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Zhu T, Chen C, Zhang X, Yang Q, Hu Y, Liu R, Zhang X, Dong Y. Differences in inpatient performance of public general hospitals following implementation of a points-counting payment based on diagnosis-related group: a robust multiple interrupted time series study in Wenzhou, China. BMJ Open 2024; 14:e073913. [PMID: 38471900 DOI: 10.1136/bmjopen-2023-073913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Abstract
OBJECTIVES This study measures the differences in inpatient performance after a points-counting payment policy based on diagnosis-related group (DRG) was implemented. The point value is dynamic; its change depends on the annual DRGs' cost settlements and points of the current year, which are calculated at the beginning of the following year. DESIGN A longitudinal study using a robust multiple interrupted time series model to evaluate service performance following policy implementation. SETTING Twenty-two public general hospitals (8 tertiary institutions and 14 secondary institutions) in Wenzhou, China. INTERVENTION The intervention was implemented in January 2020. OUTCOME MEASURES The indicators were case mix index (CMI), cost per hospitalisation (CPH), average length of stay (ALOS), cost efficiency index (CEI) and time efficiency index (TEI). The study employed the means of these indicators. RESULTS The impact of COVID-19, which reached Zhejiang Province at the end of January 2020, was temporary given rapid containment following strict control measures. After the intervention, except for the ALOS mean, the change-points for the other outcomes (p<0.05) in tertiary and secondary institutions were inconsistent. The CMI mean turned to uptrend in tertiary (p<0.01) and secondary (p<0.0001) institutions compared with before. Although the slope of the CPH mean did not change (p>0.05), the uptrend of the CEI mean in tertiary institutions alleviated (p<0.05) and further increased (p<0.05) in secondary institutions. The slopes of the ALOS and TEI mean in secondary institutions changed (p<0.05), but not in tertiary institutions (p>0.05). CONCLUSIONS This study showed a positive effect of the DRG policy in Wenzhou, even during COVID-19. The policy can motivate public general hospitals to improve their comprehensive capacity and mitigate discrepancies in treatment expenses efficiency for similar diseases. Policymakers are interested in whether the reform successfully motivates hospitals to strengthen their internal impetus and improve their performance, and this is supported by this study.
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Affiliation(s)
- Tingting Zhu
- Sir Run Run Shaw Hospital, Affiliated with the Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chun Chen
- School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xinxin Zhang
- School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Qingren Yang
- School of Innovation and Entrepreneurship, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yipao Hu
- Health Information Center, Health Commission of Wenzhou, Wenzhou, Zhejiang, China
| | - Ruoyun Liu
- School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xiangyang Zhang
- Wenzhou Medical University First Affiliated Hospital, Wenzhou, Zhejiang, China
| | - Yin Dong
- Health Community Group of Yuhuan People's Hospital, Taizhou, Zhejiang, China
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Moore L, Bérubé M, Belcaid A, Turgeon AF, Taljaard M, Fowler R, Yanchar N, Mercier É, Paquet J, Stelfox HT, Archambault P, Berthelot S, Guertin JR, Haas B, Ivers N, Grimshaw J, Lapierre A, Ouyang Y, Sykes M, Witteman H, Lessard-Bonaventure P, Gabbe B, Lauzier F. Evaluating the effectiveness of a multifaceted intervention to reduce low-value care in adults hospitalized following trauma: a protocol for a pragmatic cluster randomized controlled trial. Implement Sci 2023; 18:27. [PMID: 37420284 DOI: 10.1186/s13012-023-01279-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/28/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND While simple Audit & Feedback (A&F) has shown modest effectiveness in reducing low-value care, there is a knowledge gap on the effectiveness of multifaceted interventions to support de-implementation efforts. Given the need to make rapid decisions in a context of multiple diagnostic and therapeutic options, trauma is a high-risk setting for low-value care. Furthermore, trauma systems are a favorable setting for de-implementation interventions as they have quality improvement teams with medical leadership, routinely collected clinical data, and performance-linked to accreditation. We aim to evaluate the effectiveness of a multifaceted intervention for reducing low-value clinical practices in acute adult trauma care. METHODS We will conduct a pragmatic cluster randomized controlled trial (cRCT) embedded in a Canadian provincial quality assurance program. Level I-III trauma centers (n = 30) will be randomized (1:1) to receive simple A&F (control) or a multifaceted intervention (intervention). The intervention, developed using extensive background work and UK Medical Research Council guidelines, includes an A&F report, educational meetings, and facilitation visits. The primary outcome will be the use of low-value initial diagnostic imaging, assessed at the patient level using routinely collected trauma registry data. Secondary outcomes will be low-value specialist consultation, low-value repeat imaging after a patient transfer, unintended consequences, determinants for successful implementation, and incremental cost-effectiveness ratios. DISCUSSION On completion of the cRCT, if the intervention is effective and cost-effective, the multifaceted intervention will be integrated into trauma systems across Canada. Medium and long-term benefits may include a reduction in adverse events for patients and an increase in resource availability. The proposed intervention targets a problem identified by stakeholders, is based on extensive background work, was developed using a partnership approach, is low-cost, and is linked to accreditation. There will be no attrition, identification, or recruitment bias as the intervention is mandatory in line with trauma center designation requirements, and all outcomes will be assessed with routinely collected data. However, investigators cannot be blinded to group allocation and there is a possibility of contamination bias that will be minimized by conducting intervention refinement only with participants in the intervention arm. TRIAL REGISTRATION This protocol has been registered on ClinicalTrials.gov (February 24, 2023, # NCT05744154 ).
