Who does it first? The uptake of medical innovations in the performance of thrombolysis on ischemic stroke patients in Germany: a study based on hospital quality data

Exploring the influence of medical staffing and birth volume on observed-to-expected cesarean deliveries: a panel data analysis of integrated obstetric and gynecological departments in Germany

INTRODUCTION

Cesarean deliveries account for approximately one-third of all births in Germany, prompting ongoing discussions on cesarean section rates and their connection to medical staffing and birth volume. In Germany, the majority of departments integrate obstetric and gynecological care within a single department.

METHODS

The analysis utilized quality reports from German hospitals spanning 2015 to 2019. The outcome variable was the annual risk-adjusted cesarean section ratio-a metric comparing expected to observed cesarean sections. Explanatory variables included annual counts of physicians, midwives, and births. To account for case number-related staffing variations, full-time equivalent midwife and physician staff positions were normalized by the number of deliveries. Uni- and multivariate panel models were applied, complemented by multiple instrument variable analyses, including two-stage least square and generalized method of moments models.

RESULTS

Incorporating data from 509 integrated obstetric departments and 2089 observations, representing 2,335,839 deliveries with 720,795 cesarean sections (over 60% of all inpatient births in Germany), multivariate model with fixed effects revealed a statistically significant positive association between the number of physicians per birth and the risk-adjusted cesarean section ratio (0.004, p = 0.004). Two-stage least square instrument variable analysis (0.020, p < 0.001) and a system GMM estimator models (0.004, p < 0.001) validated these results, providing compelling evidence for a causal relationship.

CONCLUSION

The study established a robust connection between the number of physicians per birth and the risk-adjusted cesarean section ratio in integrated obstetric and gynecological departments in Germany. While the cause of the effect remains unclear, one possible explanation is a lack of specialization within these departments due to the combined provision of both obstetric and gynecological care.

What organisational and regional factors influence the outpatient provision of curettages in Germany? A longitudinal secondary data analysis using hospital quality reports data from 2013 to 2019

OBJECTIVES

The rate of outpatient therapeutic curettage is lower in Germany than in other countries, although there are no differences in patient safety between outpatient and inpatient management. In this context, outpatient surgery is economically advantageous and efficient. This study aims to identify organisational and regional factors that determine the rate of outpatient curettage in German hospitals.

METHODS

We analysed the hospital quality reports for 2013-2019, which include data from all German hospitals with gynaecology departments (n=709). These organisational data (teaching status, size, ownership, department type and hospital group) are enhanced by contextual data (degree of urbanisation, market concentration and population income). We calculated a zero-one inflated beta regression model to identify factors that influence the rate of outpatient curettages in 2019.

RESULTS

Increasing numbers of curettages are provided on an outpatient basis; accordingly, the number of inpatient curettages declined during the analysis period. In 2019, 69.6% of in-hospital curettages were performed as outpatient surgery. Hospital size is significantly negative and outpatient physician department type is significantly positively associated with outpatient curettage rates. We found no effects of hospital ownership type, degree of urbanisation or market concentration. A high income in the surgical district's population is also associated with a higher rate of outpatient curettages.

CONCLUSIONS

The analyses demonstrate that organisational factors are associated with the outpatient curettage rate. This indicates that external elements, such as reimbursements and regulations, influence outpatient surgical events in Germany, and current regulations do not incentivise hospitals to significantly increase their rate of outpatient curettages.

Conditions for the success and the feasibility of health mediation for healthcare use by underserved populations: a scoping review

OBJECTIVE

This article aims to analyse the conditions under which health mediation for healthcare use is successful and feasible for underserved populations.

METHOD

We conducted a scoping review on the conditions for effective health mediation according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews standards. We searched for articles in the following databases: PubMed, PsychINFO, Scopus and Cairn published between 1 January 2015 and 18 December 2020. We selected the articles concerning health mediation interventions or similar, implemented in high-income countries and conducted among underserved populations, along with articles that questioned their effectiveness conditions. We created a two-dimensional analysis grid of the data collected: a descriptive dimension of the intervention and an analytical dimension of the conditions for the success and feasability of health mediation.

RESULTS

22 articles were selected and analysed. The scoping review underlines many health mediation characteristics that articulate education and healthcare system navigation actions, along with mobilisation, engagement, and collaboration of local actors among themselves and with the populations. The conditions for the success and the feasability were grouped in a conceptual framework of health mediation.

CONCLUSION

The scoping review allows us to establish an initial framework for analysing the conditions for the success and the feasability of health mediation and to question the consistency of the health mediation approach regarding cross-cutting tensions and occasionally divergent logic.

