Incidence of pressure ulcers in intensive care units and direct costs of treatment: Evidence from Iran

BACKGROUND AND OBJECTIVE

Pressure ulcer (PU) is one of the important and frequent complications of hospitalization, associated with high treatment costs. The present study was conducted to determine the incidence of PU and its direct treatment costs for patients in intensive care unit (ICU) in Iran.

MATERIAL AND METHODS

In this retrospective study, medical records of 643 discharged patients from ICU of two selected hospitals were examined. The demographic and clinical data of all patients and data of resources and services usage for patients with PU were extracted through their records. Data analysis was done using logistic regression tests in SPSS 22 software. The cost of PU treatment was calculated for each grade of ulcer.

RESULTS

The findings showed that 8.9% of patients developed PU during their stay in ICU. Muscular paralysis (OR = 5.1), length of stay in ICU (OR = 4.0), diabetes (OR = 3.5) age (OR = 2.9), smoking (OR = 2.1) and trauma (OR = 1.4) were the most important risk factors of PU. The average cost of PU treatment varied from USD 12 for grade I PU to USD 66 834 for grade IV PUs. The total treatment costs for all studied patients with PU was estimated at USD 519 991.

CONCLUSION

The cost of PU treatment is significant. Since the preventive measures are more cost-effective than therapeutic measures, therefore, effective preventive interventions are recommended.

Medication adherence as a measure of the quality of care provided by physicians

OBJECTIVES

To assess the extent to which medication adherence in congestive heart failure (CHF) and diabetes may serve as a measure of physician-level quality.

STUDY DESIGN

A retrospective analysis of Medicare data from 2007 to 2009, including parts A (inpatient), B (outpatient), and D (pharmacy).

METHODS

For each disease, we assessed the correlation between medication adherence and health outcomes at the physician level. We controlled for selection bias by first regressing patient-level outcomes on a set of covariates including comorbid conditions, demographic attributes, and physician fixed effects. We then classified physicians into 3 levels of average patient medication adherence-low, medium, and high-and compared health outcomes across these groups.

RESULTS

There is a clear relationship between average medication adherence and patient health outcomes as measured at the physician level. Within the diabetes sample, among physicians with high average adherence and controlling for patient characteristics, 26.3 per 1000 patients had uncontrolled diabetes compared with 45.9 per 1000 patients among physicians with low average adherence. Within the CHF sample, also controlling for patient characteristics, the average rate of CHF emergency care usage among patients seen by physicians with low average adherence was 16.3% compared with 13.5% for doctors with high average adherence.

CONCLUSIONS

This study's results establish a physician-level correlation between improved medication adherence and improved health outcomes in the Medicare population. Our findings suggest that medication adherence could be a useful measure of physician quality, at least for chronic conditions for which prescription medications are an important component of treatment.

A Descriptive Study of Hospital- and Community-acquired Pressure Ulcers/Injuries

Hospital-acquired pressure ulcers/injuries (HAPU/I) have been a major focus of research, but information about community-acquired pressure ulcer/injuries (CAPU/I) is limited.

PURPOSE

The aim of this study was to compare HAPU/I and CAPU/I in a 620-bed academic medical center in the western United States.

METHODS

This descriptive study involved prospective/retrospective data collected from the National Data for Nursing Quality Indicators, including pressure ulcer stage (January 1, 2015, through December 31, 2017); the hospital's incident reporting system (January 1, 2017, through December 31, 2017); electronic medical records (EMR) as needed for verification; and the hospital's pressure ulcer registry (January 1, 2012, through December 31, 2017), developed by both EMR and manual extraction. Data regarding point prevalence, length of stay (LOS), source of admission, ulcer stage, and frequency of hospital encounters from patients at least 18 years of age with a pressure ulcer/injury documented in their records were abstracted. Data from pregnant or incarcerated persons and persons with missing or incomplete information on staging or origin of admission were excluded. Variables were analyzed using descriptive statistics.

