Quality of Disease Management and Risk of Mortality in English Primary Care Practices

Trends in hospital admissions and mortality from diabetes mellitus in Rio Grande do Sul: historical series 2000-2020

OBJECTIVE

To analyze the trends of hospital admissions and deaths from diabetes mellitus in the 18 host municipalities of the 19 regional health coordination offices and in Rio Grande do Sul, 2000-2020.

METHOD

Ecological study with secondary data collected in the Hospital Information System, the Mortality Information System, and the Brazilian Institute of Geography and Statistics, from 2000-2020. Coefficients were standardized using the direct method and Prais-Winsten regression analysis.

RESULTS

A downward trend wasfound in the coefficients of hospitalizations for diabetes mellitus in most cities and states. In 2020, for both areas, hospitalizations for diabetes mellitus were below the average of the period. The mortality trend remained stationary in almost all municipalities and in the state.

CONCLUSION

There was evidence of a decrease in hospitalizations and stationary mortality by DM in most municipalities analyzed, possibly due to the policies and actions implemented in the period, despite the aging of the population.

Composite measures of quality of health care: Evidence mapping of methodology and reporting

Background

Quality indicators are used to quantify the quality of care. A large number of quality indicators makes assessment of overall quality difficult, time consuming and impractical. There is consequently an increasing interest for composite measures based on a combination of multiple indicators.

Objective

To examine the use of different approaches to construct composite measures of quality of care and to assess the use of methodological considerations and justifications.

Methods

We conducted a literature search on PubMed and EMBASE databases (latest update 1 December 2020). For each publication, we extracted information on the weighting and aggregation methodology that had been used to construct composite indicator(s).

Results

A total of 2711 publications were identified of which 145 were included after a screening process. Opportunity scoring with equal weights was the most used approach (86/145, 59%) followed by all-or-none scoring (48/145, 33%). Other approaches regarding aggregation or weighting of individual indicators were used in 32 publications (22%). The rationale for selecting a specific type of composite measure was reported in 36 publications (25%), whereas 22 papers (15%) addressed limitations regarding the composite measure.

Conclusion

Opportunity scoring and all-or-none scoring are the most frequently used approaches when constructing composite measures of quality of care. The attention towards the rationale and limitations of the composite measures appears low.

Discussion

Considering the widespread use and the potential implications for decision-making of composite measures, a high level of transparency regarding the construction process of the composite and the functionality of the measures is crucial.

Multi-method versus single method appraisal of clinical quality indicators for the emergency medical services

BACKGROUND

Quality Indicator (QI) appraisal protocol is a novel methodology that combines multiple appraisal methods to comprehensively assess the 'appropriateness' of QIs for a particular healthcare setting. However, they remain inadequately explored compared to the single appraisal method approach.

OBJECTIVES

To describe and test a multi-method QI appraisal protocol versus the single method approach, against a series of QIs previously identified as potentially relevant to the prehospital emergency care setting.

METHODS

An appraisal protocol was developed consisting of two categorical-based appraisal methods, combined with the qualitative analysis of the discussion generated during the consensus application of each method. The output of the protocol was assessed and compared with the application and output of each method. Inter-rater reliability (IRR) of each particular method was evaluated prior to group consensus rating. Variation in the number of non-valid QIs and the proportion of non-valid QIs identified between each method and the protocol were compared and assessed.

RESULTS

There was mixed IRR of the individual methods. There was similarly low-to-moderate correlation of the results obtained between the particular methods (Spearman's rank correlation = 0.42, P < 0.001). From a series of 104 QIs, 11 non-valid QIs were identified that were shared between the individual methods. A further 19 non-valid QIs were identified and not shared by each method, highlighting the benefits of a multi-method approach. The outcomes were additionally evident in the group discussion analysis, which in and of itself added further input that would not have otherwise been captured by the individual methods alone.

CONCLUSION

The utilization of a multi-method appraisal protocol offers multiple benefits, when compared to the single appraisal approach, and can provide the confidence that the outcomes of the appraisal will ensure a strong foundation on which the QI framework can be successfully implemented.

Variation in anticoagulation for atrial fibrillation between English clinical commissioning groups: an observational study

BACKGROUND

Despite improvement in anticoagulation for atrial fibrillation (AF), substantial variation in anticoagulation persists between clinical commissioning groups (CCGs) and regions in England.

AIM

To identify reasons for variation between English CCGs in anticoagulation for AF.

DESIGN AND SETTING

A 4-year observational study from 2012/2013 to 2015/2016, of the national Quality and Outcomes Framework.

METHOD

Multiple regression and Pearson's correlation coefficients were used to analyse anticoagulation for AF in relation to older age, Index of Multiple Deprivation, prescription of non-vitamin K antagonist oral anticoagulants (NOACs), and exception reporting, as well as stroke hospital admission and mortality.

RESULTS

The proportion of eligible patients in England prescribed anticoagulants for AF without exceptions for clinical complexity or patient dissent increased from 65.1% in 2012/2013 to 77.9% in 2015/2016. In 2015, 290 920 additional eligible people were anticoagulated in association with use of the CHA₂DS₂VASc rather than CHADS₂ score. From 2012 to 2015, exception reporting almost halved from 20% to 10.2%. Variation in CCG anticoagulation was not associated with deprivation or NOAC use. There was a strong negative association between exception reporting representing patient complexity and anticoagulation performance, accounting for 57% of the variation in anticoagulation without exceptions (multiple regression coefficient = -0.81; 95% confidence intervals = -0.92 to -0.71; P<0.001).

