The evolution of healthcare quality measurement in the United States

Role of the Surgeon in De-Escalating Emotion During a Breast Cancer Surgery Consultation: A Qualitative Study of Patients' Experiences in Alliance A231701CD

BACKGROUND

Patient engagement in decision making can improve satisfaction with care. Studies demonstrate that patients' emotional states can be significant barriers to engaging in shared decision making.

OBJECTIVE

We sought to examine how emotion associated with a breast cancer diagnosis impacts patient experiences during the surgical consultation, and explore opportunities for surgeons to mitigate the impact of emotion.

METHODS

We conducted 30 semi-structured interviews with patients who participated in the decision aid arm of Alliance A231701CD, had low engagement, and experienced barriers to engagement. We used qualitative content analysis to analyze the interview data and organize it into overarching themes.

RESULTS

Participants recalled strong emotions with their diagnosis, describing it as devastating and shocking. Although several participants said that their emotional reaction to the diagnosis lessened over time, others expressed still feeling very anxious. Participants described ways in which their surgeon helped to de-escalate their emotional state, beginning with the establishment of rapport and continuing through treatment planning. Participants valued surgeons who they perceived to be personable and compassionate, treated them as an individual, provided reassuring and matter-of-fact information about their cancer, and efficiently communicated plans for next steps.

CONCLUSIONS

Patients with breast cancer are often emotionally overwhelmed during their surgical consults, which impedes their ability to listen and participate in decision making. However, surgeon behaviors can help de-escalate emotions. Addressing emotion is critical to support patients in reaching a decision for breast cancer surgery and is likely to improve patient satisfaction with the decision process.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov identifier: NCT03766009.

Split-sample reliability estimation in health care quality measurement: Once is not enough

OBJECTIVE

To examine the sensitivity of split-sample reliability estimates to the random split of the data and propose alternative methods for improving the stability of the split-sample method.

DATA SOURCES AND STUDY SETTING

Data were simulated to reflect a variety of real-world quality measure distributions and scenarios. There is no date range to report as the data are simulated.

STUDY DESIGN

Simulation studies of split-sample reliability estimation were conducted under varying practical scenarios.

DATA COLLECTION/EXTRACTION METHODS

All data were simulated using functions in R.

PRINCIPAL FINDINGS

Single split-sample reliability estimates can be very dependent on the random split of the data, especially in low sample size and low variability settings. Averaging split-sample estimates over many splits of the data can yield a more stable reliability estimate.

CONCLUSIONS

Measure developers and evaluators using the split-sample reliability method should average a series of reliability estimates calculated from many resamples of the data without replacement to obtain a more stable reliability estimate.

Palliative Care Clinicians' Views on Metrics for Successful Specialist Palliative Care Delivery in the ICU

CONTEXT

A quarter of palliative care (PC) clinicians' consultations are now requested from the intensive care unit (ICU). Despite this high usage, a standardized set of quality metrics for PC delivery in the ICU does not exist.

OBJECTIVES

To explore PC clinicians' views on how to best measure quality of care delivery in their role as a consultant in the ICU setting.

METHODS

Secondary analysis of a parent dataset consisting of qualitative data from semi-structured interviews exploring ways to optimize PC clinicians' role in the ICU. Nineteen participants were recruited across five academic medical centers in the US. Participants included PC physicians (n = 14), nurse practitioners (n = 2), and social workers (n = 3). Thematic analysis with an inductive approach was used to generate themes.

RESULTS

We identified two central themes: difficulties in measuring PC quality in the ICU (theme 1) and tension between the role of PC and metrics (theme 2). Theme 1 had two subthemes related to logistical challenges in measuring outcomes and PC clinicians' preference for metrics that incorporate subjective feedback from patients, family members, and the primary ICU team. Theme 2 described how PC clinicians often felt a disconnect between the goal of meeting a metric and their goals in delivering high-quality clinical care.

CONCLUSION

Our findings provide insight into PC clinician perspectives on quality metrics and identify major barriers that need to be addressed to successfully implement quality measurement in the ICU setting.

Developing quality indicators for cancer hospitals in China: a national modified Delphi process

OBJECTIVE

Although demand and supply of cancer care have been rapidly increasing in recent decades, there is a lack of systemic quality measurement for cancer hospitals in China. This study aimed to develop a set of core indicators for measuring quality of care for cancer hospitals in China.

DESIGN

The development of quality indicators was based on a literature review and a two-round modified Delphi survey. The theoretical framework and initial indicators were identified through the comprehensive literature review, and the selection of quality indicators relied on experts' consensus on the importance and feasibility of indicators by the modified Delphi process. In addition, indicator weight was identified using the analytical hierarchical process method and percentage weight method.

SETTING AND PARTICIPANTS

A panel of leading experts including oncologists, cancer care nurses, quality management experts from various regions of China were invited to participate in the two-round modified Delphi process from October to December 2020. A total of 25 experts completed the two-round modified Delphi process.

RESULTS

The experts reached consensus on a set of 47 indicators, comprising 17 structure indicators, 19 process indicators and 11 outcome indicators. Experts gave much higher weight to outcome indicators (accounting for 53.96% relative weight) than to structure (16.34%) and process (29.70%) indicators. In addition, experts also showed concerns and gave suggestions on data availability of specific outcome indicators.

CONCLUSIONS

Drawing on the comprehensive literature review and the modified Delphi process, this study developed a core set of quality indicators that can be used to evaluate quality performance of cancer hospitals. This is helpful in supporting quality cancer care in China and will provide new insights into the systemic measurement of cancer care internationally.

Assessment of Knowledge of Health Economics among Healthcare Professionals in the Kingdom of Saudi Arabia: A Cross-Sectional Study

Addressing the ongoing challenge of rising healthcare spending is crucial for ensuring the health quality of a population. At the core of healthcare systems, health professionals play a vital role in patient care and resource utilization. Despite healthcare cost concerns, health professionals often lack an understanding of health economics for optimal decision making. Accordingly, the aim of this study was to assess the knowledge of health economics among healthcare professionals in the Kingdom of Saudi Arabia. The broader goal was to identify knowledge gaps crucial for developing targeted interventions to maintain quality healthcare within the context of resource constraints. We used cross-sectional data collected from January to June 2023 and employed univariate, bivariate, and multivariable techniques for analysis. Univariate analyses were used to compare respondent proportions in socio-economic and demographic categories, bivariate analysis was used to examine the frequencies of independent variables related to the dependent variable, and a multivariate logistic regression model was used to identify the factors associated with knowledge of health economics among healthcare professionals. A total of 1056 responses were included for analysis. Approximately 35.35% of the sample possessed optimal knowledge of healthcare economics. Additionally, 58.14% of respondents considered health economics knowledge essential in their job practice, 16.95% regularly read articles on health economics, 22.06% engage in economic decision making at work, and 20.17% apply health economics techniques in their decision making. Health economics knowledge varied according to profession status, work experience, perceptions about health economics, and involvement in management tasks and decision-making processes. Generally, knowledge of health economics tended to increase with experience, positive perceptions, and engagement in administrative or management tasks. Nevertheless, knowledge of health economics is largely limited among health professionals in Saudi Arabia. Policymakers should address disparities in knowledge and perceptions of health economics through ongoing training courses and workshops. These interventions will ensure the presence of highly skilled professionals capable of implementing effective healthcare decisions and managing the increasing costs of healthcare.