RESULTS

The number of patients with data reviewed for point prevalence was 1787 for 2015, 1989 for 2016, and 1917 for 2017. For 2015, the average CAPU/I and HAPU/I point prevalence was 6.6% and 0.8%, respectively; for 2016, 6.0% and 1.5%, respectively; and for 2017, 6.9% and 0.9%, respectively. The average LOS for patients analyzed for 2017 admitted with a CAPU/I or HAPU/I was 10.5 days and 38.9 days, respectively. Hospital encounters were more frequent in the CAPU/I than in the HAPU/I group, with 821 CAPU/encounters compared to 45 HAPU/I encounters. The majority of patients with a HAPU/I (80%) or CAPU/I (65.4%) were admitted from home.

CONCLUSION

In this study, CAPU/I were more prevalent than HAPU/I and most patient encounters originated from home. More descriptive research that includes staging and source of admission is needed to document the rate of CAPU/I and characteristics of HAPU/I compared to CAPU/I in order to optimize pressure ulcer/injury practices across the continuum of care.

Knowledge and comfort change with an active learning activity on medication adherence calculations

BACKGROUND AND PURPOSE

Medication adherence is perhaps the most prominent quality measure applied to pharmacies. Teaching students about nonadherence usually takes the form of lectures and simulated pill taking exercises. While these approaches have value, activities are needed in other aspects of medication adherence.

EDUCATIONAL ACTIVITY AND SETTING

This activity was used within a didactic course on endocrine therapeutics for second-year student pharmacists at a public pharmacy college. A 50-min didactic session was followed by an active learning session on medication adherence metrics, focused on the community pharmacy setting. The active learning session had students manually calculate the proportion of days covered and medication possession ratios for two refill histories and examine the output of one simulated adherence dashboard. Students completed an online survey via the course management website before and after the activity that assessed student knowledge of concepts that comprise the proportion of days covered (PDC) metric and three items on self-reported knowledge, comfort, and confidence. The pre and post survey were compared using chi-square and paired t-tests.

FINDINGS

A total of 90 pre-surveys and 77 post-surveys were completed, with 70 having both pre- and post- data for comparison of the scaled responses. There was a statistically significant improvement in student knowledge, comfort, and confidence scores as assessed by the surveys.

DISCUSSION

A hands-on approach using a calendar and a custom database workbook appeared to help most students improve their understanding of applied medication adherence calculations.

SUMMARY

A 50-min didactic background session on medication adherence metrics followed by a 50-min adherence metric calculation activity was effective in increasing student knowledge and confidence related to calculating adherence metrics.

Measuring patient satisfaction with medical services using social media generated data

Purpose The purpose of this paper is to discuss the results of an effort to use social media generated data for measuring patient satisfaction with medical care services. Traditionally, scientifically designed patient satisfaction surveys are used to provide such measurements. The goal here is to evaluate the possibility of supplementing patient satisfaction surveys with social media generated patient satisfaction measurements such that the later can be used either as validation or replacement for the former. Although surveys are scientifically designed to yield dependable results, recent studies have revealed multiple factors relating to the methods currently used for survey data collection, that may be contributing to the limitations of many survey results. In light of such criticisms, this study explored the possibility of using the increasing popular and proactively generated consumer ratings through the pervasive social media as data source for satisfaction measurement. The average satisfaction scores created from such data are then used to compare levels of satisfaction among five types of health service businesses. Design/methodology/approach The data used in this research are garnered from the consumer review social media site called "Yelp!". Ratings and reviews that are related to health and medical services were extracted from the "Yelp!"

