Benchmarking to improve the quality of cystic fibrosis care:

Exploring the utilisation and effectiveness of implementation science strategies by cystic fibrosis registries for healthcare improvement: a systematic review

BACKGROUND

Cystic fibrosis (CF) registries capture important information in high-burden health domains to support improvement in health outcomes, although a number of unanswered questions persist, as follows. 1) Do CF registries utilise implementation science strategies to improve patient outcomes? 2) Which implementation strategies have been engaged? 3) Has the engagement of these strategies been effective in improving clinical outcomes?

METHODS

We undertook a systematic review to exploring the use of implementation science strategies by CF registries for healthcare improvement. We searched MEDLINE, Embase, Scopus, Emcare and Web of Science databases for use of Expert Recommendations for Implementing Change (ERIC) implementations and use of the Knowledge to Action framework for improvement. We used the Risk of Bias in Non-randomised Studies - of Interventions tool for risk-of-bias assessment.

RESULTS

1974 citations were identified and 12 studies included. Included studies described 45 ERIC implementation strategies from nine categories. Strategies included "use evaluative and iterative strategies" (n=9) and "develop stakeholder interrelationships" (n=10). Least-used strategies were "utilise financial strategies" (n=1), "support clinicians" category (n=3) and "provide interactive assistance" (n=2). All 12 studies utilised monitoring of knowledge use, and assessing barriers and facilitators of knowledge use. Only seven studies utilised mechanisms to sustain knowledge use.

DISCUSSION

Reported studies describe significant benefits in important CF outcomes for people with CF reported at site-specific and population levels. Studies highlighted the importance of governance, leadership, patient and family engagement, multidisciplinary engagement, quality improvement, data and analytics and research. The ready availability of clinical performance data feedback to clinicians and patients by CF registries is likely to strengthen the effectiveness of CF registries in driving healthcare improvement within a learning health system.

Lessons from other fields of medicine, Part 2: Cystic fibrosis

Cystic fibrosis (CF), first described in 1938, is a common, life-limiting monogenetic disease. The discovery of the cystic fibrosis transmembrane conductance regulator (CFTR) gene in 1989 was crucial in advancing our understanding of disease pathogenesis and paving the road for treatment aimed at the fundamental molecular defect. With the delineation of over 2000 variations in the CFTR gene, a sound understanding of the individual variations in cell biology, and electrophysiological abnormalities conferred by the most common defects propelled the advent of targeted disease-modifying therapeutics beginning in 2012. Since then, CF care has transformed beyond just symptomatic treatment to include a variety of small-molecule therapies that address the basic electrophysiologic defect and cause profound improvements in physiology, clinical manifestations, and long-term outcomes, designed to differentially address six genetic/molecular subtypes. This chapter illustrates the progress made toward how fundamental science and translational initiatives enabled personalized, mutation specific treatment. We highlight the importance of preclinical assays and mechanistically-driven development strategies that were coupled with sensitive biomarkers and a clinical trial cooperative to provide a platform for successful drug development. This convergence of academic and private partnerships, and formation of multidisciplinary care teams directed by evidence-based initiatives provide a seminal example of addressing the needs of individuals with a rare, but fatal genetic disease.

Impact of guideline-recommended dietitian assessments on weight gain in infants with cystic fibrosis

BACKGROUND

Cystic fibrosis (CF)-specialized nutrition care strives to meet normal infant growth, but the relationship of dietitian assessments to weight outcomes is unknown. We characterize nutrition management for inadequate weight gain and assess association of dietitian assessments and center-level weight-for-age Z-scores (WAZ).

METHODS

We used encounter data from 226 infants across 28 US CF Centers from the Baby Observational Nutritional study between January 2012 through December 2017. We identified dietitian assessments and consensus guideline-recommended responses to inadequate weight gain: calorie increases, pancreatic enzyme replacement therapy (PERT) increases, or shortened time to next visit. We compared center assessments by funnel plot and summarize median WAZ by center.

