Clinical and Economic Analysis of Lipid Goal Attainments in Chinese Patients with Acute Coronary Syndrome Who Received Post-Percutaneous Coronary Intervention

AIM

The recommended low-density lipoprotein cholesterol (LDL-C) levels of the guideline may be appropriate for Caucasian patients but not for other ethnic groups.

METHODS

A cohort study was conducted in Hong Kong, and acute coronary syndrome (ACS) patients who received percutaneous coronary intervention (PCI) between 2005 and 2015 were enrolled. The primary outcomes of interest were the total cost of care and cardiovascular-related cost during one-year follow-up. The cost difference by lipid goal attainments was analyzed by Poisson regression with multivariate treatment effects. The clinical outcomes achieved by lipid goal attainments in terms of major adverse cardiovascular events were analyzed by multivariate Cox regression.

RESULTS

Among the 4638 patients, 79.50%, 48.64%, and 36.14% attained the LDL-C goals of ＜2.6, ＜2.0, and ＜1.8 mmol/L for one year, respectively. Only about 16% patients achieved the ≥50% reduction from baseline. None of these lipid goals was associated with a significant reduction in the total cost of care. We only identified the clinical benefits associated with the lipid goal of ＜2.6 mmol/L. Other more stringent lipid goals seemed to bring a significant economic burden on cardiovascular-related cost, but their clinical benefits were uncertain.

CONCLUSIONS

Lowering LDL-C to achieve the guideline-recommended target levels for post-PCI ACS patients may lead to fewer cardiovascular events, but it may not necessarily lead to economic benefits within one year of follow-up.

Functionality and feedback: a realist synthesis of the collation, interpretation and utilisation of patient-reported outcome measures data to improve patient care

Background

The feedback of patient-reported outcome measures (PROMs) data is intended to support the care of individual patients and to act as a quality improvement (QI) strategy.

Objectives

To (1) identify the ideas and assumptions underlying how individual and aggregated PROMs data are intended to improve patient care, and (2) review the evidence to examine the circumstances in which and processes through which PROMs feedback improves patient care.

Design

Two separate but related realist syntheses: (1) feedback of aggregate PROMs and performance data to improve patient care, and (2) feedback of individual PROMs data to improve patient care.

Interventions

Aggregate – feedback and public reporting of PROMs, patient experience data and performance data to hospital providers and primary care organisations. Individual – feedback of PROMs in oncology, palliative care and the care of people with mental health problems in primary and secondary care settings.

Main outcome measures

Aggregate – providers’ responses, attitudes and experiences of using PROMs and performance data to improve patient care. Individual – providers’ and patients’ experiences of using PROMs data to raise issues with clinicians, change clinicians’ communication practices, change patient management and improve patient well-being.

Data sources

Searches of electronic databases and forwards and backwards citation tracking.

Review methods

Realist synthesis to identify, test and refine programme theories about when, how and why PROMs feedback leads to improvements in patient care.

Results

Providers were more likely to take steps to improve patient care in response to the feedback and public reporting of aggregate PROMs and performance data if they perceived that these data were credible, were aimed at improving patient care, and were timely and provided a clear indication of the source of the problem. However, implementing substantial and sustainable improvement to patient care required system-wide approaches. In the care of individual patients, PROMs function more as a tool to support patients in raising issues with clinicians than they do in substantially changing clinicians’ communication practices with patients. Patients valued both standardised and individualised PROMs as a tool to raise issues, but thought is required as to which patients may benefit and which may not. In settings such as palliative care and psychotherapy, clinicians viewed individualised PROMs as useful to build rapport and support the therapeutic process. PROMs feedback did not substantially shift clinicians’ communication practices or focus discussion on psychosocial issues; this required a shift in clinicians’ perceptions of their remit.

Strengths and limitations

There was a paucity of research examining the feedback of aggregate PROMs data to providers, and we drew on evidence from interventions with similar programme theories (other forms of performance data) to test our theories.

Conclusions

PROMs data act as ‘tin openers’ rather than ‘dials’. Providers need more support and guidance on how to collect their own internal data, how to rule out alternative explanations for their outlier status and how to explore the possible causes of their outlier status. There is also tension between PROMs as a QI strategy versus their use in the care of individual patients; PROMs that clinicians find useful in assessing patients, such as individualised measures, are not useful as indicators of service quality.

Future work

Future research should (1) explore how differently performing providers have responded to aggregate PROMs feedback, and how organisations have collected PROMs data both for individual patient care and to improve service quality; and (2) explore whether or not and how incorporating PROMs into patients’ electronic records allows multiple different clinicians to receive PROMs feedback, discuss it with patients and act on the data to improve patient care.

Study registration

This study is registered as PROSPERO CRD42013005938.

