding of the organizational milieu into which innovations will be introduced, as well as the organizational factors that are likely to foster or hinder the adoption and use of new technologies, care arrangements and quality improvement (QI) strategies are central to the effective implementation of research into practice. Unfortunately, much implementation research seems to not recognize or adequately address the influence and importance of organizations. Using examples from the U.S. Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI), we describe the role of organizational research in advancing the implementation of evidence-based practice into routine care settings. METHODS Using the six-step QUERI process as a foundation, we present an organizational research framework designed to improve and accelerate the implementation of evidence-based practice into routine care. Specific QUERI-related organizational research applications are reviewed, with discussion of the measures and methods used to apply them. We describe these applications in the context of a continuum of organizational research activities to be conducted before, during and after implementation. RESULTS Since QUERI's inception, various approaches to organizational research have been employed to foster progress through QUERI's six-step process. We report on how explicit integration of the evaluation of organizational factors into QUERI planning has informed the design of more effective care delivery system interventions and enabled their improved "fit" to individual VA facilities or practices. We examine the value and challenges in conducting organizational research, and briefly describe the contributions of organizational theory and environmental context to the research framework. CONCLUSION Understanding the organizational context of delivering evidence-based practice is a critical adjunct to efforts to systematically improve quality. Given the size and diversity of VA practices, coupled with unique organizational data sources, QUERI is well-positioned to make valuable contributions to the field of implementation science. More explicit accommodation of organizational inquiry into implementation research agendas has helped QUERI researchers to better frame and extend their work as they move toward regional and national spread activities.
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Affiliation(s)
- Elizabeth M Yano
- Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center of Excellence for the Study of Healthcare Provider Behaviour, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA.
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Berlowitz DR, Ash AS, Glickman M, Friedman RH, Pogach LM, Nelson AL, Wong AT. Developing a quality measure for clinical inertia in diabetes care. Health Serv Res 2006; 40:1836-53. [PMID: 16336551 PMCID: PMC1361229 DOI: 10.1111/j.1475-6773.2005.00436.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To develop a valid quality measure that captures clinical inertia, the failure to initiate or intensify therapy in response to medical need, in diabetes care and to link this process measure with outcomes of glycemic control. DATA SOURCES Existing databases from 13 Department of Veterans Affairs hospitals between 1997 and 1999. STUDY DESIGN Laboratory results, medications, and diagnoses were collected on 23,291 patients with diabetes. We modeled the decision to increase antiglycemic medications at individual visits. We then aggregated all visits for individual patients and calculated a treatment intensity score by comparing the observed number of increases to that expected based on our model. The association between treatment intensity and two measures of glycemic control, change in HbA1c during the observation period, and whether the outcome glycosylated hemoglobin (HbA1c) was greater than 8 percent, was then examined. PRINCIPAL FINDINGS Increases in antiglycemic medications occurred at only 9.8 percent of visits despite 39 percent of patients having an initial HbA1c level greater than 8 percent. A clinically credible model predicting increase in therapy was developed with the principal predictor being a recent HbA1c greater than 8 percent. There were considerable differences in the intensity of therapy received by patients. Those patients receiving more intensive therapy had greater improvements in control (p < .001). CONCLUSIONS Clinical inertia can be measured in diabetes care and this process measure is linked to patient outcomes of glycemic control. This measure may be useful in efforts to improve clinicians management of patients with diabetes.
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Abstract
Truly adequate dialysis would restore patients to full health, with functional status and length of life indistinguishable from others of the same age, sex, and race without chronic kidney disease. We are far from achieving such outcomes, however, in part because of the dearth of available evidence on which areas of care should be emphasized to get the greatest clinical and psychosocial benefits at the most affordable costs. A clear understanding of the strengths and limitations of currently available evidence can help guide researchers and clinicians in this field, and likely will lead to increasing emphasis on identification and management of comorbid conditions and a focus on preventative medicine. Optimal dialysis will be accomplished only when normal kidney functions are mimicked by artificial devices to a much greater extent than is currently the case.
