Developing quality indicators for older adults: transfer from the USA to the UK is feasible

Developing quality indicators for cross-sectoral psycho-oncology in Germany: combining the RAND/UCLA appropriateness method with a Delphi technique

BACKGROUND

Internationally, the need for appropriately structured, high-quality care in psycho-oncology is more and more recognized and quality-oriented care is to be established. Quality indicators are becoming increasingly important for a systematic development and improvement of the quality of care. The aim of this study was to develop a set of quality indicators for a new form of care, a cross-sectoral psycho-oncological care program in the German health care system.

METHODS

The widely established RAND/UCLA Appropriateness Method was combined with a modified Delphi technique. A systematic literature review was conducted to identify existing indicators. All identified indicators were evaluated and rated in a two-round Delphi process. Expert panels embedded in the Delphi process assessed the indicators in terms of relevance, data availability and feasibility. An indicator was accepted by consensus if at least 75% of the ratings corresponded to category 4 or 5 on a five-point Likert scale.

RESULTS

Of the 88 potential indicators derived from a systematic literature review and other sources, 29 were deemed relevant in the first Delphi round. After the first expert panel, 28 of the dissented indicators were re-rated and added. Of these 57 indicators, 45 were found to be feasible in terms of data availability by the second round of expert panel. In total, 22 indicators were transferred into a quality report, implemented and tested within the care networks for participatory quality improvement. In the second Delphi round, the embedded indicators were tested for their practicability. The final set includes 16 indicators that were operationalized in care practice and rated by the expert panel as relevant, comprehensible, and suitable for care practice.

CONCLUSION

The developed set of quality indicators has proven in practical testing to be a valid quality assurance tool for internal and external quality management. The study findings could contribute to traceable high quality in cross-sectoral psycho-oncology by providing a valid and comprehensive set of quality indicators.

TRIAL REGISTRATION

"Entwicklung eines Qualitätsmanagementsystems in der integrierten, sektorenübergreifenden Psychoonkologie-AP "Qualitätsmanagement und Versorgungsmanagement" zur Studie "integrierte, sektorenübergreifende Psychoonkologie (isPO)" a sub-project of the "integrierte, sektorenübergreifende Psychoonkologie (isPO)", was registered in the German Clinical Trials Register (DRKS) (DRKS-ID: DRKS00021515) on 3rd September 2020. The main project was registered on 30th October 2018 (DRKS-ID: DRKS00015326).

What is the value and impact of the adaptation process on quality indicators for local use? A scoping review

BACKGROUND

Quality indicators (QIs) are designed for improving quality of care, but the development of QIs is resource intensive and time consuming.

OBJECTIVE

To describe and identify the impact and potential attributes of the adaptation process for the local use of existing QIs.

DATA SOURCES

EMBASE, MEDLINE, CINAHL and grey literature were searched.

STUDY SELECTION

Literatures operationalizing or implementing QIs that were developed in a different jurisdiction from the place where the QIs were included.

RESULTS

Of 7704 citations identified, 10 out of 33 articles were included. Our results revealed a lack of definition and conceptualization for an adaptation process in which an existing set of QIs was applied. Four out of ten studies involved a consensus process (e.g., Delphi or RAND process) to determine the suitability of QIs for local use. QIs for chronic conditions in primary and secondary settings were mostly used for adaptation. Of the ones that underwent a consensus process, 56.3 to 85.7% of original QIs were considered valid for local use, and 2 to 21.8% of proposed QIs were newly added. Four attributes should be considered in the adaptation: 1) identifying areas/conditions; 2) a consensus process; 3) proposing adapted QIs; 4) operationalization and evaluation.

CONCLUSION

The existing QIs, although serving as a good starting point, were not adequately adapted before for use in a different jurisdiction from their origin. Adaptation of QIs under a systematic approach is critical for informing future research planning for QIs adaptation and potentially establishing a new pathway for healthcare improvement.

Assessing equity and quality indicators for older people – Adaptation and validation of the Assessing Care of Vulnerable Elders (ACOVE) checklist for the Portuguese care context

Background

Development has promoted longer and healthier lives, but the rise in the proportion of older adults poses new challenges to health systems. Susceptibilities of older persons resulting from lower knowledge about services availability, health illiteracy, lower income, higher mental decline, or physical limitations need to be identified and monitored to assure the equity and quality of health care. The aim of this study was to develop equity indicators for the Assessing Care of Vulnerable Elders (ACOVE)-3 checklist and perform the first cross-cultural adaptation and validation of this checklist into Portuguese.

Methods

A scoping literature review of determinants or indicators of health (in)equity in the care of older people was performed. A total of 5 language experts and 18 health professionals were involved in the development and validation of the equity and quality indicators through expert opinion and focus groups. Data collected from focus groups was analyzed through directed or conventional content analysis. The usefulness of the indicators was assessed by analyzing the clinical records of 30 patients.

Results

The literature review revealed that there was a worldwide gap concerning equity indicators for older people primary health care. A structured and complete checklist composed of equity and quality indicators was obtained, validated and assessed. A significant number of non-screened quality or equity related potential occurrences that could have been avoided if the proposed indicators were implemented were detected. The percentage of non-registered indicators was 76.6% for quality and 96.7% for equity.

Conclusions

Applying the proposed checklist will contribute to improve the monitoring of the clinical situation of vulnerable older people and the planning of medical and social actions directed at this group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03104-5.

Quality indicators for knee and hip osteoarthritis care: a systematic review

To provide an overview of quality indicators (QIs) for knee and hip osteoarthritis (KHOA) care and to highlight differences in healthcare settings. A database search was conducted in MEDLINE (PubMed), EMBASE, CINAHL, Web of Science, Cochrane CENTRAL and Google Scholar, OpenGrey and Prospective Trial Register, up to March 2020. Studies developing or adapting existing QI(s) for patients with osteoarthritis were eligible for inclusion. Included studies were categorised into healthcare settings. QIs from included studies were categorised into structure, process and outcome of care. Within these categories, QIs were grouped into themes (eg, physical therapy). A narrative synthesis was used to describe differences and similarities between healthcare settings. We included 20 studies with a total of 196 QIs mostly related to the process of care in different healthcare settings. Few studies included patients’ perspectives. Rigorous methods for evidence synthesis to develop QIs were rarely used. Narrative analysis showed differences in QIs between healthcare settings with regard to exercise therapy, weight counselling, referral to laboratory tests and ‘do not do’ QIs. Differences within the same healthcare setting were identified on radiographic assessment. The heterogeneity in QIs emphasise the necessity to carefully select QIs for KHOA depending on the healthcare setting. This review provides an overview of QIs outlined to their healthcare settings to support healthcare providers and policy makers in selecting the contextually appropriate QIs to validly monitor the quality of KHOA care. We strongly recommend to review QIs against the most recent guidelines before implementing them into practice.

Development and pilot testing of quality improvement indicators for integrated primary dementia care

Background

Implementation of integrated primary care is considered an important strategy to overcome fragmentation and improve quality of dementia care. However, current quality indicator (QI) sets, to assess and improve quality of care, do not address the interprofessional context. The aim of this research was to construct a feasible and content-wise valid minimum dataset (MDS) to measure the quality of integrated primary dementia care.