Funding

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

The impact of Public Reporting on clinical outcomes: a systematic review and meta-analysis

Background

To assess both qualitatively and quantitatively the impact of Public Reporting (PR) on clinical outcomes, we carried out a systematic review of published studies on this topic.

Methods

Pubmed, Web of Science and SCOPUS databases were searched to identify studies published from 1991 to 2014 that investigated the relationship between PR and clinical outcomes. Studies were considered eligible if they investigated the relationship between PR and clinical outcomes and comprehensively described the PR mechanism and the study design adopted. Among the clinical outcomes identified, meta-analysis was performed for overall mortality rate which quantitative data were exhaustively reported in a sufficient number of studies. Two reviewers conducted all data extraction independently and disagreements were resolved through discussion. The same reviewers evaluated also the quality of the studies using a GRADE approach.

Results

Twenty-seven studies were included. Mainly, the effect of PR on clinical outcomes was positive. Meta-analysis regarding overall mortality included, in a context of high heterogeneity, 10 studies with a total of 1,840,401 experimental events and 3,670,446 control events and resulted in a RR of 0.85 (95 % CI, 0.79-0.92).

Conclusions

The introduction of PR programs at different levels of the healthcare sector is a challenging but rewarding public health strategy. Existing research covering different clinical outcomes supports the idea that PR could, in fact, stimulate providers to improve healthcare quality.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1543-y) contains supplementary material, which is available to authorized users.

Collaborative quality improvement vs public reporting for percutaneous coronary intervention: A comparison of percutaneous coronary intervention in New York vs Michigan

INTRODUCTION

Public reporting (PR) is a policy mechanism that may improve clinical outcomes for percutaneous coronary intervention (PCI). However, prior studies have shown that PR may have an adverse impact on patient selection. It is unclear whether alternatives to PR, such as collaborative quality improvement (CQI), may drive improvements in quality of care and outcomes for patients receiving PCI without the unintended consequences seen with PR.

METHODS

Using National Cardiovascular Data Registry CathPCI Registry data from January 2011 through September 2012, we evaluated patients who underwent PCI in New York (NY), a state with PR (N = 51,983), to Michigan, a state with CQI (N = 53,528). We compared patient characteristics, the quality of care delivered, and clinical outcomes.

RESULTS

Patients undergoing PCI in NY had a lower-risk profile, with a lower proportion of patients with ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, or cardiogenic shock, compared with Michigan. Quality of care was broadly similar in the 2 states; however, outcomes were better in NY. In a propensity-matched analysis, patients in NY were less likely to be referred for emergent, urgent, or salvage coronary artery bypass surgery (odds ratio [OR] 0.67, 95% CI 0.51-0.88, P < .0001) and to receive blood transfusion (OR 0.7, 95% CI 0.61-0.82, P < .0001), and had lower in-hospital mortality (OR 0.72, 95% CI 0.63-0.83, P < .0001).

CONCLUSIONS

Public reporting of PCI data is associated with fewer high-risk patients undergoing PCI compared with CQI. However, in comparable samples of patients, PR is also associated with a lower risk of mortality and adverse events. The optimal quality improvement method may involve combining these 2 strategies to protect access to care while still driving improvements in patient outcomes.

Do past mortality rates predict future hospital mortality?

BACKGROUND

This study aimed to determine whether hospitals with higher historical mortality rates are independently associated with worse patient outcomes.

METHODS

Observational study of in-hospital mortality in open abdominal aortic aneurysm repair, aortic valve replacement, and coronary artery bypass graft surgery in a California in-patient database was conducted. Hospitals' annual historical mortality rates between 1998 and 2010 were calculated based on 3 years of data before each year. Results were adjusted for race, sex, age, hospital teaching status, admission year, insurance status, and Charlson comorbidity index.

RESULTS

Hospitals were divided into quartiles based on historical mortality rates. For abdominal aortic aneurysm repair, the odds ratio (OR) of in-hospital mortality for hospitals within the highest quartile of prior mortality was 1.30 compared with the lowest quartile (95% confidence interval [CI] 1.03 to 1.63). For aortic valve replacement, the OR was 1.41 for the 3rd quartile (95% CI 1.15 to 1.73) and 1.54 for the highest quartile (95% CI 1.27 to 1.87). For coronary artery bypass graft surgery, the OR was 1.33 for the 3rd (95% CI 1.2 to 1.49) and 1.58 for the highest (95% CI 1.41 to 1.76) quartiles.

CONCLUSION

Patients presenting to hospitals with high historical mortality rates have a 30% to 60% increased mortality risk compared with patients presenting to hospitals with low historical mortality rates.

Can public reporting impact patient outcomes and disparities? A systematic review

OBJECTIVE

Recent US healthcare reforms aim to improve quality and access. We synthesized evidence assessing the impact that public reporting (PR), which will be extended to the outpatient setting, has on patient outcomes and disparities.

