Profiles of quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes among patients with substance-related disorders

Application of Donabedian Three-Dimensional Model in Outpatient Care Quality: A Scoping Review

Background: The mobility of outpatients, frequent treatment sessions, and varying illness severity challenge nursing care and hinder quality improvement efforts. The Donabedian model effectively evaluates nursing quality and is widely used in operating rooms, intensive care units and oncology wards. However, its application in outpatient nursing remains unclear. Aim: To overview the Donabedian model's application in outpatient care quality. Methods: A scoping review was conducted using the Arksey and O'Malley framework, adhering to PRISMA-ScR. Searches for eligible papers were performed on PubMed, OVID, Web of Science, Embase, CNKI, CBM, and Wan Fang in June 2024. Data were analyzed narratively using an inductive approach, with visual mapping done through ArcGIS and Origin. Results: A total of 18 studies were included in the review. Literature review, Delphi and semistructured interview were widely used in the mixed method studies. The primary settings involved dental clinics and health examination centers, followed by traditional Chinese medicine clinics and pediatric clinics. The studies spanned various regions: 2 in Canada, 3 in Germany, and 13 in China. Structural indicators evaluate outpatient care systems and resources, while process indicators emphasize specialty nursing practice, safety, infection control, and humanistic care. Satisfaction, adverse events, and quality care serve as key secondary indicators for outcome assessment. Conclusions: The research on outpatient care quality based on the Donabedian model is primarily mixed, with a need to expand interventional and qualitative studies. The structure-process-outcome quality indicators have varying focuses that require further verification and coordination. Structural indicators offer more policy and resource support, while process indicators differ across outpatient specialties, leading to heterogeneous specialist nursing practice metrics. Satisfaction and adverse events are crucial components in evaluating outpatient nursing quality outcomes. Implications for Nursing Management: The application of the Donabedian model offers care managers practical ideas and references for outpatient care quality improvement.

Classes of outpatient quality of care among individuals with substance-related disorders, based on a survey and health insurance registry

OBJECTIVES

Improving quality of care for individuals with substance-related disorders (SRD) should be a priority considering SRD are associated with high morbidity. This study aimed to identify classes of individuals with SRD based on their clinical characteristics and the quality of outpatient care they received, and to verify whether better quality of care was associated with other respondent characteristics and more favorable subsequent outcomes.

METHODS

Data came from the 2013-14 and 2015-16 Canadian Community Health Survey (N = 42,099), merged with administrative data from Quebec's health insurance registry. Investigating a cohort of 1473 individuals with SRD, we conducted Latent class analysis based on the respondents' diagnoses and outpatient quality of care indicators such as access, diversity, continuity and regularity of care received in the 12 months preceding interview. Chi-Square, Fisher's exact tests or t-tests, and logistic regression associate classes with sociodemographic and health behavior (e.g., suicidal behaviors) correlates, and outcomes (repeated emergency department use, hospitalization, quality of life) over the three months following interview, respectively.

RESULTS

The study identified four classes: (1) Individuals with polysubstance-related disorders and other health disorders, receiving high diversity and moderate regularity of care (6 % of sample); (2) Individuals with alcohol-related disorders, receiving low quality of care (41 %); (3) Individuals with drug-related disorders, receiving high overall quality of care (9 %); and (4) Individuals with alcohol-related disorders, receiving high continuity of family doctor care (44 %). Classes 2 and 4 showed better social conditions (e.g., higher education), health behaviors, and subsequent outcomes than Classes 1 and 3, despite receiving lower quality of care - especially mental healthcare.

CONCLUSION

Study outcomes related more to health and social conditions than to the quality of outpatient care received, especially as outpatient care alone might not meet needs of Classes 1 and 3 individuals having important health and social issues, unmet care needs and worse outcomes. Results suggest that interventions like assertive community treatment or intensive case management with integrated SRD-mental health disorders treatment could better respond to the needs of Classes 1 and 3. Overall, enhanced care, including peer support, might benefit all individuals with SRD.

Profiles of quality of outpatient care among individuals with mental disorders based on survey and administrative data

RATIONALE

Though it is crucial to contribute to patient recovery through access, diversity, continuity and regularity of outpatient care, still today most of these are deemed nonoptimal. Identifying patient profiles based on outpatient service use and quality of care indicators might help formulate more personalized interventions and reduce adverse outcomes.

AIMS AND OBJECTIVES

This study aimed to identify profiles of individuals with mental disorders (MDs) patterned after their outpatient care use and quality of care received, and to link those profiles to individual characteristics and subsequent outcomes.

METHODS

A cohort of 5669 individuals with MDs was considered based on data from the 2013-2014 and 2015-2016 Canadian Community Health Survey, which were linked to administrative data from the Quebec health insurance registry. Latent class analysis generated profiles based on service use over the 12 months preceding each respondent's interview, and comparative analyses were used to associate profiles with sociodemographic and clinical characteristics, and health outcomes over the three following months.

RESULTS

Four profiles were identified. Profile 1 (P-1) was labelled 'Low service use'; P-2 'Moderate general practitioner (GP) care and continuity and regularity of care'; P-3 'High GP care, continuity and regularity of care, and low psychiatrist care'; and P-4 'High psychiatrist care and regularity of care, and low GP care'. Profiles 3 and 4 (~50% of the cohort) were provided with better care, but showed worse outcomes, mainly acute care use due to more complex conditions and unmet needs. Profiles 1 and 2 had better outcomes as they showed fewer risk factors such as being younger and having better social conditions.

CONCLUSION

Intensity, diversity and regularity of care were higher in profiles with more complex MDs, chronic physical illnesses, and worse perceived health conditions. Adapting specific interventions for each profile, such as assertive community treatment or intensive case management for Profile 4, is recommended.

Profiles of Emergency Department Users with Psychiatric Disorders Related to Barriers to Outpatient Care

Emergency department (ED) overcrowding is a growing problem worldwide. High ED users have been historically targeted to reduce ED overcrowding and associated high costs. Patients with psychiatric disorders, including substance-related disorders (SRDs), are among the largest contributors to high ED use. Since EDs are meant for urgent cases, they are not an appropriate setting for treating recurrent patients or replacing outpatient care. Identifying ED user profiles in terms of perceived barriers to care, service use, and sociodemographic and clinical characteristics is crucial to reduce ED use and unmet needs. Data were extracted from medical records and a survey was conducted among 299 ED patients from 2021 to 2022 in large Quebec networks. Cluster algorithms and comparison tests identified three profiles. Profile 1 had the most patients without barriers to care, with case managers, and received the best primary care. Profile 2 reported moderate barriers to care and low primary care use, best quality of life, and more serious psychiatric disorders. Profile 3 had the most barriers to care, high ED users, and lower service satisfaction and perceived mental/health conditions. Our findings and recommendations inform decision-makers on evidence-based strategies to address the unmet needs of these vulnerable populations.