Development of Quality Indicators for the Ultrasound Department through a Modified Delphi Method

This study aims to establish precise quality indicators for evaluating and enhancing ultrasound performance, employing a methodology based on a comprehensive review of the literature, expert insights, and practical application experiences. We conducted a thorough review of both the domestic and international literature on ultrasound quality control to identify potential indicators. A dedicated team was formed to oversee the complete indicator development process. Utilizing a three-round modified Delphi method, we sought expert opinions through personalized email correspondence. Subsequently, data from diverse hospital indicators were collected to validate and assess feasibility. A novel set of seven indicators was compiled initially, followed by the convening of a 36-member nationally representative expert panel. After three rounds of meticulous revisions, consensus was reached on 13 indicators across three domains. These finalized indicators underwent application in various hospital settings, demonstrating their initial validity and feasibility. The development of thirteen ultrasound quality indicators represents a significant milestone in evaluating ultrasound performance. These indicators empower hospitals to monitor changes in quality effectively, fostering efficient quality management practices.

Electronic health records and clinical documentation in medical residency programs: preparing residents to become master clinicians

OBJECTIVE

The ubiquity of electronic health records (EHRs) has made incorporating EHRs into medical practice an essential component of resident's training. Patient encounters, an important element of practice, are impacted by EHRs through factors that include increasing documentation requirements. This research sheds light on the role of EHRs on resident clinical skills development with emphasis on their role in patient encounters.

MATERIALS AND METHODS

We conducted qualitative semistructured interviews with 32 residents and 13 clinic personnel at an internal medicine residency program in a western US medical school focusing on the resident's clinic rotation.

RESULTS

Residents were learning to use the EHR to support and enhance their patient encounters, but one factor making that more challenging for many was the need to address quality measures. Quality measures could shift attention away from the primary reason for the encounter and addressing them consumed time that could have been spent diagnosing and treating the patient's chief complaint. A willingness to learn on-the-job by asking questions was important for resident development in using the EHR to support their work and improve their clinical skills.

DISCUSSION

Creating a culture where residents seek guidance on how to use the EHR and incorporate it into their work will support residents on their journey to become master clinicians. Shifting some documentation to the patient and other clinicians may also be necessary to keep from overburdening residents.

CONCLUSION

Residency programs must support residents as they develop their clinical skills to practice in a world where EHRs are ubiquitous.

Temporal Changes in Quality Indicators in a Regional System of Care After Surgical and Transcatheter Aortic Valve Replacement

Background

Historically, quality-of-care monitoring was performed separately for transcatheter and surgical aortic valve replacement (TAVR, SAVR). Using consensus indicators, we provide a global report on the quality of care for treatment of aortic stenosis across the highest-volume treatments: transfemoral (TF) TAVR, isolated SAVR, and SAVR combined with coronary artery bypass graft.

Methods

Retrospective observational cohort study of consecutive patients in a regional system of care. Primary endpoint was 30-day and 1-year mortality (2015-2019). Secondary endpoints included rate of new pacemaker, rate of readmission, and length of stay (2012-2019). Following multivariable logistic regressions, we developed mortality case-mix adjustment models to report risk estimates.

Results

The proportion of patients receiving TAVR grew from 32% to 53% (2015-2019). Those receiving TF TAVR were significantly older, with higher rates of comorbidities. Observed 30-day and 1-year all-cause mortality after TF TAVR decreased from 3.1% to 0.6% (P = 0.03), and 13.6% to 6.6% (P = 0.09), respectively; surgical mortality rates for isolated SAVR and SAVR combined with coronary artery bypass graft were low and did not change significantly over time, ranging from 0.3% to 1.4% and from 0.9% to 3.4%, respectively at 30 days, and from 0.9% to 3.4% and from 4.7% to 6.7 at 1 year. In the TF TAVR cohort, the observed vs expected ratio for 30-day and 1-year mortality decreased significantly from 1.9 (95% confidence interval [CI] 0.9, 3.5) to 0.3 (95% CI 0.1, 0.8), and from 1.3 (95% CI 0.9, 1.7) to 0.7 (95% CI 0.5, 0.99), respectively; no change occurred in risk-adjusted surgical mortality.

Conclusions

Consensus quality indicators provide unique insights on the quality of care for patients receiving treatment for aortic stenosis.

Qualitative study of international key informants' perspectives on the current and future state of healthcare quality measurement and feedback

OBJECTIVES

The aim of this study is to explore the current and future state of quality measurement and feedback and identify factors influencing measurement feedback systems, including the barriers and enablers to their effective design, implementation, use and translation into quality improvement.

DESIGN

This qualitative study used semistructured interviews with key informants. A deductive framework analysis was conducted to code transcripts to the Theoretical Domains Framework (TDF). An inductive analysis was used to produce subthemes and belief statements within each TDF domain.

SETTING

All interviews were conducted by videoconference and audio-recorded.

PARTICIPANTS

Key informants were purposively sampled experts in quality measurement and feedback, including clinical (n=5), government (n=5), research (n=4) and health service leaders (n=3) from Australia (n=7), the USA (n=4), the UK (n=2), Canada (n=2) and Sweden (n=2).

RESULTS

A total of 17 key informants participated in the study. The interview length ranged from 48 to 66 min. 12 theoretical domains populated by 38 subthemes were identified as relevant to measurement feedback systems. The most populous domains included environmental context and resources, memory, attention and decision-making, and social influences. The most populous subthemes included 'quality improvement culture', 'financial and human resource support' and 'patient-centred measurement'. There were minimal conflicting beliefs outside of 'data quality and completeness'. Conflicting beliefs in these subthemes were predominantly between government and clinical leaders.

CONCLUSIONS

Multiple factors were found to influence measurement feedback systems and future considerations are presented within this manuscript. The barriers and enablers that impact these systems are complex. While there are some clear modifiable factors in the design of measurement and feedback processes, influential factors described by key informants were largely socioenvironmental. Evidence-based design and implementation, coupled with a deeper understanding of the implementation context, may lead to enhanced quality measurement feedback systems and ultimately improved care delivery and patient outcomes.