Methods

A modified Delphi method in four rounds was performed. Stakeholders (n=15) (1) developed a preliminary QI set and (2) assessed relevance and feasibility of QIs via a survey (n=84); thereafter, (3) results were discussed for content validity during a stakeholder and (4) expert consensus meeting (n=8 and n=7, respectively). The stakeholders were professionals, informal caregivers, and care organisation managers or policy officers; the experts were professionals and researchers. The final set was pilot-tested for feasibility by multidisciplinary dementia care networks.

Results

The preliminary set consisted of 40 QIs. In the survey, mean scores for relevance ranged from 5.8 (SD=2.7) to 8.5 (SD=0.7) on a 9-point Likert scale, and 25% of all QIs were considered feasible to collect. Consensus panels reduced the set to 15 QIs to be used for pilot testing: 5 quality of care, 3 well-being, 4 network-based care, and 3 cost-efficiency QIs. During pilot testing, all QIs were fully completed, except for well-being QIs.

Conclusion

A valid and feasible MDS of QIs for primary dementia care was developed, containing innovative QIs on well-being, network-based care and cost-efficiency, in addition to quality of care QIs. Application of the MDS may contribute to development and implementation of integrated care service delivery for primary dementia care.

Quality indicators for responsible use of medicines: a systematic review

OBJECTIVE

All healthcare systems require valid ways to evaluate service delivery. The objective of this study was to identify existing content validated quality indicators (QIs) for responsible use of medicines (RUM) and classify them using multiple frameworks to identify gaps in current quality measurements.

DESIGN

Systematic review without meta-analysis.

SETTING

All care settings.

SEARCH STRATEGY

CINAHL, Embase, Global Health, International Pharmaceutical Abstract, MEDLINE, PubMed and Web of Science databases were searched up to April 2018. An internet search was also conducted. Articles were included if they described medication-related QIs developed using consensus methods. Government agency websites listing QIs for RUM were also included.

ANALYSIS

Several multidimensional frameworks were selected to assess the scope of QI coverage. These included Donabedian's framework (structure, process and outcome), the Anatomical Therapeutic Chemical (ATC) classification system and a validated classification for causes of drug-related problems (c-DRPs; drug selection, drug form, dose selection, treatment duration, drug use process, logistics, monitoring, adverse drug reactions and others).

RESULTS

2431 content validated QIs were identified from 131 articles and 5 websites. Using Donabedian's framework, the majority of QIs were process indicators. Based on the ATC code, the largest number of QIs pertained to medicines for nervous system (ATC code: N), followed by anti-infectives for systemic use (J) and cardiovascular system (C). The most common c-DRPs pertained to 'drug selection', followed by 'monitoring' and 'drug use process'.

CONCLUSIONS

This study was the first systematic review classifying QIs for RUM using multiple frameworks. The list of the identified QIs can be used as a database for evaluating the achievement of RUM. Although many QIs were identified, this approach allowed for the identification of gaps in quality measurement of RUM. In order to more effectively evaluate the extent to which RUM has been achieved, further development of QIs may be required.

Quality indicators assessing antibiotic use in the outpatient setting: a systematic review followed by an international multidisciplinary consensus procedure

Objectives

Quality indicators (QIs) assessing the appropriateness of antibiotic use are essential to identify targets for improvement and guide antibiotic stewardship interventions. The aim of this study was to develop a set of QIs for the outpatient setting from a global perspective.

Methods

A systematic literature review was performed by searching MEDLINE and relevant web sites in order to retrieve a list of QIs. These indicators were extracted from published trials, guidelines, literature reviews or consensus procedures. This evidence-based set of QIs was evaluated by a multidisciplinary, international group of stakeholders using a RAND-modified Delphi procedure, using two online questionnaires and a face-to-face meeting between them. Stakeholders appraised the QIs' relevance using a nine-point Likert scale. This work is part of the DRIVE-AB project.

Results

The systematic literature review identified 43 unique QIs, from 54 studies and seven web sites. Twenty-five stakeholders from 14 countries participated in the consensus procedure. Ultimately, 32 QIs were retained, with a high level of agreement. The set of QIs included structure, process and outcome indicators, targeting both high- and middle- to low-income settings. Most indicators focused on general practice, addressing the common indications for antibiotic use in the community (particularly urinary and respiratory tract infections), and the organization of healthcare facilities. Twelve indicators specifically addressed outpatient parenteral antimicrobial therapy (OPAT).

Conclusions

We identified a set of 32 outpatient QIs to measure the appropriateness of antibiotic use. These QIs can be used to identify targets for improvement and to evaluate the effects of antibiotic stewardship interventions.

Primary care supply and quality of care in England

We investigated the relationship between primary care supply and quality of care in England. We analysed 35 process measures of quality of care covering 13 medical conditions using English Longitudinal Study of Aging data linked to area of residence indicators. Greater GP density had a statistically significant and positive association with quality of care, and distance to GP practice had a statistically significant and negative association. The effects were concentrated in indicators of care related to cardiovascular diseases and arthritis, and on specific indicators for diabetes, incontinence and hearing problems. The results suggest that better primary care supply can improve quality of care.

A protocol for the development and piloting of quality measures to support the Healthier You: The NHS Diabetes Prevention Programme

Background

The increasing prevalence of type 2 diabetes in the UK creates an additional, potentially preventable burden on health care and service providers. The Healthier You: NHS Diabetes Prevention Programme aims to reduce the incidence of type 2 diabetes through the identification of people at risk and the provision of intensive lifestyle change support. The provision of this care can be monitored through quality measurement at both the general practice and specialist service level.

Aim

To develop quality measures through piloting to assess the validity, credibility, acceptability, reliability, and feasibility of any proposed measures.

Design & setting

The non-experimental mixed design piloting study consists of consensus testing and exploratory research with GPs, commissioners, and patients from Herefordshire, England.

Method

A mixed-method approach will be used to develop and validate measures for diabetes prevention care and evaluate their performance over a 6-month pilot period consisting of consensus testing using a modified RAND approach with GPs and commissioners; four focus groups with 8-10 participants discussing experiences of non-diabetic hyperglycaemia (NDH), perceived ability to access care and prevent diabetes, and views on potential quality measures; and piloting final measures with at least five general practices for baseline and 6-month data.

Results

The findings will inform the implementation of the diabetes prevention quality measures on a national scale while addressing any issue with validity, credibility, feasibility, and cost-effectiveness.

Conclusion

Healthcare professionals and patients have the opportunity to evaluate the reliability, acceptability, and validity of measures.

Quality indicators for care of depression in primary care settings: a systematic review

BACKGROUND

Despite the growing interest in assessing the quality of care for depression, there is little evidence to support measurement of the quality of primary care for depression. This study identified evidence-based quality indicators for monitoring, evaluating and improving the quality of care for depression in primary care settings.

METHODS

Ovid MEDLINE and Ovid PsycINFO databases, and grey literature, including relevant organizational websites, were searched from 2000 to 2015. Two reviewers independently selected studies if (1) the study methodology combined a systematic literature search with assessment of quality indicators by an expert panel and (2) quality indicators were applicable to assessment of care for adults with depression in primary care settings. Included studies were appraised using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument, which contains four domains and 20 items. A narrative synthesis was used to combine the indicators within themes. Quality indicators applicable to care for adults with depression in primary care settings were extracted using a structured form. The extracted quality indicators were categorized according to Donabedian's 'structure-process-outcome' framework.

