Combining administrative data feedback, reflection and action planning to engage primary care professionals in quality improvement: qualitative assessment of short term program outcomes

Examining nursing processes in primary care settings using the Chronic Care Model: an umbrella review

BACKGROUND

While there is clear evidence that nurses can play a significant role in responding to the needs of populations with chronic conditions, there is a lack of consistency between and within primary care settings in the implementation of nursing processes for chronic disease management. Previous reviews have focused either on a specific model of care, populations with a single health condition, or a specific type of nurses. Since primary care nurses are involved in a wide range of services, a comprehensive perspective of effective nursing processes across primary care settings and chronic health conditions could allow for a better understanding of how to support them in a broader way across the primary care continuum. This systematic overview aims to provide a picture of the nursing processes and their characteristics in chronic disease management as reported in empirical studies, using the Chronic Care Model (CCM) conceptual approach.

METHODS

We conducted an umbrella review of systematic reviews published between 2005 and 2021 based on the recommendations of the Joanna Briggs Institute. The methodological quality was assessed independently by two reviewers using the AMSTAR 2 tool.

RESULTS

Twenty-six systematic reviews and meta-analyses were included, covering 394 primary studies. The methodological quality of most reviews was moderate. Self-care support processes show the most consistent positive outcomes across different conditions and primary care settings. Case management and nurse-led care show inconsistent outcomes. Most reviews report on the clinical components of the Chronic Care Model, with little mention of the decision support and clinical information systems components.

CONCLUSIONS

Placing greater emphasis on decision support and clinical information systems could improve the implementation of nursing processes. While the need for an interdisciplinary approach to primary care is widely promoted, it is important that this approach not be viewed solely from a clinical perspective. The organization of care and resources need to be designed to support contributions from all providers to optimize the full range of services available to patients with chronic conditions.

PROSPERO REGISTRATION

CRD42021220004.

Thought Leader Perspectives on the Benefits, Barriers, and Enablers for Routinely Collected Electronic Health Data to Support Professional Development: Qualitative Study

BACKGROUND

Hospitals routinely collect large amounts of administrative data such as length of stay, 28-day readmissions, and hospital-acquired complications; yet, these data are underused for continuing professional development (CPD). First, these clinical indicators are rarely reviewed outside of existing quality and safety reporting. Second, many medical specialists view their CPD requirements as time-consuming, having minimal impact on practice change and improving patient outcomes. There is an opportunity to build new user interfaces based on these data, designed to support individual and group reflection. Data-informed reflective practice has the potential to generate new insights about performance, bridging the gap between CPD and clinical practice.

OBJECTIVE

This study aims to understand why routinely collected administrative data have not yet become widely used to support reflective practice and lifelong learning.

METHODS

We conducted semistructured interviews (N=19) with thought leaders from a range of backgrounds, including clinicians, surgeons, chief medical officers, information and communications technology professionals, informaticians, researchers, and leaders from related industries. Interviews were thematically analyzed by 2 independent coders.

RESULTS

Respondents identified visibility of outcomes, peer comparison, group reflective discussions, and practice change as potential benefits. The key barriers included legacy technology, distrust with data quality, privacy, data misinterpretation, and team culture. Respondents suggested recruiting local champions for co-design, presenting data for understanding rather than information, coaching by specialty group leaders, and timely reflection linked to CPD as enablers to successful implementation.

CONCLUSIONS

Overall, there was consensus among thought leaders, bringing together insights from diverse backgrounds and medical jurisdictions. We found that clinicians are interested in repurposing administrative data for professional development despite concerns with underlying data quality, privacy, legacy technology, and visual presentation. They prefer group reflection led by supportive specialty group leaders, rather than individual reflection. Our findings provide novel insights into the specific benefits, barriers, and benefits of potential reflective practice interfaces based on these data sets. They can inform the design of new models of in-hospital reflection linked to the annual CPD planning-recording-reflection cycle.