Five changes needed to Scottish cancer policy to support necessary transformation of services

Whilst Scottish healthcare policy has not yet set a clear direction for service transformation needed in lieu of budgetary constraints, it is important that policy makers are cognisant of where policy can support healthcare professionals to overcome barriers to service development, and better meet demand. An analysis of Scottish cancer policy is presented, informed by learning gained from supporting development of cancer services as a practitioner, insights from undertaking health service research, and known barriers to service developments. This paper is structured as five recommendations to policy-makers: the need to develop a shared understanding of quality care between policy makers and healthcare professionals to guide service development in the same direction; revisiting of partnership working given developing health and social care landscape; empowerment of national and regional networks and working groups to develop and implement Gold Standard care in speciality services; sustainability in the development of cancer services; and development of guidance relating to how services should be using and developing patient capacities within cancer services.

Benchmarking: a novel measuring tool for outcome comparisons in surgery

INTRODUCTION

Benchmarking, a novel measuring tool for outcome comparisons, is a recent concept in surgery. The objectives of this review are to examine the concept, definition, and evolution of benchmarking and its application in surgery.

METHODS

The literature about benchmarking was reviewed through an ever-narrowing search strategy, commencing from the concept, definition, and evolution of benchmarking to the application of benchmarking and experiences of benchmarking in surgery. PubMed, Web of Science, Embase, and Science Direct databases were searched until 20 September 2022, in the English language according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.

RESULTS

In the first phase of the literature search, the development of benchmarking was identified. The definitions of benchmarking evolved from a surveying term to a novel quality-improvement tool to assess the best achievable results in surgery. In the second phase, a total of 23 studies were identified about benchmarking in surgery, including esophagectomy, hepatic surgery, pancreatic surgery, rectum resection, and bariatric surgery. All studies were multicenter analyses from national, international, or global expert centers. Most studies (87.0%) adopted the definition that benchmark was the 75th percentile of the median values of centers. Performance metrics to define benchmarks were clinically relevant intraoperative and postoperative outcome indicators.

CONCLUSION

Benchmarking in surgery is a novel quality-improvement tool to define and measure the best achievable results, establishing a meaningful reference to evaluate surgical performance.

A Quality Framework to Address Racial and Ethnic Disparities in Emergency Department Care

The emergency department serves as a vital source of health care for residents in the United States, including as a safety net. However, patients from minoritized racial and ethnic groups have historically experienced disproportionate barriers to accessing health care services and lower quality of services than White patients. Quality measures and their application to quality improvement initiatives represent a critical opportunity to incentivize health care systems to advance health equity and reduce health disparities. Currently, there are no nationally recognized quality measures that track the quality of emergency care delivery by race and ethnicity and no published frameworks to guide the development and prioritization of quality measures to reduce health disparities in emergency care. To address these gaps, the American College of Emergency Physicians (ACEP) convened a working group of experts in quality measurement, health disparities, and health equity to develop guidance on establishing quality measures to address racial and ethnic disparities in the provision of emergency care. Based on iterative discussion over 3 working group meetings, we present a summary of existing emergency medicine quality measures that should be adapted to track racial and ethnic disparities, as well as a framework for developing new measures that focus on disparities in access to emergency care, care delivery, and transitions of care.

The impact of price transparency and competition on hospital costs: a research on all-payer claims databases

Background

Public reporting has been considered effective in reducing health care costs by mitigating information asymmetry in the market as payers have incorporated publicly available information mandates into pay-for-performance programs and value-based purchasing. Therefore, hospitals have faced increasing pressures to provide price transparency. Despite the widespread promotion of healthcare transparency, the effectiveness of public reporting has not yet been sufficiently understood. This study analyzed the impact of transparency policy and competition on hospital costs by taking the state operations of all-payer claims databases (APCDs) as a case of interest.

Methods

We employed a fixed-effects regression, which allows the generation of hospital-specific effects, in accordance with the suggestion by the Hausman test. The study samples comprise nonprofit and for-profit general acute care hospitals in the United States for 2011–2017. The finalized dataset ranges from 3547 observations in 2011 to 3405 observations in 2015 after removing missing values.

Results

We found that hospitals in the states with APCDs tend to bear higher average operating expenses than those without APCDs, which may indicate that states maintaining higher healthcare expenditures are more attentive to a price transparency initiative and tend to adopt APCDs. With regard to competition, the results showed that weak market competition is significantly associated with higher operating costs, supporting the traditional competition theory. However, the combined effect of APCDs and competition did not indicate a significant association with operating expenses. Further investigation showed a continued tendency for a weak intensity of competition to be linked to lower hospital operating costs in states without APCDs. For those located in non-APCD adopted states, market consolidation helped hospitals coordinate care more effectively, economize operating costs, and enjoy economies of scale due to their large size. Similar trends did not appear in APCD-adopted states except for in 2015.

Conclusions

This study observed limited evidence of the impact of APCDs and market competition. Our findings suggest that states need to make multifaceted efforts to contain hospital costs, not solely depending on the rollout of cost information or market competition. Market concentration may lead to coordinated care or cost economization in some cases. Still, the existing literature also demonstrates some potentially harmful impacts of increased concentration in the healthcare market, such as inefficient use of resources, unilateral market power, and deterrence of innovation. The introduction of a price transparency tool may require additional policy actions that take market competition into consideration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08711-x.

Secondary use of data extracted from a clinical information system to assess the adherence of tidal volume and its impact on outcomes

OBJECTIVES

To extract data from clinical information systems to automatically calculate high-resolution quality indicators to assess adherence to recommendations for low tidal volume.

DESIGN

We devised two indicators: the percentage of time under mechanical ventilation with excessive tidal volume (>8mL/kg predicted body weight) and the percentage of patients who received appropriate tidal volume (≤8mL/kg PBW) at least 80% of the time under mechanical ventilation. We developed an algorithm to automatically calculate these indicators from clinical information system data and analyzed associations between them and patients' characteristics and outcomes.

SETTINGS

This study has been carried out in our 30-bed polyvalent intensive care unit between January 1, 2014 and November 30, 2019.

PATIENTS

All patients admitted to intensive care unit ventilated >72h were included.

INTERVENTION

Use data collected automatically from the clinical information systems to assess adherence to tidal volume recommendations and its outcomes.

MAIN VARIABLES OF INTEREST

Mechanical ventilation days, ICU length of stay and mortality.

RESULTS

Of all admitted patients, 340 met the inclusion criteria. Median percentage of time under mechanical ventilation with excessive tidal volume was 70% (23%-93%); only 22.3% of patients received appropriate tidal volume at least 80% of the time. Receiving appropriate tidal volume was associated with shorter duration of mechanical ventilation and intensive care unit stay. Patients receiving appropriate tidal volume were mostly male, younger, taller, and less severely ill. Adjusted intensive care unit mortality did not differ according to percentage of time with excessive tidal volume or to receiving appropriate tidal volume at least 80% of the time.

CONCLUSIONS

Automatic calculation of process-of-care indicators from clinical information systems high-resolution data can provide an accurate and continuous measure of adherence to recommendations. Adherence to tidal volume recommendations was associated with shorter duration of mechanical ventilation and intensive care unit stay.