RESULTS

The search revealed 3838 studies. Four additional publications were identified through grey literature searching. Thirty-nine articles were reviewed in detail and seven met the inclusion criteria. According to the AIRE domains, all studies were clear on purpose and stakeholder involvement, while formal endorsement and usage of indicators in practice were scarcely described. A total of 53 quality indicators were identified from the included studies, many of which overlap conceptually or in content: 15 structure, 33 process and four outcome indicators. This study identified quality indicators for evaluating primary care for depression among adult patients.

CONCLUSIONS

The identified set of indicators address multiple dimensions of depression care and provide an excellent starting point for further development and use in primary care settings.

The dynamics of quality: a national panel study of evidence-based standards

Background

Shortfalls in the receipt of recommended health care have been previously reported in England, leading to preventable poor health.

Objectives

To assess changes over 6 years in the receipt of effective health-care interventions for people aged 50 years or over in England with cardiovascular disease, depression, diabetes or osteoarthritis; to identify how quality varied with participant characteristics; and to compare the distribution of illness burden in the population with the distributions of diagnosis and treatment.

Setting and participants

Information on health-care quality indicators and participant characteristics was collected using face-to-face structured interviews and nurse visits in participants’ homes by the English Longitudinal Study of Ageing in 2004–5, 2006–7, 2008–9 and 2010–11. A total of 16,773 participants aged 50 years or older were interviewed at least once and 5114 were interviewed in all four waves; 5404 reported diagnosis of one or more of four conditions in 2010–11.

Main outcome measures

Percentage of indicated health care received by eligible participants for 19 quality indicators: seven for cardiovascular disease, three for depression, five for diabetes and four for osteoarthritis, and condition-level quality indicator achievement, including achievement of a bundle of three diabetes indicators.

Analysis

Changes in quality indicator achievement over time and variations in quality with participant characteristics were tested with Pearson’s chi-squared test and logistic regression models. The size of inequality between the hypothetically wealthiest and poorest participants, for illness burden, diagnosis and treatment, was estimated using slope indices of wealth inequality.

Results

Achievement of indicators for cardiovascular disease was 82.7% [95% confidence interval (CI) 79.9% to 85.5%] in 2004–5 and 84.2% (95% CI 82.1% to 86.2%) in 2010–11, for depression 63.3% (95% CI 57.6% to 69.0%) and 59.8% (95% CI 52.4% to 64.3%), for diabetes 76.0% (95% CI 74.1% to 77.8%) and 76.5% (95% CI 74.8% to 78.1%), and for osteoarthritis 31.2% (95% CI 28.5% to 33.8%) and 35.6% (95% CI 34.2% to 37.1%). Achievement of the diabetes care bundle was 67.8% (95% CI 64.5% to 70.9%) in 2010–11. Variations in quality by participant characteristics were generally small. Diabetes indicator achievement was worse in participants with cognitive impairment [odds ratio (OR) 0.5, 95% CI 0.4 to 0.7] and better in those living alone (OR 1.7, 95% CI 1.3 to 2.0). Hypertension care was better for those aged over 74 years (vs. 50–64 years) (OR 3.2, 95% CI 2.0 to 5.3). Osteoarthritis care was better for those with severe (vs. mild) pain (OR 1.8, 95% CI 1.4 to 2.2), limiting illness (OR 1.8, 95% CI 1.5 to 2.1), and obesity (OR 1.6, 95% CI 1.2 to 2.0). Previous non-achievement of the diabetes care bundle was the biggest predictor of non-achievement 2 years later (OR 3.3, 95% CI 2.2 to 4.7). Poorer participants were always more likely than wealthier participants to have illness burden (statistically significant OR 3.9 to 16.0), but not always more likely to be diagnosed or receive treatment (0.2 to 5.3).

Conclusions

Shortfalls in quality of care for these four conditions have persisted over 6 years, with only half of the level of indicated health care achieved for osteoarthritis, compared with the other three conditions. Quality for osteoarthritis improved slightly over time but remains poor. The relatively high prevalence of specific illness burden in poorer participants was not matched by an equally high prevalence of diagnosis or treatment, suggesting that barriers to equity may exist at the stage at diagnosis. Further research is needed into the association between quality and health system characteristics at the level of clinicians, general practices or hospitals, and regions. Linkage to routinely collected data could provide information on health service characteristics at the individual patient level.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Quality indicators for the primary care of osteoarthritis: a systematic review

OBJECTIVE

To identify valid and feasible quality indicators for the primary care of osteoarthritis (OA).

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

Electronic reference databases (MEDLINE, EMBASE, CINAHL, HMIC, PsychINFO), quality indicator repositories, subject experts.

ELIGIBILITY CRITERIA

Eligible articles referred to adults with OA, focused on development or implementation of quality indicators, and relevant to UK primary care. An English language restriction was used. The date range for the search was January 2000 to August 2013. The majority of OA management guidance has been published within this time frame.

DATA EXTRACTION

Relevant studies were quality assessed using previous quality indicator methodology. Two reviewers independently extracted data. Articles were assessed through the Outcome Measures in Rheumatology filter; indicators were mapped to management guidance for OA in adults. A narrative synthesis was used to combine the indicators within themes.

RESULTS

10,853 articles were identified from the search; 32 were included in the review. Fifteen indicators were considered valid and feasible for implementation in primary care; these related to assessment non-pharmacological and pharmacological management. Another 10 indicators were considered less feasible, in various aspects of assessment and management. A small number of recommendations had no published corresponding quality indicator, such as use of topical non-steroidal anti-inflammatory drugs. No negative ('do not do') indicators were identified.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

There are well-developed, feasible indicators of quality of care for OA which could be implemented in primary care. Their use would assist the audit and quality improvement for this common and frequently disabling condition.

Quality of care for hip and knee osteoarthritis at family medicine clinics: lessons from Mexico

OBJECTIVE

(i) To develop quality-of-care indicators suitable for evaluation of care for knee and hip osteoarthritis (KHOA) at the primary care level using data from the electronic health records (EHRs) and (ii) to evaluate the quality of care that patients with KHOA receive at family medicine clinics (FMCs).

DESIGN

(i) Development of indicators following the RAND-UCLA method. (ii) A cross-sectional analysis of quality-of-care provided for patients with osteoarthritis.

SETTING

Four FMCs in Mexico City.

PARTICIPANTS

Knee and hip osteoarthritis patients, older than 19 years.

SOURCE OF THE INFORMATION

2009 EHR data.

MAIN OUTCOME MEASURES

Quality of care was evaluated using six indicators developed in the first stage of this study.

RESULTS

The quality of care evaluation identified that 26.1% of patients were advised in regard to physical exercise, and weight loss was encouraged in 19.7%. Only 5% of patients received acetaminophen as an initial oral analgesic; 54% of patients at risk for gastrointestinal complications received gastroprotective medicines. On average, the percentage of recommended care received was lower for patients who attended only one visit with family physician (17.6%) and higher for those with >3 visits (41.9%).

CONCLUSION

The quality of osteoarthritis care at FMCs in Mexico is suboptimal relative to the standards of care and requires continuous evaluation and implementation of improvement strategies.