DATABASE

The types of services that are identified by consumers are standardized to typologies that are traditionally used in health service research. Five types of services were targeted - general practice physician offices, physician specialty services, dentists, hospitals and physical therapy services. The "five-star" rating systems were re-coded to form a five-point ordinal scale variable to represent "satisfaction score". Findings The Yelp! data-based measurement of patient satisfaction produced an overall satisfaction score of 3.8 (SD=1.7) for the sampled services. The average satisfaction score per type of service ranged from 3.16 (SD=1.83) for specialty physicians to 4.52 (SD=1.57) for physical therapists. In general, dentists and physical therapists received higher average satisfaction scores as compared to the other medical services. Research limitations/implications Because this study was meant to evaluate the utility of social media generated data to measure satisfaction, in general, the estimates cannot be construed as representative of any underlying geographically defined population. They, however, do have a "cohort" interpretability. This limitation is not inherent to the use of the data source. If some geographically identifiable representation of the measurement data is desired, identifiable business data can be generated from the Yelp! system to specifically target relevant populations following the method that are tested in this study. Practical implications Under certain circumstances, such as the size and maturity of the gathered data, social media generated data can be a useful as a "fortuitous" alternative to satisfaction surveys for evaluating patient satisfaction with medical care. This is propitious as there have been some indication by studies that the advent of communication media in the twenty-first century may be undermining the reliability of scientifically designed surveys. Originality/value The use of social media generated data as "alternative" or "secondary" data source for research use is currently being widely investigated. To the author's knowledge, this is the only paper that evaluated the use of "Yelp!" data as a possible source for population-based formal satisfaction measurement for healthcare services.

Do Skilled Nursing Facilities Selected to Participate in Preferred Provider Networks Have Higher Quality and Lower Costs?

OBJECTIVE

To determine whether skilled nursing facilities (SNFs) chosen by health systems to participate in preferred provider networks exhibited differences in quality, costs, and patient outcomes relative to other SNFs after accounting for differences in case mix.

DATA SOURCES

Medicare provider and claims data, 2012 and 2013.

STUDY DESIGN

We compared SNFs included in preferred networks relative to other SNFs in the same market, prior to the establishment of preferred provider networks.

DATA EXTRACTION METHODS

We linked the SNFs in our sample to facility characteristics and quality data. We identified SNF admissions and hospitalizations in claims data and limited the analysis to patients discharged from the hospitals in our sample. We obtained patient characteristics from Medicare summary files and the preceding hospital stay.

PRINCIPAL FINDINGS

Preferred SNFs exhibited better performance across publicly reported quality measures. Patients admitted to preferred SNFs exhibited shorter stays, lower Medicare payments, and lower probability of SNF readmission relative to nonpreferred SNFs.

CONCLUSIONS

Our results imply that health systems selected SNFs with lower resource use and better performance on quality measures. Thus, the trend toward preferred provider networks could have implications for Medicare spending and patient health.

Are Teaching Hospitals Treated Fairly in the Hospital-Acquired Condition Reduction Program?

PURPOSE

To identify the factors associated with total Hospital-Acquired Condition Reduction Program (HACRP) score and with receiving a Centers for Medicare and Medicaid Services (CMS) penalty (1% reduction in payment to those hospitals in the lowest-performing quartile of HACRP scores) for fiscal years (FYs) 2015-2017 with a particular focus on trends over this period.

METHOD

The authors evaluated the following variables: (1) type of hospital (teaching vs. nonteaching); (2) disproportionate patient percentage; (3) case mix index (CMI); (4) number of staffed beds; (5) length of stay (LOS); (6) gross patient revenue; and (7) region, using data from CMS and the American Hospital Directory. They conducted multivariate linear and logistic regressions.

RESULTS

A total of 2,249 hospitals were included. The mean total HACRP scores across hospitals for FY15, FY16, and FY17 were 5.38, 5.35, and 5.18, respectively. In FY15, 21.2% (476/2,249) of hospitals received a penalty compared with 22.6% (508/2,249) in FY16 and 31.3% (704/2,249) in FY17 (P < .001). The logistic regression model showed that teaching hospitals, larger hospitals (> 400 beds), hospitals with high CMI or long LOS, and hospitals in the Northeast and Western United States were more likely to receive a penalty. Teaching hospitals and larger hospitals did not improve their scores over time compared with nonteaching and small hospitals.