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Affiliation(s)
- Michael Butman
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, USA
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McCarthy M, Jonasson O, Chang CH, Pickard AS, Giobbie-Hurder A, Gibbs J, Edelman P, Fitzgibbons R, Neumayer L. Assessment of patient functional status after surgery. J Am Coll Surg 2005; 201:171-8. [PMID: 16038812 DOI: 10.1016/j.jamcollsurg.2005.03.035] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2004] [Revised: 03/28/2005] [Accepted: 03/30/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND Improvement in day-to-day functioning is a valued outcome of surgical intervention. A new functional status assessment instrument, the Activities Assessment Scale (AAS), was designed for a randomized clinical trial evaluating laparoscopic versus open hernia repair procedures. STUDY DESIGN The study data set included 2,164 patients at baseline and 1,562 patients at 3-month followup. Only male patients were enrolled in the trial. The psychometric characteristics of the AAS were examined in statistical analyses of cross-sectional and longitudinal data from the trial. Correlational analyses, factor analyses, and t-tests were used to evaluate scale performance. RESULTS We found that the AAS was a reliable measure (Cronbach's Coefficient Alpha =0.85) in the patient population studied. Factor analyses identified three subscales (sedentary activities; ambulatory activities; work and exercise activities). Construct validity was demonstrated by a correlation of 0.65 between the AAS and the physical functioning (PF) dimension of the SF-36 (p < 0.001); comparisons between clinical subgroups further confirmed its validity (p < 0.001). Patients reporting improvement on the physical functioning dimension after surgery showed an effect size of 1.20 for preoperative-postoperative change in their AAS scores. CONCLUSIONS The AAS has been demonstrated to be a reliable, valid, and clinically responsive instrument that can be used to evaluate patient functioning after hernia surgery. It is easy to administer and requires less than 5 minutes of patient time to complete. This measurement system may prove useful in assessing surgical outcomes in both research and office practice settings.
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Affiliation(s)
- Martin McCarthy
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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22
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Abstract
OBJECTIVE This study describes public policymakers' experiences with the feasibility of using information from quality of care assessment activities. The objective is to improve the ability to match quality evaluation tools with policymakers' information needs. DESIGN US state administrative policymakers were interviewed about use of quality of care information and knowledge, attitudes, and experiences with information from specific types of measures. PARTICIPANTS A purposive sample of 82 key informants from Medicaid program administrations in 48 states. MAIN MEASURE Users of information from each of eight targeted types of quality of care measurement methods were compared with non-users based upon their levels of knowledge, perceived characteristics of quality of care information, and perceived characteristics of the policy situation. RESULTS Participants indicated that some types of quality measurement methods have been useful, whereas others have not. Extent of quality assessment information use, and the measurement methods utilized, varied widely. Two factors were associated with the use of information from particular quality assessment methods: information needs of the policymakers and their perceptions of the characteristics, including strengths and weaknesses, of particular measurement methods. CONCLUSIONS These policymakers had positive attitudes about quality assessment, were knowledgeable about types of methods, and had a variety of potential uses for quality-related information. Yet, perceptions and experiences with different types of measurement methods varied. We describe a set of quality assessment methods with complementary characteristics that could provide a relatively inclusive picture of quality of care and better address policymaker information needs.
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Affiliation(s)
- Jacqueline J Fickel
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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Chan KS, Wenzel S, Orlando M, Montagnet C, Mandell W, Becker K, Ebener P. How important are client characteristics to understanding treatment process in the therapeutic community? THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2005; 30:871-91. [PMID: 15624553 DOI: 10.1081/ada-200037556] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Prior research has demonstrated that therapeutic communities (TCs) are effective at improving posttreatment outcomes for substance abusers. However, little is known about the in-treatment experience for clients with different backgrounds, experiences, and needs. The aim of this study is to examine the in-treatment experience for different clients by exploring the relationships between treatment process and client characteristics. A comprehensive measure of treatment process, operationalized as Community Environment and Personal Change and Development and change was administered to 447 adults and 148 adolescents receiving treatment at community-based TC programs in New York, California, and Texas. Data on demographic characteristics, substance use and treatment history, and client risk factors were extracted from intake interviews and analyzed separately for adolescent and adult residents. Multivariate general linear models were used to examine the effect of client variables on treatment process, after controlling for treatment duration and program effects. Within adult programs, clients who were 25 years or older, female, and had a prior drug treatment experience had higher Community Environment scores. Adolescents with one or more arrests within the past 2 years had lower scores on both process dimensions of Community Environment and Personal Development and Change. Our results indicate the need to understand why adult clients who are younger, male, and have no prior treatment history and adolescent clients with recent arrests reported lower ratings of treatment process. Future research should also examine the role of modifiable mediators so that appropriate strategies to enhance therapeutic engagement may be developed as necessary.