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventive Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Faculty of Nursing, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Amina Belcaid
- Institut national d'excellence en santé et services sociaux, Bd Laurier, Québec, Qc, 2535, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, On, Canada
| | - Robert Fowler
- Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, On, Canada
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, 3280 Hospital Dr. NW, Calgary, Ab, Canada
| | - Éric Mercier
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Jérôme Paquet
- Department of Surgery, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr. NW, Calgary, Al, Canada
| | - Patrick Archambault
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Jason R Guertin
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, 149 College St, Toronto, On, Canada
| | - Noah Ivers
- Department of Family and Community Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St 4Th Floor, Toronto, On, Canada
| | - Jeremy Grimshaw
- Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, On, Canada
| | - Alexandra Lapierre
- Faculty of Nursing, Université de Montréal, Chem. de La Côte-Sainte-Catherine, Montréal, Qc, 2375, Canada
| | - Yongdong Ouyang
- Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, On, Canada
| | - Michael Sykes
- Department of Nursing, Midwifery, and Health, Northumbria University, Ellison PI, Newcastle, UK
| | - Holly Witteman
- Department of Family and Emergency Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Paule Lessard-Bonaventure
- Department of Surgery, Division of Neurosurgery, Université Laval, 1050 Av. de La Médecine, Québec, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, 553 St. Kilda Rd, Melbourne, Victoria, VIC 3004, Australia
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
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Truchot J, Benhamed A, Batomen B, Boucher V, Malo C, Chauny JM, de Champlain F, Émond M. Trauma team leader and early mortality: An interrupted time series analysis. Am J Emerg Med 2022; 62:32-40. [DOI: 10.1016/j.ajem.2022.09.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/22/2022] [Accepted: 09/28/2022] [Indexed: 11/27/2022] Open
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Bhaumik S, Hannun M, Dymond C, DeSanto K, Barrett W, Wallis LA, Mould-Millman NK. Prehospital triage tools across the world: a scoping review of the published literature. Scand J Trauma Resusc Emerg Med 2022; 30:32. [PMID: 35477474 PMCID: PMC9044621 DOI: 10.1186/s13049-022-01019-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/19/2022] [Indexed: 01/15/2023] Open
Abstract
Background Accurate triage of the undifferentiated patient is a critical task in prehospital emergency care. However, there is a paucity of literature synthesizing currently available prehospital triage tools. This scoping review aims to identify published tools used for prehospital triage globally and describe their performance characteristics. Methods A comprehensive search was performed of primary literature in English-language journals from 2009 to 2019. Papers included focused on emergency medical services (EMS) triage of single patients. Two blinded reviewers and a third adjudicator performed independent title and abstract screening and subsequent full-text reviews. Results Of 1521 unique articles, 55 (3.6%) were included in the final synthesis. The majority of prehospital triage tools focused on stroke (n = 19; 35%), trauma (19; 35%), and general undifferentiated patients (15; 27%). All studies were performed in high income countries, with the majority in North America (23, 42%) and Europe (22, 40%). 4 (7%) articles focused on the pediatric population. General triage tools aggregate prehospital vital signs, mental status assessments, history, exam, and anticipated resource need, to categorize patients by level of acuity. Studies assessed the tools’ ability to accurately predict emergency department triage assignment, hospitalization and short-term mortality. Stroke triage tools promote rapid identification of patients with acute large vessel occlusion ischemic stroke to trigger timely transport to diagnostically- and therapeutically-capable hospitals. Studies evaluated tools’ diagnostic performance, impact on tissue plasminogen activator administration rates, and correlation with in-hospital stroke scales. Trauma triage tools identify patients that require immediate transport to trauma centers with emergency surgery capability. Studies evaluated tools’ prediction of trauma center need, under-triage and over-triage rates for major trauma, and survival to discharge. Conclusions The published literature on prehospital triage tools predominantly derive from high-income health systems and mostly focus on adult stroke and trauma populations. Most studies sought to further simplify existing triage tools without sacrificing triage accuracy, or assessed the predictive capability of the triage tool. There was no clear ‘gold-standard’ singular prehospital triage tool for acute undifferentiated patients. Trial registration Not applicable.
Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01019-z.
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Affiliation(s)
- Smitha Bhaumik
- Department of Emergency Medicine, Denver Health and Hospital Authority, 777 Bannock St, Denver, CO, 80204, USA.,Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Merhej Hannun
- Department of Family Medicine, Reading Hospital - Tower Health, 420 South 5th Avenue, West Reading, PA, 19611, USA
| | - Chelsea Dymond
- Department of Emergency Medicine, Providence St Joseph Hospital, 2700 Dolbeer St, Eureka, CA, 95501, USA
| | - Kristen DeSanto
- Strauss Health Sciences Library, School of Medicine, University of Colorado Anschutz Medical Campus, 12950 E. Montview Blvd., Mail Stop A003, Aurora, CO, 80045, USA
| | - Whitney Barrett
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, 1 University of New Mexico, MSC11 6025, Albuquerque, NM, 87131, USA
| | - Lee A Wallis
- Division of Emergency Medicine, Groote Schuur Hospital, University of Cape Town, F51 Old Main Building, Observatory, Cape Town, 7935, South Africa
| | - Nee-Kofi Mould-Millman
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA. .,Division of Emergency Medicine, Groote Schuur Hospital, University of Cape Town, F51 Old Main Building, Observatory, Cape Town, 7935, South Africa.
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Bracewell N, Winchester DE. Accreditation in health care: does it make any difference to patient outcomes? BMJ Qual Saf 2021; 30:845-847. [PMID: 33542065 DOI: 10.1136/bmjqs-2020-012533] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 01/09/2023]
Affiliation(s)
- Natalie Bracewell
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
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Batomen B, Moore L, Strumpf E, Yanchar NL, Thakore J, Nandi A. Trauma system accreditation and patient outcomes in British Columbia: an interrupted time series analysis. Int J Qual Health Care 2020; 32:677-684. [PMID: 33057668 DOI: 10.1093/intqhc/mzaa133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/11/2020] [Accepted: 10/06/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE We aim to assess the impact of several accreditation cycles of trauma centers on patient outcomes, specifically in-hospital mortality, complications and hospital length of stay. DESIGN Interrupted time series. SETTING British Columbia, Canada. PARTICIPANTS Trauma patients admitted to all level I and level II trauma centers between January 2008 and March 2018. EXPOSURE Accreditation. MAIN OUTCOMES AND MEASURES We first computed quarterly estimates of the proportions of in-hospital mortality, complications and survival to discharge standardized for change in patient case-mix using prognostic scores and the Aalen-Johansen estimator of the cumulative incidence function. Piecewise regressions were then used to estimate the change in levels and trends for patient outcomes following accreditation. RESULTS For in-hospital mortality and major complications, the impact of accreditation seems to be associated with short- and long-term reductions after the first cycle and only short-term reductions for subsequent cycles. However, the 95% confidence intervals for these estimates were wide, and we lacked the precision to consistently conclude that accreditation is beneficial. CONCLUSIONS Applying a quasi-experimental design to time series accounting for changes in patient case-mix, our results suggest that accreditation might reduce in-hospital mortality and major complications. However, there was uncertainty around the estimates of accreditation. Further studies looking at clinical processes of care and other outcomes such as patient or health staff satisfaction are needed.
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Affiliation(s)
- Brice Batomen
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Meredith Charles House, 1130 Pine Avenue West, Room B9, Montreal, QC, H3A 1A3, Canada.,Institute for Health and Social Policy, and Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Charles Meredith House, 1030 Pine Avenue W. office # 102, Montreal, Canada
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, 1401, 18e rue, local Z-215, Québec (Québec), G1J 1Z4, QC, Canada
| | - Erin Strumpf
- Department of Epidemiology, Biostatistics, and Occupational Health and Department of Economics, McGill University, Purvis Hall, 1020 Pine Ave W. Montreal, QC, H3A 1A2, Canada
| | - Natalie L Yanchar
- Clinical Professor in Surgery, University of Calgary, Alberta Children's Hospital, 28 Oki Drive NW, Calgary, AB, T3B 6A8, Canada
| | - Jaimini Thakore
- Provincial Lead, Data, Evaluation & Analytics, Trauma Services BC, Bristish Columbia, Canada
| | - Arijit Nandi
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Meredith Charles House, 1130 Pine Avenue West, Room B9, Montreal, QC, H3A 1A3, Canada.,Institute for Health and Social Policy, and Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Charles Meredith House, 1030 Pine Avenue W. office # 102, Montreal, Canada
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