METHODS

A systematic review using PRISMA guidelines identified studies addressing the impact of PR on patient outcomes and disparities.

RESULTS

Of the 1970 publications identified, 25 were relevant, spanning hospitals (16), nursing homes (5), emergency rooms (1), health plans (2), and home health agencies (1). Evidence of effect on patient outcomes was mixed, with 6 studies reporting a favorable effect, 9 a mixed effect, 9 a null effect, and 1 a negative effect. One study found a mixed effect of PR on disparities.

CONCLUSION

The evidence of the impact of PR on patient outcomes is lacking, with limited evidence that PR has a favorable effect on outcomes in nursing homes. There is little evidence supporting claims that PR will have an impact on disparities or in the outpatient setting.

PRACTICE IMPLICATIONS

Health systems should collect information on patient-relevant outcomes. The lack of evidence does not necessarily imply a lack of effect, and a research gap exists regarding patient-relevant outcomes and PR.

Is preventable harm the right patient safety metric?

Despite increasing attention and discussion, patient harm remains an important issue in health care. Defining and identifying harm remains challenging, and little standardization in approach exists. This summary describes an approach to identifying hospital-wide preventable harm with focused safety efforts using the Preventable Harm Index as a measure of progress and as a metric to motivate improvement. Our hospital's significant decrease in serious safety events, mortality, and preventable harm is outlined.

National assessment of melanoma care using formally developed quality indicators

PURPOSE

There is considerable variation in the quality of cancer care delivered in the United States. Assessing care by using quality indicators could help decrease this variability. The objectives of this study were to formally develop valid quality indicators for melanoma and to assess hospital-level adherence with these measures in the United States.

METHODS

Quality indicators were identified from available literature, consensus guidelines, and melanoma experts. Thirteen experts ranked potential measures for validity on the basis of the RAND/University of California, Los Angeles Appropriateness Methodology. Adherence with individual valid indicators and a composite measure of all indicators were assessed at 1,249 Commission on Cancer hospitals by using the National Cancer Data Base (NCDB; 2004 through 2005).

RESULTS

Of 55 proposed quality indicators, 26 measures (47%) were rated as valid. These indicators assessed structure (n = 1), process (n = 24), and outcome (n = 1). Of the 26 measures, 10 are readily assessable by using cancer registry data. Adherence with valid indicators ranged from 11.8% to 96.5% at the patient level and 3.7% to 83.0% at the hospital level. (Adherence required that >OR= 90% of patients at a hospital receive concordant care.) Most hospitals were adherent with 50% or fewer of the individual indicators (median composite score, five; interquartile range, four to seven). Adherence was higher for diagnosis and staging measures and was lower for treatment indicators.

CONCLUSION

There is considerable variation in the quality of melanoma care in the United States. By using these formally developed quality indicators, hospitals can assess their adherence with current melanoma care guidelines through feedback mechanisms from the NCDB and can better direct quality improvement efforts.

Assessment of pancreatic cancer care in the United States based on formally developed quality indicators

BACKGROUND

Pancreatic cancer outcomes vary considerably among hospitals. Assessing pancreatic cancer care by using quality indicators could help reduce this variability. However, valid quality indicators are not currently available for pancreatic cancer management, and a composite assessment of the quality of pancreatic cancer care in the United States has not been done.

METHODS

Potential quality indicators were identified from the literature, consensus guidelines, and interviews with experts. A panel of 20 pancreatic cancer experts ranked potential quality indicators for validity based on the RAND/UCLA Appropriateness Methodology. The rankings were rated as valid (high or moderate validity) or not valid. Adherence with valid indicators at both the patient and the hospital levels and a composite measure of adherence at the hospital level were assessed using data from the National Cancer Data Base (2004-2005) for 49 065 patients treated at 1134 hospitals. Summary statistics were calculated for each individual candidate quality indicator to assess the median ranking and distribution.

RESULTS

Of the 50 potential quality indicators identified, 43 were rated as valid (29 as high and 14 as moderate validity). Of the 43 valid indicators, 11 (25.6%) assessed structural factors, 19 (44.2%) assessed clinical processes of care, four (9.3%) assessed treatment appropriateness, four (9.3%) assessed efficiency, and five (11.6%) assessed outcomes. Patient-level adherence with individual indicators ranged from 49.6% to 97.2%, whereas hospital-level adherence with individual indicators ranged from 6.8% to 99.9%. Of the 10 component indicators (contributing 1 point each) that were used to develop the composite score, most hospitals were adherent with fewer than half of the indicators (median score = 4; interquartile range = 3-5).

CONCLUSIONS

Based on the quality indicators developed in this study, there is considerable variability in the quality of pancreatic cancer care in the United States. Hospitals can use these indicators to evaluate the pancreatic cancer care they provide and to identify potential quality improvement opportunities.