Retrospective analysis of adherence to HIV treatment and healthcare utilization in a commercially insured population

AIMS

Single-tablet regimens (STRs) can improve antiretroviral therapy (ART) adherence; however, the relationship between long-term adherence and patient healthcare resource utilization (HRU) is unclear. The objective of this study was to assess long-term ART adherence among people living with HIV (PLHIV) using STRs and multi-tablet regimens (MTRs) and compare HRU over time by adherence.

MATERIALS AND METHODS

This retrospective study analyzed medical and pharmacy claims (Optum Clinformatics Data Mart Database). Included PLHIV were aged ≥18 years, had ≥1 medical claim with an HIV diagnosis, and had pharmacy claims for a complete STR or MTR. Adherence was analyzed as the proportion of days covered (PDC), stratified as ≥95%, very high; 90-95%, high; 80-90%, moderate; <80%, low. Cumulative all-cause and HIV-related HRU were calculated across 4 years. Among PLHIV with ≥4-year follow-up, HRU was assessed by adherence.

RESULTS

Among 15,153 PLHIV included, 63% achieved PDC ≥90% during Year 1. Among the subgroup of PLHIV with ≥4-year follow-up (N = 3,818), the proportion maintaining PDC ≥90% fell from 67% in Year 1 to 54% by Year 4. The difference from Years 1 to 4 in the proportion of PLHIV with PDC ≥90% was 13% and 17% in the STR and MTR groups, respectively. Cumulative HRU across the 4-year follow-up was higher in PLHIV with low vs high adherence (27% with low adherence had ≥1 emergency room visit vs 17% for very high, p < .0001; 15% with low adherence had ≥1 inpatient stay vs 7% for very high, p < .0001).

CONCLUSIONS

ART adherence showed room for improvement, particularly over the long term. PLHIV receiving STRs exhibited higher adherence vs those receiving MTRs; this difference increased over time. The proportion of PLHIV with higher HRU was significantly higher among those with lower adherence and became greater over time. Interventions and alternative therapies to improve adherence among PLHIV should be explored.

Clinical characteristics and health-related quality of life of patients with recurrent pericarditis in the United States: findings from a patient survey

Background

Recurrent pericarditis (RP) is characterized by recurrence of symptoms of pericarditis after the original episode has ceased for 4–6 weeks. Though RP is associated with significant morbidity, there is little information regarding the impact of RP on patients' health-related quality of life (HRQOL).

Purpose

To describe clinical characteristics of and HRQOL burden in patients with RP in the United States.

Methods

An IRB-approved web-based survey was conducted among patients ≥18 years old with RP who experienced ≥1 recurrence during the prior 12 months. Respondents were recruited from the RHAPSODY clinical trial recruitment database. Patients who met the survey inclusion criteria were asked to provide information on their demographic/clinical characteristics, treatments for RP, and to complete an 11-point pericarditis pain numerical rating scale, the Patient Global Impression of Pericarditis Severity scale, the Patient-Reported Outcomes Measurement Information System® (PROMIS®) Global Health and Sleep Disturbance scales, and questions about the impact of RP on daily life.

Results

Of the 83 respondents with RP included in the study, 25% responded while experiencing a recurrence. Most respondents were Caucasian (76%) and 55% were female, with mean (standard deviation [SD]) age of 49.3 (13.7) years. Patients frequently reported history of hypertension (39%), anxiety (37%), and depression (34%); 16% and 15% of patients reported having pre-existing autoimmune disease and diabetes, respectively. About half (49%) of patients reported ≥3 recurrences in the prior year, and 40% visited the ER and 25% were hospitalized for their most recent recurrence. Among patients not actively experiencing a recurrence, 37% reported that the duration of their prior episode lasted ≥8 days. Medications most frequently used for RP and pain in the prior year included non-steroidal anti-inflammatory drugs (82%), colchicine (63%), and corticosteroids (29%). Commonly reported symptoms included chest pain (93%), shortness of breath (66%), weakness/fatigue (64%), and heart palpitations (52%). Two-thirds of patients rated the severity of symptoms during the most recent RP episode as moderately severe to very severe, and 48% reported “quite a bit” or “very much” fear of pericarditis recurrence. The mean (SD) value for worst pericarditis pain (0–10 scale) during the recent recurrence was 6.1 (2.3), with 48% reporting severe pain (≥7 on the scale). Patients had substantially worse mean [SD] T scores for PROMIS physical health (37.6 [8.6]), mental health (42.8 [9.9]), and sleep disturbance (60.6 [8.3]) than the general population (50 [10]).

