Improving the quality of care for patients with cystic fibrosis

Association of Pseudomonas aeruginosa incident infections with adherence to cystic fibrosis foundation care guidelines

BACKGROUND

Care guidelines for cystic fibrosis (CF) have been developed to enhance consistent care and to improve health outcomes. We determined if adherence to CF care guidelines predicted P. aeruginosa incidence rates (Pa-IR) at U.S. CF centers in 2018.

METHODS

This cross-sectional CF Foundation Patient Registry study included 82 adult and 132 pediatric centers. Adherence to 12 guidelines was defined categorically (guideline met) or as a continuous measure (proportion of patients being treated/evaluated per guideline). Association of adherence to individual guidelines with Pa-IR, accounted for center and patient characteristics relevant to Pa-IR and were modeled using random forests and weighted-least-squares (WLS) analyses.

RESULTS

The mean Pa-IR was 0.2 cases/patient-years at risk (SE 0.0074) for all centers combined. Guideline adherence was lowest for ≥4 bacterial cultures/year (54% of centers) and annual oral glucose tolerance test (OGTT) (48% of centers), and highest for annual non-tuberculous mycobacteria (NTM) sputum culture (98%). The mean number of guidelines met was 6.7 and higher for pediatric (7.3) than adult (5.6) centers, (p<0.001). The number of guidelines met correlated negatively with Pa-IR (β=-0.007, p = 0.043). Macrolide prescription and annual OGTT per guideline were associated with lower and higher Pa-IR, respectively. Centers with lower center-wide lung function, higher proportion of pwCF with low body-mass index, and location in the Southwest had higher Pa-IR.

CONCLUSION

Overall adherence to guidelines was high except for performing ≥4 bacterial cultures/year and OGTT. Higher Pa-IR was associated with center characteristics and lower guideline adherence. The lower Pa-IR with greater adherence to guidelines suggests that focusing on quality care can positively impact Pa-IR.

Transforming the nutrition care model for infants with cystic fibrosis: A qualitative study of clinicians' perspectives

Clinician perspectives may inform health service strategies to meet optimal nutrition needs for infants with cystic fibrosis (CF). We conducted a qualitative study with CF-specialized dietitians (registered dietitians [RDs]) and physicians between July to December 2020 to characterize the current state of infant nutrition care delivery and organize input into a conceptual model to inform CF care program strategies. Among 42 participants, 36 completed survey responses and 6 completed interviews; 93% were RDs. Three global themes emerged in the current care model: nutrition management, family centered connections, and collaborative care delivery. Within nutrition management, clinicians emphasized providing education, setting goals, and maintaining adequate follow-up with families. Under family centered connections, clinicians expressed the need to foster relationships with families and link families to resources for assistance to social stressors such as food insecurity. Collaborative care delivery for clinicians interviewed was defined by sharing expertise from across the interdisciplinary team. Based on the timing of this study, clinicians reported compelling examples for various modes of telehealth and home weight monitoring to facilitate and support these domains of nutrition care, including potential advantages for education, supporting family needs, and communication. We integrate these themes to propose a conceptual model to organize complementary in-person and telehealth activities and enhance quality infant CF nutrition care delivery. Future implementation can refine this model through testing of practical telehealth interventions to optimize nutrition outcomes for infants with CF.

Working towards consensus in the management of pediatric chronic rhinosinusitis in cystic fibrosis

OBJECTIVE

The prevalence of chronic rhinosinusitis (CRS), defined by mucosal thickening on imaging, approaches 100% in the cystic fibrosis (CF) population. CRS is associated with significant morbidity in CF, including its ability to trigger pulmonary exacerbations. CRS in CF is typically managed by pediatricians, otolaryngologists and pulmonologists. This survey evaluates the variance in practice patterns of CRS in CF amongst specialists.

METHODS

This is a cross-sectional, electronic survey in which maximum variation purposive sampling was used by a multi-disciplinary group of pediatric, otolaryngology and pulmonology providers in order to select a survey population with expertise in CRS in CF patients. The survey was distributed to 381 practitioners from September to October 2019.

