Development of a set of strategy-based system-level cancer care performance indicators in Ontario, Canada

OBJECTIVES

To develop a set of scientifically sound and managerially useful system-level cancer care performance indicators for public reporting in Ontario, Canada.

IMPLEMENTATION

Using a modified Delphi panel method, comprising a systematic literature review and multiple rounds of structured feedback from 34 experts, the Cancer Quality Council of Ontario developed a set of quality indicators spanning cancer prevention through to end-of-life care. To be useful to decision-makers and providers, indicator selection criteria included a clear focus on the cancer system, relevance to a diversity of cancer providers, a strong link to the mission and strategic objectives of the cancer system, clear directionality of indicator results, presence of targets and/or benchmarks, feasibility of populating the indicator, and credibility of the measure as an indicator of quality. To ensure that the selected indicators would measure progress over time against specific and widely accepted goals, we created a strategy map based on the five strategic objectives of the Ontario cancer system: (i) to improve the measurement and reporting of cancer quality, (ii) to increase the use of evidence and innovation in decision-making, (iii) to improve access to cancer services and reduce waiting times, (iv) to increase efficiency across the system, (v) to reduce the burden of cancer. An analysis of the mean indicator ratings by experts, and the strategy mapping exercise resulted in the identification of 36 indicators deemed suitable for routine performance measurement of the Ontario cancer system.

LESSONS LEARNED

The resulting instrument incorporates a credible evidence basis for performance measurement aligned to the five strategic goals for the Ontario cancer system. It represents the integrating of a management culture, focused on the implementation of a new strategic direction for the cancer system, with the underlying evidence-based culture of clinicians.

Redefining primary pediatric care for children with special health care needs: the primary care medical home

PURPOSE OF REVIEW

As considerations of the quality of health care have matured, the role of pediatric primary care providers and models for the delivery of primary care have received growing attention. Particularly for children with chronic conditions, the need for proactive, planned, and coordinated care delivered in partnership with consumers has become more apparent. The primary care medical home has emerged as a model favored by national organizations representing pediatricians and family physicians as well as national public health policy makers, yet implementation of this model remains limited and the evidence base for its value is not yet highly developed.

RECENT FINDINGS

Most studies of primary care outcomes involve individual elements of the medical home such as care coordination and continuity of care. Limited data that are emerging from studies of the medical home model as a whole in practice settings suggest improvements in patient satisfaction and in some areas of utilization. No data are available that examine specific functional or physical health outcomes associated with primary care models like the medical home.

SUMMARY

The pediatric primary care medical home provides a care model for both well children and those with special health care needs that expands primary care services beyond those provided in the examination room by individual providers to include systemic services such as patient registries, explicit care planning and care coordination, planned co-management with specialists, patient advocacy, and patient education. There is an immediate need for large-scale, practice-based studies of the outcomes for children and youth, providers, and the health care system when such improvements in primary care are implemented.

Medical home, obesity, acute otitis media, and otitis media with effusion

Four areas of pediatric office practice are reviewed: the medical home concept, obesity, acute otitis media, and otitis media with effusion. The concept of the medical home in the care of children with special health care needs, its effect on health care outcomes, and its application to office practice are discussed. The epidemiology and causes of obesity are covered along with options for obesity screening and prevention. Diagnosis and therapy of acute otitis media and otitis media with effusion are reviewed along with discussion of recent practice guidelines for both entities.

A integralidade na prática (ou sobre a prática da integralidade)

O artigo faz uma reflexão sobre as manifestações ou os signos da integralidade na prática em saúde, buscando facilitar o reconhecimento de experiências que estejam avançando e permitir que elas sejam posteriormente analisadas. Pretende também contribuir para que cada vez mais atores se engajem na construção de práticas pautadas pela integralidade. Parte-se do princípio de que o que caracteriza a integralidade é a apreensão ampliada das necessidades e a habilidade de reconhecer a adequação da oferta ao contexto específico da situação no qual se dá o encontro do sujeito com a equipe de saúde; e defender a integralidade nas práticas é defender que a oferta de ações de saúde deva estar sintonizada com o contexto específico de cada encontro.