Barriers and facilitators to the uptake of new medicines into clinical practice: a systematic review

BACKGROUND

Implementation and uptake of novel and cost-effective medicines can improve patient health outcomes and healthcare efficiency. However, the uptake of new medicines into practice faces a wide range of obstacles. Earlier reviews provided insights into determinants for new medicine uptake (such as medicine, prescriber, patient, organization, and external environment factors). However, the methodological approaches used had limitations (e.g., single author, narrative review, narrow search, no quality assessment of reviewed evidence). This systematic review aims to identify barriers and facilitators affecting the uptake of new medicines into clinical practice and identify areas for future research.

METHOD

A systematic search of literature was undertaken within seven databases: Medline, EMBASE, Web of Science, CINAHL, Cochrane Library, SCOPUS, and PsychINFO. Included in the review were qualitative, quantitative, and mixed-methods studies focused on adult participants (18 years and older) requiring or taking new medicine(s) for any condition, in the context of healthcare organizations and which identified factors affecting the uptake of new medicines. The methodological quality was assessed using QATSDD tool. A narrative synthesis of reported factors was conducted using framework analysis and a conceptual framework was utilised to group them.

RESULTS

A total of 66 studies were included. Most studies (n = 62) were quantitative and used secondary data (n = 46) from various databases, e.g., insurance databases. The identified factors had a varied impact on the uptake of the different studied new medicines. Differently from earlier reviews, patient factors (patient education, engagement with treatment, therapy preferences), cost of new medicine, reimbursement and formulary conditions, and guidelines were suggested to influence the uptake. Also, the review highlighted that health economics, wider organizational factors, and underlying behaviours of adopters were not or under explored.

CONCLUSION

This systematic review has identified a broad range of factors affecting the uptake of new medicines within healthcare organizations, which were grouped into patient, prescriber, medicine, organizational, and external environment factors. This systematic review also identifies additional factors affecting new medicine use not reported in earlier reviews, which included patient influence and education level, cost of new medicines, formulary and reimbursement restrictions, and guidelines.

REGISTRATION

PROSPERO database (CRD42018108536).

A risk score for prediction of symptomatic intracerebral haemorrhage following thrombolysis

BACKGROUND AND PURPOSE

Intravenous recombinant tissue plasminogen activator (rt-PA) remains the only FDA approved pharmacological therapy for acute ischemic stroke (AIS), but this treatment is associated with symptomatic intracerebral haemorrhage (SICH). The aim of this study was to derive and validate an accurate measure of SICH risk in ischemic stroke patients treated with rt-PA using data readily available from patient clinical records.

METHODS

Demographics, physiological parameters, and clinical data were obtained from 1,270 ischemic stroke patients treated with thrombolysis at 20 hospitals. This included age, sex, weight, blood pressure, glucose levels, smoking preferences, and presence of previous clinical conditions. Using a bivariate analysis on a training dataset of 890 patients, SICH cases were compared against SICH-free patients and key risk factors associated with SICH were identified. Continuous variables were stratified using k-means clustering, and odds ratios computed for each of the categorical risk factors employed in the risk score. The SICH risk score, which was assessed using an independent validation dataset comprising 380 patients, was defined between 0 and 53, and stratified into 4 categories: very low risk (0-6), low risk (7-12), moderate risk (13-19), and high risk (>20).

RESULTS

Older age (age > 75 years), higher blood pressure, higher severity of stroke, pre-treatment antithrombotic and history of hypertension and hyperlipidaemia, were shown to be significant risk factors for SICH following rt-PA treatment (p < 0.05). A number of interaction effects with age produced greater overall SICH risk than that of individual variables alone, including age*weight, age*NIHSS, age*diastolic blood pressure, and age*hypertension. The SICH prediction tool demonstrated a C-statistic of 0.75 for continuous risk scoring (0-53) and 0.71 for stratified risk levels.

CONCLUSION

A novel, computationally efficient risk score utilising data readily available from patient clinical records was shown to predict SICH risk following thrombolysis treatment with high accuracy. This tool may be useful for pre-screening patients for SICH risk to reduce the morbidity and mortality associated with thrombolysis treatment.

Hospital contextual factors affecting the implementation of health technologies: a systematic review

Background

To keep a high quality of assistance it is important for hospitals to invest in health technologies (HTs) that have the potential of improving health outcomes. Even though guidance exists on how HTs should be introduced, used and dismissed, there is a surprising gap in literature concerning the awareness of hospitals in the actual utilization of HTs.

Methods

We performed a systematic literature review of qualitative and quantitative studies aimed at investigating hospital contextual factors that influence the actual utilization of HTs. PubMed, Scopus, Web of Science, Econlit and Ovid Medline electronic databases were searched to retrieve articles published in English and Italian from January 2000 to January 2019. The quality of the included articles was assessed using the Critical Appraisal Skills Programme checklist for qualitative studies, Newcastle-Ottawa Scale for the cross-sectional studies and the Mixed Methods Appraisal Tool for mixed method studies.