Development and evaluation of the accuracy of an indicator of the appropriateness of interventional cardiology generated from a French registry

Background

Development of appropriateness indicators of medical interventions has become a major quality-of-care issue, especially in the domain of interventional cardiology (IC). The objective of this study was to develop and evaluate the accuracy of an indicator of the appropriateness of interventional cardiology acts (invasive coronary angiographies (ICA) and percutaneous coronary interventions (PCI)) in patients with coronary stable disease and silent ischemia, automated from a French registry.

Methods

All ICA and PCI recorded in a Regional IC Registry (ACIRA) and operated for a stable coronary artery disease or silent ischemia from January 1st to December 31th 2013 in eight IC hospitals of Aquitaine, southwestern France, were included.

The indicator was developed to reflect European guidelines. Classification of appropriateness by the indicator, measured on the registry database, was compared to the classification of a reference standard (expert judgment applied through complete record review) on a random sample of 300 interventions.

Accuracy parameters were estimated. A second version of the indicator was defined, based on the analysis of false negative and positive results, and its accuracy estimated.

Results

The second indicator accuracy was: sensitivity 63.5% (95% confidence interval CI [51.7–75.3]), specificity 76.0% (95%CI [70.4–81.6]), PPV 43.0% (95% CI [33.0–53.0]) and NPV 88.0% (95% CI [83.4–92.6]). When stratified on the type of act, parameters were better for ICA alone than for PCI.

Conclusions

Accuracy of the indicator should raise with improvement of database quality. Despite its average accuracy, it is already used as a benchmark indicator for cardiologists. It is sent annually to each IC center with value of the indicator at the region level to allow a comparison.

Physicians' Choice of Board Certification Activity Is Unaffected by Baseline Quality of Care: The TRADEMaRQ Study

PURPOSE

Physicians' use of self-assessment to guide quality improvement or board certification activities often does not correlate with more objective measures, and they may spend valuable time on activities that support their strengths instead of addressing gaps. Our objective was to study whether viewing quality measures, with peer comparisons, would affect the selection of certification activities.

METHODS

We conducted a cluster-randomized controlled trial-the Trial of Data Exchange for Maintenance of certification and Raising Quality (TRADEMaRQ)-with 4 partner organizations during 2015-2017. Physicians were presented their quality data within their online certification portfolios before (intervention) vs after (control) they chose board certification activities. The primary outcome was whether the selected activity addressed a quality gap (a quality area in which the physician scored below the mean for the study population).

RESULTS

Of 2,570 invited physicians, 254 physicians completed the study: 130 in the intervention group and 124 in the control group. Nearly one-fifth of participating physicians did not complete any certification activities during the study. A sizable minority of those in the intervention group, 18.4%, never reviewed their quality dashboard. Overall, just 27.2% of completed certification activities addressed a quality gap, and there was no significant difference in this outcome in the intervention group vs the control group in either bivariate or adjusted analyses (odds ratio = 1.28; 95% CI, 0.90-1.82).

CONCLUSIONS

Physicians did not use quality performance data in choosing certification activities. Certification boards are being pressed to make their programs relevant to practice, less burdensome, and supportive of quality improvement in alignment with value-based payment models. Using practice data to drive certification choices would meet these goals.

Challenges and Strategies for Improving COPD Primary Care Services in Quebec: Results of the Experience of the COMPAS+ Quality Improvement Collaborative

Introduction

Management of chronic obstructive pulmonary disease (COPD) remains a challenge in primary care and multiple barriers can limit implementation of COPD guidelines. Since 2016, a quality improvement (QI) collaborative, called COMPAS+, has been implemented across the province of Quebec (Canada) to support improvement of chronic disease management in primary care. The aim of this study was to describe the main COPD quality problems reported by participating teams and the strategies they proposed and implemented to improve COPD primary care services in Quebec.

Methods

Sixteen sites in four different regions of Quebec were engaged in the COMPAS+ intervention to improve primary care services delivered to people living with COPD. A total of 14 workshop reports, 31 QI action plans and 4 regional final reports underwent content analysis. Key COPD quality problems were first identified and, for each of them, root causes were classified according to the domains and constructs of the Consolidated Framework for Implementation Research. Proposed strategies were organized according to the intervention function types described in the Behavior Change Wheel.