Conclusions

RP is a burden on the daily lives of patients, resulting in severe pain and impaired quality-of-life including poor physical and mental health, sleep disturbance, and fear of recurrence. This study demonstrates the unmet need for therapies that can rapidly resolve symptoms and prevent recurrences.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Kiniksa Pharmaceuticals Corp.

The associations between organizational culture, organizational structure and quality management in European hospitals

OBJECTIVE

To better understand associations between organizational culture (OC), organizational management structure (OS) and quality management in hospitals.

DESIGN

A multi-method, multi-level, cross-sectional observational study.

SETTING AND PARTICIPANTS

As part of the DUQuE project (Deepening our Understanding of Quality improvement in Europe), a random sample of 188 hospitals in 7 countries (France, Poland, Turkey, Portugal, Spain, Germany and Czech Republic) participated in a comprehensive questionnaire survey and a one-day on-site surveyor audit. Respondents for this study (n = 158) included professional quality managers and hospital trustees.

MAIN OUTCOME MEASURES

Extent of implementation of quality management systems, extent of compliance with existing management procedures and implementation of clinical quality activities.

RESULTS

Among participating hospitals, 33% had a clan culture as their dominant culture type, 26% an open and developmental culture type, 16% a hierarchical culture type and 25% a rational culture type. The culture type had no statistically significant association with the outcome measures. Some structural characteristics were associated with the development of quality management systems.

CONCLUSION

The type of OC was not associated with the development of quality management in hospitals. Other factors (not culture type) are associated with the development of quality management. An OS that uses fewer protocols is associated with a less developed quality management system, whereas an OS which supports innovation in care is associated with a more developed quality management system.

A checklist for patient safety rounds at the care pathway level

OBJECTIVE

To define a checklist that can be used to assess the performance of a department and evaluate the implementation of quality management (QM) activities across departments or pathways in acute care hospitals.

DESIGN

We developed and tested a checklist for the assessment of QM activities at department level in a cross-sectional study using on-site visits by trained external auditors.

SETTING AND PARTICIPANTS

A sample of 292 hospital departments of 74 acute care hospitals across seven European countries. In every hospital, four departments for the conditions: acute myocardial infarction (AMI), stroke, hip fracture and deliveries participated.

MAIN OUTCOME MEASURES

Four measures of QM activities were evaluated at care pathway level focusing on specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies and clinical review (CR).

RESULTS

Participating departments attained mean values on the various scales between 1.2 and 3.7. The theoretical range was 0-4. Three of the four QM measures are identical for the four conditions, whereas one scale (EBOP) has condition-specific items. Correlations showed that every factor was related, but also distinct, and added to the overall picture of QM at pathway level.

CONCLUSION

The newly developed checklist can be used across various types of departments and pathways in acute care hospitals like AMI, deliveries, stroke and hip fracture. The anticipated users of the checklist are internal (e.g. peers within the hospital and hospital executive board) and external auditors (e.g. healthcare inspectorate, professional or patient organizations).

Evidence-based organization and patient safety strategies in European hospitals

OBJECTIVE

To explore how European hospitals have implemented patient safety strategies (PSS) and evidence-based organization of care pathway (EBOP) recommendations and examine the extent to which implementation varies between countries and hospitals.

DESIGN

Mixed-method multilevel cross-sectional design in seven countries as part of the European Union-funded project 'Deepening our Understanding of Quality improvement in Europe' (DUQuE).

SETTING AND PARTICIPANTS

Seventy-four acute care hospitals with 292 departments managing acute myocardial infarction (AMI), hip fracture, stroke, and obstetric deliveries. Main outcome measure Five multi-item composite measures-one generic measure for PSS and four pathway-specific measures for EBOP.

