What is quality in long covid care? Lessons from a national quality improvement collaborative and multi-site ethnography

BACKGROUND

Long covid (post covid-19 condition) is a complex condition with diverse manifestations, uncertain prognosis and wide variation in current approaches to management. There have been calls for formal quality standards to reduce a so-called "postcode lottery" of care. The original aim of this study-to examine the nature of quality in long covid care and reduce unwarranted variation in services-evolved to focus on examining the reasons why standardizing care was so challenging in this condition.

METHODS

In 2021-2023, we ran a quality improvement collaborative across 10 UK sites. The dataset reported here was mostly but not entirely qualitative. It included data on the origins and current context of each clinic, interviews with staff and patients, and ethnographic observations at 13 clinics (50 consultations) and 45 multidisciplinary team (MDT) meetings (244 patient cases). Data collection and analysis were informed by relevant lenses from clinical care (e.g. evidence-based guidelines), improvement science (e.g. quality improvement cycles) and philosophy of knowledge.

RESULTS

Participating clinics made progress towards standardizing assessment and management in some topics; some variation remained but this could usually be explained. Clinics had different histories and path dependencies, occupied a different place in their healthcare ecosystem and served a varied caseload including a high proportion of patients with comorbidities. A key mechanism for achieving high-quality long covid care was when local MDTs deliberated on unusual, complex or challenging cases for which evidence-based guidelines provided no easy answers. In such cases, collective learning occurred through idiographic (case-based) reasoning, in which practitioners build lessons from the particular to the general. This contrasts with the nomothetic reasoning implicit in evidence-based guidelines, in which reasoning is assumed to go from the general (e.g. findings of clinical trials) to the particular (management of individual patients).

CONCLUSION

Not all variation in long covid services is unwarranted. Largely because long covid's manifestations are so varied and comorbidities common, generic "evidence-based" standards require much individual adaptation. In this complex condition, quality improvement resources may be productively spent supporting MDTs to optimise their case-based learning through interdisciplinary discussion. Quality assessment of a long covid service should include review of a sample of individual cases to assess how guidelines have been interpreted and personalized to meet patients' unique needs.

STUDY REGISTRATION

NCT05057260, ISRCTN15022307.

International standards of care in thoracic oncology: A narrative review of clinical quality indicators

Unwarranted variations in lung cancer care are widely described. Clinical Quality Indicators (CQIs) enable the systematic identification and alleviation of variations in care and other evidence-practice gaps. The aim of this review was to describe and evaluate lung cancer CQIs utilised internationally, in order to provide a substrate for the development of Australasian lung cancer CQIs and future quality improvement initiatives. A literature search was performed to identify relevant publications; references were excluded if they did not explicitly define original lung cancer-specific quality indicators, or were review or opinion articles. Ultimately, 48 publications containing 661 individual CQIs were evaluated. Although almost all references were published in the last decade, CQIs did not always reflect contemporary standards of care. For example, there were just sixteen CQIs regarding biomarker profiling, eleven CQIs regarding multidisciplinary team review, and three clinical trial enrolment CQIs. Of 307 lung cancer treatment CQIs, almost half (137) pertain to surgical resection; a treatment option available to a minority of lung cancer patients. Consumer engagement during indicator development was uncommon. In conclusion, whilst CQIs are widely measured and reported, they are not always consistent with evidence-based practice, nor do they reliably support the holistic evaluation of the lung cancer care continuum. Moving forward, Australia and New Zealand must adopt a unified, evidence-based and patient-centred approach to drive meaningful improvements in practice.

Variations in policies for accessing elective musculoskeletal procedures in the English National Health Service: A documentary analysis

OBJECTIVE

The overall aim of this study was to investigate how commissioning policies for accessing clinical procedures compare in the context of the English National Health Service. Our primary objective was to compare policy wording and categorise any variations identified. Our secondary objective was to explore how any points of variation relate to national guidance.