Results

Four key COPD quality problems were identified: 1) lack of organization/coordination of COPD services, 2) lack of screening services coordination, 3) lack of interprofessional communication and collaboration and 4) lack of treatment adherence. Main root causes explaining these quality gaps were 1) lack of awareness of COPD, 2) lack of professional knowledge, 3) lack of definition of professional roles, 4) lack of resources and tools for COPD prevention, diagnosis, and follow-up, 5) lack of communication tools, 6) lack of integration of the patient-as-partner approach, and 7) lack of adaptation of patient education to their specific needs. Multiple strategies were proposed to improve healthcare professionals’ education and interprofessional collaboration and communication.

Conclusion

QI collaborative activities can support achieving understanding of QI challenges healthcare organizations face to improve COPD services.

Evaluating implementation and impact of a provincial quality improvement collaborative for the management of chronic diseases in primary care: the COMPAS+ study protocol

BACKGROUND

Chronic conditions such as diabetes and chronic obstructive pulmonary disease (COPD) are common and burdensome diseases primarily managed in primary care. Yet, evidence points to suboptimal quality of care for these conditions in primary care settings. Quality improvement collaboratives (QICs) are organized, multifaceted interventions that can be effective in improving chronic disease care processes and outcomes. In Quebec, Canada, the Institut national d'excellence en santé et en services sociaux (INESSS) has developed a large-scale QIC province-wide program called COMPAS+ that aims to improve the prevention and management of chronic diseases in primary care. This paper describes the protocol for our study, which aims to evaluate implementation and impact of COMPAS+ QICs on the prevention and management of targeted chronic diseases like diabetes and COPD.

METHODS

This is a mixed-methods, integrated knowledge translation study. The quantitative component involves a controlled interrupted time series involving nine large integrated health centres in the province. Study sites will receive one of two interventions: the multifaceted COMPAS+ intervention (experimental condition) or a feedback only intervention (control condition). For the qualitative component, a multiple case study approach will be used to achieve an in-depth understanding of individual, team, organizational and contextual factors influencing implementation and effectiveness of the COMPAS+ QICs.

DISCUSSION

COMPAS+ is a QI program that is unique in Canada due to its integration within the governance of the Quebec healthcare system and its capacity to reach many primary care providers and people living with chronic diseases across the province. We anticipate that this study will address several important gaps in knowledge related to large-scale QIC projects and generate strong and useful evidence (e.g., on leadership, organizational capacity, patient involvement, and implementation) having the potential to influence the design and optimisation of future QICs in Canada and internationally.

Critical reflection in leadership development

Purpose

This paper explores the role of critical reflection in the context of leadership development and how it is measured. The purpose of this paper is to review theoretical and empirical research that captures the application of critical reflection in leadership development.

Design/methodology/approach

This study is an integrative literature review of peer-reviewed journal articles on critical reflection in leadership development. The search revealed 172 peer-reviewed journal articles based on the search terms. The authors conducted a staged review of the abstracts and identified a final sample of 27 empirical articles and 12 non-empirical articles for review.

Findings

The findings of this review show that critical reflection is an essential tool for leadership development and has been utilized in a variety of ways and through multiple theoretical perspectives. Despite being relied on heavily in leadership development, the measurement for critical reflection is not well established in the literature.

Originality/value

The researchers propose a conceptual model that integrates the phases and levels of critical reflection as well as the desired outcomes in leadership development. Implications for leadership development are also discussed.

Quality of essential newborn care and neonatal resuscitation at health facilities in Afghanistan: a cross-sectional assessment

OBJECTIVE

To assess readiness and quality of essential newborn care and neonatal resuscitation practices in public health facilities in Afghanistan.

DESIGN

Cross-sectional assessment.

SETTING

226 public health facilities in Afghanistan, including 77 public health facilities with at least five births per day (high-volume facilities) and 149 of 1736 public health facilities with fewer than five births per day (low-volume facilities).

PARTICIPANTS

Managers of 226 public health facilities, 734 skilled birth attendants (SBAs) working at these facilities, and 643 women and their newborns observed during childbirth at 77 high-volume health facilities.