RESULTS

Potassium chloride had only been removed from general medication stocks in 9.4-30.5% of different pathways wards and patients were adequately identified with wristband in 43.0-59.7%. Although 86.3% of areas treating AMI patients had immediate access to a specialist physician, only 56.0% had arrangements for patients to receive thrombolysis within 30 min of arrival at the hospital. A substantial amount of the total variance observed was due to between-hospital differences in the same country for PSS (65.9%). In EBOP, between-country differences play also an important role (10.1% in AMI to 57.1% in hip fracture).

CONCLUSIONS

There were substantial gaps between evidence and practice of PSS and EBOP in a sample of European hospitals and variations due to country differences are more important in EBOP than in PSS, but less important than within-country variations. Agencies supporting the implementation of PSS and EBOP should closely re-examine the effectiveness of their current strategies.

Involvement of patients or their representatives in quality management functions in EU hospitals: implementation and impact on patient-centred care strategies

OBJECTIVE

The objective of this study was to describe the involvement of patients or their representatives in quality management (QM) functions and to assess associations between levels of involvement and the implementation of patient-centred care strategies.

DESIGN

A cross-sectional, multilevel

STUDY DESIGN

that surveyed quality managers and department heads and data from an organizational audit.

SETTING

Randomly selected hospitals (n = 74) from seven European countries (The Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey).

PARTICIPANTS

Hospital quality managers (n = 74) and heads of clinical departments (n = 262) in charge of four patient pathways (acute myocardial infarction, stroke, hip fracture and deliveries) participated in the data collection between May 2011 and February 2012.

MAIN OUTCOME MEASURES

Four items reflecting essential patient-centred care strategies based on an on-site hospital visit: (1) formal survey seeking views of patients and carers, (2) written policies on patients' rights, (3) patient information literature including guidelines and (4) fact sheets for post-discharge care. The main predictors were patient involvement in QM at the (i) hospital level and (ii) pathway level.

RESULTS

Current levels of involving patients and their representatives in QM functions in European hospitals are low at hospital level (mean score 1.6 on a scale of 0 to 5, SD 0.7), but even lower at departmental level (mean 0.6, SD 0.7). We did not detect associations between levels of involving patients and their representatives in QM functions and the implementation of patient-centred care strategies; however, the smallest hospitals were more likely to have implemented patient-centred care strategies.

CONCLUSIONS

There is insufficient evidence that involving patients and their representatives in QM leads to establishing or implementing strategies and procedures that facilitate patient-centred care; however, lack of evidence should not be interpreted as evidence of no effect.

The use of on-site visits to assess compliance and implementation of quality management at hospital level

OBJECTIVE

Stakeholders of hospitals often lack standardized tools to assess compliance with quality management strategies and the implementation of clinical quality activities in hospitals. Such assessment tools, if easy to use, could be helpful to hospitals, health-care purchasers and health-care inspectorates. The aim of our study was to determine the psychometric properties of two newly developed tools for measuring compliance with process-oriented quality management strategies and the extent of implementation of clinical quality strategies at the hospital level.

DESIGN

We developed and tested two measurement instruments that could be used during on-site visits by trained external surveyors to calculate a Quality Management Compliance Index (QMCI) and a Clinical Quality Implementation Index (CQII). We used psychometric methods and the cross-sectional data to explore the factor structure, reliability and validity of each of these instruments.

SETTING AND PARTICIPANTS

The sample consisted of 74 acute care hospitals selected at random from each of 7 European countries.

MAIN OUTCOME MEASURES

The psychometric properties of the two indices (QMCI and CQII).

RESULTS

Overall, the indices demonstrated favourable psychometric performance based on factor analysis, item correlations, internal consistency and hypothesis testing. Cronbach's alpha was acceptable for the scales of the QMCI (α: 0.74-0.78) and the CQII (α: 0.82-0.93). Inter-scale correlations revealed that the scales were positively correlated, but distinct. All scales added sufficient new information to each main index to be retained.

CONCLUSION

This study has produced two reliable instruments that can be used during on-site visits to assess compliance with quality management strategies and implementation of quality management activities by hospitals in Europe and perhaps other jurisdictions.

