Weekly variation in quality of care for acute ST-segment elevation myocardial infarction by day and time of admission: a retrospective observational study

Effect of admission time of arrival on quality of in-hospital care in acute ischemic stroke patients in China

OBJECTIVES

The quality of care for patients may be partly determined by the time they are admitted to the hospital. This study was conducted to explore the effect of admission time and describe the pattern and magnitude of weekly variation in the quality of patient care.

STUDY DESIGN

A retrospective observational study.

METHODS

Data were collected from the Medical Care Quality Management and Control System for Specific (Single) Diseases in China. A total of 238,122 patients treated for acute ischemic stroke between January 2015 and December 2017 were included. The primary outcomes were completion of the ten process indicators and in-hospital death.

RESULTS

The quality of in-hospital care varied according to hospital arrival time. We identified several patterns of variation across the days of the week. In the first pattern, the quality of four indicators, such as stroke physicians within 15 min, was lowest for arrivals between 08:00 and 11:59, increased throughout the day, and peaked for arrivals between 20:00 and 23:59 or 00:00 and 03:59. In the second pattern, the quality of four indicators, such as the application of antiplatelet therapy within 48 h, was not significantly different between days and weeks. There was no difference in in-hospital mortality between the different admission times.

CONCLUSIONS

The effect of admission time on the quality of in-hospital care of patients with acute ischemic stroke showed several diurnal patterns. Detecting the times when quality is relatively low may lead to quality improvements in health care. Quality improvement should also focus on reducing diurnal temporal variation.

Trends in care quality in China from 2011 to 2017: An analysis based on the National Specific (Single) Disease Monitoring System

Background

The Ministry of Health of China conducted a study targeting in single-disease quality control in 2009, aimed to strengthen quality management and improve health care services. This study retrospectively investigated the trends of quality indicators for six monitored diseases 2011-2017 to evaluate the improvement of care quality for the first batch of single-disease.

Methods

We extracted data from the National Specific (Single) Disease Monitoring System for 2011-2017. We focused on six conditions: acute myocardial infarction, heart failure, community-acquired pneumonia, coronary artery bypass graft, hip / knee replacement, and acute ischemic stroke. A total of 56 quality indicators (QIs) were adopted to monitor the quality change and determine the trends in care quality. We also calculated the hospital process composite performance (HPCP) using a denominator-based weighting method for each hospital per year. The estimated annual percentage changes (EAPC) 2011-2017 were calculated at national and regional levels.

Results

The results showed that use of four QIs had significant downward trends, whereas 25 QIs (including reversed indicators) showed significant upward trends from 2011 to 2017. The greatest improvement was observed in CAP-4 (antibiotic treatment within four hours after admission to the hospital for critical pneumonia) in the central region (EAPC = 48.36, 95% CI = 15.92-89.87); while the largest decrease appeared in AIS-1 (thrombolytic therapy within 4.5 hours of symptom onset) in the western region (EAPC = -13.44, 95% CI = -24.98,-0.11). An increased HPCP was observed in four diseases nationwide, but not for acute myocardial infarction and heart failure. However, there were significant differences across regions in the process of care and outcomes, with the performance of Eastern and Western regions showing remarkable advantages compared with the Central region.

Conclusions

We provide evidence for major advancement in care quality in China nationwide. However, the improvement of care in China was unbalanced geographically and should be carefully considered. Future challenges include expanding the coverage of quality monitoring, greater delivery efficiency, and region-balanced health care.

The quality disparity of stroke care over time: An analysis based on the national dataset from 2011 to 2017

BACKGROUND

Adherence to evidence-based hospital stroke care is variable and may change over time. It is important to determine which process measures are associated with variation in outcome. In a large dataset, we analyzed the association between process and outcome and the fluctuations of indicators over time, and identified quality indicators (QIs) that should be prioritized for improving the quality of stroke care.

METHODS

We analyzed data from 123,259 patients diagnosed with acute ischemic stroke (AIS) who were treated at 109 large tertiary hospitals in China between January 2011 and May 2017. In total, 12 stroke treatment indicators were selected to calculate the hospital process composite performance (HPCP). Hospitals were divided into subgroups according to the time trend of HPCP estimated by the Group-Based Model. We analyzed the influence of hospital subgroups on the patient outcomes using a multi-level model and explored the QIs that led to variation.