RESULTS

175 participants responded (45% response rate). Ten (of 54) statements achieved 75% consensus agreement. Consensus statements included: The decision to pursue surgical intervention for CRS in CF is a multi-disciplinary approach (94%; n = 146); maximal medical management should include nasal saline irrigation (93%; n = 142), topical steroids (75%; n = 117), maximal medical management should not include intravenous steroids (79%; n = 122); image guidance in surgery is necessary for all surgery involving the frontal sinuses (77%; n = 43), and all revision surgery(80%, n = 45); the appropriate setting for sinus surgery in a CF patient varies depending on patient presentation (89%; n = 133); post-operative regimen should include nasal saline (93%; n = 137); but does depend on the severity of disease discovered intra-operatively (84%; n = 124); post-operative antibiotics should be guided by intra-operative culture data (82%; n = 121).

CONCLUSIONS

There is a great deal of variation amongst specialists in the treatment of CRS in CF, however 10 statements met consensus criteria and should be considered when forming clinical care guidelines in this population.

Population Management: A Tool to Improve Timely Care in Pediatric and Young Adult Patients with Inflammatory Bowel Disease

Background

Maintenance of health leads to better outcomes in patients with chronic illness. ImproveCareNow, an international inflammatory bowel disease (IBD) quality improvement (QI) network, recommends maintenance-of-health visits twice a year. We identified a gap in care, with only 64% of IBD patients having documented visits within 200 days. Therefore, we sought to improve our follow-up rate to a goal of 80%.

Methods

Using population management (PM) reports, we identified patient-, data-, and treatment-related reasons for no documented visit within 200 days. We used the Pareto chart, key drivers, and process flow mapping and implemented changes using Plan-Do-Study-Act (PDSA) cycles to improve follow-up visit rates. Outcomes were presented using a control run chart with pre- and post- intervention data.

Results

The most common reasons for no visits were patient nonadherence with appointments (50%) and relocation/transition to an adult provider (25%). The median percentage of documented visits within 200 days increased from 64% to 83% (p < 0.0001), and this increase has been sustained for one year.

Conclusions

Using the PM tool and focused QI interventions improved data quality and the percentage of patients with a documented visit within 200 days. The process is simple and can be applied to patients with other chronic illnesses.

Phenotypic severity scoring system and categorisation for prune belly syndrome: application to a pilot cohort of 50 living patients

OBJECTIVE

To design a novel system of scoring prune belly syndrome (PBS) phenotypic severity at any presenting age and apply it to a large pilot cohort.

PATIENTS AND METHODS

From 2000 to 2017, patients with PBS were recruited to our prospective PBS study and medical records were cross-sectionally analysed, generating individualised RUBACE scores. We designed the pragmatic RUBACE-scoring system based on six sub-scores (R: renal, U: ureter, B: bladder/outlet, A: abdominal wall, C: cryptorchidism, E: extra-genitourinary, generating the acronym RUBACE), yielding a potential summed score of 0-31. The 'E' score was used to segregate syndromic PBS and PBS-plus variants. The cohort was scored per classic Woodard criteria and RUBACE scores compared to Woodard category.

RESULTS

In all, 48 males and two females had a mean (range) RUBACE score of 13.8 (8-25) at a mean age of 7.3 years. Segregated by phenotypic categories, there were 39 isolated PBS (76%), six syndromic PBS (12%) and five PBS-plus (10%) cases. The mean RUBACE scores for Woodard categories 1, 2, and 3 were 20.5 (eight patients), 13.8 (25), and 10.6 (17), respectively (P < 0.001).

CONCLUSIONS

RUBACE is a practical, organ/system level, phenotyping tool designed to grade PBS severity and categorise patients into isolated PBS, syndromic PBS, and PBS-plus groups. This standardised system will facilitate genotype-phenotype correlations and future prospective multicentre studies assessing medical and surgical treatment outcomes.