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Affiliation(s)
- Kitty S Chan
- Health Services Research and Development Center, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Hampton House, 6th Floor, 624 North Broadway, Baltimore, MD 21205, USA.
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O'Brien MM, Shroyer ALW, Moritz TE, London MJ, Grunwald GK, Villanueva CB, Thottapurathu LG, MaWhinney S, Marshall G, McCarthy M, Henderson WG, Sethi GK, Grover FL, Hammermeister KE. Relationship Between Processes of Care and Coronary Bypass Operative Mortality and Morbidity. Med Care 2004; 42:59-70. [PMID: 14713740 DOI: 10.1097/01.mlr.0000102295.08379.57] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Information is limited regarding the effects of processes of care on cardiac surgical outcomes. Correspondingly, many recommended cardiac surgical processes of care are derived from animal experiments or clinical judgment. This report from the VA Cooperative Study in Health Services, "Processes, Structures, and Outcomes of Cardiac Surgery," focuses on the relationships between 3 process groups (preoperative evaluation, intraoperative care, and supervision by senior physicians) and a composite outcome, perioperative mortality and morbidity. METHODS Data on 734 risk, process, and structure variables were collected prospectively on 3,988 patients who underwent coronary artery bypass grafting at 14 VA medical centers between 1992 and 1996. Data reduction was accomplished by examining data completeness and variation across sites and surgeon, using previously published data and clinical judgment. We then applied multivariable logistic regression to the 39 remaining processes of care to determine which were related to the composite outcome after adjusting for 17 patient-related risk factors and controlling for intraoperative complications. RESULTS Our first analysis showed several measures of operative duration, the use of inotropic agents, transesophageal echo, lowest systemic temperature, and hemoconcentration/ultrafiltration, to be powerful predictors of the composite outcome. Because the use of inotropic agents and operative duration may be related to an intermediate outcome (eg, intraoperative complications), we performed a second analysis omitting these processes. The use of intraoperative transesophageal echo and hemoconcentration/ultrafiltration remained significantly associated with an increased risk of an event (odds ratios 1.60 and 1.36, respectively). CONCLUSIONS Our results viewed in the context of past studies suggest the possibility that inotropic use, TEE, and hemoconcentration/ultrafiltration may have adverse effects on operative outcome. Further evaluation of these processes of care using observational data, as well as randomized trials when feasible, would be of interest.
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Affiliation(s)
- Maureen M O'Brien
- Medical Research Service, Denver VA Medical Center, Denver, CO 80220, USA
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26
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Ween JE, Shutter LA. Modern stroke unit. Top Stroke Rehabil 2003; 9:1-11. [PMID: 14523713 DOI: 10.1310/cehl-j3gc-yyje-kq2w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The modern stroke unit is making significant contributions to the care of stroke victims and is proving to be an effective, cost-saving enterprise. The precise factors that contribute to the efficacy of these units have yet to be identified, but a combination of protocolized approaches to patient care, critical paths, a focus of expertise, and heightened index of suspicion for comorbidities all probably play a role. This article outlines the basic features of a modern stroke unit and surveys the literature on stroke unit outcomes.