METHODS

This study entailed documentary analysis of commissioning policies that stipulated criteria for accessing eight elective musculoskeletal procedures. For each procedure, we retrieved policies held by regions with higher and lower rates of clinical activity relative to the national average. Policies were subjected to content and thematic analysis, using constant comparison techniques. Matrices and descriptive reports were used to compare themes across policies for each procedure and derive categories of variation that arose across two or more procedures. National guidance relating to each procedure were identified and scrutinised, to explore whether these provided context for explaining the policy variations.

RESULTS

Thirty-five policy documents held by 14 geographic regions were included in the analysis. Policies either focused on a single procedure/treatment or covered several procedures/treatments in an all-encompassing document. All policies stipulated criteria that needed to be fulfilled prior to accessing treatment, but there were inconsistences in the evidence cited. Policies varied in recurring ways, with respect to specification of non-surgical treatments and management, requirements around time spent using non-surgical approaches, diagnostic requirements, requirements around symptom severity and disease progression, and use of language, in the form of terms and phrases ('threshold modifiers') which could open up or restrict access to care. National guidance was identified for seven of the procedures, but this guidance did not specify criteria for accessing the procedures in question, making direct comparisons with regional policies difficult.

CONCLUSIONS

This, to our knowledge, is the first study to identify recurring ways in which policies for accessing treatment can vary within a single-payer system with universal coverage. The findings raise questions around whether formulation of commissioning policies should receive more central support to promote greater consistency - especially where evidence is uncertain, variable or lacking.

Variability in COVID-19 in-hospital mortality rates between national health service trusts and regions in England: A national observational study for the Getting It Right First Time Programme

BACKGROUND

A key first step in optimising COVID-19 patient outcomes during future case-surges is to learn from the experience within individual hospitals during the early stages of the pandemic. The aim of this study was to investigate the extent of variation in COVID-19 outcomes between National Health Service (NHS) hospital trusts and regions in England using data from March-July 2020.

METHODS

This was a retrospective observational study using the Hospital Episode Statistics administrative dataset. Patients aged ≥ 18 years who had a diagnosis of COVID-19 during a hospital stay in England that was completed between March 1st and July 31st, 2020 were included. In-hospital mortality was the primary outcome of interest. In secondary analysis, critical care admission, length of stay and mortality within 30 days of discharge were also investigated. Multilevel logistic regression was used to adjust for covariates.

FINDINGS

There were 86,356 patients with a confirmed diagnosis of COVID-19 included in the study, of whom 22,944 (26.6%) died in hospital with COVID-19 as the primary cause of death. After adjusting for covariates, the extent of the variation in-hospital mortality rates between hospital trusts and regions was relatively modest. Trusts with the largest baseline number of beds and a greater proportion of patients admitted to critical care had the lowest in-hospital mortality rates.

INTERPRETATION

There is little evidence of clustering of deaths within hospital trusts. There may be opportunities to learn from the experience of individual trusts to help prepare hospitals for future case-surges.

Exploring variation in the performance of planned birth: A mixed method study

OBJECTIVE

Variation in practice in relation to indications and timing for both induction of labour (IOL) and planned caesarean section (CS) clearly exists. However, the extent of this variation, and how this variation is explained by clinicians remains unclear. The aim of this study was to map the variation in IOL and planned CS at eight Australian hospitals, and understand why variation occurs from the perspective of clinicians at these hospitals. Our ultimate aim was to identify opportunities for improvement as evidenced by hospital data, clinician experiences, and feedback.

DESIGN

A two-phased mixed method study using sequential explanatory study design. The first phase consisted of an analysis of routinely collected patient data to map variation between hospitals. The second phase consisted of focus groups with clinicians to gain their perspectives on the reasons for variation.

SETTING AND PARTICIPANTS

Patient data consisted of routine data from 19,073 women giving birth at eight Sydney hospitals between November 2017 and October 2018. Focus groups were attended by a total of 61 medical staff and 121 midwives.