Epidemiology of Rare Lung Diseases: The Challenges and Opportunities to Improve Research and Knowledge

Rare lung diseases encompass a broad spectrum of conditions and affect an estimated 1.2-2.5 million people in North America and 1.5-3 million people in Europe. While individual rare lung diseases affect less than 1 in 2000 individuals, collectively they have a significant impact upon the population at large. Hence it is vital to understand firstly the epidemiology and subsequently the pathogenesis and clinical course of these disorders. Through a greater understanding of these aspects of disease, progress can be made in reducing symptoms, containing healthcare costs and utilizing resources efficiently. Furthermore, a greater understanding of the pathobiology of rare lung diseases can inform both the pathogenesis and management of more common pulmonary disorders.In this chapter we review how epidemiological approaches and the utilization of patient registries has improved the knowledge and management of rare lung diseases. We further focus on the epidemiology of several of the more widely known rare pulmonary disorders, including idiopathic pulmonary fibrosis (IPF), cystic fibrosis (CF) and alpha-1 antitrypsin deficiency (AATD). To conclude we describe how patient advocacy groups and foundations have driven advances in research and management of ultra-rare lung diseases, namely, the major strides made in the management and understanding of lymphangioleiomyomatosis (LAM) and pulmonary alveolar proteinosis (PAP).We conclude that the models used to study some of the rarest of diseases may be successfully adopted by other rare and common disease communities, leading to improved care and the possibility of novel therapeutic options.

[Quality of care in inflammatory bowel disease]

Since inflammatory bowel disease (IBD) is a chronic and relapsing disorder, maintaining high quality of care plays an important role in the management of patients with IBD. To develop process-based quality indicator set to improve quality of care, the indicator should be based directly on evidence and consensus. Initially, ImproveCareNow group demonstrated quality improvement by learning how to apply quality improvement methods to improve the care of pediatric patients with IBD. The American Gastroenterological Association has developed adult IBD physician performance measures set and Crohn's and Colitis Foundation of America (CCFA) has developed a set of ten most highly rated process and outcome measures. Recently, The Emerging Practice in IBD Collaborative (EPIC) group generated defining quality indicators for best-practice management of IBD in Canada. Quality of Care through the Patient's Eyes (QUOTE-IBD) was developed as a questionnaire to measure quality of care through the eyes of patients with IBD, and it is widely used in European countries. The current concept of quality of care as well as quality indicator will be discussed in this article.

Variation in Care of Inflammatory Bowel Diseases Patients in Crohn's and Colitis Foundation of America Partners: Role of Gastroenterologist Practice Setting in Disease Outcomes and Quality Process Measures

BACKGROUND

As variation in care has previously been linked to quality, we aimed to describe variations in inflammatory bowel diseases care by gastroenterology (GI) practice setting.

METHODS

We performed a cross-sectional study within the Crohn's and Colitis Foundation of America Partners and used bivariate analyses to compare patient characteristics by GI practice setting (GI-academic [GIA], GI-private, or GI-other). Regression models were used to describe the effects of provider type on steroid use, disease activity, and the quality of life.

RESULTS

The study included 12,083 patients with inflammatory bowel diseases (7576 with Crohn's disease [CD] and 4507 with ulcerative colitis [UC]). Nearly 95% reported visiting a GI provider annually. Also, CD patients seen by GIA were younger, better educated, used less 5-aminosalicylate agents, and had higher biologic and immunomodulator use (P < 0.001 for all). On multivariate analysis of CD patients, GIA used less steroids when compared with GI-private (odds ratio, 0.84; 95% confidence interval, 0.67-1.06) or GI-other (odds ratio, 0.66; 95% confidence interval, 0.49-0.89). GIA patients were more likely to be in remission, have flu vaccine, and have better quality of life. UC patients seen by GIA were younger, had more hospitalizations, and previous surgery (P < 0.001 for all). No differences existed for steroid use, remission, flu vaccine, or quality of life for UC care on bivariate or multivariate analyses.

CONCLUSIONS

Significant variations in care patterns and quality measures exist for CD across GI provider types, without similar variation in UC care. Interventions to reduce variations in care could improve the quality of care in CD.