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Affiliation(s)
- Jon Erik Ween
- Stroke Program, Loma Linda University, Casa Colina Centers for Rehabilitation, Loma Linda, California, USA
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Brasel KJ, Weigelt JA, Christians KK, Somberg LB. The value of process measures in evaluating an evidence-based guideline. Surgery 2003; 134:605-10; discussion 610-12. [PMID: 14605621 DOI: 10.1016/s0039-6060(03)00339-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Linking the process of evidence-based guidelines to outcomes is difficult. We hypothesized that the process of implementing an evidence-based clinical guideline for blunt splenic trauma would reduce resource consumption and improve outcome. METHODS Time periods were divided into period 1 (7/1/96-6/30/99) and period 2 (7/1/99-6/30/01). On 7/1/99 our American College of Surgeons-verified level I trauma center instituted an evidence-based approach for managing splenic trauma incorporating hemodynamic normality as the process measure triggering clinical decisions. Outcomes included the number of hemodynamically normal patients treated without operation, patient death, length of stay, and cost. RESULTS Two hundred thirty-one patients had blunt splenic injury; 115 patients were seen during period 1 and 116 during period 2. Hemodynamically normal patients undergoing splenectomy decreased during period 2 (P<.05). Median length of stay was 8 days in period 1 and 6 days in period 2 (P<.03). Cost per patient was $34,972 US dollars in period 1 and $24,037 US dollars in period 2 (P<.03). The mortality rate was unchanged. CONCLUSIONS Compliance with evidence-based data in the management of blunt splenic injury improved rates of nonoperative management, decreased hospital days, and did not change mortality rates. An evidence-based clinical guideline evaluated with process measures can reduce resource use and improve outcome in a trauma program.
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Affiliation(s)
- Karen J Brasel
- Department of Surgery, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 52336, USA
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Hammermeister K, Gethoffer H. Reducing major vascular events among VA primary care patients: an extraordinary opportunity. CLINICAL CORNERSTONE 2003; Suppl 1:S2-10. [PMID: 14699986 DOI: 10.1016/s1098-3597(03)90048-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
Data from randomized trials document that the frequency of major vascular events can be significantly reduced by lowering serum cholesterol and systolic blood pressure in high-risk patients. The recent publication of the Heart Protection Study (HPS) provided randomized trial evidence to support the recommendation of the National Cholesterol Education Program Adult Treatment Panel III to broaden statin use to include patients whose risk for a coronary event is equivalent to that among patients with manifest coronary artery disease, such as those with diabetes or cerebral, aortic, or peripheral vascular disease. Similarly, recent meta-analyses of hypertension trials provide us precise estimates of the benefits of lowering blood pressure. Risk and risk reduction data from these trials were applied to 153,305 Veterans Health Administration primary care patients to assess the health impact and costs of lowering cholesterol and blood pressure more aggressively in this population. Based on the results, it was estimated that 98,598 major vascular events might be prevented and $302,074,587 saved over 5 years if all patients were treated according to the HPS criteria and the recommendations of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. It is anticipated that achieving these goals will not be possible without significant, innovative system changes, such as disease management programs with electronic chart abstraction to identify patients who do not meet these recommendations.
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Affiliation(s)
- Karl Hammermeister
- Denver Veterans Health Administration Medical Center, University of Colorado Health Sciences Center, Denver, Colorado, USA
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Heggestad T. Do hospital length of stay and staffing ratio affect elderly patients' risk of readmission? A nation-wide study of Norwegian hospitals. Health Serv Res 2002; 37:647-65. [PMID: 12132599 PMCID: PMC1434663 DOI: 10.1111/1475-6773.00042] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To test whether there is an association between hospital operating conditions such as average length of stays (LOS) and staffing ratio, and elderly patients' risk of readmission. DATA SOURCES The main data source was a national patient database of admissions to all acute-care Norwegian hospitals during the year of 1996. STUDY DESIGN It is a cross-sectional study, where Cox' regression analysis was used to test the factors acting on the probability of early unplanned readmission (within 30 days), and later occuring ones. The principal hospital variables included average hospital LOS and staffing ratio (discharges per man-years of personnel). Adjusting patient variables in the model included age, gender, and cost-weights of the Diagnosis Related Groups (DRGs). DATA EXTRACTION METHODS The selected material included discharges from 59 hospitals, and 113,055 elderly patients (> or = 67 years). Multiple admissions to the same hospital were linked together chronologically, and additional hospital data were matched on. To maximize the association between the index stay and the defined outcome (unplanned readmission), no intervening planned admission was accepted. PRINCIPAL FINDINGS Being admitted to a hospital with relatively short average LOS increased the patient's risk of early readmission significantly. In addition it was found that more intensive care (more staff) could have a compensatory effect. Furthermore, the predictive factors were shown to be time dependent, as hospital variables had much less impact on readmissions occurring late (within 90-180 days). CONCLUSIONS The results give support to the assumption of a link between hospital operating conditions and patient outcome.