RESULTS

Hospital data analysis found substantial variation, before and after adjustment for case-mix, in rates of both IOL (adjusted rates 27.6%-42%) and planned CS (adjusted rate 15.4%-22.6%). Planned CS by gestation also showed variation, although after restricting analysis to term (≥37 weeks gestation) births, variation was reduced. At focus groups, five main themes explaining variation emerged: local guidelines, policies and procedures (inconsistency and ambiguity); uncertainty of the evidence/what is best practice (contradictory research and different interpretations of evidence); clinician preferences, beliefs and values; the culture of the unit; and organisational influences (access to specialised clinics, theatre time).

KEY CONCLUSIONS

Considerable variation in IOL and planned CS, even after case-mix adjustment, was found in this sample of Australian hospitals. Engagement with hospital clinicians identified likely sources of this variation and enabled clinicians at each hospital to consider appropriate local responses to address variation, such as more detailed review of their planned birth cases.

IMPLICATIONS FOR PRACTICE

At a macro level, measures to reduce unwarranted variation should initially focus on consistent national guidelines, while supporting equitable access to operating theatres for optimal CS timing, and shared decision-making training to reduce influence of clinician preference.

Making shared decisions in relation to planned caesarean sections: What are we up to?

OBJECTIVE

To map the literature in relation to shared decision making (SDM) for planned caesarean section (CS), particularly women's experiences in receiving the information they need to make informed decisions, their knowledge of the risks and benefits of CS, the experiences and attitudes of clinicians in relation to SDM, and interventions that support women to make informed decisions.

METHODS

Using a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, PubMed, Maternity and Infant Care, MEDLINE, and Web of Science were searched for the period from 2008 to 2018.

RESULTS

34 studies were included, with 9750 women and 3313 clinicians. Overall women reported limited SDM, and many did not have the information required to make informed decisions. Clinicians generally agreed with SDM, while recognising it often does not occur. Decision aids and educational interventions were viewed positively by women.

CONCLUSION

Many women were not actively involved in decision-making. Decision aids show promise as a SDM-enhancing tool. Studies that included clinicians suggest uncertainty regarding SDM, although willingness to engage.

PRACTICE IMPLICATIONS

Moving from clinician-led decision-making to SDM for CS has potential to improve patient experiences, however this will require considerable clinician training, and implementation of SDM interventions.

Survival After an Acute Heart Failure Admission. Twelve-Month Outcomes From the NSW HF Snapshot Study

BACKGROUND

The New South Wales (NSW) Heart Failure Snapshot sought to provide a contemporaneous profile of patients admitted with acute heart failure. We have previously reported the baseline results, and this paper reports the 30-day and 12-month outcomes.

METHODS

A prospective audit of consecutive patients admitted to 24 teaching hospitals across NSW and the Australian Capital Territory in July-August 2013 with acute heart failure. Follow-up data were obtained by integration of hospital administrative records and follow-up phone calls with the patients.

RESULTS

Eight hundred eleven (811) patients were recruited across the 24 sites. The NSW HF Snapshot was an elderly cohort (77 ± 14 yrs) with high comorbidity (mean Charlson Comorbidity Index 3.5 ± 2.6), and 71% were frail at baseline. Twenty-four per cent (24%) of patients were readmitted within 30-days post discharge. One hundred seventy-eight (178) patients died within 12 months post discharge. The independent predictors of death were frailty (Hazard Ratio 1.98 [95% Confidence interval 1.18-3.30]; p < 0.01) Charlson Comorbidity Index (HR 1.06 [95% CI 1.00-1.13]; p = 0.05); New York Heart Association (NYHA) class 4 (HR 2.62 [95% CI 1.32-5.22]; p < 0.01); eGFR<30 ml/min/1.73 m² (HR 2.16 [95% CI 1.45-3.21]; p < 0.01); hypokalaemia at discharge (HR 2.55 [95% CI 1.44-4.51]; p < 0.01) and readmission within 30 days of baseline admission (HR 2.13 [95% CI 1.49-3.13]; p < 0.01).