Patient Characteristics and Clinical Outcomes Associated With Conservative Treatment for Spine Pain in Women Experiencing Socioeconomic Challenges

OBJECTIVE

The purpose of this study was to describe patient demographics and pain changes for women over the course of care in a chiropractic program.

METHODS

We performed a retrospective cross-sectional analysis of a prospective quality assurance database from the Mount Carmel Clinic (MCC) in Winnipeg, Manitoba, Canada. Pain scores were reported on an 11-point Numeric Rating Scale. Baseline and discharge Numeric Rating Scale scores were compared for each spinal and extremity region through Wilcoxon signed rank tests to determine if clinically meaningful or statistically significant differences were present.

RESULTS

The sample population attained was 348 primarily middle-aged (mean = 43.0, SD = 14.96) women with obesity (body mass index = 31.3 kg/m2, SD = 7.89) referred to the MCC chiropractic program by their primary care physician (65.2%) for an average of 15.6 (SD = 18.49) treatments. Clinically meaningful median baseline to discharge changes in pain by spine region were observed (Cervical = -2, Thoracic = -2, Lumbar = -3, Sacroiliac = -3), each of which yielded statistical significance (P < .001).

CONCLUSION

This retrospective analysis found that the MCC chiropractic program serves middle-aged women with obesity experiencing socioeconomic challenges. Pain reductions were reported, regardless of the region of complaint, temporally associated with a course of chiropractic care.

Classifying outcomes in secondary and tertiary care clinical quality registries-an organizational case study with the COMET taxonomy

BACKGROUND

The choice of what patient outcomes are included in clinical quality registries is crucial for comparable and relevant data collection. Ideally, a uniform outcome framework could be used to classify the outcomes included in registries, steer the development of outcome measurement, and ultimately enable better patient care through benchmarking and registry research. The aim of this study was to compare clinical quality registry outcomes against the COMET taxonomy to assess its suitability in the registry context.

METHODS

We conducted an organizational case study that included outcomes from 63 somatic clinical quality registries in use at HUS Helsinki University Hospital, Finland. Outcomes were extracted and classified according to the COMET taxonomy and the suitability of the taxonomy was assessed.

RESULTS

HUS clinical quality registries showed great variation in outcome domains and in number of measures. Physiological outcomes were present in 98%, resource use in all, and functioning domains in 62% of the registries. Patient-reported outcome measures were found in 48% of the registries.

CONCLUSIONS

The COMET taxonomy was found to be mostly suitable for classifying the choice of outcomes in clinical quality registries, but improvements are suggested. HUS Helsinki University Hospital clinical quality registries exist at different maturity levels, showing room for improvement in life impact outcomes and in outcome prioritization. This article offers an example of classifying the choice of outcomes included in clinical quality registries and a comparison point for other registry evaluators.

Enhancing Quality Measurement With Clinical Information: A Use Case of Body Mass Index Change Among Children Taking Second Generation Antipsychotics

OBJECTIVE

We sought to examine the extent to which body mass index (BMI) was available in electronic health records for Florida Medicaid recipients aged 5 to 18 years taking Second-Generation Antipsychotics (SGAP). We also sought to illustrate how clinical data can be used to identify children most at-risk for SGAP-induced weight gain, which cannot be done using process-focused measures.

METHODS

Electronic health record (EHR) data and Medicaid claims were linked from 2013 to 2019. We quantified sociodemographic differences between children with and without pre- and post-BMI values. We developed a linear regression model of post-BMI to examine pre-post changes in BMI among 4 groups: 1) BH/SGAP+ children had behavioral health conditions and were taking SGAP; 2) BH/SGAP- children had behavioral health conditions without taking SGAP; 3) children with asthma; and 4) healthy children.

RESULTS

Of 363,360 EHR-Medicaid linked children, 18,726 were BH/SGAP+. Roughly 4% of linked children and 8% of BH/SGAP+ children had both pre and post values of BMI required to assess quality of SGAP monitoring. The percentage varied with gender and race-ethnicity. The R2 for the regression model with all predictors was 0.865. Pre-post change in BMI differed significantly (P < .0001) among the groups, with more BMI gain among those taking SGAP, particularly those with higher baseline BMI.

CONCLUSION

Meeting the 2030 Centers for Medicare and Medicaid Services goal of digital monitoring of quality of care will require continuing expansion of clinical encounter data capture to provide the data needed for digital quality monitoring. Using linked EHR and claims data allows identifying children at higher risk for SGAP-induced weight gain.

Considerations When Aggregating Data to Measure Performance Across Levels of the Health Care System

BACKGROUND

Measuring quality at varying levels of the health care system requires attribution, a process of determining the patients and services for which each level is responsible. However, it is important to ensure that attribution approaches are equitable; otherwise, individuals may be assigned differentially based upon social determinants of health.

METHODS

First, we used Medicaid claims (2010-2018) from Michigan to assess the proportion of children with sickle cell anemia who had less than 12 months enrollment within a single Medicaid health plan and could therefore not be attributed to a specific health plan. Second, we used the Medicaid Analytic eXtract data (2008-2009) from 26 states to simulate adapting the 30-Day Pediatric All-Condition Readmission measure to the Accountable Care Organization (ACO) level and examined the proportion of readmissions that could not be attributed.

RESULTS

For the sickle cell measure, an average of 300 children with sickle cell anemia were enrolled in Michigan Medicaid each year. The proportion of children that could not be attributed to a Medicaid health plan ranged from 12.2% to 89.0% across years. For the readmissions measure, of the 1,051,365 index admissions, 22% were excluded in the ACO-level analysis because of being unable to attribute the patient to a health plan for the 30 days post discharge.

CONCLUSIONS

When applying attribution models, it is essential to consider the potential to induce health disparities. Differential attribution may have unintentional consequences that deepen health disparities, particularly when considering incentive programs for health plans to improve the quality of care.

Optimized Use of the Electronic Health Record and Other Clinical Resources to Enhance the Management of Hypogonadal Men

Electronic health records (EHRs) have enabled electronic documentation of a tremendous amount of clinical data. EHRs have the potential to improve communication between patients and their providers, facilitate quality improvement and outcomes research, and reduce medical errors. Conversely, EHRs have also increased clinician burnout, information clutter, and depersonalization of the interactions between patients and their providers. Increasing clinician input into EHR design, providing access to technical help, streamlining of workflow, and the use of custom templates that have fewer requirements for evaluation and management coding can reduce this burnout and increase the utility of this advancing technology.

[AKTIN - The German Emergency Department Data Registry - real-time data from emergency medicine : Implementation and first results from 15 emergency departments with focus on Federal Joint Committee's guidelines on acuity assessment]

BACKGROUND

Emergency care in Germany is in transition. Emergency departments (EDs) treat their patients based on symptoms and acuity. However, this perspective is not reflected in claims data. The aim of the AKTIN project was to establish an Emergency Department Data Registry as a data privacy-compliant infrastructure for the use of routine medical data.