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Abstract
The purpose of this paper is to review the methods used to measure quality of stroke care. Relevant articles were searched for on Medline using the following key words: stroke, quality, outcome of care, process of care, structure of care. Articles that examined how to measure the quality of stroke care and that examined difficulties in the measurement of care outcomes, processes, and structures were selected. Selected articles were reviewed to summarise methods used to measure quality of stroke care and the primary outcome measures of the studies were extracted. Conclusions were drawn about the best ways to measure the quality of stroke care. Practical problems in using outcome measures to monitor quality of care include the consequences of case mix and difficulties in risk adjustment. Clinicians may use process measures to understand differences in outcome. Once a process of care has been linked to an outcome measure, this care process should be measured. The national sentinel audit for stroke is an audit tool used to examine the quality of the processes of stroke care.
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Affiliation(s)
- Kieran Walsh
- Colchester General Hospital, Colchester, Essex SS16 5NL, UK.
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31
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Meyer GS, Massagli MP. The forgotten component of the quality triad: can we still learn something from "structure"? THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 2001; 27:484-93. [PMID: 11556257 DOI: 10.1016/s1070-3241(01)27042-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Quality assessment was founded on structural measures, such as accreditation status of facilities, credentialing of providers, and type of provider. Recent efforts in measures development have focused on processes and outcomes because research has suggested that structural measures are not strong markers of the quality of care at the health plan or provider levels. Nevertheless, the literature on the quality of health care contains a number of examples illustrating the potential application of structural measures to the assessment of quality. The continued development of measures of structure-which would at least measure aspects of the physical environment, working conditions, organizational culture, and provider satisfaction--may be helpful because generalizing from studies of process and outcome requires specification of the conditions under which these linkages are found. A ROAD MAP FOR MEASURES DEVELOPMENT The Leapfrog Group of large purchasers has promoted the application of three patient safety "leaps" that are, in essence, structural measures: the use of computerized physician order entry, the selective referral of patients to high-volume providers for certain procedures, and the availability of board-certified critical care specialists in intensive care units. Structural measures, like process and outcomes measures, face the same challenges of standardization, reliability, validity, and portability. Field testing of potential measures will be required to examine the feasibility and added value of these measures in real-world settings. CONCLUSION Research to date suggests that a new cadre of structural measures of health care quality, which have largely been overlooked in the recent measures development boom, have the potential to fill in important gaps in our ability to assess quality.
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Affiliation(s)
- G S Meyer
- Center for Quality Improvement and Patient Safety, AHRQ, 6011 Executive Boulevard, Suite 200, Rockville, MD 20852, USA.
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32
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Abstract
The USA can boast a long history of investigation into quality failings in health care. From Ernest Codman and Abraham Flexner in the opening decades of this century through to the intense activity of the 1980s and 1990s, much careful study has exposed extraordinary and at times scandalous deficiencies in the quality of care (Millenson 1997; Chassin & Galvin 1998; Schuster et al. 1998). Yet we are still far from developing 'industrial strength' quality in health care: in all but a few isolated areas, such as general anaesthesia, 'six sigma quality' (i.e. a handful of errors per million) seems wishful thinking (Chassin 1998). Pockets of excellence and innovation notwithstanding, the dominant experience of the past two decades has been an increasing ability to document quality failings and a seeming inability to mobilize effective action (Coye & Detmer 1998). The rich literature on health-care quality that has sprung up over the past few decades has largely failed to provide a clear direction for quality improvement activity. This paper analyses some of the reasons why this might be so. Contrasting the relative absence of progress on health-care quality with the relative success of disease epidemiology provides some illuminating parallels. In essence, study of the quality of care has focused largely on providing a 'descriptive epidemiology'. Much more work is needed yet to unravel the underlying pathology of quality failings, in order to empower development of an 'aetiological epidemiology' of quality in health care. Such understanding is essential as a precursor to targeted and effective preventative and remedial action.