RESULTS

The HPCP trends for stroke indicators of 109 hospitals over 7 years were divided into two groups (Group 1, low-HPCP; Group 2, high-HPCP). After adjusting for patient age, medical insurance, comorbidities, patterns of admission, and NIHSS-scores, patients in the high-HPCP group presented higher rate of independence and longer length of stay compared to the low-HPCP group. The multi-level model showed that there was a statistically significant difference in the utilization rate between the two groups, with most marked differences seen in emergency assessment and function evaluation indicators.

CONCLUSION

Variation in the quality of stroke care exists across hospitals, and better adherence to guideline-based care is associated with improved outcomes. We found that QIs related to emergency examination and functional assessment were the main factors differing between good and poor adherers to stroke indicators, suggesting that quality improvement in stroke care could prioritize these QIs.

Association between tea consumption and prevention of coronary artery disease: A systematic review and dose-response meta-analysis

Background

Evidence from previous studies reporting on the relationship between tea consumption and its preventive effect on coronary artery disease (CAD) has conflicting outcomes. With the accumulation of new clinical evidence, we conducted this meta-analysis to assess tea consumption and CAD risk.

Methods

We searched PubMed, EMBASE, Cochrane Library, and Medline databases for published observational studies from their inception to May 2022. A random-effects model was used to calculate risk ratios with 95% confidence intervals. We also conducted linear and non-linear dose-response meta-analyses to analyze the association. We regarded that one cup equals 237 mL. Subgroup analyses and univariate meta-regression were conducted to explore the source of heterogeneity.

Results

A total of 35 studies, including 24 on green tea and 11 on black tea consumption, were included in this meta-analysis. An inverse association for the risk of CAD was observed for black tea (RR: 0.85; 95% CI: 0.76, 0.96) and green tea (RR: 0.93; 95% CI: 0.88, 0.99). The dose-response meta-analysis showed that drinking less than four cups of black tea daily may effectively prevent CAD, while more than 4-6 cups/d will promote disease risk. Furthermore, the dose-response relationship between green tea consumption and the prevention of CAD showed that the risk of CAD gradually decreased as green tea consumption increased. We also demonstrated that the more cups of green tea consumed, the lower the risk of CAD. In the subgroup analysis by continent, a significant negative correlation between CAD risk and green tea consumption was observed in the Asian population (RR: 0.92; 95% CI: 0.85, 0.99) but not in the western population [North America (RR: 0.97; 95% CI: 0.92, 1.03), Europe/Oceana (RR: 0.91; 95% CI: 0.78, 1.07)].

Conclusions

Higher green tea consumption was associated with reduced CAD risk, but drinking more than 4-6 cups of black tea per day may increase the risk. This study offers new insight into the relationship between tea consumption and its preventive effect on CAD. However, further large prospective cohort studies are needed to validate these findings.

Systematic review registration

The protocol of this systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) system (CRD42022348069).

Quality-of-care comparison of stroke: The reliability and robustness of ranking by process or outcome measures

BACKGROUND AND AIM

Discussion on the most rational types of performance measures for care quality comparisons has received increasing attention. The important consideration is to what extent will the measure detect a genuine difference in the underlying quality. In this study, we aimed to compare the ranking of hospitals on the performance of individual indicators, composite scores (CS, that were calculated by the method of opportunity-based score on patient-level), and in-hospital outcome of acute ischemic stroke across hospitals, and determined the reliability and robustness of the three types of ranking.

METHODS

We analyzed data from 15,090 patients diagnosed with acute ischemic stroke who were treated at 184 large tertiary hospitals from January 2014 to May 2017. We ranked the hospital effects of recombinant tissue plasminogen activator (rt-PA) and CS and independence (modified Rankin Scale ≤2) at discharge based on fixed- and random-effects regression models before and after case-mix adjustment. We assessed the time-robustness of the hospital effects and calculated the rankability by relating the uncertainty within the hospital and the total hospital variation "beyond chance."

RESULTS

After case-mix and reliability adjustment, we estimated that 84.03% of the variance in CS between hospitals was due to true quality differences. The uncertainty within hospitals caused a poor (49.51%) rankability in rt-PA and moderate rankability (63.34%) in independence at discharge. The hospital rankings of CS were more robust across years compared with rt-PA and independence.

CONCLUSIONS

Our data indicated that CS is the optimal measure to indicate the quality-of-care variation of acute ischemic stroke between hospitals.