RESULTS

Of 2,527 visits, 808 (32%) visits had identified inadequate weight gain, distributed in 216 infants. Assessments occurred in 1953 visits (77%), but varied widely between centers (range 17% - 98%). For inadequate weight gain, most and least common responses were calorie increase (64%) and PERT increase (21%). Funnel plot analysis identified 4 high-performers for frequent dietitian assessments (range 92% - 98%) and 4 under-performers (range 17% - 56%). High-performers treated inadequate weight gain more often with adequate calories (24/30, 80% v. 12/23, 52%) and closer follow up (104/164, 63% v. 60/120, 49%) compared to under-performers. Three of 4 high-performing sites met center nutrition goals for positive median WAZ at 2 years old unlike 3 under-performers (WAZ_High 0.33 v. WAZ_Low -0.15), despite similar patient characteristics.

CONCLUSION

We characterized multicenter variation in dietitian assessments, identifying opportunities to improve care delivery to target early nutrition outcomes.

Understanding FEV1 for the purpose of cystic fibrosis registry comparisons: Does bias in annual review FEV1 affect between-centre comparison within the UK? An analysis of registry data

RATIONALE, AIMS, AND OBJECTIVE

We previously demonstrated that annual review %FEV₁ underestimates lung health of adults with CF compared with %FEV₁ captured during periods of clinical stability. This has implications in the comparisons against registries with encounter-based FEV₁ , such as the United States. It is uncertain whether this bias affects between-centre comparison within the United Kingdom. Previous funnel plot analyses have identified variation in annual review %FEV₁ according to centre size; hence, we investigated whether paired differences between annual review and best %FEV₁ also vary according to centre size.

METHODS

This registry analysis included 18 adult CF centres in the United Kingdom with ≥80% completeness for best FEV₁ data in 2014. Mean discrepancy between annual review and best %FEV₁ is a surrogate for the extent by which annual review %FEV₁ underestimates lung health, and was plotted against centre size. A local polynomial regression (LOESS) curve was used to explore the relationship between the two variables. An appropriate model is fitted based on the LOESS curve to determine the strength of relationship between discrepancies in %FEV₁ and centre size.

RESULTS

There is an inverted U-shaped relationship between mean discrepancies in %FEV₁ and centre size. A regression of the paired mean difference in %FEV₁ against centre size showed a significant improvement in the goodness of fit for a quadratic model (R²  = 23.8% for a quadratic model compared with 0.4% for a linear one; P = 0.048 for the quadratic term).

CONCLUSIONS

Annual review %FEV₁ underestimated lung health of adults from small and large centres in the United Kingdom to a greater extent compared with medium-sized centres. A plot of %FEV₁ against centre size (eg, funnel plot comparison) would be affected by systematic bias in annual review %FEV₁ . Therefore, annual review %FEV₁ is an unreliable metric to compare health outcomes of adult CF centres within the United Kingdom.

Developing key performance indicators for a tertiary children's hospital network

Objective The aim of this study is to describe the experience of developing key performance indicators (KPIs) for Sydney Children's Hospital Network (SCHN), the largest paediatric healthcare entity in Australia. Methods Beginning with a published methodology, the process of developing KPIs involved five phases: (1) identification of potential KPIs referencing the organisational strategic plan and pre-existing internal and external documents; (2) consolidation into a pragmatic set; (3) analysis of potential KPIs against selection criteria; (4) mapping these back against the strategic plan and management structure; and (5) presentation to key stakeholders to ensure suitability and traction. Consistent with the strategic plan, a subset of indicators was selected to address quality of care for children from priority populations. Results A pragmatic list of 60 mandated and 50 potential KPIs was created from the 328 new and 397 existing potentially relevant KPIs generated by the executive team. Of these, 20 KPIs were selected as the most important; 65% were process measures. The majority of mandated KPIs were process measures. Of the KPIs selected to highlight inequities, there were proportionately more outcome measures (44% outcome, 27% process). Less than one-third could currently be measured by the organisation and were thus aspirational. Conclusion Developing a KPI suite requires substantial time, effort and organisational courage. A structured approach to performance measurement and improvement is needed to ensure a balanced suite of KPIs that can be expected to drive an organisation to improve child health outcomes. Future directions for SCHN include a systematic approach to implementation beyond the mandated KPIs, including KPIs that reflect equity and improved outcomes for priority populations, development of meaningful measures for the aspirational KPIs, adding structure KPIs and measurement of changes in child health outcomes related to the development of this KPI process. What is known about the topic? Health services are increasingly required to demonstrate accountability through KPIs. There is a body of literature on both theoretical frameworks for measuring performance and a long list of possible measures, however developing a meaningful suite of KPIs remains a significant challenge for individual organisations. What does this paper add? This paper describes lessons learned from the practical, pragmatic application of a published methodology to develop a suite of KPIs for the largest paediatric healthcare entity in Australia. It provides a select list of the highest-level KPIs selected by the organisation to stimulate further discussion among similar organisations in relation to KPI selection and implementation. What are the implications for practitioners? Developing and implementing a suite of meaningful KPIs for a large organisation requires courage, an understanding of health informatics, stakeholder engagement, stamina and pragmatism. The process we describe can be replicated and/or modified as needed, with discussion of key lessons learned to help practitioners plan ahead.