Results

We included 33 articles, which were of moderate to high methodological quality. The included articles mostly addressed the contextual factors that impact the implementation of information and communication technologies (ICTs). Overall, for all HTs, the hospital contextual factors were part of four categories: hospital infrastructure, human resource management, financial resources and leadership styles.

Conclusion

Our systematic review reported that the contextual factors influencing the HTs utilization at hospital level are mainly explored for ICTs. Several factors should be considered when planning the implementation of a new HTs at hospital level. A potential publication bias might be present in our work, since we included articles published only in English and Italian Language, from January 2000 to January 2019. There remains a gap in the literature on the facilitators and barriers influencing the implementation and concrete utilization of medical and surgical HTs, suggesting the need for further studies for a better understanding.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06423-2.

What Really Matters? Organizational Versus Regional Determinants of Hospitals Providing Medical Service Centres

By adding medical service centres (MSCs) to their range of services, hospitals can participate in the outpatient sector. The aim of the MSC guideline (2004) was to ensure high quality health care in rural areas. It is unknown if organizational or regional factors influence hospitals providing services via MSCs. Our analyses focus on the identification of factors that explain the operation of an MSC by hospitals. The data are based on the mandatory structured quality reports of German hospitals (n = 1,605). These organizational data (teaching status, size and ownership) are supplemented by settlement structure and contextual data (e.g., location, doctor density). We estimated a cross-sectional multilevel logistic regression model to identify determinants of hospitals operating MSCs. In 2017, 27% of 1,605 hospitals had one or more MSCs. On an organizational level, for-profit ownership (-) and the number of beds (+) were significant determinants of providing MSCs. The analyses show that the interaction between settlement structure and ownership has an influence on the operation of an MSC. Organizational factors determine the provision of MSCs, with regional determinants playing a role as well. This indicates that hospital behaviour is difficult to predict and that individual factors shape both profit orientation and responsibility for sufficient health care in the region.

Cluster-Randomized Trial of Thrombolysis Implementation Support in Metropolitan and Regional Australian Stroke Centers: Lessons for Individual and Systems Behavior Change

Background Intravenous thrombolytic therapy (IVT) with tissue plasminogen activator for acute ischemic stroke is underutilized in many parts of the world. Randomized trials to test the effectiveness of thrombolysis implementation strategies are limited. Methods and Results This study aimed to test the effectiveness of a multicomponent, multidisciplinary tissue plasminogen activator implementation package in increasing the proportion of thrombolyzed cases while maintaining accepted benchmarks for low rates of intracranial hemorrhage and high rates of functional outcomes at 3 months. A cluster randomized controlled trial of 20 hospitals in the early stages of thrombolysis implementation across 3 Australian states was undertaken. Monitoring of IVT rates during the baseline period allowed hospitals (the unit of randomization) to be grouped into 3 baseline IVT strata-very low rates (0% to ≤4.0%); low rates (>4.0% to ≤10.0%); and moderate rates (>10.0%). Hospitals were randomized to an implementation package (experimental group) or usual care (control group) using a 1:1 ratio. The 16-month intervention was based on behavioral theory and analysis of the steps, roles, and barriers to rapid assessment for thrombolysis eligibility and involved comprehensive strategies addressing individual and system-level change. The primary outcome was the difference in tissue plasminogen activator proportions between the 2 groups postintervention. The absolute difference in postintervention IVT rates between intervention and control hospitals adjusted for baseline IVT rate and stratum was not significant (primary outcome rate difference=1.1% (95% CI -1.5% to 3.7%; P=0.38). Rates of intracranial hemorrhage remained below international benchmarks. Conclusions The implementation package resulted in no significant change in tissue plasminogen activator implementation, suggesting that ongoing support is needed to sustain initial modifications in behavior. Clinical Trial Registration URL: www.anzctr.org.au Unique identifiers: ACTRN12613000939796 and U1111-1145-6762.

Acute Ischemic Stroke Hospital Admissions, Treatment, and Outcomes in Poland in 2009-2013

Introduction

Ischemic stroke (IS) still constitutes a serious problem for public health worldwide. The data on its burden in Poland before 2009 is limited and came only from a few metropolitan areas.

The aims of the study were

To assess temporal trends in the hospital admissions, treatment, and outcomes of IS in Poland in 2009-2013, to identify risk factors for IS mortality and to compare the results with other countries.