OUTCOME MEASURES

Availability of knowledgeable SBAs, availability of supplies and compliance with global guidelines for essential newborn care and neonatal resuscitation practices.

RESULTS

At high-volume facilities, 569/636 (87.9%) of babies were dried immediately after birth, 313/636 (49.2%) were placed in skin-to-skin contact with their mother and 581/636 (89.7%) had their umbilical cord cut with a sterile blade or scissors. A total of 87 newborn resuscitation attempts were observed. Twenty-four of the 87 (27.5%) began to breath or cry after simply clearing the airway or on stimulation. In the remaining 63 (72.5%) cases, a healthcare worker began resuscitation with a bag and mask; however, only 54 (62%) used a correct size of mask and three babies died as their resuscitation with bag and mask was unsuccessful.

CONCLUSIONS

The study indicates room for improvement of the quality of neonatal resuscitation practices at public health facilities in Afghanistan, requiring only strengthening of the current best practices in newborn care. Certain basic and effective aspects of essential newborn care that can be improved on with little additional resources were also missing, such as skin-to-skin contact of the babies with their mother. Improvement of compliance with the standard newborn care practices must be ensured to reduce preventable newborn mortality and morbidity in Afghanistan.

Improving developmental care in primary practice for disadvantaged children

Our primary objective was to assess if sustained participation in continuous quality improvement (CQI) activities could improve delivery of 'basic developmental care' to disadvantaged children in primary care settings. Secondary objectives were to assess if delivery of developmental care differed by age and geographic location.Data were analysed using multivariable logistic regression and generalised estimating equations. 109 indigenous primary care centres across Australia from 2012 to 2014 and2466 client files from indigenous children aged 3-59 months were included. Outcome measures were delivery of basic developmental care.We found that the proportion of children who received basic developmental care ranged from 55% (advice about physical and mental stimulation of child) (1279, 55.1%) to 74% (assessment of developmental milestones) (1510, 73.7%). Ninety-three per cent (92.6%, 88) of children received follow-up care. Centres with sustained CQI participation (completed three or more consecutive audit cycles) (508, 53.9%) were twofold more likely to deliver basic developmental care compared with centres without sustained CQI (completed less than three consecutive audit cycles) (118, 31.0%) (adjusted OR (aOR) 2.37, 95% CI 1.33 to 4.23). Children aged 3-11 months (229, 54.9%) were more likely to receive basic developmental care than children aged 24-59 months (151, 38.5%) (aOR 2.42, 95% CI 1.67 to 3.51). Geographic location had little effect (aOR 0.68, 95% CI 0.30 to 1.53). Overall our study found that sustained CQI can improve basic developmental care in primary care settings. However, many disadvantaged children are not receiving services. Improved resourcing of developmental care and CQI in primary care centres is needed.

Accuracy of administrative databases in detecting primary breast cancer diagnoses: a systematic review

OBJECTIVE

To define the accuracy of administrative datasets to identify primary diagnoses of breast cancer based on the International Classification of Diseases (ICD) 9th or 10th revision codes.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, Web of Science and the Cochrane Library (April 2017).

ELIGIBILITY CRITERIA

The inclusion criteria were: (a) the presence of a reference standard; (b) the presence of at least one accuracy test measure (eg, sensitivity) and (c) the use of an administrative database.

DATA EXTRACTION

Eligible studies were selected and data extracted independently by two reviewers; quality was assessed using the Standards for Reporting of Diagnostic accuracy criteria.

DATA ANALYSIS

Extracted data were synthesised using a narrative approach.