Epidemiology of Rare Lung Diseases: The Challenges and Opportunities to Improve Research and Knowledge

Rare lung diseases encompass a broad spectrum of conditions and affect an estimated 1.2-2.5 million people in North America and 1.5-3 million people in Europe. While individual rare lung diseases affect less than 1 in 2000 individuals, collectively they have a significant impact upon the population at large. Hence it is vital to understand firstly the epidemiology and subsequently the pathogenesis and clinical course of these disorders. Through a greater understanding of these aspects of disease, progress can be made in reducing symptoms, containing healthcare costs and utilizing resources efficiently. Furthermore, a greater understanding of the pathobiology of rare lung diseases can inform both the pathogenesis and management of more common pulmonary disorders.In this chapter we review how epidemiological approaches and the utilization of patient registries has improved the knowledge and management of rare lung diseases. We further focus on the epidemiology of several of the more widely known rare pulmonary disorders, including idiopathic pulmonary fibrosis (IPF), cystic fibrosis (CF) and alpha-1 antitrypsin deficiency (AATD). To conclude we describe how patient advocacy groups and foundations have driven advances in research and management of ultra-rare lung diseases, namely, the major strides made in the management and understanding of lymphangioleiomyomatosis (LAM) and pulmonary alveolar proteinosis (PAP).We conclude that the models used to study some of the rarest of diseases may be successfully adopted by other rare and common disease communities, leading to improved care and the possibility of novel therapeutic options.

Using different methods to process forced expiratory volume in one second (FEV 1) data can impact on the interpretation of FEV 1 as an outcome measure to understand the performance of an adult cystic fibrosis centre: A retrospective chart review

Background: Forced expiratory volume in one second (FEV 1) is an important cystic fibrosis (CF) prognostic marker and an established endpoint for CF clinical trials. FEV 1 is also used in observation studies, e.g. to compare different centre's outcomes. We wished to evaluate whether different methods of processing FEV 1 data can impact on a centre's outcome. Methods: This is a single-centre retrospective analysis of routinely collected data from 2013-2016 which included 208 adults with CF. Year-to-year %FEV 1 change was calculated by subtracting best %FEV 1 at Year 1 from Year 2 (i.e. negative values indicate %FEV 1 decline), and compared using Friedman test. Three methods were used to process %FEV 1 data. First, %FEV 1 calculated with Knudson equation was extracted directly from spirometer machines. Second, FEV 1 volume were extracted then converted to %FEV 1 using clean height data and Knudson equation. Third, FEV 1 volume were extracted then converted to %FEV 1 using clean height data and GLI equation. In addition, %FEV 1 decline calculated using GLI equation was adjusted for baseline %FEV 1 to understand the impact of case-mix adjustment. Results: There was a trend of reduction in %FEV 1 decline with all three data processing methods but the magnitude of %FEV 1 decline differed. Median change in %FEV 1 for 2013-2014, 2014-2015 and 2015-2016 was -2.0, -1.0 and 0.0 respectively using %FEV 1 in Knudson equation whereas the median change was -1.1, -0.9 and -0.3 respectively using %FEV 1 in the GLI equation. A statistically significant p-value (0.016) was only obtained when using %FEV 1 in Knudson equation extracted directly from spirometer machines. Conclusions: Although the trend of reduction in %FEV 1 decline was robust, different data processing methods yielded varying results when %FEV 1 decline was compared using a standard related group non-parametric statistical test. Observational studies with %FEV 1 decline as an outcome measure should carefully consider and clearly specify the data processing methods used.