Avaliação da integralidade: conferindo sentido para os pactos na programação de metas dos sistemas municipais de saúde

Diretriz política, ideal ou objetivo, a integralidade torna-se um atributo relevante na avaliação da qualidade do cuidado e dos sistemas de saúde. Discute-se o significado desse conceito na prática de alguns serviços e sistemas de saúde, analisando metodologias para sua operacionalização. No Brasil, predomina uma percepção ampliada com ênfase no caráter completo, contínuo e coordenado do cuidado e da gestão. Destaca-se a importância de associar a avaliação da integralidade com medidas de acesso, sugerindo-se a escolha de indicadores dos pactos de metas das programações municipais para seu monitoramento. Tal iniciativa poderia aumentar a validade do instrumental de avaliação existente, numa perspectiva comunicativa.

Interdisciplinary breast cancer care: declaring and improving the standard

The contemporary management of breast cancer is a complex endeavor that requires a truly collaborative team approach, characterized by ongoing communication and active information-sharing among the multiple disciplines involved. Programs designed to provide comprehensive breast cancer management by a team of multidisciplinary specialists were introduced in the late 1970s and have been increasing slowly. Patients attending comprehensive breast centers receive care from a broad-based multidisciplinary team that most often includes surgeons, radiologists, pathologists, medical oncologists, radiation oncologists, plastic/reconstructive surgeons, primary care physicians, gynecologists, nurses, social workers, patient advocates, and genetic risk counselors. At the heart of comprehensive, interdisciplinary breast care is the consensus planning conference that brings together team members on a regular basis to discuss individual patient cases and develop comprehensive treatment plans. This interactive and dynamic forum has become integral to the interdisciplinary management of breast diseases and results in an increased level of communication between the participating health-care professionals and the patients they treat. Several professional organizations, most prominently the American Society of Breast Disease, promote and support an interdisciplinary approach to breast care.

Comprehensive health assessment for newly arrived refugee children in Australia

Providing appropriate and responsive care to refugees from diverse backgrounds and with unique health needs is challenging. Refugee children may present with a wide range of conditions, which may be unfamiliar to health professionals in developed countries. Additionally, refugees may experience unfamiliarity with the Australian health system and distrust of authority figures and/or medical practitioners. This article provides an overview of the priority areas in health and health management for paediatric refugee patients for paediatricians as well as other relevant health care providers caring for this group. Specific issues covered include general health assessment, infectious diseases, immunization, growth and nutrition, oral health, development and disability, mental health and child protection. Comprehensive health assessment can assist in identifying children at risk of poor health and to provide them with timely and effective care, advocacy and appropriate referral.

Community-based, acute posttraumatic stress management: a description and evaluation of a psychosocial-intervention continuum

Much of today's psychological trauma can be identified as resulting from sudden and seemingly random events, and particularly from events that involve the loss of human life. This article presents a perspective on how behavioral health providers may approach the design, development, and implementation of community-based psychological trauma interventions. These interventions allow those community members most affected by the trauma to play a central role in the resolution of, and community adaptation to, traumatic losses. After a brief discussion of "critical incident stress debriefing"--a common form of psychological "first aid" that is sometimes used following traumatic events that affect a community--the article turns to the description of a community-based trauma-response program that provides a continuum-of-care model for the care and management of individual and group reactions to shared, traumatic events. A recent evaluation of that program, which was developed by the Community Services Program of the Trauma Center in Boston, is presented as an important first step toward determining the types of community-based responses that show promise in our efforts to ameliorate the impact of traumatic events in communities nationwide and internationally.

Policy statement: organizational principles to guide and define the child health care system and/or improve the health of all children

The American Academy of Pediatrics proposed a definition of the medical home in a 1992 policy statement. Efforts to establish medical homes for all children have encountered many challenges, including the existence of multiple interpretations of the "medical home" concept and the lack of adequate reimbursement for services provided by physicians caring for children in a medical home. This new policy statement contains an expanded and more comprehensive interpretation of the concept and an operational definition of the medical home.