CONCLUSIONS

A reevaluation of the scoring methodology for the HACRP is needed. CMS could stratify hospitals into homogeneous categories and apply penalties to those that have the worst scores in each category.

Massive hemorrhage protocol activation in obstetrics: a 5-year quality performance review

BACKGROUND

A structured approach to hemorrhagic emergencies in obstetrics has gained popularity with the implementation of massive hemorrhage protocols. The trauma literature suggests that routine quality reviews should be in place to improve patient outcomes. The aim of this study was to develop quality indicators and assess compliance by the clinical team.

METHODS

A multidisciplinary team set the institutional quality indicators for the massive hemorrhage protocol review. A retrospective review of all obstetrical massive hemorrhage protocol activation events from September 2010 to January 2015 was performed. All protocol events occurred before the creation of the quality indicators. Data were retrieved from patient records.

RESULTS

There were 17 (0.09%) protocol activations for 19 790 deliveries during the study period. All 17 (100%) patients received at least one unit of red blood cells. Overactivation, defined as the transfusion of <2 units of red blood cells, occurred in two cases (12%). Common causes of non-compliance were: 24% (4/17) temperature monitoring, 18% (3/17) lactate measurement, 41% (7/17) arterial blood gas sampling, and 18% (3/17) hemoglobin maintenance within the target range of 55-95 g/L. Admission to intensive care and peripartum hysterectomy occurred in 12 and 5 cases (71% and 29%), respectively.

CONCLUSIONS

Suboptimal compliance was found in multiple areas, which may be attributable to the low frequency of activation of our massive haemorrhage protocol in obstetrics. The quality targets identified in this report can act as a basis for other institutions developing quality indicators to evaluate performance.

Limitations of Using Pediatric Respiratory Illness Readmissions to Compare Hospital Performance

BACKGROUND

Adult hospital readmission rates can reliably identify meaningful variation in hospital performance; however, pediatric condition-specific readmission rates are limited by low patient volumes.

OBJECTIVE

To determine if a National Quality Forum (NQF)-endorsed measure for pediatric lower respiratory illness (LRI) 30-day readmission rates can meaningfully identify high- and low-performing hospitals.

DESIGN

Observational, retrospective cohort analysis. We applied the pediatric LRI measure and several variations to evaluate their ability to detect performance differences.

SETTING

Administrative claims from all hospital admissions in California (2012-2014).

PATIENTS

Children (age <18 years) with LRI (primary diagnosis: bronchiolitis, influenza, or pneumonia; or LRI as a secondary diagnosis with a primary diagnosis of respiratory failure, sepsis, bacteremia, or asthma).

MEASUREMENTS

Thirty-day hospital readmission rates and costs. Hierarchical regression models adjusted for age, gender, and chronic conditions were used.

RESULTS

Across all California hospitals admitting children (n = 239) using respiratory readmission rates, no outlier hospitals were identified with (1) the NQF-endorsed metric, (2) inclusion of primary asthma or secondary asthma exacerbation diagnoses, or (3) inclusion of 30-day emergency revisits. By including admissions for asthma, adding emergency revisits, and merging 3 years of data, we identified 9 outlier hospitals (2 high-performers, 7 low-performers). There was no association of hospital readmission rates with costs.

CONCLUSIONS

Using a nationally-endorsed quality measure of inpatient pediatric care, we were unable to identify meaningful variation in hospital performance without broadening the metric definition and merging multiple years of data. Utilizers of pediatric-quality measures should consider modifying metrics to better evaluate the quality of pediatric care at low-volume hospitals.

FUNDING

Supported by the Agency for Healthcare Research and Quality (K08 HS24592 to SVK and U18HS25297 to MDC and NSB) and the National Institute of Child Health and Human Development (K23HD065836 to NSB). The funding agency played no role in the study design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the manuscript for publication.