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Affiliation(s)
- H T Davies
- Department of Management, University of St Andrew's, St Andrew's, UK
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Pawlson G. Sheps' approaches to the quality of hospital care. J Health Serv Res Policy 2000; 5:250-2. [PMID: 11184962 DOI: 10.1177/135581960000500410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- G Pawlson
- National Committee for Quality Assurance, Washington, DC 20036, USA
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Rosenheck R, Fontana A, Stolar M. Assessing quality of care: administrative indicators and clinical outcomes in posttraumatic stress disorder. Med Care 1999; 37:180-8. [PMID: 10024122 DOI: 10.1097/00005650-199902000-00008] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Although the use of quality of care indicators based on data collected for administrative purposes has become widespread, the relationship between those measures and clinical outcomes has yet to be evaluated. RESEARCH DESIGN This study used hierarchical linear modeling to examine the relationship between 12 performance indicators derived from administrative data sets and 6 clinical outcome measures addressing symptoms, substance abuse, and social functions. SUBJECTS Patient interviews were conducted with 4,165 veterans 4 months after their discharge from 62 specialized VA inpatient programs for treatment of Posttraumatic Stress disorder. RESULTS Five of twelve administrative measures were significantly associated with at least one of the clinical outcome measures, which was all in the expected directions. The number of hospital readmissions during the 6 months after the index discharge was significantly related to poor outcomes on all 5 of 6 measures. Measures of readmission and post-discharge hospital use were more strongly and consistently related to outcome than to measures of access, intensity, or continuity of outpatient care. CONCLUSION Administrative data, especially measures of hospital readmission, are significantly related to clinical outcomes. Correlations, however, are small to modest in magnitude indicating that these 2 types of performance measures assess different aspects of quality and can not be substituted for one another.
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Affiliation(s)
- R Rosenheck
- Northeast Program Evaluation Center, Yale University Department of Psychiatry, VAMC West Haven, CT 06516, USA
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Jayr C. [Repercussion of postoperative pain, benefits attending to treatment]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1998; 17:540-54. [PMID: 9750793 DOI: 10.1016/s0750-7658(98)80039-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Physiological responses to postoperative acute pain may impede organ functions (cardiovascular, pulmonary, coagulation, endocrine, gastrointestinal, central nervous system, etc). Pain alleviation improves patient's comfort, but also may minimise perioperative stress response, physiological responses and postoperative organ dysfunction, assist postoperative nursing and physiotherapy, enhance clinical outcome, and potentially shorten the hospital stay. Potent postoperative analgesia, especially by epidural route, may be associated with reduction in incidence and severity of many perioperative dysfunctions. Peridural analgesia using local anaesthetics is the best technique for decreasing postoperative stress after lower abdominal or lower limb surgery. Analgesia using either epidural or high doses of morphine may improve some cardiac variables such as tachycardia and ischaemia, but does not change the incidence of severe cardiac complications. For patients undergoing vascular or orthopaedic surgery, epidural analgesia can improve clinical outcome by preventing the development of arterial or venous thromboembolic complications. However, in comparative studies, the control groups did not receive adequate prophylactic treatment for thromboembolic complications. Epidural analgesia can hasten the return of gastrointestinal motility and shorten the hospital stay. Postoperative mental dysfunction is decreased using intravenous PCA morphine in the elderly. Epidural analgesia with local anaesthetics improves postoperative respiratory function but, for unknown reasons, these benefits are not associated with a decrease in respiratory complications. On balance, the mode of acute pain relief decreases adverse physiological responses and many intermediate outcome variables; however, there is inconclusive evidence that it affects clinical outcome. Major advances in postoperative recovery can be achieved by early aggressive perioperative care, including potent analgesia, early mobilisation and oral nutrition. As a result, the hospital stay may be shortened.