METHODS

Data from the respective documentation systems are continuously transmitted to local data warehouses using a standardized interface. They are available for several applications such as internal reports but also multicentre studies, in compliance with data privacy regulations. Based on a 12-months period we evaluate the population with focus on acuity assessment (triage) and vital parameters in combination with presenting complaints.

RESULTS

For the period April 2018 to March 2019, 436,149 cases from 15 EDs were available. A triage level is documented in 86.0% of cases, and 70.5% were triaged within 10 min of arrival. Ten EDs collected a presenting complaint regularly (82.3%). The respective documentation of vital signs shows plausible patterns.

CONCLUSIONS

The AKTIN registry provides an almost real-time insight into German EDs, regardless of the primary documentation system and health insurance claims data. The Federal Joint Committee's requirements are largely met. Standardized presenting complaints allow for symptom-based analyses as well as health surveillance.

Development of an Innovative Digital Data Collection System for Routine Mental Health Care Delivery in Rural Haiti

Mental health information systems in low-resource settings are scarce worldwide. Data collection was accurate, yet sustainable staffing was a challenge when using task-shared clinical providers for data collection in health centers in rural Haiti. Integrating mental health data collection within existing data collection systems would help close this key gap.

Introduction:

Effective digital health management information systems (HMIS) support health data validity, which enables health care teams to make programmatic decisions and country-level decision making in support of international development targets. In 2015, mental health was included within the Sustainable Development Goals, yet there are few applications of HMIS of any type in the practice of mental health care in resource-limited settings. Zanmi Lasante (ZL), one of the largest providers of mental health care in Haiti, developed a digital data collection system for mental health across 11 public rural health facilities.

Program Intervention:

We describe the development, implementation, and evaluation of the digital system for mental health data collection at ZL. To evaluate system reliability, we assessed the number of missing monthly reports. To evaluate data validity, we calculated concordance between the digital system and paper charts at 2 facilities. To evaluate the system's ability to inform decision making, we specified and then calculated 4 priority indicators.

Results:

The digital system was missing 5 of 143 monthly reports across all facilities and had 74.3% (55/74) and 98% (49/50) concordance with paper charts. It was possible to calculate all 4 indicators, which led to programmatic changes in 2 cases. In response to implementation challenges, it was necessary to use strategies to increase provider buy-in and ultimately to introduce dedicated data clerks to keep pace with data collection and protect time for clinical work.

Lessons Learned:

While demonstrating the potential of collecting mental health data digitally in a low-resource rural setting, we found that it was necessary to consider the ongoing roles of paper records alongside digital data collection. We also identified the challenge of balancing clinical and data collection responsibilities among a limited staff. Ongoing work is needed to develop truly sustainable and scalable models for mental health data collection in resource-limited settings.

A study to determine if and how bereavement support programs provided by Irish and Canadian hospices are evaluated

A study of the bereavement programs provided by hospices in Ireland and the Canadian province of Alberta was done to determine if and how these are evaluated for efficacy. All but one hospice offered multiple different bereavement programs, with routine in-house evaluations of all programs performed. In all cases, staff and client unsolicited and solicited comments made during and at the end of each program provided data for continuing program refinement. Most hospices also routinely employed a self-devised questionnaire to gain specific sought information to retain or change programs. Other information, including news about program developments elsewhere, was also actively sought for program adoption or for the improvement of existing programs. With most bereavement programs having been in place for many years, participants were confident their programs are needed, safe, and effective. Their continuing quest for high-quality programming, however, meant they were active in monitoring these programs and in seeking developments in this field.

Standardized Postoperative Adverse Event Data Collection to Document, Inform, and Improve Patient Care

There is great potential for standardized postoperative adverse events data collection to document, inform, audit, and feedback, all to optimize patient care. Adverse events, defined as any deviation from expected recovery from surgery, have harmful implications for patients, their families, and clinicians. Postoperative adverse events occur frequently in thoracic surgery, predominately due to the high-stakes (ie, high potential for cure) and high-risk (ie, vital physiology and anatomy and preexisting disease) nature of the surgery. As discussed, engaging surgeons in audit and feedback practices informed by standardized data collection would generate consensus recommendations to reduce adverse events and improve patient outcomes.

The age-friendly public health center satisfaction scale: development and psychometric evaluation

Purpose

The study aimed to develop a reliable and valid instrument that could be used to assess the age-friendly Public Health Center Satisfaction (APHCS) among older people.

Design/methodology/approach

A cross-sectional study was performed to assess the psychometric properties of the scale. The study was conducted in Manado City, Indonesia, from August to November of 2019 using stratified random sampling. A review of the literature and content analysis identified subscales and items to be included in the instrument. The 268 participants aged = 60 years were completed for psychometric evaluation with a response rate of 83.8%. Data were analyzed with descriptive statistics, Exploratory Factor Analysis (EFA), Cronbach's Alpha, t-test, one-way ANOVA, and Person/Spearmen correlations.

Findings

The final scale consists of a three-factor structure with 16 items, which were accounted for 68.99% of the total variation in response. The Cronbach's alpha of the total APHCS was 0.88, which indicated the high reliability and acceptance of the instrument. Also, the concurrent validity was demonstrated by the significant differences in mean and associations among the APHCS scale, the age-friendly Public Health Center (PHCC) utilization, and individual variables, with r ranging from −0.13 to 0.30 (p < 0.05).

Research limitations/implications

Older people are more likely to use PHCCs than others, and they have higher expectations about health services. This study has highlighted the need for action on the quality of healthcare by providers and national authorities. High-quality primary healthcare that sees clients as partners, considering the needs and capacities of elderly clients should be provided as standard. The APHCS scale can enhance our understanding of elderly satisfaction toward the age-friendly PHCC program. Also, the instrument can be used for monitoring and measuring institutions, which is a basis for policymakers to improve and develop the age-friendly PHCC program.

Originality/value

The APHCS scale is a valid and reliable instrument for getting information about the satisfaction of the elderly toward the age-friendly PHCC program.

The Impact of Public Reporting Schemes and Market Competition on Hospital Efficiency

In the wake of growing attempts to assess the validity of public reporting, much research has examined the effectiveness of public reporting regarding cost or quality of care. However, relatively little is known about whether transparency through public reporting significantly influences hospital efficiency despite its emerging expectations for providing value-based care. This study aims to identify the dynamics that transparency brought to the healthcare market regarding hospital technical efficiency, taking the role of competition into account. We compare the two public reporting schemes, All-Payer Claims Database (APCD) and Hospital Compare. Employing Data Envelopment Analysis (DEA) and a cross-sectional time-series Tobit regression analysis, we found that APCD is negatively associated with hospital technical efficiency, while hospitals facing less competition responded significantly to increasingly transparent information by enhancing their efficiency relative to hospitals in more competitive markets. We recommend that policymakers take market mechanisms into consideration jointly with the introduction of public reporting schemes in order to produce the best outcomes in healthcare.