Patient characteristics predicting failure to receive indicated care for type 2 diabetes

AIMS

To determine which patient characteristics were associated with failure to receive indicated care for diabetes over time.

METHODS

English Longitudinal Study of Ageing participants aged 50 or older with diabetes reported receipt of care described by four diabetes quality indicators (QIs) in 2008-9 and 2010-11. Annual checks for glycated haemoglobin (HbA1c), proteinuria and foot examination were assessed as a care bundle (n=907). A further QI (n=759) assessed whether participants with cardiac risk factors were offered ACE inhibitors or angiotensin II receptor blockers (ARBs). Logistic regression modelled associations between failure to receive indicated care in 2010-11 and participants' socio-demographic, lifestyle and health characteristics, diabetes self-management knowledge, health literacy, and previous QI achievement in 2008-9.

RESULTS

A third of participants (2008-9=32.8%; 2010-11=32.2%) did not receive all annual checks in the care bundle. Nearly half of those eligible were not offered ACE inhibitors/ARBs (2008-9=44.6%; 2010-11=44.5%). Failure to receive a complete care bundle was associated with lower diabetes self-management knowledge (odds ratio (OR) 2.05), poorer cognitive performance (1.78), or having previously received incomplete care (3.32). Participants who were single (OR=2.16), had low health literacy (1.50) or had received incomplete care previously (6.94) were more likely to not be offered ACE inhibitors/ARBs. Increasing age (OR=0.76) or body mass index (OR=0.70) was associated with lower odds of failing to receive this aspect of care.

CONCLUSIONS

Quality improvement initiatives for diabetes might usefully target patients with previous receipt of incomplete care, poor knowledge of annual diabetes care processes, and poorer cognition and health literacy.

Self-reported quality of care for older adults from 2004 to 2011: a cohort study

BACKGROUND

little is known about changes in the quality of medical care for older adults over time.

OBJECTIVE

to assess changes in technical quality of care over 6 years, and associations with participants' characteristics.

DESIGN

a national cohort survey covering RAND Corporation-derived quality indicators (QIs) in face-to-face structured interviews in participants' households.

PARTICIPANTS

a total of 5,114 people aged 50 or more in four waves of the English Longitudinal Study of Ageing.

METHODS

the percentage achievement of 24 QIs in 10 general medical and geriatric clinical conditions was calculated for each time point, and associations with participants' characteristics were estimated using logistic regression.

RESULTS

participants were eligible for 21,220 QIs. QI achievement for geriatric conditions (cataract, falls, osteoarthritis and osteoporosis) was 41% [95% confidence interval (CI): 38-44] in 2004-05 and 38% (36-39) in 2010-11. Achievement for general medical conditions (depression, diabetes mellitus, hypertension, ischaemic heart disease, pain and cerebrovascular disease) improved from 75% (73-77) in 2004-05 to 80% (79-82) in 2010-11. Achievement ranged from 89% for cerebrovascular disease to 34% for osteoarthritis. Overall achievement was lower for participants who were men, wealthier, infrequent alcohol drinkers, not obese and living alone.

CONCLUSION

substantial system-level shortfalls in quality of care for geriatric conditions persisted over 6 years, with relatively small and inconsistent variations in quality by participants' characteristics. The relative lack of variation by participants' characteristics suggests that quality improvement interventions may be more effective when directed at healthcare delivery systems rather than individuals.

Quality indicators for palliative care: update of a systematic review

CONTEXT

In 2007, a systematic review revealed a number of quality indicators referring mostly to palliative care outcomes and processes. Psychosocial and spiritual aspects were scarcely represented. Most publications lacked a detailed description of the development process. With many initiatives and further developments expected, an update is needed.

OBJECTIVES

This update gives an overview of the published quality indicators for palliative care and identifies any new developments since 2007 regarding the number and type of indicators developed and the methodology applied.

METHODS

The same literature search as in the 2007 review was used to identify relevant publications up to October 2011. Publications describing development processes or characteristics of quality indicators for palliative care were selected by two reviewers independently.

RESULTS

The literature search resulted in 435 hits in addition to the 650 hits found in the previous review. Thirteen new publications were selected in addition to the 16 publications selected earlier, describing 17 sets of quality indicators containing 326 indicators. These cover all domains of palliative care as defined by the U.S. National Consensus Project. Most indicators refer to care processes or outcomes. The extent to which methodological characteristics are described varies widely.

CONCLUSION

Recent developments in measuring quality of palliative care using quality indicators are mainly quantitative in nature, with a substantial number of new indicators being found. However, the quality of the development process varies considerably between sets. More consistent and detailed methodological descriptions are needed for the further development of these indicators and improved quality measurement of palliative care.

[Transferability of patient safety indicators to the German hospital setting: results of a Delphi survey]

AIM

To assess the transferability of 14 evidence-based patient safety indicators (PSI) to the German hospital system.

METHODS

A two-staged modified multidisciplinary Delphi process was used, applying the scientific criteria of the QUALIFY instrument.

RESULTS

Eleven of the 14 PSI were judged to be transferable to and feasible in the German hospital setting.

CONCLUSIONS

The consented PSI are potentially suitable for German quality assurance measurement. Prior to implementation, further operationalisation and empirical validation is recommended.

Evaluating the quality of colorectal cancer care across the interface of healthcare sectors

Background

Colorectal cancer (CRC) has a high prevalence in western countries. Diagnosis and treatment of CRC is complex and requires multidisciplinary collaboration across the interface of health care sectors. In Germany, a new nationwide established program aims to provide quality information of healthcare delivery across different sectors. Within this context, this study describes the development of a set of quality indicators charting the whole pathway of CRC-care including data specifications that are necessary to operationalize these indicators before practice testing.

Methods

Indicators were developed following a systematic 10 step modified ‘RAND/UCLA Appropriateness Method’ which involved a multidisciplinary panel of thirteen participants. For each indicator in the final set, data specifications relating to sources of quality information, data collection procedures, analysis and feedback were described.

Results

The final indicator set included 52 indicators covering diagnostic procedures (11 indicators), therapeutic management (28 indicators) and follow-up (6 indicators). In addition, 7 indicators represented patient perspectives. Primary surgical tumor resection and pre-operative radiation (rectum carcinoma only) were perceived as most useful tracer procedures initiating quality data collection. To assess the quality of CRC care across sectors, various data sources were identified: medical records, administrative inpatient and outpatient data, sickness-funds billing code systems and patient survey.

Conclusion

In Germany, a set of 52 quality indicators, covering necessary aspects across the interfaces and pathways relevant to CRC-care has been developed. Combining different sectors and sources of health care in quality assessment is an innovative and challenging approach but reflects better the reality of the patient pathway and experience of CRC-care.

Evaluating quality of care for patients with type 2 diabetes using electronic health record information in Mexico

BACKGROUND

Several low and middle-income countries are implementing electronic health records (EHR). In the near future, EHRs could become an efficient tool to evaluate healthcare performance if appropriate indicators are developed. The aims of this study are: a) to develop quality of care indicators (QCIs) for type 2 diabetes (T2DM) in the Mexican Institute of Social Security (IMSS) health system; b) to determine the feasibility of constructing QCIs using the IMSS EHR data; and c) to evaluate the quality of care (QC) provided to IMSS patients with T2DM.