Using different methods to process forced expiratory volume in one second (FEV 1) data can impact on the interpretation of FEV 1 as an outcome measure to understand the performance of an adult cystic fibrosis centre: A retrospective chart review

Background: Forced expiratory volume in one second (FEV 1) is an important cystic fibrosis (CF) prognostic marker and an established endpoint for CF clinical trials. FEV 1 is also used in observation studies, e.g. to compare different centre's outcomes. We wished to evaluate whether different methods of processing FEV 1 data can impact on centre outcome. Methods: This is a single-centre retrospective analysis of routinely collected data from 2013-2016 among 208 adults. Year-to-year %FEV 1 change was calculated by subtracting best %FEV 1 at Year 1 from Year 2 (i.e. negative values indicate fall in %FEV 1), and compared using Friedman test. Three methods were used to process %FEV 1 data. First, %FEV 1 calculated with Knudson equation was extracted directly from spirometer machines. Second, FEV 1 volume were extracted then converted to %FEV 1 using clean height data and Knudson equation. Third, FEV 1 volume were extracted then converted to %FEV 1 using clean height data and GLI equation. In addition, year-to-year variation in %FEV 1 calculated using GLI equation was adjusted for baseline %FEV 1 to understand the impact of case-mix adjustment. Results: Year-to-year fall in %FEV 1 reduced with all three data processing methods but the magnitude of this change differed. Median change in %FEV 1 for 2013-2014, 2014-2015 and 2015-2016 was -2.0, -1.0 and 0.0 respectively using %FEV 1 in Knudson equation whereas the median change was -1.1, -0.9 and -0.3 respectively using %FEV 1 in the GLI equation. A statistically significant p-value (0.016) was only obtained when using %FEV 1 in Knudson equation extracted directly from spirometer machines. Conclusions: Although the trend of reduced year-to-year fall in %FEV 1 was robust, different data processing methods yielded varying results when year-to-year variation in %FEV 1 was compared using a standard related group non-parametric statistical test. Observational studies with year-to-year variation in %FEV 1 as an outcome measure should carefully consider and clearly specify the data processing methods used.

Does current reporting of lung function by the UK cystic fibrosis registry allow a fair comparison of adult centres?

BACKGROUND

Outcome data for UK cystic fibrosis centres are publicly available in an annual report, which ranks centres by median FEV₁% predicted. We wished to assess whether there are differences in lung function outcomes between adult centres that might imply differing standards of care.

METHODS

UK Registry data from 4761 subjects at 34 anonymised adult centres were used to calculate mean FEV₁% and rate of change of lung function for 2007-13. These measures were used to rank centres and compare outcomes.

RESULTS

There are minor differences between centres for mean FEV₁% for some years of the study and for rate of change of lung function over the study period. However, rankings are critically dependent on the outcome measure chosen and centre variation becomes negligible once patient population characteristics are taken into account.

CONCLUSIONS

We have demonstrated that the ranking of centres is biased and any apparent difference in respiratory outcomes is unlikely to be related to differing standards of care between centres.

Cystic fibrosis

Cystic fibrosis is an autosomal recessive, monogenetic disorder caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The gene defect was first described 25 years ago and much progress has been made since then in our understanding of how CFTR mutations cause disease and how this can be addressed therapeutically. CFTR is a transmembrane protein that transports ions across the surface of epithelial cells. CFTR dysfunction affects many organs; however, lung disease is responsible for the vast majority of morbidity and mortality in patients with cystic fibrosis. Prenatal diagnostics, newborn screening and new treatment algorithms are changing the incidence and the prevalence of the disease. Until recently, the standard of care in cystic fibrosis treatment focused on preventing and treating complications of the disease; now, novel treatment strategies directly targeting the ion channel abnormality are becoming available and it will be important to evaluate how these treatments affect disease progression and the quality of life of patients. In this Primer, we summarize the current knowledge, and provide an outlook on how cystic fibrosis clinical care and research will be affected by new knowledge and therapeutic options in the near future. For an illustrated summary of this Primer, visit: http://go.nature.com/4VrefN.

Inter-hospital variation in the frequency of sinus surgery in children with cystic fibrosis

BACKGROUND

Chronic rhinosinusitis and nasal polyposis are common conditions in cystic fibrosis (CF). Approximately 2-3% of pediatric CF patients per year have sinus disease requiring surgery. The purpose of this study was to evaluate the variation of sinus surgery rates in pediatric CF patients across multiple US pediatric hospitals.