Healthcare quality assessments: no guarantees of same outcomes for different socio-economic stroke patients

BACKGROUND

Healthcare quality assessment is being conducted in many countries. Although improving health equity is one of the major objectives of medical quality assessment, it is not clear whether different socio-economic statuses show the same health outcomes even in the same medical quality hospitals. No study has directly compared the health outcomes of different socio-economic statuses in the same hospitals nationwide.

OBJECTIVE

To determine whether the mortality rate of acute stroke patients differs according to socioeconomic status.

METHODS

This study was a retrospective, observational study of patients who were subject to acute stroke quality assessment in 2013. A total of 10 399 stroke cases were included in the study. When evaluating the mortality rate, the researchers analysed 10 228 cases, after excluding 171 cases that were measured twice for the same person. The levels of socio-economic status were divided according to the use of medical benefits, either National Health Insurance (NHI) for general population or Medical Aid (MA) for the vulnerable. The primary outcomes measured according to socio-economic status were in-hospital mortality rate and 1-year follow-up mortality rate of stroke patients. The secondary outcome was the composite performance score.

RESULTS

MA recipients had a higher in-hospital mortality rate (12.5 vs. 8.3%, P < 0.001) and 1-year follow-up mortality rate (14.9 vs. 10.8%, P < 0.001) than NHI subscribers. MA recipients had slightly lower scores than NHI subscribers (83.2 vs. 84.4, P = 0.02). In hospitals of the same grade, MA recipients had lower performance scores than NHI subscribers, although the difference was not statistically significant.

CONCLUSIONS

There is a difference in mortality and healthcare performance according to socio-economic status in stroke patients in Korea. Efforts to improve equity are needed, including the development and monitoring of equality indicators and developing policies for healthcare equity.

"Goals of Care Conversations Don't Fit in a Box": Hospice Staff Experiences and Perceptions of Advance Care Planning Quality Measurement

CONTEXT

With rising concerns about quality of care in hospice, federal agencies recently began mandating quality measurement in hospice, including measures of advance care planning (ACP).

OBJECTIVES

To characterize hospice providers' experiences with ACP quality measurement and their reflections on ways to improve it.

METHODS

Semi-structured in-depth interviews of fifty-one hospice providers from various clinical backgrounds and organizational roles in four geographically diverse non-profit, community-based hospices in the U.S. Participants were queried about their experiences with and barriers to ACP quality measurement processes in their organization, opinions about the impacts of federally mandated quality measures, and ideas for improvement. Data were analyzed using thematic analysis with an interdisciplinary team, facilitated by ATLAS.ti and Excel.

RESULTS

Four key findings of the ACP quality measurement experience for hospice staff included variation, barriers, attitudes, and recommendations for improvement. 1) Variation: Within and across organizations, participants applied a variety of processes to measure ACP quality, and exposure to and experiences with quality measurement varied based on organizational role. 2) Barriers: ACP quality measurement was impeded by limited resources, technological problems, and measurement challenges. 3) Attitudes: Participants' opinions of recently implemented federally mandated requirements for ACP quality measurement highlighted numerous downsides, unintended consequences, and few upsides. 4) Recommendations: improvements included personalizing ACP quality measures, elevating the importance of quality measurement, and streamlining processes.

CONCLUSION

Hospice staff take ACP quality measurement seriously, but insufficient organizational resources and regulatory bureaucracy create challenges. Efforts to enhance ACP quality measure nuance and assess outcomes are needed to improve care.

The Impact of Socioeconomic Status on Hospital Accessibility in Otorhinolaryngological Disease in Korea

This study aimed to investigate the impact of socioeconomic status (SES) on otorhinolaryngology disease severity status diagnosed at the first hospital visit. We conducted a retrospective study over 20 years (2000-2019). Otorhinolaryngological diseases included chronic rhinosinusitis (CRS), sensorineural hearing loss (SNHL), oral ulcer, and malignant neoplasms. A logistic regression model was employed to assess the effect of SES on the severity of each disease at the first hospital visit. The severity of CRS increased in patients with lower SES (P = .028). The severities of SNHL (P = .032) and oral ulcer (P < .001) also associated with SES. In contrast, between the low- and high-SES groups observed no differences in cancer stage (P = .845). Patients with SNHL, oral ulcer, and CRS had a more severe disease status in the low-SES group than in the high-SES group at the first hospital visit. Efforts to increase hospital accessibility for low-SES otorhinolaryngological patients should be made.

Development of An All-Payer Quality Program for the Pennsylvania Rural Health Model

PURPOSE

Measuring rural health care quality is challenging, and payer and government reporting requirements are frequently misaligned. The Pennsylvania Rural Health Model, a multipayer global budget demonstration for rural hospitals, initially required the proposal of an All-Payer Quality (APQ) Program in which participating payers would have held participating hospitals accountable for performance on a common set of quality measures. We sought to identify quality measures appropriate for use in APQ measurement and reporting programs for globally budgeted rural hospitals.

METHODS

A method was devised to identify, assess, and select quality measures from an environmental scan of core measure sets. An initial screen identified measures that were relevant, valid, and reliable. Four reviewers then independently assessed measures that passed the initial screen on a Likert scale of 1-5 for relevance, validity, reliability, responsiveness, alignment, and feasibility, and they selected a proposed measure set guided by prespecified measure set criteria.

RESULTS

The 4 reviewers selected 10 quality measures from a list of 344 measures drawn from 8 core measure sets. One hundred twenty-five measures satisfied screening criteria and were assessed. The mean total score was 21.5/30 (95% CI: 17.0-26.0). Inter-rater reliability was moderate (intraclass correlation coefficient range 0.544-0.656).

CONCLUSION

A formal performance measure selection methodology can generate a set of rural-appropriate health care quality measures for a multipayer rural hospital global budget program. This methodology could be replicated to select quality measures for inclusion in rural multipayer quality measurement and reporting programs.

Automatic generation of minimum dataset and quality indicators from data collected routinely by the clinical information system in an intensive care unit

BACKGROUND

Quality indicators (QIs) are being increasingly used in medicine to compare and improve the quality of care delivered. The feasibility of data collection is an important prerequisite for QIs. Information technology can improve efforts to measure processes and outcomes. In intensive care units (ICU), QIs can be automatically measured by exploiting data from clinical information systems (CIS).

OBJECTIVE

To describe the development and application of a tool to automatically generate a minimum dataset (MDS) and a set of ICU quality metrics from CIS data.

METHODS

We used the definitions for MDS and QIs proposed by the Spanish Society of Critical Care Medicine and Coronary Units. Our tool uses an extraction, transform, and load process implemented with Python to extract data stored in various tables in the CIS database and create a new associative database. This new database is uploaded to Qlik Sense, which constructs the MDS and calculates the QIs by applying the required metrics. The tool was tested using data from patients attended in a 30-bed polyvalent ICU during a six-year period.