CONCLUSION

Anticoagulation for AF has improved substantially in England in association with considerable increases in the eligible population as a result of decreased exception reporting and the use of the CHA₂DS₂VASc score. There is still substantial room for improvement in most CCGs because, even allowing for exceptions, nine out of 10 CCGs failed to achieve 90% anticoagulation.

Health Equity Indicators for the English NHS: a longitudinal whole-population study at the small-area level

Background

Inequalities in health-care access and outcomes raise concerns about quality of care and justice, and the NHS has a statutory duty to consider reducing them.

Objectives

The objectives were to (1) develop indicators of socioeconomic inequality in health-care access and outcomes at different stages of the patient pathway; (2) develop methods for monitoring local NHS equity performance in tackling socioeconomic health-care inequalities; (3) track the evolution of socioeconomic health-care inequalities in the 2000s; and (4) develop ‘equity dashboards’ for communicating equity findings to decision-makers in a clear and concise format.

Design

Longitudinal whole-population study at the small-area level.

Setting

England from 2001/2 to 2011/12.

Participants

A total of 32,482 small-area neighbourhoods (lower-layer super output areas) of approximately 1500 people.

Main outcome measures

Slope index of inequality gaps between the most and least deprived neighbourhoods in England, adjusted for need or risk, for (1) patients per family doctor, (2) primary care quality, (3) inpatient hospital waiting time, (4) emergency hospitalisation for chronic ambulatory care-sensitive conditions, (5) repeat emergency hospitalisation in the same year, (6) dying in hospital, (7) mortality amenable to health care and (8) overall mortality.

Data sources

Practice-level workforce data from the general practice census (indicator 1), practice-level Quality and Outcomes Framework data (indicator 2), inpatient hospital data from Hospital Episode Statistics (indicators 3–6) and mortality data from the Office for National Statistics (indicators 6–8).

Results

Between 2004/5 and 2011/12, more deprived neighbourhoods gained larger absolute improvements on all indicators except waiting time, repeat hospitalisation and dying in hospital. In 2011/12, there was little measurable inequality in primary care supply and quality, but inequality was associated with 171,119 preventable hospitalisations and 41,123 deaths amenable to health care. In 2011/12, > 20% of Clinical Commissioning Groups performed statistically significantly better or worse than the England equity benchmark.

Limitations

General practitioner supply is a limited measure of primary care access, need in deprived neighbourhoods may be underestimated because of a lack of data on multimorbidity, and the quality and outcomes indicators capture only one aspect of primary care quality. Health-care outcomes are adjusted for age and sex but not for other risk factors that contribute to unequal health-care outcomes and may be outside the control of the NHS, so they overestimate the extent of inequality for which the NHS can reasonably be held responsible.

Conclusions

NHS actions can have a measurable impact on socioeconomic inequality in both health-care access and outcomes. Reducing inequality in health-care outcomes is more challenging than reducing inequality of access to health care. Local health-care equity monitoring against a national benchmark can be performed using any administrative geography comprising ≥ 100,000 people.

Future work

Exploration of quality improvement lessons from local areas performing well and badly on health-care equity, improved methods including better measures of need and risk and measures of health-care inequality over the life-course, and monitoring of other dimensions of equity. These indicators can also be used to evaluate the health-care equity impacts of interventions and make international health-care equity comparisons.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Primary care consultation rates among people with and without severe mental illness: a UK cohort study using the Clinical Practice Research Datalink

OBJECTIVES

Little is known about service utilisation by patients with severe mental illness (SMI) in UK primary care. We examined their consultation rate patterns and whether they were impacted by the introduction of the Quality and Outcomes Framework (QOF), in 2004.

DESIGN

Retrospective cohort study using individual patient data collected from 2000 to 2012.

SETTING

627 general practices contributing to the Clinical Practice Research Datalink, a large UK primary care database.

PARTICIPANTS

SMI cases (346,551) matched to 5 individuals without SMI (1,732,755) on age, gender and general practice.

OUTCOME MEASURES

Consultation rates were calculated for both groups, across 3 types: face-to-face (primary outcome), telephone and other (not only consultations but including administrative tasks). Poisson regression analyses were used to identify predictors of consultation rates and calculate adjusted consultation rates. Interrupted time-series analysis was used to quantify the effect of the QOF.

RESULTS

Over the study period, face-to-face consultations in primary care remained relatively stable in the matched control group (between 4.5 and 4.9 per annum) but increased for people with SMI (8.8-10.9). Women and older patients consulted more frequently in the SMI and the matched control groups, across all 3 consultation types. Following the introduction of the QOF, there was an increase in the annual trend of face-to-face consultation for people with SMI (average increase of 0.19 consultations per patient per year, 95% CI 0.02 to 0.36), which was not observed for the control group (estimates across groups statistically different, p=0.022).

CONCLUSIONS

The introduction of the QOF was associated with increases in the frequency of monitoring and in the average number of reported comorbidities for patients with SMI. This suggests that the QOF scheme successfully incentivised practices to improve their monitoring of the mental and physical health of this group of patients.