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Affiliation(s)
- C Jayr
- Département d'analgésie-anesthésie-réanimation, institut Gustave-Roussy, Villejuif, France
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36
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Randolph AG, Guyatt GH, Carlet J. Understanding articles comparing outcomes among intensive care units to rate quality of care. Evidence Based Medicine in Critical Care Group. Crit Care Med 1998; 26:773-81. [PMID: 9559619 DOI: 10.1097/00003246-199804000-00032] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Comparisons of risk-adjusted outcomes among intensive care units (ICUs) is a relatively new but rapidly expanding area of ICU health services research. By investigating those factors that lead ICUs to have patient outcomes that differ from the average, the overall quality of care across ICUs may be improved. Our goal is to teach clinicians how to evaluate these types of articles. CLINICAL EXAMPLE: An article describing the development and application of an index used to assess the clinical performance and cost-effectiveness of 25 ICUs. RECOMMENDATIONS Valid comparisons of the outcomes among ICUs are made when: a) the outcome measures are accurate and comprehensive; b) the ICUs being compared serve similar patients; c) the sampling of patients is sufficient and unbiased; d) appropriate risk adjustment is undertaken by applying a valid model to reliably collected data; and e) the comparisons focus on care delivered in the ICU. To evaluate the results of the study, clinicians must evaluate how confident they are that the outcome differences being described are clinically important. Before changes in ICU policy are made based on these outcome differences, it is important to clarify which factors might have resulted in these extreme outcomes and whether these results are applicable in the ICU population that will see the impact of the changes. CONCLUSION The potential for misinterpretation of outcome performance ratings may decrease if articles describing outcome differences are evaluated, using the criteria outlined in this article.
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Affiliation(s)
- A G Randolph
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, ON, Canada
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Rosenheck R, Cicchetti D. A mental health program report card: a multidimensional approach to performance monitoring in public sector programs. Community Ment Health J 1998; 34:85-106. [PMID: 9559242 DOI: 10.1023/a:1018720414126] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This report presents a comprehensive, multi-dimensional mental health program performance monitoring system that has recently been implemented in the Department of Veterans Affairs. Principles underlying the development of the system are reviewed and 68 specific monitors are described addressing four major performance domains: access, inpatient care, outpatient care, and economic performance. Simple methods are presented for identifying outliers, for generating summary performance scores across series' of related monitors, and for adjusting results for differences in patient characteristics across locales. Although still technically imperfect, and therefore requiring continuous improvement, monitoring systems such as the one presented can be useful tools guiding and improving service delivery and mental health system performance, and providing a medium of accountability to consumers and other stakeholders.
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Affiliation(s)
- R Rosenheck
- Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven 06516, USA
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Abstract
Outcomes research is a quantitative assessment of the results of care. Outcomes analysis provides information that benefits the physician, the patient, the institution and the health care purchasers. It provides relevant and timely information for the assessment of the heart centre's performance. Outcomes data have proven to be useful to the attending physicians by providing a basis for clinical decision making. Patients may be appraised of the usual results and the risks of various treatment strategies and make informed decisions on their care. The purchasers of health care will be better informed regarding the costs and effectiveness of the care being delivered. O'Connor et al. have stated that methods of improving care are often discussed but are difficult to achieve due to processes of care being hidden from view. Outcomes research is a comprehensive performance evaluation strategy that may be used to discover the impact of these hidden aspects of care. This technology of the patient's experience is bringing cardiac surgery to a new level of excellence.
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Affiliation(s)
- R C Groom
- Maine Medical Center, Portland 04102, USA
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Teague GB, Ganju V, Hornik JA, Johnson JR, McKinney J. The MHSIP mental health report card. A consumer-oriented approach to monitoring the quality of mental health plans. Mental Health Statistics Improvement Program. EVALUATION REVIEW 1997; 21:330-341. [PMID: 10183285 DOI: 10.1177/0193841x9702100307] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Health care report cards have been endorsed as a mechanism for efficiently comparing key quantifiable aspects of performance across a range of health systems or plans. There are challenges in determining what to measure; how to gather and analyze data; and how to report, interpret, and use findings. Mental health has received little attention, and a consumer perspective is typically not included. The proposed MHSIP mental health report card (MMHRC) addresses these concerns. General issues for report cards are discussed, and the MMHRC is described in terms of content, data sources and quality, and analysis and reporting.