Clinicians' experiences with the fragile X clinical and research consortium

The objectives of the study were to assess the attitudes and experiences of clinicians involved in a consortium of clinics serving people with fragile X-associated disorders to gauge satisfaction with the consortium and its efforts to improve quality of life for patients and the community. An internet survey was sent to 26 fragile X (FX) clinic directors participating in the Fragile X Clinical and Research Consortium (FXCRC). Respondents were asked to complete 19 questions on consortium performance and outcomes relevant for their own clinic. The response rate was 84% (22/26), with two surveys providing incomplete data. Assistance with clinic establishment, opportunities for research collaborations, and access to colleagues and information were highly valued. Approximately 76% of clinicians reported improvements in patient care and 60% reported an increase in patient services. There was a 57% increase in participation in a FX-related clinical trial among clinics since joining the FXCRC (24% vs. 81%). Overall, respondents reported primarily positive experiences from participation in the FXCRC. Common suggestions for improvement included additional financial support and increased utilization of collected patient data for research purposes. Additionally, a Clinic Services Checklist was administered annually to examine changes in services offered over time. There were several important changes regarding the provision of services by clinics, often with multiple clinics changing with respect to a service. In conclusion, the FXCRC has led to the establishment and sustainment of fragile X clinics in the U.S., fostered cooperation among fragile X clinicians, and provided clinics with a platform to share recommendations and best practices to maximize quality of life for their patients and the overall fragile X community. The results from the survey and checklist also provide suggestions to strengthen the FXCRC and enhance future collaborations among FXCRC members. © 2016 Wiley Periodicals, Inc.

Hypertransaminasemia in Newly Diagnosed Pediatric Patients With Celiac Disease

OBJECTIVES

The aim of the present study was to determine the proportion of pediatric patients with celiac disease (CD) who had transaminases obtained at diagnosis and to determine the proportion with hypertransaminasemia.

METHODS

Data from newly diagnosed patients with CD at Nationwide Children's Hospital from February 2007 to March 2014 were retrospectively reviewed. Alanine transaminase (ALT) and aspartate transaminase (AST) values at diagnosis and after initiation of a gluten-free diet (GFD) were assessed.

RESULTS

Of 388 patients (mean age 10.1 ± 4.4 years, 235 girls), 185 (47.7%) had transaminases obtained at the time of diagnosis. Twenty-eight of one hundred eighty-five (15.1%) had an elevated ALT and/or AST level with an average ALT 2.52 × upper limit of normal (ULN) and AST 1.87 × ULN. Those with hypertransaminasemia were younger than those with normal levels (6.31 ± 4.75 vs 11.00 ± 4.28 years, P < 0.0001). Sex, symptoms at diagnosis, and weight, height, and body mass index z scores were not predictive of elevated transaminases. Of the 21 patients with hypertransaminasemia at diagnosis who had repeat laboratory test results after starting the GFD, 15 (71.4%) normalized whereas 6 (28.6%) remained elevated.

CONCLUSIONS

There is variation in practice among pediatric gastroenterologists in the assessment of transaminases in children with CD. Hypertransaminasemia is present at diagnosis in a significant proportion of children with CD although at a lower frequency than previously reported. Younger patients are more likely to have an elevation in transaminases. Abnormal transaminases normalize in the majority of patients within 1 year after initiation of a GFD.

Improving HPV Vaccination Rates Using Maintenance-of-Certification Requirements

BACKGROUND

Many pediatricians are now required to participate in American Board of Pediatrics Maintenance of Certification (MOC) Part IV programs focused on improving health care quality, but the benefits of participation are unproven.

METHODS

Twenty-seven primary care pediatricians from 11 primary care practices participated in a 1-year MOC program for human papillomavirus (HPV) vaccine. Participants received education and electronic health record (EHR)-generated performance feedback reports with their rates of captured HPV immunization opportunities (dose given at eligible visit) and those of peers. In each of 3 cycles, clinicians collectively identified a goal for improvement. Rates of captured opportunities among adolescents 11 to <18 years old were tabulated, and statistical process control charts were created to evaluate changes over time among participants compared with 200 nonparticipants. Provider perceptions of the program and time invested were recorded via survey.