RESULTS

From 2929 records screened 21 studies were included (data collection period between 1977 and 2011). Eighteen studies evaluated ICD-9 codes (11 of which assessed both invasive breast cancer (code 174.x) and carcinoma in situ (ICD-9 233.0)); three studies evaluated invasive breast cancer-related ICD-10 codes. All studies except one considered incident cases.The initial algorithm results were: sensitivity ≥80% in 11 of 17 studies (range 57%-99%); positive predictive value was ≥83% in 14 of 19 studies (range 15%-98%) and specificity ≥98% in 8 studies. The combination of the breast cancer diagnosis with surgical procedures, chemoradiation or radiation therapy, outpatient data or physician claim may enhance the accuracy of the algorithms in some but not all circumstances. Accuracy for breast cancer based on outpatient or physician's data only or breast cancer diagnosis in secondary position diagnosis resulted low.

CONCLUSION

Based on the retrieved evidence, administrative databases can be employed to identify primary breast cancer. The best algorithm suggested is ICD-9 or ICD-10 codes located in primary position.

TRIAL REGISTRATION NUMBER

CRD42015026881.

Examining the artist-patient relationship in palliative care. A thematic analysis of artist reflections on encounters with palliative patients

BACKGROUND

Although therapeutic arts are used in the palliative care setting, little has been described about what happens during the artist-patient encounter and how these interactions can complement and integrate into the interdisciplinary model of palliative care. The objective of this study is to describe the artist-patient encounter and how artists can function in the palliative interdisciplinary model of care.

METHODS

Authors reviewed 229 reports written by artists about encounters with palliative patients, and performed thematic analysis on 95.

RESULTS

Artists describe physical, emotional and spiritual responses by patients including relaxation, invigoration and accessing spirituality, some of which were unique to the artist-patient interaction. Artists also described personal reactions including themes of professional fulfillment, kinship and empathy with patient suffering. Themes surrounding the artist-patient bond and trust also emerged.

CONCLUSIONS

The artist-patient encounter has an effect on both patients and artists, and can create a therapeutic relationship between them. Artists provide unique perspectives and contribute to care paradigms when integrated with  the palliative team.

Improving diabetes care at primary care level with a multistrategic approach: results of the DIAPREM programme

AIM

To present results, 1 year postimplementation at primary care level, of an integrated diabetes care programme including systemic changes, education, registry (clinical, metabolic, and therapeutic indicators), and disease management (DIAPREM).

METHODS

We randomly selected and trained 15 physicians and 15 nurses from primary care units of La Matanza County (intervention-IG) and another 15 physicians/nurses to participate as controls (control-CG). Each physician-nurse team controlled and followed up 10 patients with type 2 diabetes for 1 year; both groups used structured medical records. Patients in IG had quarterly clinical appointments, whereas those in CG received traditional care. Statistical data analysis included parametric/nonparametric tests according to data distribution profile and Chi-squared test for proportions.

RESULTS

After 12 months, the dropout rate was significantly lower in IG than in CG. Whereas in IG HbA1c, blood pressure and lipid profile levels significantly decreased, no changes were recorded in CG. Drug prescriptions showed no significant changes in IG except a decrease in oral monotherapy.

CONCLUSIONS

DIAPREM is an expedient and simple multistrategic model to implement at the primary care level in order to decrease patient dropout and improve control and treatment adherence, and quality of care of people with diabetes.

Multistrategic approach to improve quality of care of people with diabetes at the primary care level: Study design and baseline data

AIM

To test the one year-post effect of an integrated diabetes care program that includes system changes, education, registry (clinical, metabolic and therapeutic indicators) and disease management (DIAPREM), implemented at primary care level, on care outcomes and costs.

METHODS

We randomly selected 15 physicians and 15 nurses from primary care units of La Matanza County to be trained (Intervention-IG) and another 15 physicians/nurses to use as controls (Control-CG). Each physician-nurse team controlled and followed up 10 patients with type 2 diabetes for one year; both groups use structured medical data registry. Patients in IG had quarterly clinical appointments whereas those in CG received traditional care. DIAPREM includes system changes (use of guidelines, programmed quarterly controls and yearly visits to the specialist) and education (physicians' and nurses' training courses). Statistical data analysis included parametric/nonparametric tests according to data distribution profile and Chi-squared test for proportions.