METHODS

We used a three-stage mixed methods approach: a) development of QCIs following the RAND-UCLA method; b) EHR data extraction and construction of indicators; c) QC evaluation using EHR data from 25,130 T2DM patients who received care in 2009.

RESULTS

We developed 18 QCIs, of which 14 were possible to construct using available EHR data. QCIs comprised both process of care and health outcomes. Several flaws in the EHR design and quality of data were identified. The indicators of process and outcomes of care suggested areas for improvement. For example, only 13.0% of patients were referred to an ophthalmologist; 3.9% received nutritional counseling; 63.2% of overweight/obese patients were prescribed metformin, and only 23% had HbA1c <7% (or plasma glucose≤130 mg/dl).

CONCLUSIONS

EHR data can be used to evaluate QC. The results identified both strengths and weaknesses in the electronic information system as well as in the process and outcomes of T2DM care at IMSS. This information can be used to guide targeted interventions to improve QC.

Studies pertaining to the ACOVE quality criteria: a systematic review

PURPOSE

To identify and uniformly describe studies employing the Assessing Care Of Vulnerable Elders (ACOVE) quality indicators within a comprehensive thematic model that reflects how the indicators were used.

DATA SOURCES

A systematic search of MEDLINE, EMBASE and CINAHL was conducted.

STUDY SELECTION

English-language studies meeting our criteria published prior to January 2010. Data extraction Included studies were analyzed and described by two independent researchers.

RESULTS OF DATA SYNTHESIS

A total of 41 articles met our selection criteria. Studies were classified into the themes 'Application of indicators' (32 studies) and '

ANALYSIS

and development of indicators' (13 studies). 'Application' studies included assessing quality of care, influencing behavior of health professionals and examining the association of quality of care with other factors. 'Analysis and development' included studies developing new indicator sets, and those adapting and validating the original quality indicators to new settings.

CONCLUSIONS

The indicators were used in a wide range of applications with two main foci: the assessment of quality of care for elderly patients, and investigating the feasibility of similar indicators and their adaptation to new settings. Very few of the studies published to date have addressed the goal of care improvement. We foresee an important role for application of indicators that proactively help health-care professionals to deliver the right care at the right time, for example by resorting to decision support systems.

Does quality of care for hypertension in primary care vary with postcode area deprivation? An observational study

Background

Hypertension is a common major risk factor for stroke and coronary heart disease. Little is known about how achievement of financially incentivised and non-incentivised indicators of quality of care varies with deprivation, or about the effect of financial incentives on health inequalities in hypertension. General practices in the UK have received financial incentives for high quality care since 2004. This study set out to assess the variations in achievement of incentivised and non-incentivised quality indicators for hypertension by patient area deprivation, before and after the introduction of financial incentives.

Methods

Achievement of 14 quality indicators for hypertension in 304 patient participants in 18 general practices in Norfolk, England was assessed one year before (2003) and one year after (2005) the introduction of financial incentives. Four indicators were incentivised and 10 were non-incentivised. Each participant's postcode was linked to an index of multiple deprivation score.

Results

The range of achievement of incentivised quality indicators was 65-94% in the least deprived third of participants, and 77-94% in the most deprived third in 2003 and 2005 combined. For non-incentivised indicators, the range was 7-85% in the least deprived and 24-93% in the most deprived third.

Achievement of incentivised quality indicators in 2003 and 2005 combined did not vary significantly by area deprivation. Achievement of three of 10 non-incentivised indicators was higher in participants from more deprived postcode areas: providing lifestyle advice (odds ratio 1.34, 95% confidence interval 1.00-1.79), assessment of peripheral vascular disease (1.54, 1.02-2.35) and electrocardiography (1.38, 1.04-1.82).

Conclusions

Participants from more deprived areas received at least the same, and sometimes better, quality of care than those from less deprived areas. Quality of care for hypertension in general practice may not follow the inequitable distribution seen with some other conditions.

Development of prescribing-safety indicators for GPs using the RAND Appropriateness Method

BACKGROUND

In the UK, a process of revalidation is being introduced to allow doctors to demonstrate that they meet current professional standards, are up-to-date, and fit to practise. Given the serious risks to patients from hazardous use of medicines it will be appropriate, as part of the revalidation process, to assess the safety of prescribing by GPs.

AIM

To identify a set of potential prescribing-safety indicators for the purposes of revalidation of individual GPs in the UK.

DESIGN AND SETTING

The RAND Appropriateness Method was used to identify, develop, and obtain agreement on the indicators in UK general practice.

METHOD

Twelve GPs from across the UK with a wide variety of characteristics assessed indicators for appropriateness of use in revalidation.

RESULTS

Forty-seven safety indicators were considered appropriate for assessing the prescribing safety of individual GPs for the purposes of revalidation (appropriateness was defined as an overall panel median score of ≥ 7 (on a 1-9 scale), with no more than three panel members rating the indicator outside the 3-point distribution around the median]. After removing indicators that were variations on the same theme, a final set of 34 indicators was obtained; these cover hazardous prescribing across a range of therapeutic areas, hazardous drug-drug combinations, prescribing with a history of allergy, and inadequate laboratory-test monitoring.

CONCLUSION

This study identified a set of 34 indicators that were considered, by a panel of 12 GPs, to be appropriate for use in assessing the safety of GP prescribing for the purposes of revalidation. Violation of any of the 34 indicators indicates a potential patient-safety problem.

Framework and indicator testing protocol for developing and piloting quality indicators for the UK quality and outcomes framework

BACKGROUND

Quality measures should be subjected to a testing protocol before being used in practice using key attributes such as acceptability, feasibility and reliability, as well as identifying issues derived from actual implementation and unintended consequences. We describe the methodologies and results of an indicator testing protocol (ITP) using data from proposed quality indicators for the United Kingdom Quality and Outcomes Framework (QOF).

METHODS

The indicator testing protocol involved a multi-step and methodological process: 1) The RAND/UCLA Appropriateness Method, to test clarity and necessity, 2) data extraction from patients' medical records, to test technical feasibility and reliability, 3) diaries, to test workload, 4) cost-effectiveness modelling, and 5) semi-structured interviews, to test acceptability, implementation issues and unintended consequences. Testing was conducted in a sample of representative family practices in England. These methods were combined into an overall recommendation for each tested indicator.

RESULTS

Using an indicator testing protocol as part of piloting was seen as a valuable way of testing potential indicators in 'real world' settings. Pilot 1 (October 2009-March 2010) involved thirteen indicators across six clinical domains and twelve indicators passed the indicator testing protocol. However, the indicator testing protocol identified a number of implementation issues and unintended consequences that can be rectified or removed prior to national roll out. A palliative care indicator is used as an exemplar of the value of piloting using a multiple attribute indicator testing protocol - while technically feasible and reliable, it was unacceptable to practice staff and raised concerns about potentially causing actual patient harm.

CONCLUSIONS

This indicator testing protocol is one example of a protocol that may be useful in assessing potential quality indicators when adapted to specific country health care settings and may be of use to policy-makers and researchers worldwide to test the likely effect of implementing indicators prior to roll out. It builds on and codifies existing literature and other testing protocols to create a field testing methodology that can be used to produce country specific quality indicators for pay-for-performance or quality improvement schemes.