RESULTS

Participating clinicians missed fewer opportunities for HPV vaccination than nonparticipants. MOC participants significantly increased their captured opportunities relative to nonparticipating clinicians by 5.7 percentage points for HPV dose 1 at preventive visits and by 0.7 and 5.6 percentage points for doses 1 and 2, respectively, at acute visits. There were no significant differences for other doses. The estimated program cost was $662/participant. Of the participating pediatricians, 96% felt the effort to participate was warranted, and half would not have joined the project without the MOC requirement.

CONCLUSIONS

Participation in MOC Part IV improved vaccination at modest cost and with high pediatrician satisfaction, demonstrating benefits of the program that may help to inform future initiatives.

Sustained improvement in nutritional outcomes at two paediatric cystic fibrosis centres after quality improvement collaboratives

OBJECTIVE

To describe the characteristics of sustained improved nutritional outcomes through the use of quality improvement (QI) methodology.

DESIGN

Retrospective analysis of a QI intervention in two institutions, implemented as part of larger national collaboratives.

SETTING

Paediatric cystic fibrosis (CF) programmes in academic centres in Alabama and Illinois.

PARTICIPANTS

All paediatric patients enrolled in the CF Foundation (CFF) Patient Data Registry were included.

INTERVENTIONS

Improved and sustained nutrition outcomes occurred through implementation of the CFF practice guidelines for CF nutrition management via care delivery processes, nutritional interventions, team engagement and data display.

MEASUREMENT

Mean body mass index (BMI) percentile, percentage of patients less than 50th percentile and percentage less than 10th percentile for all patients aged 2-20 years were tracked through run charts and statistical process control charts. Mann-Whitney U and χ(2) tests were used to determine significance between each centre and national outcomes.

RESULTS

Each centre achieved rapid improvement in mean BMI percentile in patients, one centre rising from the 40th percentile in 2001 to the 49th percentile in 2003, the other rising from the 37th percentile in 2003 to the 45th percentile in 2004. These centres have also maintained improved nutritional outcomes, so that they were at the 60th and 55th percentiles, respectively, in 2011. Sustained improvement was accomplished through QI methodology, use of data as a driver for improvement and a change in culture.

CONCLUSIONS

Participation in collaboratives led to improved nutrition outcomes while a strong culture of QI facilitated sustained improvement.

Innovative care model for patients with complex muscle diseases

PURPOSE OF REVIEW

Many neuromuscular disorders require complex multisystem management. This is especially true for the rapidly growing numbers of young adults surviving congenital and childhood onset conditions following improved multidisciplinary care and the routine use of home ventilation. Surveys from the United Kingdom and Netherlands indicate that neuromuscular disorder patients report their services to be at best 'average' and more often 'poor' in quality. Centralization of care to a small number of specialist centres to increase critical mass and thus improve the expertise of clinical teams has been recommended.

RECENT FINDINGS

A recent audit of unplanned hospital admissions for neuromuscular disorder patients has substantiated data from patient surveys. Patients often had no access to a neuromuscular specialist or had fragmented care; 37.5% of 359 unplanned neuromuscular disorder emergency admissions were identified as potentially avoidable.

SUMMARY

A Neuromuscular Complex Care Centre has recently opened in the United Kingdom to provide holistic patient-centred care in a purpose built adapted environment with high staff to patient ratio. Elective multisystem assessments will be co-ordinated into a 'one stop' admission, bringing the specialists to the patient. The centre will provide first point of contact with 24-h telephone access 7 days a week and will advise and support local hospitals on the management of acutely unwell patients. Regular multidisciplinary meetings of specialized consultants and therapists will improve communication and maximize outcomes. In the long term, we anticipate this high-quality development to be cost-effective in reducing the frequency of outpatient appointments and emergency/critical care admissions.