Measuring Interdisciplinary Team Performance in a Long-Term Care Setting

OBJECTIVES

The objectives of this study were to test the reliability and the validity of a survey instrument for assessing interdisciplinary team performance in long-term care settings and to measure team performance in the Program of All-Inclusive Care for the Elderly (PACE).

RESEARCH DESIGN AND METHODS

The analysis is based on 1220 surveys completed by team members of 26 PACE programs. Cronbach's alphas, analysis of variance, and regression models were used to assess the reliability and the validity of the instrument. Multivariate regression analysis was used to examine factors associated with team performance in PACE.

RESULTS

Cronbach's alphas ranging from 0.76 to 0.89 demonstrate good-to-high reliability for all domains of the team process and performance (effectiveness). Construct validity is demonstrated through the results of the regression analysis showing that leadership, communication, coordination, and conflict management are positive and significant (P <0.001) predictors of team cohesion and team effectiveness. The data also support the appropriateness of aggregating individual-level responses to the unit level. Perceived team effectiveness significantly (P <0.05) increases with: age of the respondents; longer length of the team's professional work experience; shorter duration of the team's PACE experience; more ethnically diverse composition of the team; greater ethnic concordance between team members and the participants; and greater perceived resource availability.

CONCLUSIONS

Several of the factors influencing team effectiveness in PACE are potentially modifiable and, therefore, could offer insights for improving team practice.

Effect of a comprehensive intervention program targeting general practice staff on quality of life in patients at high cardiovascular risk: a randomized controlled trial

BACKGROUND

We implemented a comprehensive intervention program targeting general practice staff, that proved successful in optimizing practice organization and clinical decision-making. In this paper, health-related quality of life (HRQL) is investigated as a clinical outcome.

OBJECTIVE

To evaluate the effect of the implementation of an intervention program on the HRQL in patients at high cardiovascular risk.

RESEARCH DESIGN

Randomized controlled trial. Intervention practices (n = 62) received a comprehensive intervention program (by means of outreach visitors) lasting 21 months. HRQL of patients at high cardiovascular risk was assessed by the MOS 36-Item Short-Form Health Survey (SF-36), at baseline and after intervention. Three patient categories were distinguished: diabetes mellitus, cardiovascular disease and hypertension.

RESULTS

HRQL deteriorated in all respondents, but more pronounced in the control group. In diabetes patients the differences between intervention and control group were significant for the Vitality and Mental Health scales, with mean difference in change of 3.93 (95% CI: 1.08-6.78) and 3.71 (95% CI: 0.73-6.68), respectively. Patients with cardiovascular disease had significantly different changes on three scales: physical functioning (3.57, 95% CI: 0.71-6.43), vitality (3.01, 95% CI: 0.72-5.30) and social functioning (3.96, 95% CI: 0.50-7.42). In patients with hypertension, there were no differences between the intervention and control group.

CONCLUSION

Our comprehensive intervention program resulted in changes in HRQL on several domains, particularly in patients with diabetes and cardiovascular disease.

Reducing clinical variations with clinical pathways: do pathways work?

OBJECTIVE

To test clinical pathways in a variety of Italian health care organizations in 2000-2002 to measure performance in decreasing process and outcome variations.

DESIGN

Creation of indicators, specific for each clinical pathway, to measure variations in the care processes and outcomes. Pre- and post-analysis model to evaluate the possible effect of the clinical pathways on each indicator.

SETTING

We tested the clinical pathways in six sites, each with different clinical pathways.

RESULTS

Reductions in health care macro-variation phenomena (length of stay, patient pathways, etc.) and in performance micro-variation (variations in diagnostic and therapeutic prescriptions, protocol implementation, etc.) were shown in sites where pathways were implemented successfully. A significant improvement in outcome for patients who were treated according to the clinical pathway for heart failure was also demonstrated.