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Affiliation(s)
- G B Teague
- Department of Community Mental Health, Florida Mental Health Institute, University of South Florida, Tampa 33612, USA
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Treurniet HF, Essink-Bot ML, Mackenbach JP, van der Maas PJ. Health-related quality of life: an indicator of quality of care? Qual Life Res 1997; 6:363-9. [PMID: 9248318 DOI: 10.1023/a:1018435427116] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
There is an increasing interest in the use of outcome indicators to monitor the quality of care. Traditionally, outcome indicators have been based mainly on biological indicators reflecting death or disease. Now that various instruments for health status measurement have become available, questions have been raised as to the potential application of health status scores in monitoring the quality of care. This paper identifies conditions which should be fulfilled before such applications can be recommended. Firstly, the relationship between care delivery processes and health status outcomes must be established. In order to achieve this, health status measures which are clearly able to detect health status variations between groups of patients (i.e. discriminative ability) and variations over time (i.e. sensitivity to change) are needed. Secondly, health status data should be available, preferably from established data collection registries (e.g. computerized hospital records or national registries) where data relating to the description of variations in health status (between physicians, hospitals, regions, etc.) are routinely collected. Thirdly, methods should be found to collect additional data, including 'case-mix' information and health status reference data, in order to enable the interpretation of variations in health status. Because most of these conditions are currently not being fulfilled, we conclude that the state-of-the-art of health status measurement has not yet matured sufficiently to allow for the use of health status as an indicator of quality of care. The present paper provides a framework for both future research and data collection that is needed to improve the applicability of health status measures as quality-of-care indicators.
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Affiliation(s)
- H F Treurniet
- Erasmus University, Department of Public Health, Rotterdam, The Netherlands.
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Shroyer AL, Marshall G, Warner BA, Johnson RR, Guo W, Grover FL, Hammermeister KE. No continuous relationship between Veterans Affairs hospital coronary artery bypass grafting surgical volume and operative mortality. Ann Thorac Surg 1996; 61:17-20. [PMID: 8561546 DOI: 10.1016/0003-4975(95)00830-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The purpose of this study was to determine whether risk-adjusted coronary artery bypass grafting mortality rates are significantly related to coronary artery bypass grafting surgical procedure volume within the Department of Veterans Affairs hospital system. METHODS From April 1987 to September 1992, expected mortality rates were calculated for 23,986 coronary artery bypass grafting procedures performed at 44 different Veterans Affairs hospitals. RESULTS This study found a statistically significant relationship between annual hospital coronary artery bypass grafting volume and observed mortality rates (p < 0.02). However, no statistically significant relationship between coronary artery bypass grafting volume and risk-adjusted operative mortality was found (p = 0.10). Using analysis of variance on hospital-level data, hospitals with 100 or less cases per year have higher observed to expected mortality ratios than hospitals performing more than 100 cases per year (p = 0.03). Using Poisson regression models, however, a volume threshold could not be found. CONCLUSIONS These findings are consistent with the current Veterans Affairs policy requirements to periodically review quality at low-volume hospitals.
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Affiliation(s)
- A L Shroyer
- Denver Veterans Affairs Medical Center, Division of Cardiothoracic Surgery, CO 80220, USA
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Abstract
There are a number of limitations to current models of risk-adjusted outcome, continuous quality improvement, the most important of which are the reliance on chart abstraction for data collection, the focus on a procedure rather than a disease with several treatment options, and the emphasis on outcomes--particularly the identification of care providers with high rates of adverse outcomes. In this article, I describe a paradigm that combines clinical information management with quality of care assessment and improvement and that emphasizes the participation of care providers. This participatory continuous improvement model is a synthesis of three existing concepts: (1) continuous quality improvement, (2) intellectually and altruistically motivated self-examination and self-improvement, and (3) a modern medical information system. Important design elements of the participatory continuous improvement model to overcome these limitations include (1) a patient population defined by a disease, or diseases, rather than by a treatment to allow for assessment of the appropriateness and access to care; (2) a database that includes all important patient-level risk, treatment (process), and outcome information; (3) data input by the care provider at the point of care; (4) timely information feedback to care providers in a nonadversarial environment; and (5) public accountability. I believe that participatory continuous improvement models can provide the framework for psychologically sound ways to positively influence practice behaviors, and that this will, in turn, result in improved access to care, quality of care, and cost-effectiveness of care.
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THE BENEFITS OF CONTINUOUS PERFORMANCE MEASUREMENT. Nurs Clin North Am 1977. [DOI: 10.1016/s0029-6465(22)02212-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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