Sociodemographic attributes and spina bifida outcomes

BACKGROUND

A National Spina Bifida Patient Registry (NSBPR) was begun in 2009 to help understand the natural history of spina bifida (SB) and the effects of treatments provided by SB clinics. We used the NSBPR to explore the relationship of sociodemographic characteristics with SB outcomes.

METHODS

Using NSBPR data collected in 2009 to 2012, we examined the unadjusted association between demographic characteristics and 4 SB outcomes: bowel continence, bladder continence, mobility, and presence of pressure sores. We then developed multivariable logistic models to explore these relationships while controlling for SB clinic, SB type, and level of lesion.

RESULTS

Data were available on 2054 patients <22 years of age from 10 SB clinics. In the multivariable models, older age groups were more likely to have continence and pressure sores and less likely to be community ambulatory. Males and patients without private insurance were less likely to be continent and community ambulatory. Non-Hispanic blacks were less likely to be continent. Level of lesion was associated with all outcomes; SB type was associated with all but pressure sores; and all outcomes except community ambulation showed significant variation across clinic sites.

CONCLUSIONS

Sociodemographic attributes are associated with SB outcomes. In particular, males, non-Hispanic blacks, and patients without private insurance have less favorable outcomes, and age has an impact as well. These characteristics need to be considered by clinicians who care for this patient population and factored into case-mix adjustment when evaluating variation in clinical and functional outcomes among different SB clinics.

Inter-hospital variation in the frequency of sinus surgery in children with cystic fibrosis

BACKGROUND

Chronic rhinosinusitis and nasal polyposis are common conditions in cystic fibrosis (CF). Approximately 2-3% of pediatric CF patients per year have sinus disease requiring surgery. The purpose of this study was to evaluate the variation of sinus surgery rates in pediatric CF patients across multiple US pediatric hospitals.

METHODS

The Pediatric Health Information System (PHIS) compiles inpatient administrative data from 42 pediatric hospitals. We conducted a retrospective analysis of PHIS for the period January 1, 2008 to January 1, 2011 to evaluate frequency of sinus surgery at each hospital. We identified CF patients and sinus surgery during inpatient encounters using ICD-9 codes. Demographic data and data for each hospital on hospital size, number of pediatric otolaryngologists, average FEV1, and percentage of patients meeting minimum care guidelines were collected. Twenty-nine hospitals were included in analysis using mixed-effects logistic regression models for occurrence of sinus surgery.

RESULTS

We identified 5,194 CF patients, accounting for 18,788 unique encounters among 29 hospitals. 880 patients underwent 1,397 sinus operations. Total number of CF patients at each institution ranged from 39 to 364 and total number of sinus surgeries ranged from 4 to 205, over the 3-year period. Variation in the rate of sinus surgery with hospital encounter was observed (1-24%). Hospital-average lung function (P = 0.56), number of otolaryngologists (P = 0.65) were not found to be predictors of sinus surgery. The size of the CF center (P = 0.01), hospital size (P = 0.05), and age at admission (P ≤ 0.0001) were associated with an increased frequency of sinus surgery. However, with multivariable analysis, only size of the CF center and age of admission remained statistically significant predictors of surgery with admission.

CONCLUSIONS

There is large variation in the incidence of sinus surgery for CF in 29 of the largest freestanding pediatric hospitals. This study highlights remarkable variation in clinical practice and underscores the need for further research into the indications and benefits of sinus surgery in pediatric patients with CF. Pediatr Pulmonol. 2015; 50:231-235. © 2014 Wiley Periodicals, Inc.

Economic Burden And Health-Related Quality Of Life Of Patients With Cystic Fibrosis In Bulgaria

Objective:The aim of this study was to determine the economic burden from a societal perspective and health-related quality of life (HRQOL) of patients with cystic fibrosis (CF) in Bulgaria.

Materials and methods:We conducted a cross-sectional study of 33 patients with CF and 17 caregivers from Bulgaria. Data on socio-demographic characteristics, health resource utilisation, informal care, labor productivity losses and HRQOL were collected from questionnaires completed by patients or their caregivers. HRQOL was evaluated with the EuroQol 5-domain (EQ-5D-3L) questionnaire.