CONCLUSION

In one of the largest prospective audits of acute heart failure outcomes in Australia, we found that short-term readmissions and mortality at 12 months remain high but were largely driven by patient-level factors.

A process evaluation of the first year of Leading Change, Adding Value

BACKGROUND

Leading Change, Adding Value (LCAV) is a national framework to support transformational change across health and social care.

DESIGN

a qualitative approach of semi-structured interviews was used to capture information on how LCAV has been disseminated in its early stages from the perspective of key stakeholders and partners. This also included looking at how it might be embedded into everyday practice.

METHODS

data collection took place over a 3-month period between January and March 2017. Twenty semi-structured telephone interviews were conducted with key LCAV partners and stakeholders from across health and social care. Perceptions were sought as to how LCAV has been, and may be, used by frontline staff following initial dissemination and any potential barriers and enablers to taking the framework forward.

RESULTS

a thematic framework analysis of data identified a three-theme paradigm to evaluate LCAV: past-where has this come from? Present-where is it now? Future-where is this going?.

CONCLUSION

a programme of dissemination events and examples of good practice in the form of case studies have been valuable tools to engage nursing, midwifery and care staff across health and social care. Continuing to establish networks of frontline staff engaging with LCAV and supporting each other will help facilitate best practice sharing, and multi-professional and cross-boundary working.

Decision making tools for managing waiting times and treatment rates in elective surgery

Background

Waiting times for elective treatments, including elective surgery, are a source of public concern and therefore are on policy makers’ agenda. The long waiting times have often been tackled through the allocation of additional resources, in an attempt to reduce them, but results are not straightforward. At the same time, researchers have reported wide geographical variations in the provision of elective care not driven by patient needs or preferences but by other factors.

The paper analyses the relationship between waiting times and treatment rates for nine high-volume elective surgical procedures in order to support decision making regarding the availability of these services for the citizens. Using the framework already proposed for the diagnostic services, we identify different patterns that can be followed to align the supply with patient needs in the Italian context.

Methods

After measuring the waiting times and the treatment rates for nine procedures in the 34 districts in Tuscany, we performed correlation analyses. Then, we plotted the results in a matrix cross-checking waiting times and rates. By doing so, we identified four different contexts that require a second step analysis to tackle unwarranted geographical variations and ensure timely care to patients. Finally, for each district and elective surgical procedure, we measured the economic impact of the different treatment rates in order to evaluate whether there are any supply criticalities and eventually some room for maneuver. We also included active and passive mobility of patients.

Results

The results show a high degree of variation both in treatment rates and waiting times, especially for the orthopaedic procedures: knee replacement, knee arthroscopy and hip replacement. The analysis performed for the nine interventions shows that the 34 districts are in varying positions in the waiting time-treatment rate matrix, suggesting that there is no straightforward relationship between rates and waiting times. Each combination in the matrix may have different determinants that require healthcare managers to adopt diversified strategies. The decision making process needs to be supported by a two-level analysis: the first one to put in place the matrix that cross-checks waiting times and treatment rates, the second one to analyse the characteristics of each quadrant and the improvement actions that can be proposed.

Conclusions

In Italy, waiting times in elective surgical services are a main policy issue with a relevant geographical variation. Our analysis reveals that this variation is due to multiple elements. In order to avoid simplistic approaches that do not solve the problem but often lead to increased expenditure, policy makers and healthcare managers should follow a two-step strategy firstly identifying the type of context and secondly analysing the impact of elements such as resource productivity, resource availability, patients’ preferences and care appropriateness. Only in some cases it is required to increase the service supply.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4199-6) contains supplementary material, which is available to authorized users.