Methods

The data from the Polish Stroke Registry were analyzed. The data concerned all subjects hospitalized due to IS (classified according to the ICD10 classification as I63.0-I63.9) as primary diagnosis in Poland in 2009-2013. Temporal trends in treatment and outcome were analyzed. Hospital admissions rates as well as case fatality and 12-month mortality rates were calculated.

Results

Altogether, 360,556 patients (47.5% of males) were hospitalized due to IS in Poland in 2009-2013. The median of age was 75 years, IQR 18 (Women 78, IQR 14 vs. Men 70, IQR 17; p < 0.001). The hospital admissions age-standardized annual rate for IS in Poland in 2013 was 8% lower than in 2009 (169 vs. 157/100,000; p for trend < 0.001). In-hospital case fatality has slightly decreased (from 13.6% in 2009 to 12.9% in 2013; p for trend < 0.001). One-year posthospital mortality rate has not changed (19.3% in 2009 and 2013). The percentage of IS subjects treated with intravenous thrombolysis was low but increased from 1.7% in 2009 to 6.3% in 2013 (p for trend <0.001).

Conclusion

Since 2009, Poland has had national epidemiological data on the hospital admissions, treatment, and outcomes in IS. The data indicate a slow improvement of in-hospital survival and suggest the need for better stroke prevention and further dissemination of reperfusion therapy.

Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial

Background

Little is known about how to discourage clinicians from ordering low-value services. Our objective was to test whether clinicians committing their future selves (ie, precommitting) to follow Choosing Wisely recommendations with decision supports could decrease potentially low-value orders.

Methods

We conducted a 12-month stepped wedge cluster randomised trial among 45 primary care physicians and advanced practice providers in six adult primary care clinics of a US community group practice.Clinicians were invited to precommit to Choosing Wisely recommendations against imaging for uncomplicated low back pain, imaging for uncomplicated headaches and unnecessary antibiotics for acute sinusitis. Clinicians who precommitted received 1–6 months of point-of-care precommitment reminders as well as patient education handouts and weekly emails with resources to support communication about low-value services.The primary outcome was the difference between control and intervention period percentages of visits with potentially low-value orders. Secondary outcomes were differences between control and intervention period percentages of visits with possible alternate orders, and differences between control and 3-month postintervention follow-up period percentages of visits with potentially low-value orders.

Results

The intervention was not associated with a change in the percentage of visits with potentially low-value orders overall, for headaches or for acute sinusitis, but was associated with a 1.7% overall increase in alternate orders (p=0.01). For low back pain, the intervention was associated with a 1.2% decrease in the percentage of visits with potentially low-value orders (p=0.001) and a 1.9% increase in the percentage of visits with alternate orders (p=0.007). No changes were sustained in follow-up.

Conclusion

Clinician precommitment to follow Choosing Wisely recommendations was associated with a small, unsustained decrease in potentially low-value orders for only one of three targeted conditions and may have increased alternate orders.

Trial registration number

NCT02247050; Pre-results.

Isoquercetin Ameliorates Cerebral Impairment in Focal Ischemia Through Anti-Oxidative, Anti-Inflammatory, and Anti-Apoptotic Effects in Primary Culture of Rat Hippocampal Neurons and Hippocampal CA1 Region of Rats

Ischemic stroke is a major disability and cause of death worldwide due to its narrow therapeutic time window. Neuroprotective agent is a promising strategy to salvage acutely ischemic brain tissue and extend the therapeutic time window for stroke treatment. In this study, we aimed to evaluate the neuroprotective effects of isoquercetin in (1) primary culture of rat hippocampal neurons exposure on oxygen and glucose deprivation and reperfusion (OGD/R) injury and (2) rats subjected to transient middle cerebral artery occlusion and reperfusion (MCAO/R) injury. The results showed that isoquercetin post-treatment reduced the infarct size, number of apoptotic cells, oxidative stress, and inflammatory response after ischemia and reperfusion injury. The underlying mechanism study indicated that the neuroprotective effects of isoquercetin were elicited via suppressing the activation of toll-like receptor 4 (TLR4), nuclear factor-kappa B (NF-κB) and caspase-1; the phosphorylation of ERK1/2, JNK1/2, and p38 mitogen-activated protein kinase (MAPK); and the secretion of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and IL-6. In addition, isoquercetin also effectively alleviated hippocampus neuron apoptosis by regulation of cyclic AMP responsive element-binding protein (CREB), Bax, Bcl-2, and caspase-3. Our report provided new considerations into the therapeutic action and the underlying mechanisms of isoquercetin to improve brain injury in individuals who have suffered from ischemic stroke. As a potent anti-inflammatory and anti-oxidative compound with neuroprotective capacities, the beneficial effects of isoquercetin when used to treat ischemic stroke and related diseases in humans warrant further studies.