RESULTS

Baseline data from both groups showed comparable values and 20-30% of them did not perform HbA1c and lipid profile measurements. Majority were obese, 59% had HbA1C ≥7%, 86% fasting blood glucose ≥100mg/dL, 45%, total cholesterol ≥200mg/dL, and 92% abnormal HDL- and LDL-cholesterol values. Similarly, micro and macroangiopathic complications had not been detected in the previous year. Most patients received oral antidiabetic agents (monotherapy), and one third was on insulin (mostly a single dose of an intermediate/long-acting formulation). Most people with hypertension received specific drug treatment but only half of them reached target values; dyslipidemia treatment showed similar data.

CONCLUSIONS

Baseline data demonstrated the need of implementing an intervention to improve diabetes care and treatment outcomes.

Using Large-Scale Linkage Data to Evaluate the Effectiveness of a National Educational Program on Antithrombotic Prescribing and Associated Stroke Prevention in Primary Care

BACKGROUND

The National Prescribing Service (NPS) MedicineWise Stroke Prevention Program, which was implemented nationally in 2009-2010 in Australia, sought to improve antithrombotic prescribing in stroke prevention using dedicated interventions that target general practitioners. This study evaluated the impact of the NPS MedicineWise Stroke Prevention Program on antithrombotic prescribing and primary stroke hospitalizations.

METHOD AND RESULTS

This population-based time series study used administrative health data linked to 45 and Up Study participants with a high risk of cardiovascular disease (CVD) to assess the possible impact of the NPS MedicineWise program on first-time aspirin prescriptions and primary stroke-related hospitalizations. Time series analysis showed that the NPS MedicineWise program was significantly associated with increased first-time prescribing of aspirin (P=0.03) and decreased hospitalizations for primary ischemic stroke (P=0.03) in the at-risk study population (n=90 023). First-time aspirin prescription was correlated with a reduction in the rate of hospitalization for primary stroke (P=0.02). Following intervention, the number of first-time aspirin prescriptions increased by 19.8% (95% confidence interval, 1.6-38.0), while the number of first-time stroke hospitalizations decreased by 17.3% (95% confidence interval, 1.8-30.0).

CONCLUSIONS

Consistent with NPS MedicineWise program messages for the high-risk CVD population, the NPS MedicineWise Stroke Prevention Program (2009) was associated with increased initiation of aspirin and a reduced rate of hospitalization for primary stroke. The findings suggest that the provision of evidence-based multifaceted large-scale educational programs in primary care can be effective in changing prescriber behavior and positively impacting patient health outcomes.

Validity of breast, lung and colorectal cancer diagnoses in administrative databases: a systematic review protocol

INTRODUCTION

Breast, lung and colorectal cancers constitute the most common cancers worldwide and their epidemiology, related health outcomes and quality indicators can be studied using administrative healthcare databases. To constitute a reliable source for research, administrative healthcare databases need to be validated. The aim of this protocol is to perform the first systematic review of studies reporting the validation of International Classification of Diseases 9th and 10th revision codes to identify breast, lung and colorectal cancer diagnoses in administrative healthcare databases.

METHODS AND ANALYSIS

This review protocol has been developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) 2015 statement. We will search the following databases: MEDLINE, EMBASE, Web of Science and the Cochrane Library, using appropriate search strategies. We will include validation studies that used administrative data to identify breast, lung and colorectal cancer diagnoses or studies that evaluated the validity of breast, lung and colorectal cancer codes in administrative data. The following inclusion criteria will be used: (1) the presence of a reference standard case definition for the disease of interest; (2) the presence of at least one test measure (eg, sensitivity, positive predictive values, etc) and (3) the use of data source from an administrative database. Pairs of reviewers will independently abstract data using standardised forms and will assess quality using a checklist based on the Standards for Reporting of Diagnostic accuracy (STARD) criteria.

ETHICS AND DISSEMINATION

Ethics approval is not required. We will submit results of this study to a peer-reviewed journal for publication. The results will serve as a guide to identify appropriate case definitions and algorithms of breast, lung and colorectal cancers for researchers involved in validating administrative healthcare databases as well as for outcome research on these conditions that used administrative healthcare databases.

TRIAL REGISTRATION NUMBER

CRD42015026881.