Do we need individualised prescribing quality assessment? The case of diabetes treatment

Prescribing quality assessment is increasingly used in improvement programs and pay-for-performance policies. Within the area of diabetes many quality indicators have been developed. Some measure prescribing on a general level, e.g. calculating percentages of patients prescribed any statins. Others are very specific, e.g. percentages of patients with an elevated LDL-cholesterol in whom lipid-lowering treatment is started unless contraindicated or return to control within 3 months. Although the latter seems more precise, we question how far one should go in developing such indicators. Using the example of diabetes treatment, we highlight the need, opportunities, and feasibility of assessing prescribing quality in the context of individualised treatment. We conclude that it is not realistic to develop indicators that take all possible aspects of therapy non-response, intolerance and patient preferences into account. We do recommend further development of indicators that better address subpopulations in need of adjusted treatment, such as elderly or patients with comorbidity.

Quality indicators for in-hospital pharmaceutical care of Dutch elderly patients: development and validation of an ACOVE-based quality indicator set

BACKGROUND

In 2001, the ACOVE (Assessing Care Of Vulnerable Elders) quality indicators (QIs) were developed in the US to measure the quality of care of vulnerable elderly patients. However, the ACOVE QI set was developed mainly to assess the overall quality of care of community-dwelling vulnerable elders (as opposed to hospitalized elderly). Therefore, they need to be adapted when used in a non-US hospital setting. In addition, the ACOVE QIs depend on patient and caretaker interviews to assess the quality of care.

OBJECTIVE

The aim of this study was to develop and validate a set of explicitly phrased QIs to measure (without the need for interviews) the quality of pharmaceutical care of elderly hospitalized patients in the Netherlands.

STUDY DESIGN

The QI set was developed based on the ACOVE QIs, Dutch national guidelines, evidence from the literature and expert opinion. The QI set focused on in-hospital pharmaceutical care and was evaluated in terms of whether the QIs were able to assess the quality of care using medical records and a hospital information system. In three review rounds, the QI set was adapted and judged on face and content validity. The feasibility of implementation of the QI set and inter-rater reliability were determined.

SETTING

The study was conducted between September 2007 and August 2008 in a tertiary 1002-bed university hospital. RESEARCH TEAM: Two pharmacists were responsible for the selection and adaptation of QIs. An internist-geriatrician, a physician with experience in quality assurance and internal medicine and a senior hospital pharmacist formed the expert panel responsible for reviewing the QIs.

MEASUREMENTS

Fleiss' κ values and the intraclass correlation coefficient were calculated for inter-rater reliability.

RESULTS

An 87-item QI set was accepted by the expert panel. Of this set, 49 QIs were based on ACOVE QIs and 38 QIs were newly added. The QI set demonstrated excellent inter-rater reliability and good feasibility.

CONCLUSIONS

We developed a valid and reliable set of QIs to efficiently assess the quality of the in-hospital pharmaceutical care provided to elderly Dutch patients.

Developing and implementing quality standards for memory services: The Memory Services National Accreditation Programme (MSNAP)

BACKGROUND

The lack of a consistent model means that the quality and characteristics of memory services can vary greatly. Quality standards have been successfully applied in a range of healthcare settings which allow services to implement improvements where necessary. A nationally agreed set of quality standards would help fulfil this need for UK memory services.

OBJECTIVES

To develop a set of standards for memory services to form the basis of a quality improvement initiative (Memory Services National Accreditation Programme [MSNAP]).

METHOD

The standards development process involved five main elements: Literature review/content analysis; key stakeholder workshop; email and postal consultation; consensus meeting; and final consultation/obtaining endorsements. Thirteen memory services in the northwest of England participated in the pilot programme, during which the draft set of quality standards were applied through the processes of self review and peer review.

RESULTS

The finalised version consisted of 148 quality standards categorised along the following domains: management; resources available to support assessment and diagnosis; assessment and diagnosis; and ongoing care management and follow-up. The pilot stage highlighted standards representing common areas where improvements had been made, such as ascertaining whether the patient wished to know their diagnosis, and areas where more attention was still required, for example surveying referrers, patients and carers about their experiences of the service.

CONCLUSION

It was possible to develop and field test nationally agreed quality standards for memory services. We believe that by implementing MSNAP it will be possible to improve the quality of UK memory services.

Quality indicators for multiple sclerosis

Determining whether persons with multiple sclerosis (MS) receive appropriate, comprehensive healthcare requires tools for measuring quality. The objective of this study was to develop quality indicators for the care of persons with MS. We used a modified version of the RAND/UCLA Appropriateness Method in a two-stage process to identify relevant MS care domains and to assess the validity of indicators within high-ranking care domains. Based on a literature review, interviews with persons with MS, and discussions with MS providers, 25 MS symptom domains and 14 general health domains of MS care were identified. A multidisciplinary panel of 15 stakeholders of MS care, including 4 persons with MS, rated these 39 domains in a two-round modified Delphi process. The research team performed an expanded literature review for 26 highly ranked domains to draft 86 MS care indicators. Through another two-round modified Delphi process, a second panel of 18 stakeholders rated these indicators using a nine-point response scale. Indicators with a median rating in the highest tertile were considered valid. Among the most highly rated MS care domains were appropriateness and timeliness of the diagnostic work-up, bladder dysfunction, cognition dysfunction, depression, disease-modifying agent usage, fatigue, integration of care, and spasticity. Of the 86 preliminary indicators, 76 were rated highly enough to meet predetermined thresholds for validity. Following a widely accepted methodology, we developed a comprehensive set of quality indicators for MS care that can be used to assess quality of care and guide the design of interventions to improve care among persons with MS.

A systematic literature review: prescribing indicators related to type 2 diabetes mellitus and cardiovascular risk management

PURPOSE

Valid prescribing indicators (PI) are needed for reliable assessment of prescribing quality. The purpose of this study is to describe the validity of existing PI for type 2 diabetes mellitus and cardiovascular risk management.

METHODS

We conducted a systematic literature search for studies describing the development and assessment of relevant PIs between January 1990 and January 2009. We grouped identified PI as drug- or disease-oriented, and according to the aspects of prescribing addressed and the additional clinical information included. We reviewed the clinimetric characteristics of the different types of PI.

RESULTS

We identified 59 documents describing the clinimetrics of 16 types of PI covering relevant prescribing aspects, including first-choice treatment, safety issues, dosing, costs, sufficient and timely treatment. We identified three types of drug-oriented, and five types of disease-oriented PI with proven face and content validity as well as operational feasibility in different settings. PI focusing on treatment modifications were the only indicators that showed concurrent validity. Several solutions were proposed for dealing with case-mix and sample size problems, but their actual effect on PI scores was insufficiently assessed. Predictive validity of individual PI is not yet known.

CONCLUSION

We identified a range of existing PI that are valid for internal quality assessment as they are evidence-based, accepted by professionals, and reliable. For external use, problems of patient case-mix and sample size per PI should be better addressed. Further research is needed for selecting indicators that predict clinical outcomes.

Methods to identify the target population: implications for prescribing quality indicators

Background

Information on prescribing quality is increasingly used by policy makers, insurance companies and health care providers. For reliable assessment of prescribing quality it is important to correctly identify the patients eligible for recommended treatment. Often either diagnostic codes or clinical measurements are used to identify such patients. We compared these two approaches regarding the outcome of the prescribing quality assessment and their ability to identify treated and undertreated patients.