CONCLUSIONS

The overall purpose of clinical pathways is to improve outcome by providing a mechanism to coordinate care and to reduce fragmentation, and ultimately cost. Our results demonstrated that it is possible to achieve this goal. Although controversial elements still exist, we think that clinical pathways can have a positive impact on quality in health care.

Integralidade da atenção e integração de serviços de saúde: desafios para avaliar a implantação de um "sistema sem muros"

Neste texto, partimos do pressuposto de que a integralidade da atenção é um eixo prioritário da investigação e avaliação dos serviços e sistemas de saúde, estruturados como redes assistenciais interorganizacionais que articulam dimensões clínicas, funcionais, normativas e sistêmicas em sua operacionalização, reconhecendo que nenhuma organização reúne a totalidade dos recursos e competências necessárias para a solução dos problemas de saúde de uma população, em seus diversos ciclos de vida. Em virtude da complexidade desse "sistema sem muros", que elimina as barreiras de acesso entre os diversos níveis de atenção, em resposta às necessidades de saúde nos âmbitos local e regional, julgamos oportuno compartilhar algumas "lições preliminares" aprendidas em experiências pessoais e na literatura sobre a integração de serviços, que nos parecem de interesse comum aos pesquisadores e gestores comprometidos com a sua implantação.

Primary care quality: community health center and health maintenance organization

OBJECTIVE

This study compares the primary health care quality of community health centers (CHCs) and health maintenance organizations (HMOs) in South Carolina to elucidate the quality of CHC performance relative to mainstream settings such as the HMO.

METHODS

Mail surveys were used to obtain data from 350 randomly selected HMO users. Surveys with follow-up interviews were conducted to obtain data from 540 randomly selected CHC users. A validated adult primary care assessment tool was used in both surveys. Multivariate analyses were performed to assess the association of health care setting (HMO versus CHC) with primary care quality while controlling for sociodemographic and health care characteristics.

RESULTS

After controlling for sociodemographic and health care use measures, CHC patients demonstrated higher scores in several primary care domains (ongoing care, coordination of service, comprehensiveness, and community orientation) as well as total primary care performance.

CONCLUSION

Users of CHC are more likely than HMO users to rate their primary health care provider as good, except in the area of ease of first contact. The positive rating of the CHC is particularly impressive after taking into account that many CHC users have characteristics associated with poorer ratings of care.

Patient and provider factors related to comprehensive arthritis care in a community setting in Ontario, Canada

OBJECTIVE

To determine factors that correlate with recommendations for nonpharmacologic and pharmacologic interventions (comprehensive therapy) in community dwelling adults.

METHODS

Eligible participants were >/= 55 years of age with hip and knee arthritis symptoms and disability. Comprehensive therapy was classified as a recommendation for exercise and weight loss (if required) and any pharmacotherapy.

RESULTS

Only one-half of participants received a recommendation for comprehensive therapy. Participants who had seen a specialist and a therapist were almost twice as likely to receive a recommendation for comprehensive therapy.

CONCLUSION

In our setting, many people with hip or knee arthritis were not receiving even minimum recommended treatment. Changes in educational and organizational policies are needed to address this situation.

Building an award-winning women's health ambulatory service and beyond

Many barriers exist for the provision of high-quality health care to inner-city minority women. The barriers include access to care, compliance problems, financial concerns, system navigation issues, as well as language barriers. This article describes the transition of the Women's Ambulatory Health Services at Hartford Hospital from a traditional clinic model to a culturally sensitive private practice model. The road to transition was paved by valuable input from staff as well as patients. The final product was a much more efficient, inviting model that catered to the needs of the community.

The Institute of Medicine "Chasm" report: implications for depression collaborative care models

The Institute of Medicine report "Crossing the Quality Chasm: A New Health Care System for the 21st Century" describes the barriers in the American health care system to improving quality of care and outcomes of chronic illness. This article describes how depression collaborative care models as well as newer research aimed at organizational and economic issues have addressed these barriers in order to improve outcomes for patients with depression in primary care systems.