Results:Median annual costs of CF in Bulgaria were € 24 152 per patient in 2012 as a reference year. Median annual costs for children were found to be significantly higher than those for adults – € 31 945 vs. € 15 714 (p = 0.012). This outcome came from statistically significant differences in costs for main informal carer (p < 0.001) and costs for other informal carers (p = 0.022). As a single cost item, drugs had the biggest monetary impact. Median annual drug costs were € 13 059. Bulgarian CF patients showed low HRQOL results – 50 median VAS score and 0.592 median health utilities. A quarter of patients even rated their health state as worse than death.

Conclusion:CF patients from Eastern Europe remain a vulnerable population with risk factors for worse health outcomes. Our study provided a state-of-the art analysis that facilitates the elaboration, adoption and application of targeted public health policies to tackle CF-related problems at national and European level.

Pulmonary function outcomes for assessing cystic fibrosis care

BACKGROUND

Assessing cystic fibrosis (CF) patient quality of care requires the choice of an appropriate outcome measure. We looked systematically and in detail at pulmonary function outcomes that potentially reflect clinical practice patterns.

METHODS

Epidemiologic Study of Cystic Fibrosis data were used to evaluate six potential outcome variables (2002 best FVC, FEV(1), and FEF(25-75) and rate of decline for each from 2000 to 2002). We ranked CF care sites by outcome measure and then assessed any association with practice patterns and follow-up pulmonary function.

RESULTS

Sites ranked in the top quartile had more frequent monitoring, treatment of exacerbations, and use of chronic therapies and oral corticosteroids. The follow-up rate of pulmonary function decline was not predicted by site ranking.

CONCLUSIONS

Different pulmonary function outcomes associate slightly differently with practice patterns, although annual FEV(1) is at least as good as any other measure. Current site ranking only moderately predicts future ranking.

Quality improvement and pay for performance: barriers to and strategies for success

Linking health-care quality improvement to payment appears straightforward. Improve the care that one provides to one's patients, and one is rewarded financially. Should one fail to improve care, then one is financially penalized. However, this strategy assumes that health-care workers and administrators possess the necessary tools and knowledge to improve care and that the metrics being measured have been rigorously tested. Although health-care workers and hospitals are publically committed to reducing inappropriate care, improving patient safety, achieving better health outcomes, and holding down costs, many are unsure how to do this effectively. We present the case that it is not usually the people who create the problems in our health system; rather, it is the processes of the care-delivery system that require change. Incentivizing performance improvement using simple metrics is unlikely to work before using compensation strategies to incentivize behavior change in clinical systems. But prior to even doing this, leaders and physicians must first create accurate performance measures and understand improvement science.

Can outcomes in Duchenne muscular dystrophy be improved by public reporting of data?

OBJECTIVE

To review current approaches for obtaining patient data in Duchenne muscular dystrophy (DMD) and consider how monitoring and comparing outcome measures across DMD clinics could facilitate standardized and improved patient care.

METHODS

We reviewed annual standardized data from cystic fibrosis (CF) clinics and DMD care guidelines and consensus statements; compared current approaches to obtain DMD patient data and outcome measures; and considered the best method for implementing public reporting of outcomes, to drive improvements in health care delivery.

RESULTS

Current methods to monitor DMD patient information (MD STARnet, DuchenneConnect, and TREAT-NMD) do not yet provide patients with comparative outcome data. The CF patient registry allows for reporting of standard outcomes across clinics and is associated with improved CF outcomes. A similar patient registry is under development for the Muscular Dystrophy Association (MDA) clinic network. Suggested metrics for quality care include molecular diagnosis, ambulatory status and age at loss of ambulation, age requiring ventilator support, and survival.

CONCLUSIONS

CF longevity has increased by almost 33% from 1986 to 2010, in part due to a CF patient registry that has been stratified by individual care centers since 1999, and publically available since 2006. Implementation of outcome reporting for MDA clinics might promote a similar benefit to patients with DMD.