Development and validation of an index to assess hospital quality management systems

Objective

The aim of this study was to develop and validate an index to assess the implementation of quality management systems (QMSs) in European countries.

Design

Questionnaire development was facilitated through expert opinion, literature review and earlier empirical research. A cross-sectional online survey utilizing the questionnaire was undertaken between May 2011 and February 2012. We used psychometric methods to explore the factor structure, reliability and validity of the instrument.

Setting and participants

As part of the Deepening our Understanding of Quality improvement in Europe (DUQuE) project, we invited a random sample of 188 hospitals in 7 countries. The quality managers of these hospitals were the main respondents.

Main Outcome Measure

The extent of implementation of QMSs.

Results

Factor analysis yielded nine scales, which were combined to build the Quality Management Systems Index. Cronbach's reliability coefficients were satisfactory (ranging from 0.72 to 0.82) for eight scales and low for one scale (0.48). Corrected item-total correlations provided adequate evidence of factor homogeneity. Inter-scale correlations showed that every factor was related, but also distinct, and added to the index. Construct validity testing showed that the index was related to recent measures of quality. Participating hospitals attained a mean value of 19.7 (standard deviation of 4.7) on the index that theoretically ranged from 0 to 27.

Conclusion

Assessing QMSs across Europe has the potential to help policy-makers and other stakeholders to compare hospitals and focus on the most important areas for improvement.

DUQuE quality management measures: associations between quality management at hospital and pathway levels

Objective

The assessment of integral quality management (QM) in a hospital requires measurement and monitoring from different perspectives and at various levels of care delivery. Within the DUQuE project (Deepening our Understanding of Quality improvement in Europe), seven measures for QM were developed. This study investigates the relationships between the various quality measures.

Design

It is a multi-level, cross-sectional, mixed-method study.

Setting and Participants

As part of the DUQuE project, we invited a random sample of 74 hospitals in 7 countries. The quality managers of these hospitals were the main respondents. Furthermore, data of site visits of external surveyors assessing the participating hospitals were used.

Main Outcome Measures

Three measures of QM at hospitals level focusing on integral systems (QMSI), compliance with the Plan-Do-Study-Act quality improvement cycle (QMCI) and implementation of clinical quality (CQII). Four measures of QM activities at care pathway level focusing on Specialized expertise and responsibility (SER), Evidence-based organization of pathways (EBOP), Patient safety strategies (PSS) and Clinical review (CR).

Results

Positive significant associations were found between the three hospitals level QM measures. Results of the relationships between levels were mixed and showed most associations between QMCI and department-level QM measures for all four types of departments. QMSI was associated with PSS in all types of departments.

Conclusion

By using the seven measures of QM, it is possible to get a more comprehensive picture of the maturity of QM in hospitals, with regard to the different levels and across various types of hospital departments.

Is having quality as an item on the executive board agenda associated with the implementation of quality management systems in European hospitals: a quantitative analysis

Objective

To assess whether there is a relationship between having quality as an item on the board's agenda, perceived external pressure (PEP) and the implementation of quality management in European hospitals.

Design

A quantitative, mixed method, cross-sectional study in seven European countries in 2011 surveying CEOs and quality managers and data from onsite audits.

Participants

One hundred and fifty-five CEOs and 155 quality managers.

Setting

One hundred and fifty-five randomly selected acute care hospitals in seven European countries (Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey).

Main outcome measure(s)

Three constructs reflecting quality management based on questionnaire and audit data: (i) Quality Management System Index, (ii) Quality Management Compliance Index and (iii) Clinical Quality Implementation Index. The main predictor was whether quality performance was on the executive board's agenda.

Results

Discussing quality performance at executive board meetings more often was associated with a higher quality management system score (regression coefficient b = 2.53; SE = 1.16; P = 0.030). We found a trend in the associations of discussing quality performance with quality compliance and clinical quality implementation. PEP did not modify these relationships.

Conclusions

Having quality as an item on the executive board's agenda allows them to review and discuss quality performance more often in order to improve their hospital's quality management. Generally, and as this study found, having quality on the executive board's agenda matters.