Medical practice variation: public reporting a first necessary step to spark change

From previous work, we know that medical practice varies widely, and that unwarranted variation signals low value for patients and society. We also know that public reporting helps to create awareness of the need for quality improvement. Despite the availability of rich data, most Western countries have no routine surveillance of the geographic distribution of utilization, costs, and outcomes of healthcare, including trends in variation over time. This paper highlights the role of transparent public reporting as a necessary first step to spark change and reduce unwarranted variation. Two recent examples of public reporting are presented to illustrate possible ways to reduce unwarranted variation and improve care. We conclude by introducing the Value Improvement Cycle, which underscores that reporting is only a necessary first step, and suggests a path toward developing a multi-stakeholder approach to change.

Outcomes of a Quality Improvement Program to Reduce Hospital-acquired Pressure Ulcers in Pediatric Patients

Hospital-acquired pressure injuries (PIs) present a significant challenge to pediatric providers.

PURPOSE

The purpose of this quality improvement program was to develop and implement a debrief protocol and to evaluate compliance with and the implementation of a comprehensive prevention bundle to decrease the overall incidence and severity of pediatric pressure ulcers (PUs)/PIs in a free-standing children's hospital.

METHODS

As a member of the Children's Hospitals Solution for Patients Safety national network, a PU Hospital Acquired Conditions (HAC) team was created in 2013, followed by the development and implementation of a PU occurrence debrief tool and discussion guide and implementation of multiple staff educational strategies and a comprehensive prevention bundle. The PU occurrence debriefing occurred within 24 to 48 hours of a PU. Incidence data were collected annually from 2014 until 2017.

RESULTS

Compliance on implementation and documentation of bundle elements ranged from 88% to 94%, and PU/PI incidence decreased by 30% from 2014 to 2016 and by 40% in 2017. The overall PU rate was 0.0057 in 2014, 0.0050 in 2015, 0.0036 in 2016, and 0.0023 in 2017; 65% of all PUs were device-related. Of those, >50% were related to respiratory devices, 25% to peripheral intravenous catheters/central lines, 10% to tracheostomies, and 15% to other devices. Respiratory device-related PUs decreased by 50% in the pediatric intensive care unit, by 80% in the neonatal unit, and eliminated completely in extracorporeal membrane oxygenation patients.

CONCLUSION

The debriefing process, debriefing tool, educational programs, and prevention bundle reduced the rate of hospital-acquired PIs in pediatric patients and propagated a culture of safety.

Quality of care indicators for a resuscitation unit: A descriptive study and proposal

There are lack of indicators of quality of care in resuscitation units of emergency departments. With the aim of proposing a series of indicators to evaluate the quality of care delivered in hospital resuscitation areas, we conducted a descriptive study of 7579 admissions to the resuscitation unit of an emergency department at a Spanish hospital between 2012 and 2016. The proposed indicators were the percentage of patients attending to the emergency department admitted to the resuscitation area by level of triage, the length of stay, the percentage of patients moved to intensive care and surgery at disposition, the mortality in the area or in the emergency department within 24 hours of disposition, and the data completeness. A majority of the patients (62.6%) were men and the median age was 68 years. Over 99% of the required data were recorded. Median length of stay in the resuscitation unit was 0.87 hours (interquartile range, 0.5-1.5). Approximately 80% of patients categorized as an emergency on admission to the emergency department were admitted to the resuscitation unit, although the proportion of urgency patients was higher. The main disposition destination was a trauma cubicle (82.3% of cases). Mortality was 0.41%.Specific indicators are needed to assess the quality of care delivery in resuscitation units. We believe that our findings will provide new insights into the work done to date in this field.

Measures matter: A scoping review of maternal and newborn indicators

BACKGROUND

A variety of global-level monitoring initiatives have recommended indicators for tracking progress in maternal and newborn health. As a first step supporting the work of WHO's Mother and Newborn Information for Tracking Outcomes and Results (MoNITOR) Technical Advisory Group, we aimed to compile and synthesize recommended indicators in order to document the landscape of maternal and newborn measurement and monitoring.