Systematic review: The role of race and socioeconomic factors on IBD healthcare delivery and effectiveness

BACKGROUND

Race and socioeconomic status (SES) significantly affect the content and delivery of healthcare for multiple chronic disease states. Inflammatory bowel disease (IBD) is a set of complex, chronic diseases with the potential for significant morbidity if the content or delivery of healthcare is suboptimal. However, the literature related to race, SES, and IBD remains fragmented.

METHODS

Using guidelines published by the Centre for Reviews and Dissemination, we performed a systematic review of the world's literature to identify studies related to: 1) IBD, 2) race/ethnicity, 3) SES, 4) healthcare delivery, and 5) healthcare effectiveness.

RESULTS

We identified 40 studies that met inclusion criteria. Twenty-four studies (60%) assessed the role of SES and 21 (53%) evaluated race. Topics addressed by these studies included: 1) Utilization of Medical and Surgical Therapy; 2) Adherence to Medical Therapy; 3) Clinical Outcomes; 4) Healthcare Access and Utilization; 5) Disease Perception and Knowledge; and 6) Employment/Insurance. We identified race- and SES-based disparities in the content of medical and surgical healthcare, utilization of inpatient and ambulatory medical care, adherence to medical therapy, and disease perceptions and knowledge. Several studies also identified race- and SES-based disparities in outcomes for IBD, including in-hospital mortality rates and health-related quality of life.

CONCLUSIONS

Race- and SES-based disparities in the delivery and effectiveness of healthcare for patients with IBD exist in numerous domains, yet studies remain limited in their scope and breadth. Concerted, prospective, multicenter efforts are needed to address underlying causes for disparities and to identify methods of reducing and eliminating disparities.

Nongenetic influences on cystic fibrosis outcomes

PURPOSE OF REVIEW

Despite dramatic improvements over the last several decades, tremendous variation exists in cystic fibrosis (CF) health outcomes. Genetic explanations for variations in disease progression are a promising source of information regarding disease biology and pathophysiology, but an understanding of nongenetic factors provides more immediate tools for improving disease outcomes.

RECENT FINDINGS

The clinical course of CF for any individual with CF is determined by the interaction of genetic endowment (including CFTR and modifier genes), the physical environment (including environmental tobacco smoke, outdoor pollution, and pathogenic microorganisms), the sociodemographic, cultural, and family context (which mediates stress, social support, and disease self-management skills), and variations in delivery and acceptance of healthcare treatments. The evidence linking socioeconomic status (SES) with CF outcomes continues to be strong, and appears to be primarily due to associations with environmental and sociocultural stressors and disease-management behaviors rather than barriers in access to healthcare.

SUMMARY

Attempts to eliminate detrimental environmental exposures, improve disease self-management skills, and ensure consistently optimal healthcare practices will likely decrease variations in outcomes including SES-related disparities. Low SES is an important marker of adverse exposures and outcomes which are present throughout the CF population.

The use of a cystic fibrosis patient registry to assess outcomes and improve cystic fibrosis care in Germany

PURPOSE OF REVIEW

Cystic fibrosis (CF) patient registries have become an important epidemiological tool for demography, networking, and quality management. This review describes recent developments in patient registries, outcome research, and pilot projects in quality improvement.

RECENT FINDINGS

National and international CF registry efforts have been producing consolidated data. Classical outcome indicators describing nutritional status and lung function are now being used in a more precise way, based on body mass index percentiles and longitudinal data. Projects involving single centers and quality groups, such as the German benchmarking project, have been showing that quality improvement is possible and that negative developments do not necessarily have to be accepted in CF.

SUMMARY

CF provides a model of the link between healthcare delivery and outcomes in patients. CF registry data can be used to improve quality in CF healthcare. Quality improvement is a continuous endeavor involving the reinforcement of standards and programs as well as individual attitudes and soft skills. One particularly powerful technique is benchmarking, that is, learning from the best.