RESULTS

We describe the definitions and metrics, and we report the MDS and QI measurements obtained through the analysis of 4546 admissions. The results show that our ICU's performance on the QIs analyzed meets the standards proposed by our national scientific society.

CONCLUSIONS

This is the first step toward using a tool to automatically obtain a set of actionable QIs to monitor and improve the quality of care in ICUs, eliminating the need for professionals to enter data manually, thus saving time and ensuring data quality.

Identification of quality gaps in healthcare services using the SERVQUAL instrument and importance-performance analysis in medical intensive care: a prospective study at a medical center in Taiwan

Background

Assessing patients’ expectations and perceptions of health service delivery is challenging. To understand the service quality in intensive care units (ICUs), we investigated the expected and perceived service quality of ICU care.

Methods

We conducted this study at an ICU of a university-affiliated medical center in Taiwan from April to September 2019. Admitted patients or their family members responded to a questionnaire survey adopted from the SERVQUAL instrument consisting of 22 items in five dimensions. The questionnaire was provided on ICU admission for expectation and before ICU discharge for perception. We analyzed the quality gaps between the surveys and applied important-performance analysis (IPA).

Results

A total of 117 patients were included (62.4% males, average age: 65.9 years, average length of stay: 10.1 days, and 76.9% survival to ICU discharge). The overall weighted mean scores for the surveys were similar (4.57 ± 0.81 and 4.58 ± 0.52, respectively). The ‘tangibles’ dimension had a higher perception than expectation (3.99 ± 0.55 and 4.31 ± 0.63 for expectation and perception, respectively, p < 0.001). IPA showed that most of the items in ‘reliability,’ ‘responsiveness’ and ‘assurance’ were located in the quadrant of high expectation and high perception, whereas most of the items in ‘tangibles’ and ‘empathy’ were located in the quadrant of low expectation and low perception. One item (item 1 for ‘tangibles’) was found in the quadrant of high expectation and low perception.

Conclusions

The SERVQUAL approach and IPA might provide useful information regarding the feedback by patients and their families for ICU service quality. In most aspects, the performance of the ICU satisfactorily matched the needs perceived by the patients and their families.

Perception of Patient Safety Culture in the Framework of the Psychosocial Care Network in Western Amazon: A Cross-Sectional Study

The culture of patient safety should be considered a guiding principle for different areas of health. This research presents the results of an analysis on Patient Safety Culture (PSC), according to the perception of health professionals who work in the Psychosocial Care Network, through a descriptive observational cross-sectional study, using the Hospital Survey on Patient Safety Culture in a municipality in the Western Amazon of Brazil. Sixty-nine (69) professionals expressed that the best dimensions evaluated were: “expectations and actions to promote the safety of supervisors and managers” (75%) and “support from hospital management to patient safety” (64%). The worst evaluations were: “non-punitive responses to errors” (27%) and “general perceptions about patient safety” (35%), demonstrating that there still is a culture of fear of causing harm and the need for educational actions on patient safety. In general, all professionals have close contact with patients, regardless of the length on duty; however, the weekly workload and turnover in this sector is leading to a greater chance of errors. The analysis of the internal reliability of the dimensions ranged from 0.12 to 0.89. Only one-third of the respondents scored PSC as “Good” in the studied institutions and 63 out 69 professionals did not report any adverse events in the last 12 months. There are weaknesses in the observed perception of PSC and the obtained results show opportunities and challenges for improvements in the study system.

Racial and Ethnic Disparities in Patient Experiences in the United States: 4-Year Content Analysis of Twitter

BACKGROUND

Racial and ethnic minority groups often face worse patient experiences compared with the general population, which is directly related to poorer health outcomes within these minority populations. Evaluation of patient experience among racial and ethnic minority groups has been difficult due to lack of representation in traditional health care surveys.

OBJECTIVE

This study aims to assess the feasibility of Twitter for identifying racial and ethnic disparities in patient experience across the United States from 2013 to 2016.

METHODS

In total, 851,973 patient experience tweets with geographic location information from the United States were collected from 2013 to 2016. Patient experience tweets included discussions related to care received in a hospital, urgent care, or any other health institution. Ordinary least squares multiple regression was used to model patient experience sentiment and racial and ethnic groups over the 2013 to 2016 period and in relation to the implementation of the Patient Protection and Affordable Care Act (ACA) in 2014.

RESULTS

Racial and ethnic distribution of users on Twitter was highly correlated with population estimates from the United States Census Bureau's 5-year survey from 2016 (r²=0.99; P<.001). From 2013 to 2016, the average patient experience sentiment was highest for White patients, followed by Asian/Pacific Islander, Hispanic/Latino, and American Indian/Alaska Native patients. A reduction in negative patient experience sentiment on Twitter for all racial and ethnic groups was seen from 2013 to 2016. Twitter users who identified as Hispanic/Latino showed the greatest improvement in patient experience, with a 1.5 times greater increase (P<.001) than Twitter users who identified as White. Twitter users who identified as Black had the highest increase in patient experience postimplementation of the ACA (2014-2016) compared with preimplementation of the ACA (2013), and this change was 2.2 times (P<.001) greater than Twitter users who identified as White.

CONCLUSIONS

The ACA mandated the implementation of the measurement of patient experience of care delivery. Considering that quality assessment of care is required, Twitter may offer the ability to monitor patient experiences across diverse racial and ethnic groups and inform the evaluation of health policies like the ACA.

The White/Black hierarchy institutionalizes White supremacy in nursing and nursing leadership in the United States

BACKGROUND

Black/African American nurses (BAANs) in the United States (US) experience barriers to career advancement.

AIM

The specific aims of this study were to a) explore how the perception of racism or racial bias affects the motivation of Black/African American nurses (BAANs) in the United States (US) to seek and apply for nursing leadership and faculty positions, and b) to characterize the racism-related barriers that BAANs perceive that prevent them from moving forward with their careers in academia and nursing leadership.

METHOD

As part of a qualitative focused ethnographic study, 30 nurses who self-identified as BAAN, had a bachelor's degree or higher, and had at least five years of nursing experience were interviewed. Qualitative data underwent thematic analysis.

RESULT

Although five themes were identified, four were established in the literature, and one - Nursing Leadership Dynamics (NLD) - was novel. A complex network of NLDs that served to both prevent the success of BAANs as well as threaten their job security and health was identified.

CONCLUSION

This study identified a multi-faceted, tightly-woven system of NLDs that serves to continually institutionalize and enforce a white/black hierarchy and white supremacy in nursing at all levels in the US, including education.

Steering by their own lights: Why regulators across Europe use different indicators to measure healthcare quality

•

Indicator sets differ in how they define, measure, and assess healthcare quality.

•

National sets shaped by varying governance traditions and healthcare system configuration.

•

Targeting of quality dimensions and hospital activities shaped by system-specific ‘demand-side’ pressures.

•

Measurement styles shaped by ‘supply-side’ constraints on data access and indicator construction.

•

International benchmarking is easier when healthcare systems and governance traditions are similar.