METHODS

We conducted a scoping review of indicators proposed by global multi-stakeholder groups to suggest next steps to further support maternal and newborn measurement and monitoring. Indicators pertaining to pregnancy, childbirth, and postpartum/postnatal and newborn care were extracted and included in the indicator compilation, together with key indicator metadata. We examined patterns and relationships across the compiled indicators.

RESULTS

We identified 140 indicators linked to maternal and newborn health topics across the continuum of service provision. Fifty-five indicators relate to inputs and processes, 30 indicators relate to outputs, outcomes comprise 37 indicators in the database, and 18 impact indicators. A quarter of indicators proposed by global groups is either under development/discussion or is considered "aspirational", highlighting the currently evolving monitoring landscape. Although considerable efforts have been made to harmonize indicator recommendations, there are still relatively few indicators shared across key monitoring initiatives and some of those that are shared may have definitional variation.

CONCLUSION

Rapid, wide-ranging work by a number of multi-stakeholder groups has resulted in a substantial number of indicators, many of which partially overlap and many are not supported with adequate documentation or guidance. The volume of indicators, coupled with the number of initiatives promoting different indicator lists, highlight the need for strengthened coordination and technical leadership to harmonize recommendations for improved measurement and monitoring of data related to maternal and newborn heath.

Evaluating the Impact of the Venous Thromboembolism Outcome Measure on the PSI 90 Composite Quality Metric

INTRODUCTION

Patient Safety Indicator (PSI) 90 is a composite measure widely used in federal pay-for-performance and public reporting programs. A component metric of PSI 90, venous thromboembolism (VTE) rate, has been shown to be subject to surveillance bias and not a valid measure for hospital quality comparisons. A study was conducted to examine how hospital PSI 90 scores would change if the VTE measure were removed from calculation of this composite measure.

METHODS

Using 2014 Medicare inpatient claims data, PSI 90 scores were calculated with and without the VTE measure for 3,203 hospitals. Hospital characteristics obtained from the American Hospital Association Annual Survey and Centers for Medicare & Medicaid Services Payment Update Impact File were merged with PSI 90 scores.

RESULTS

Removing the VTE outcome measure from the calculation of PSI 90 version 5 improved PSI 90 scores for 17.1% of hospitals but lowered scores for 20.8% of hospitals, while 62.1% had no change in scores. Hospitals were more likely to improve on PSI 90 when the VTE measure was removed if they were larger (odds ratio [OR] = 1.60; 95% confidence interval [CI] = 1.00-2.58), were major teaching hospitals (OR = 1.76; 95% CI = 1.10-2.79), had greater technological resources (OR = 2.03; 95% CI = 1.40-2.94), or cared for sicker patients (OR = 1.12; 95% CI = 1.01-1.25).

CONCLUSION

Inclusion of the surveillance bias-prone VTE outcome measure in the PSI 90 composite disproportionately penalizes larger, academic hospitals and those that care for sicker patients. Removal of the VTE outcome measure from PSI 90 should be strongly considered.

Variation in Triple Aim Measures: Implications of Clinical Signatures in Family Medicine Residency Programs

BACKGROUND

Evidence from several specialties suggests that practice patterns developed in residency influence the quality and cost of care long after completion of training. Improving the quality, cost, and patient experience of care (the "Triple Aim") is foundational to future health systems change.

OBJECTIVE

We measured variation in Triple Aim measures among family medicine residency programs in a regional quality improvement collaborative (I³ Population Health Collaborative).

METHODS

We calculated medians and interquartile ranges for each of 11 Triple Aim measures and compared them with median splits of population and practice characteristics, including payer mix, patient race and age, electronic health record used, registry use, and National Committee for Quality Assurance patient-centered medical home recognition.