METHODS

The Pediatric Health Information System (PHIS) compiles inpatient administrative data from 42 pediatric hospitals. We conducted a retrospective analysis of PHIS for the period January 1, 2008 to January 1, 2011 to evaluate frequency of sinus surgery at each hospital. We identified CF patients and sinus surgery during inpatient encounters using ICD-9 codes. Demographic data and data for each hospital on hospital size, number of pediatric otolaryngologists, average FEV1, and percentage of patients meeting minimum care guidelines were collected. Twenty-nine hospitals were included in analysis using mixed-effects logistic regression models for occurrence of sinus surgery.

RESULTS

We identified 5,194 CF patients, accounting for 18,788 unique encounters among 29 hospitals. 880 patients underwent 1,397 sinus operations. Total number of CF patients at each institution ranged from 39 to 364 and total number of sinus surgeries ranged from 4 to 205, over the 3-year period. Variation in the rate of sinus surgery with hospital encounter was observed (1-24%). Hospital-average lung function (P = 0.56), number of otolaryngologists (P = 0.65) were not found to be predictors of sinus surgery. The size of the CF center (P = 0.01), hospital size (P = 0.05), and age at admission (P ≤ 0.0001) were associated with an increased frequency of sinus surgery. However, with multivariable analysis, only size of the CF center and age of admission remained statistically significant predictors of surgery with admission.

CONCLUSIONS

There is large variation in the incidence of sinus surgery for CF in 29 of the largest freestanding pediatric hospitals. This study highlights remarkable variation in clinical practice and underscores the need for further research into the indications and benefits of sinus surgery in pediatric patients with CF. Pediatr Pulmonol. 2015; 50:231-235. © 2014 Wiley Periodicals, Inc.

Symptoms of depression impact the course of lung function in adolescents and adults with cystic fibrosis

Background

Epidemiological studies report high rates of depression among patients with cystic fibrosis (CF). Assuming a causal relationship between depression and the progression of CF, our hypothesis is that elevated symptoms of depression would be a predictor of worse lung function after two years.

Methods

In the context of the TIDES study, 473 German patients with CF (age 12–53 years, FEV₁% predicted M = 66.2, range 13–137) completed the Hospital Anxiety and Depression Scale (HADS). Lung function (FEV₁% predicted) was assessed at baseline and followed up two years later. Repeated measures analysis was performed involving the level of FEV₁% and the level of depressive symptoms at baseline as independent factors and FEV₁% at the 2-year follow-up as the dependent variable.

Results

Interaction between lung function and depression at baseline significantly affected the change in lung function at the 2-years observation interval. The largest decline in FEV₁% occurred in depressed patients with good lung function at baseline. In contrast, patients without any clinically relevant depressive symptoms and with poor lung function at baseline showed a slight increase two years later.

Conclusion

The findings emphasise the need to screen patients with CF for symptoms of depression and to treat co-morbid depression.

Pulmonary function outcomes for assessing cystic fibrosis care

BACKGROUND

Assessing cystic fibrosis (CF) patient quality of care requires the choice of an appropriate outcome measure. We looked systematically and in detail at pulmonary function outcomes that potentially reflect clinical practice patterns.

METHODS

Epidemiologic Study of Cystic Fibrosis data were used to evaluate six potential outcome variables (2002 best FVC, FEV(1), and FEF(25-75) and rate of decline for each from 2000 to 2002). We ranked CF care sites by outcome measure and then assessed any association with practice patterns and follow-up pulmonary function.

RESULTS

Sites ranked in the top quartile had more frequent monitoring, treatment of exacerbations, and use of chronic therapies and oral corticosteroids. The follow-up rate of pulmonary function decline was not predicted by site ranking.

CONCLUSIONS

Different pulmonary function outcomes associate slightly differently with practice patterns, although annual FEV(1) is at least as good as any other measure. Current site ranking only moderately predicts future ranking.

Advances in the diagnosis and treatment of cystic fibrosis

CF is a genetic, life-shortening, multisystem disease that is most commonly diagnosed through newborn screen performed in all 50 states in the United States. In the past, therapies for CF lung disease have primarily targeted the downstream effects of a dysfunctional CFTR protein. Newer CFTR modulator therapies, targeting the basic defect in CF, are available for a limited group of people with CF, and offer the hope of improved treatment options for many more people with CF in the near future. Best practice is directed by consensus clinical care guidelines from the CFF and is provided with a multidisciplinary approach by the team at the CF care center and the primary care office.