Despite widespread faith that quality indicators are key to healthcare improvement and regulation, surprisingly little is known about what is actually measured in different countries, nor how, nor why. To address that gap, this article compares the official indicator sets--comprising some 1100 quality measures-- used by statutory hospital regulators in England, Germany, France, and the Netherlands. The findings demonstrate that those countries’ regulators strike very different balances in: the dimensions of quality they assess (e.g. between safety, effectiveness, and patient-centredness); the hospital activities they target (e.g. between clinical and non-clinical activities and management); and the ‘Donabedian’ measurement style of their indicators (between structure, process and outcome indicators). We argue that these contrasts reflect: i) how the distinctive problems facing each country’s healthcare system create different ‘demand-side’ pressures on what national indicator sets measure; and ii) how the configuration of national healthcare systems and governance traditions create ‘supply-side’ constraints on the kinds of data that regulators can use for indicator construction. Our analysis suggests fundamental differences in the meaning of quality and its measurement across countries that are likely to impede international efforts to benchmark quality and identify best practice.

Does the Association Between Age and Major Illness Vary by Healthcare System Quality?

This study builds on research into global aging, by offering a multiple-indicator test of whether national healthcare system quality modifies the association between age and major illness. Recent individual-level data on morbidity among respondents aged 50 or older (16 countries; 2014 European Social Survey) are merged with nation-level healthcare indicators. Healthcare system quality is assessed using a subjective, evaluation-based approach and an objective, attributable-mortality approach. Lagged nation-level economic and health indicators are controlled to help isolate healthcare system effects. Results across subjective and objective approaches to healthcare system quality are strikingly consistent. While older individuals showed approximately a 10% reduction in probability of major illness when residing in countries with higher healthcare quality, associations between age and morbidity indices combining number and severity of illness showed greater modification by healthcare quality, with reductions around 18%. Taken together, results are suggestive of healthcare’s protective role in reducing age-related illness and disability.

Clinical indicators for common paediatric conditions: Processes, provenance and products of the CareTrack Kids study

BACKGROUND

In order to determine the extent to which care delivered to children is appropriate (in line with evidence-based care and/or clinical practice guidelines (CPGs)) in Australia, we developed a set of clinical indicators for 21 common paediatric medical conditions for use across a range of primary, secondary and tertiary healthcare practice facilities.

METHODS

Clinical indicators were extracted from recommendations found through systematic searches of national and international guidelines, and formatted with explicit criteria for inclusion, exclusion, time frame and setting. Experts reviewed the indicators using a multi-round modified Delphi process and collaborative online wiki to develop consensus on what constituted appropriate care.

RESULTS

From 121 clinical practice guidelines, 1098 recommendations were used to draft 451 proposed appropriateness indicators. In total, 61 experts (n = 24 internal reviewers, n = 37 external reviewers) reviewed these indicators over 40 weeks. A final set of 234 indicators resulted, from which 597 indicator items were derived suitable for medical record audit. Most indicator items were geared towards capturing information about under-use in healthcare (n = 551, 92%) across emergency department (n = 457, 77%), hospital (n = 450, 75%) and general practice (n = 434, 73%) healthcare facilities, and based on consensus level recommendations (n = 451, 76%). The main reason for rejecting indicators was 'feasibility' (likely to be able to be used for determining compliance with 'appropriate care' from medical record audit).

CONCLUSION

A set of indicators was developed for the appropriateness of care for 21 paediatric conditions. We describe the processes (methods), provenance (origins and evolution of indicators) and products (indicator characteristics) of creating clinical indicators within the context of Australian healthcare settings. Developing consensus on clinical appropriateness indicators using a Delphi approach and collaborative online wiki has methodological utility. The final indicator set can be used by clinicians and organisations to measure and reflect on their own practice.

Clinical Registries in Ophthalmology

TOPIC

Clinical registries in ophthalmology.

CLINICAL RELEVANCE

In recent years, advancements in digital technology and increasing use of electronic medical records in health systems have led to the dramatic growth in large clinical data sets. Clinical data registries are organized systems that collect data on patients diagnosed with a disease or condition or who undergo a certain procedure.

METHODS

A search of the PUBMED database was conducted in January 2018 for clinical registries in ophthalmology.

RESULTS

Ninety-seven clinical eye registries were found, with significant growth in numbers in the last 4 decades. The most common conditions captured were blindness or low vision, corneal transplantation, glaucoma, and cataract surgery. Most registries originate in the European region, North America, and Australia. Nine registries had multinational coverage, whereas 48 were national registries. As the numbers and scope of clinical registries have expanded, valuable observational data have been used to study real-world clinical outcomes in healthcare quality measurement and improvement and to develop new guidelines and standards. Pertinent areas of its use include studying treatments and outcomes in cataract surgery, corneal transplantation, and macular degeneration.

CONCLUSIONS

The use of clinical registries for quality improvement and research has grown significantly in the last few decades, and this trend will continue as information technology infrastructures develop.

Call to action: Better care, better health, and greater value in college health

It is time for action by leaders across higher education to strengthen quality improvement (QI) in college health, in pursuit of better care, better health, and increased value - goals closely linked to students' learning and success. The size and importance of the college student population; the connections between wellbeing, and therefore QI, and student success; the need for improved standards and greater accountability; and the positive contributions of QI to employee satisfaction and professionalism all warrant a widespread commitment to building greater capacity and capability for QI in college health. This report aims to inspire, motivate, and challenge college health professionals and their colleagues, campus leaders, and national entities to take both immediate and sustainable steps to bring QI to the forefront of college health practice - and, by doing so, to elevate care, health, and value of college health as a key pathway to advancing student success.

Developing a Quality Measurement Strategy in an Academic Primary Care Setting: An Environmental Scan

PURPOSE

The purpose of this project was to: (1) develop a strategy for primary care quality measurement using an environmental scan and interviews to identify best practices and candidate measures; (2) present recommendations to facilitate successful measurement.

METHODS

Following stakeholder interviews and review of existing measures, we created a three-tiered recommendation system for selecting and implementing measures. We also developed a framework for reviewing and prioritizing measures and prepared a detailed project report.

RESULTS

Interviews provided a broader perspective on measuring quality, including implementing measures, measuring value, and identifying measurement gaps. Our recommendations fall into three tiers: Tier 1 measures can be implemented quickly and include clinical processes and outcomes for preventive care and disease states. Tier 2 measures require modifications to electronic health record, workflows, and/or staff preparation. Tier 3 (Strategic Vision) addresses topics that should be incorporated in the future to ensure high-quality primary care (adherence, patient activation, patient experience, teamness, staff satisfaction, and value), and infrastructure development to support ongoing quality measurement.

CONCLUSIONS

Implementing a quality measurement strategy is challenging and labor-intensive but is necessary to improve healthcare quality. Our work demonstrates the effort and investment required to progress quality measurement and offers recommendations for successfully undertaking this type of endeavor.