RESULTS

All 22 participating family medicine residency programs provided baseline data. The number of practices reporting data on individual measures ranged from 9 to 17 (41%-77%). We found variation averaging 51% across all measures, from a low of 12% for readmission rates to 94% for emergency department visit rates. Variations were stable over time. We found no significant relationships between practice or population characteristics and measures, nor between practice characteristics and outcomes variation.

CONCLUSIONS

The 22 family medicine residency programs in our study showed substantial variation in quality, cost, and patient experience of care. These variations did not appear to result from differences in practice characteristics, payer mix, or patient demographics.

Analysis of quality antimicrobial agent use in the emergency department of a tertiary care hospital

OBJECTIVES

To describe modifiable factors related to inappropriate antimicrobial treatment in the observation area of an emergency department to explore practices that can be targeted for change through a program to improve emergency use of antimicrobial agents, the PROA program in its spanish observations.

MATERIAL AND METHODS

Cross-sectional serial point-prevalence study of all antimicrobial prescriptions for patients under observation in the department in February and March 2015.The main outcome measure was the frequency of antimicrobial treatment that was inappropriate according the center's guidelines. Two evaluators assessed appropriateness.

RESULTS

We analyzed 406 antimicrobial treatments. The main clinical syndromes were pneumonia (24%), urinary infections (22%), and nonpneumonia lower respiratory infections (22%). We found that 51.5% of the antimicrobial treatments were inappropriate. Factors associated with inappropriate prescriptions were a failure to analyze microbiologic samples before treating (61%), failure to specify the focus of infection in the case records (73%), and failure to meet the definition of sepsis (58%).

CONCLUSION

Fewer than half the antimicrobial treatments were appropriate as prescribed. Signs of serious infection, specification of the focus of infection in the patient's records, and the analysis of biologic samples were independent predictors of quality care (appropriate antimicrobial prescription). These factors can be targeted for training in the development of a specific emergency department program to improve this aspect of care.

Continuing Education Meets the Learning Organization: The Challenge of a Systems Approach to Patient Safety

Since the release of the report of the Institute of Medicine on medical errors and patient safety in November 1999, health policy makers and health care leaders in several nations have sought solutions that will improve the safety of health care. This attention to patient safety has highlighted the importance of a learning approach and a systems approach to quality measurement and improvement. Balanced with the need for public disclosure of performance, confidential reporting with feedback is one of the prime ways that nations such as the United States, Canada, the United Kingdom, and Australia have approached this challenge. In the United States, the Quality Interagency Coordination Task Force has convened federal agencies that are involved in health care quality improvement for a coordinated initiative. Based on an investment in a strong research foundation in health care quality measurement and improvement, there are eight key lessons for continuing education if it is to parlay the interest in patient safety into enhanced continuing education and quality improvement in learning health care systems. The themes for these lessons are (1) informatics for information, (2) guidelines as learning tools, (3) learning from opinion leaders, (4) learning from the patient, (5) decision support systems, (6) the team learning together, (7) learning organizations, and (8) just-in-time and point-of care delivery.

Public/private ownership and quality of care: Evidence from Danish nursing homes

The involvement of private for-profit (FP) and not-for-profit (NFP) providers in the otherwise public delivery of welfare services is gradually changing the Nordic welfare state towards a more market-oriented mode of service delivery. This article examines the relationship between ownership and quality of care in public and private FP and NFP nursing homes in Denmark. The analysis draws on original survey data and administrative registry data (quality inspection reports) for the full population of almost 1000 nursing homes in Denmark. Quality is measured in terms of structural quality, process quality and outcome quality. We find that public nursing homes have a higher structural quality (in terms of, for instance, staffing), while FP providers perform better in terms of process quality (e.g. in the form of individualised care). NFP providers perform well in terms of structural criteria such as employment of full-time staff and receive fewer critical comments in the inspection reports. However, the results depend to some extent upon the method of data collection, which underlines the benefits of using multiple data sources to examine the relationship between ownership and the quality of care.