Methods

The approaches were compared using electronic health records for 3214 diabetes patients from 70 general practitioners. We selected three existing prescribing quality indicators (PQI) assessing different aspects of treatment in patients with hypertension or who were overweight. We compared population level prescribing quality scores and proportions of identified patients using definitions of hypertension or being overweight based on diagnostic codes, clinical measurements or both.

Results

The prescribing quality score for prescribing any antihypertensive treatment was 93% (95% confidence interval 90-95%) using the diagnostic code-based approach, and 81% (78-83%) using the measurement-based approach. Patients receiving antihypertensive treatment had a better registration of their diagnosis compared to hypertensive patients in whom such treatment was not initiated. Scores on the other two PQI were similar for the different approaches, ranging from 64 to 66%. For all PQI, the clinical measurement -based approach identified higher proportions of both well treated and undertreated patients compared to the diagnostic code -based approach.

Conclusions

The use of clinical measurements is recommended when PQI are used to identify undertreated patients. Using diagnostic codes or clinical measurement values has little impact on the outcomes of proportion-based PQI when both numerator and denominator are equally affected. In situations when a diagnosis is better registered for treated than untreated patients, as we observed for hypertension, the diagnostic code-based approach results in overestimation of provided treatment.

Patients' attitudes of dementia screening across the Atlantic

BACKGROUND

Dementia is a common and growing global public health problem. It leads to a high burden of suffering for society with an annual cost of $100 billion in the US and $10 billion in the UK. New strategies for both treatment and prevention of dementia are currently being developed. Implementation of these strategies will depend on the presence of a viable community or primary care based dementia screening and diagnosis program and patient acceptance of such a program.

OBJECTIVE

To compare the acceptance, perceived harms and perceived benefits of dementia screening among older adults receiving their care in two different primary health care systems in two countries.

DESIGN

A Cross-sectional study.

SETTING

Primary care clinics in Indianapolis, USA and Kent, UK.

PARTICIPANTS

A convenience sample of 245 older adults (Indianapolis, n = 125; Kent, n = 120).

OUTCOMES

Acceptance of dementia screening and its perceived harms and benefits as determined by a 52-item questionnaire (PRISM-PC questionnaire).

RESULTS

Four of the five domains were significantly different across the two samples. The UK sample had significantly higher dementia screening acceptance scores (p < 0.05); higher perceived stigma scores (p < 0.05); higher perceived loss of independence scores (p < 0.01); and higher perceived suffering scores (p < 0.01) than the US sample. Both groups perceived dementia screening as beneficial (p = 0.218). After controlling for prior experience with dementia, acceptance and stigma were marginalized.

CONCLUSIONS

Older adults attending primary care clinics across the Atlantic value dementia screening but have significant concerns about dementia screening although these concerns differed between the two countries. Low acceptance rates and high rates of perceived harms might be a significant barrier for the introduction of treatment or preventive methods for dementia in the future.

Recorded quality of care for depression in general practice: an observational study

BACKGROUND

Depression is a leading cause of disease and disability internationally, and is responsible for many primary care consultations. Little is known about the quality of primary care for depression in the UK.

AIM

To determine the prevalence of good-quality primary care for depression, and to analyse variations in quality by patient and practice characteristics.

DESIGN OF STUDY

Retrospective observational study.

SETTING

Eighteen general practices in England.

METHOD

Medical records were examined for 279 patients. The percentage of eligible participants diagnosed with depression who received the care specified by each of six quality indicators in 2002 and 2004 was assessed. Associations between quality achievement and age, sex, patient deprivation score, timepoint, and practice size were estimated using logistic regression.

RESULTS

There was very wide variation in achievement of different indicators (range 1-97%). Achievement was higher for indicators referring to treatment and follow-up than for indicators referring to history taking. Achievement of quality indicators was low overall (37%). Quality did not vary significantly by patient or practice characteristics.

CONCLUSION

There is substantial scope for improvement in the quality of primary care for depression, if the highest achievement rates could be matched for all indicators. Given the lack of variation by practice characteristics, system-level and educational interventions may be the best ways to improve quality. The equitable distribution of quality by patient deprivation score is an important achievement that may be challenging to maintain as quality improves.

Recorded quality of primary care for osteoarthritis: an observational study

BACKGROUND

Osteoarthritis is the most common chronic disease in the UK, with greater prevalence in women, older people, and those with poorer socioeconomic status. Effective treatments are available, yet little is known about the quality of primary care for this disabling condition.

AIM

To measure the recorded quality of primary care for osteoarthritis, and assess variations by patient and/or practice characteristics.

DESIGN OF STUDY

Retrospective observational study.

SETTING

Eighteen general practices in England.

METHOD

Records of 320/393 randomly selected patients with osteoarthritis (response rate 81%) were reviewed. High-quality health care was specified by nine quality indicators. Logistic regression modelling assessed variations in quality by age, sex, deprivation, severity, time since diagnosis, and practice size.

RESULTS

There was substantial variation in the recorded achievement of individual indicators (range 5% to 90%). The percentage of eligible patients whose records show that they received care in the form of information provision ranged from 17% to 30%. For regular assessment indicators the range was 27% to 43%, and for treatment indicators the range was 5% to 90%. Recorded achievement of quality indicators was higher in those with more severe osteoarthritis (odds ratio [OR] 1.38, 95% CI=1.13 to 1.69) and in older patients (OR 1.14, 95% CI=1.02 to 1.28). There were no significant variations by deprivation score.

CONCLUSION

This study has demonstrated the feasibility of using existing robust quality indicators to measure the quality of primary care for osteoarthritis, and has found considerable scope for improvement in the recording of high-quality care. The lack of variation between practices suggests that system-level initiatives may be needed to achieve improvement. One challenge will be to improve care for all, without losing the equitable distribution of care identified.

Development of evidence-based performance measures for bipolar disorder: overview of methodology

The STAndards for BipoLar Excellence (STABLE) Project was organized in 2005 to improve quality of care for bipolar disorder by developing and testing a set of evidence-based clinical process performance measures related to identifying, assessing, managing, and coordinating care for bipolar disorder. This article first briefly reviews the literature on the science of performance measurement and the use of performance measures as a tool for quality improvement. It then presents a detailed overview of the methodology used to develop the STABLE performance measures. Steps included choosing a clinical area to be measured, selecting key aspects of care for measurement, designing specifications for the measures, developing a data collection strategy, testing the scientific strength (validity, reliability, feasibility) of the measures, and obtaining, analyzing, and reporting conformance findings for the measures. Five of the STABLE measures have been endorsed by the National Quality Forum as part of their Standardizing Ambulatory Care Performance Measures project: screening for bipolar mania/hypomania in patients diagnosed with depression, assessment for risk of suicide, assessment for substance use, screening for hyperglycemia when atypical antipsychotic agents are prescribed, and monitoring change in level of functioning in response to treatment. Additional STABLE measures will be submitted to appropriate national organizations in the future. It is hoped that these measures will be used in quality assessment activities and that the results will inform efforts to improve care for individuals with bipolar disorder.