Quality of Care in the United Kingdom after Removal of Financial Incentives

BACKGROUND

The benefits of pay-for-performance schemes in improving the quality of care remain uncertain. There is little information on the effect of removing incentives from existing pay-for-performance schemes.

METHODS

We conducted interrupted time-series analyses of electronic medical record (EMR) data from 2010 to 2017 for 12 quality-of-care indicators in the United Kingdom's Quality and Outcomes Framework for which financial incentives were removed in 2014 and 6 indicators for which incentives were maintained. We estimated the effects of removing incentives on changes in performance on quality-of-care measures.

RESULTS

Complete longitudinal data were available for 2819 English primary care practices with more than 20 million registered patients. There were immediate reductions in documented quality of care for all 12 indicators in the first year after the removal of financial incentives. Reductions were greatest for indicators related to health advice, with a reduction of 62.3 percentage points (95% confidence interval [CI], -65.6 to -59.0) in EMR documentation of lifestyle counseling for patients with hypertension. Changes were smaller for indicators involving clinical actions that automatically update the EMR, such as laboratory testing, with a reduction of 10.7 percentage points (95% CI, -13.6 to -7.8) in control of cholesterol in patients with coronary heart disease and 12.1 percentage points (95% CI, -13.6 to -10.6) for thyroid-function testing in patients with hypothyroidism. There was little change in performance on the 6 quality measures for which incentives were maintained.

CONCLUSIONS

Removal of financial incentives was associated with an immediate decline in performance on quality measures. In part, the decline probably reflected changes in EMR documentation, but declines on measures involving laboratory testing suggest that incentive removal also changed the care delivered.

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.

A step-wise approach to developing indicators to compare the performance of maternity units using hospital administrative data

Hospital administrative data are attractive for comparing performance of maternity units because of their often large sample sizes, lack of selection bias and the relatively low costs of accessing these data compared with conducting primary data collection. However, using administrative data to develop indicators can also present challenges including varying data quality, the limited detail on clinical risk factors and a lack of structural and user experience measures. This review illustrates how to develop performance indicators for maternity units using hospital administrative data, including methods to address the challenges that administrative data pose.

TWEETABLE ABSTRACT

How to develop maternity indicators from administrative data.

Performance assessment of the inpatient medical services of a clinical subspecialty: A case study with risk adjustment based on diagnosis-related groups in China

Diagnosis-related groups (DRGs) have been receiving increasing attention in health service research in China. In the present study, we used the 2014 Beijing-Diagnosis Related Groups (BJ-DRGs) to evaluate the inpatient service performance of the clinical subspecialty "major operation of the digestive system" of a cancer specialist hospital.The research hospital is one of 16 public municipal hospitals overseen by the Beijing Health Bureau ("16 hospitals"). Discharge data collected between 2008 and 2015 were drawn from the front pages of the medical records of these hospitals. After the data were reported to the Beijing Public Health Information Centre, as well as being grouped using the BJ-DRGs. We evaluated the service performance of this subspecialty in terms of capacity, efficiency, and service quality, based on the BJ-DRGs risk adjustment tool.From 2008 to 2015, the total weight of the subspecialty in the research hospital increased annually. In 2015, the cases in this hospital accounted for 50.27% of the total in 16 hospitals. The time consumption index was 0.91, whereas the charge consumption index was 1.24, which was 24% higher than the average in16 hospitals. The mortality rates of the middle-low risk groups (GB15 and GB25) in the research hospital and the 16 hospitals were zero, while the mortality rates for the middle-high risk groups (GB11 and GB23) in the research hospital were significantly lower than those in 16 hospitals.The service capacity of the subspecialty steadily increased in the research hospital. However, the hospital must offer more attention to complex digestive disease cases (GB11/GB23) and strictly control hospitalization expenses, while maintaining the advantages of service efficiency and quality.

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.