Selecting process quality indicators for the integrated care of vulnerable older adults affected by cognitive impairment or dementia

Background

This study aimed at evaluating face and content validity, feasibility and reliability of process quality indicators developed previously in the United States or other countries. The indicators can be used to evaluate care and services for vulnerable older adults affected by cognitive impairment or dementia within an integrated service system in Quebec, Canada.

Methods

A total of 33 clinical experts from three major urban centres in Quebec formed a panel representing two medical specialties (family medicine, geriatrics) and seven health or social services specialties (nursing, occupational therapy, psychology, neuropsychology, pharmacy, nutrition, social work), from primary or secondary levels of care, including long-term care. A modified version of the RAND^®/University of California at Los Angeles (UCLA) appropriateness method, a two-round Delphi panel, was used to assess face and content validity of process quality indicators. The appropriateness of indicators was evaluated according to a) agreement of the panel with three criteria, defined as a median rating of 7–9 on a nine-point rating scale, and b) agreement among panellists, judged by the statistical measure of the interpercentile range adjusted for symmetry. Feasibility of quality assessment and reliability of appropriate indicators were then evaluated within a pilot study on 29 patients affected by cognitive impairment or dementia. For measurable indicators the inter-observer reliability was calculated with the Kappa statistic.

Results

Initially, 82 indicators for care of vulnerable older adults with cognitive impairment or dementia were submitted to the panellists. Of those, 72 (88%) were accepted after two rounds. Among 29 patients for whom medical files of the preceding two years were evaluated, 63 (88%) of these indicators were considered applicable at least once, for at least one patient. Only 22 indicators were considered applicable at least once for ten or more out of 29 patients. Four indicators could be measured with the help of a validated questionnaire on patient satisfaction. Inter-observer reliability was moderate (Kappa = 0.57).

Conclusion

A multidisciplinary panel of experts judged a large majority of the initial indicators valid for use in integrated care systems for vulnerable older adults in Quebec, Canada. Most of these indicators can be measured using patient files or patient or caregiver interviews and reliability of assessment from patient-files is moderate.

[Validation of indicators of the management of cognitive impairment in geriatric assessment units]

OBJECTIVE

To analyze and adapt a set of quality indicators for assessment and management of patients with cognitive disorders, which are seen very frequently in geriatric assessment units in Quebec.

DESIGN

Modified Delphi technique.

SETTING

Province of Quebec.

PARTICIPANTS

Seven clinicians from 3 different medical faculties in Quebec were selected for their expertise in dementia and geriatric care.

METHOD

From among the indicators developed in 2001 using the RAND method, 22 items selected for their relevance to evaluation and management of cognitive disorders were adapted to clinical practice in the Quebec hospital system. These indicators, along with evidence from the literature, were submitted by mail to a panel of experts. The experts were asked to rate, on a scale of 1 to 9, their level of agreement with the indicators in terms of their validity and quality and the need for them to be recorded in patients' medical charts. For an indicator to be retained, it had to be accepted according to its median value, to be rated in the upper third of the scale, and to be approved by the panelists. Indicators not accepted at first were modified according to experts' comments and then re-submitted to the same panel for a second round.

RESULTS

Of 22 indicators submitted in the first round, 21 were validated. They covered assessment, investigation, evaluation, treatment, and follow-up. The indicator found questionable was modified and then accepted during the second round.

CONCLUSION

This study identified 22 indicators relevant to assessment and management of patients with cognitive disorders in geriatric assessment units. These indicators will serve as a basis for evaluation of dementia in a larger study of the quality of care in all short-term geriatric assessment units in Quebec.

Appropriate prescribing in elderly people: how well can it be measured and optimised?

Prescription of medicines is a fundamental component of the care of elderly people, and optimisation of drug prescribing for this group of patients has become an important public-health issue worldwide. Several characteristics of ageing and geriatric medicine affect medication prescribing for elderly people and render the selection of appropriate pharmacotherapy a challenging and complex process. In the first paper in this series we aim to define and categorise appropriate prescribing in elderly people, critically review the instruments that are available to measure it and discuss their predictive validity, critically review recent randomised controlled intervention studies that assessed the effect of optimisation strategies on the appropriateness of prescribing in elderly people, and suggest directions for future research and practice.

Quality of clinical primary care and targeted incentive payments: an observational study

BACKGROUND

Payments for recorded evidence of quality of clinical care in UK general practices were introduced in 2004.

AIM

To examine the relationship between changes in recorded quality of care for four common chronic conditions from, 2003 to 2005, and the payment of incentives.

DESIGN OF STUDY

Retrospective observational study comparing incentivised and non-incentivised indicators of quality of care.

SETTING

Eighteen general practices in England.

METHOD

Medical records were examined for 1156 patients. The percentage of eligible quality indicators achieved for each patient was assessed in 2003 and 2005. Twenty-one quality indicators referred to asthma and hypertension: six subject to and 15 not subject to incentive payments. Another 15 indicators referred to depression and osteoarthritis which were not subject to incentive payments.

RESULTS

A significant increase occurred for the six indicators linked to incentive payments: from 75% achieved in 2003 to 91% in 2005 (change = 16%, 95% confidence interval [CI] = 10 to 22%, P <0.01). A significant increase also occurred for 15 other indicators linked to 'incentivised conditions'; 53 to 64% (change = 11%, 95% CI = 6 to 15%, P <0.01). The 'non-incentivised conditions' started at a lower achievement level, and did not increase significantly: 35 to 36% (change = 2%, 95% CI = -1 to 4%, P = 0.19).

CONCLUSION

The introduction of financial incentives was associated with substantial apparent quality improvement for incentivised conditions. For non-incentivised conditions, quality did not appear to improve. Patients with non-incentivised conditions may be at risk of poorer quality care.

Impact of patient-reported outcome measures on routine practice: a structured review

RATIONALE, AIMS AND OBJECTIVES

Regular use of patient-reported outcome measures (PROMs) by health care providers in their routine practice may help to improve the quality of care, but more evidence is needed before routine use of PROMs can be recommended. A structured review was undertaken to examine whether and how regular use of PROMs might improve routine practice.

METHODS

A systematic search of Medline accessed through Webspirs Silverplatter was undertaken for the years 1976-2004. Controlled trials in English evaluating the impact of clinical use of PROMs on routine practice were included. Data regarding study design, characteristics of PROMs feedback, patient populations and study results were extracted by three reviewers.

RESULTS

Feedback of PROMs results to health care providers appears to have a substantial impact on some processes of care, particularly on diagnosis of mental health conditions. However, the impact on patient health status is less consistent. Most of the published studies evaluated PROMs as a one-off screening technology and measured only provider behaviours and patient health outcomes.

CONCLUSIONS

The pattern of results suggests a general lack of clarity in the field, especially regarding appropriate goals for PROMs and the mechanisms by which they might achieve them. To fully evaluate their role in routine practice, studies need to use PROMs that capture issues of importance to patients and to measure impacts relating to the patient-provider relationship and patient contributions to their well-being. Until studies evaluate PROMs as a means facilitate patient-centred care, their full potential in clinical practice will remain unknown.

Quality of Care

A tool was developed, using the nominal group and Delphi techniques, to explore healthcare staff's perceptions of the quality of hospital care provided in the United Kingdom compared with a tool from the United States. Similarities were identified in many core areas; however, there were several differences between the UK and US tools. This article identifies the process and findings and discusses possible reasons for similarities and differences between the tools.