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Laginha BI, Rapport F, Smith A, Wilkinson D, Cust AE, Braithwaite J. Systematic development of quality indicators for skin cancer management in primary care: a mixed-methods study protocol. BMJ Open 2022; 12:e059829. [PMID: 35725249 PMCID: PMC9214379 DOI: 10.1136/bmjopen-2021-059829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Australia has the highest incidence of skin cancer in the world, with two out of three Australians expected to be diagnosed with skin cancer in their lifetime. Such incidence necessitates large-scale, effective skin cancer management practices. General practitioners (in mainstream practice and in skin cancer clinics) play an important role in skin cancer care provision, making decisions based on relevant evidence-based guidelines, protocols, experience and training. Diversity in these decision-making practices can result in unwarranted variation. Quality indicators are frequently implemented in healthcare contexts to measure performance quality at the level of the clinician and healthcare practice and mitigate unwarranted variation. Such measurements can facilitate performance comparisons between peers and a standard benchmark, often resulting in improved processes and outcomes. A standardised set of quality indicators is yet to be developed in the context of primary care skin cancer management. AIMS This research aims to identify, develop and generate expert consensus on a core set of quality indicators for skin cancer management in primary care. METHODS This mixed-methods study involves (1) a scoping review of the available evidence on quality indicators in skin cancer management in primary care, (2) identification and development of a core set of quality indicators through interviews/qualitative proforma surveys with participants, and (3) a focus group involving discussion of quality indicators according to Nominal Group Technique. Qualitative and quantitative data will be collected and analysed using thematic and descriptive statistical analytical methods. ETHICS AND DISSEMINATION Approval was granted by the university's Research Ethics Committee (HREC no. 520211051532420). Results from this study will be widely disseminated in publications, study presentations, educational events and reports.
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Affiliation(s)
- Bela Ines Laginha
- Faculty of Medicine, Health and Human Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Frances Rapport
- Faculty of Medicine, Health and Human Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Andrea Smith
- University of Sydney, a joint venture with Cancer Council NSW, The Daffodil Centre, Sydney, New South Wales, Australia
| | - David Wilkinson
- National Skin Cancer Centres, South Brisbane, Queensland, Australia
| | - Anne E Cust
- University of Sydney, a joint venture with Cancer Council NSW, The Daffodil Centre, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Faculty of Medicine, Health and Human Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Lundmark R, Hasson H, Richter A, Khachatryan E, Åkesson A, Eriksson L. Alignment in implementation of evidence-based interventions: a scoping review. Implement Sci 2021; 16:93. [PMID: 34711259 PMCID: PMC8554825 DOI: 10.1186/s13012-021-01160-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/02/2021] [Indexed: 11/22/2022] Open
Abstract
Background Alignment (i.e., the process of creating fit between elements of the inner and outer context of an organization or system) in conjunction with implementation of an evidence-based intervention (EBI) has been identified as important for implementation outcomes. However, research evidence has so far not been systematically summarized. The aim of this scoping review is therefore to create an overview of how the concept of alignment has been applied in the EBI implementation literature to provide a starting point for future implementation efforts in health care. Methods We searched for peer-reviewed English language articles in four databases (MEDLINE, Cinahl, Embase, and Web of Science) published between 2003 and 2019. Extracted data were analyzed to address the study aims. A qualitative content analysis was carried out for items with more extensive information. The review was reported according to the preferred reporting items for systematic reviews and meta-analyses extension for scoping review (PRISMA-ScR) guidelines. Results The database searches yielded 3629 publications, of which 235 were considered potentially relevant based on the predetermined eligibility criteria, and retrieved in full text. In this review, the results of 53 studies are presented. Different definitions and conceptualizations of alignment were found, which in general could be categorized as structural, as well as social, types of alignments. Whereas the majority of studies viewed alignment as important to understand the implementation process, only a few studies actually assessed alignment. Outcomes of alignment were focused on either EBI implementation, EBI sustainment, or healthcare procedures. Different actors were identified as important for creating alignment and five overall strategies were found for achieving alignment. Conclusions Although investigating alignment has not been the primary focus of studies focusing on EBI implementation, it has still been identified as an important factor for the implementation success. Based on the findings from this review, future research should incorporate alignment and put a stronger emphasize on testing the effectiveness of alignment related to implementation outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01160-w.
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Affiliation(s)
- Robert Lundmark
- Department of Psychology, Umeå University, SE 901 87, Umeå, Sweden.
| | - Henna Hasson
- Procome research group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.,Unit for implementation and evaluation, Center for Epidemiology and Community Medicine, Stockholm County Council, SE 171 29, Stockholm, Sweden
| | - Anne Richter
- Procome research group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.,Unit for implementation and evaluation, Center for Epidemiology and Community Medicine, Stockholm County Council, SE 171 29, Stockholm, Sweden
| | - Ermine Khachatryan
- Unit for implementation and evaluation, Center for Epidemiology and Community Medicine, Stockholm County Council, SE 171 29, Stockholm, Sweden
| | - Amanda Åkesson
- Unit for implementation and evaluation, Center for Epidemiology and Community Medicine, Stockholm County Council, SE 171 29, Stockholm, Sweden
| | - Leif Eriksson
- Unit for implementation and evaluation, Center for Epidemiology and Community Medicine, Stockholm County Council, SE 171 29, Stockholm, Sweden
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3
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Steenbruggen RA, van Oorsouw R, Maas M, Hoogeboom TJ, Brand P, Wees PVD. Development of quality indicators for departments of hospital-based physiotherapy: a modified Delphi study. BMJ Open Qual 2020; 9:bmjoq-2019-000812. [PMID: 32576577 PMCID: PMC7312452 DOI: 10.1136/bmjoq-2019-000812] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 12/17/2022] Open
Abstract
Background International hospital accreditation instruments, such as Joint Commission International (JCI) and Qmentum, focus mainly on hospital policy and procedures and do not specifically cover a profession such as hospital-based physiotherapy. This justifies the need for a quality system to which hospital-based physiotherapy can better identify, based on a common framework of quality indicators for effective quality management. Objective This study aimed to identify the most important quality indicators of a hospital-based physiotherapy department in the eyes of hospital-based physiotherapists and their managers. Methods Based on input from three focus groups and a structured literature review, a first set of quality indicators for hospital physiotherapy was assembled. After checking this set for duplicates and for overlap with JCI and Qmentum, it formed the starting point of a modified Delphi procedure. In two rounds, 17 hospital-based physiotherapy experts rated the quality indicators on relevance through online surveys. In a final consensus meeting, quality indicators were established, classified in quality themes and operationalised by describing for each theme the rationale, specifications, domain and type of indicator. Results Three focus groups provided 120 potential indicators, which were complemented with 18 potential indicators based on literature. After duplicate and overlap check and the Delphi procedure, these 138 potential indicators were reduced to a set of 56 quality indicators for hospital-based physiotherapy. Finally, these 56 indicators were condensed into 7 composite indicators, each representing a quality theme based on definitions of the European Foundation for Quality Management. Conclusion A set of 56 quality indicators, condensed into 7 composite indicators each representing a quality theme, was developed to assess the quality of a hospital-based physiotherapy department.
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Affiliation(s)
- Rudi A Steenbruggen
- IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- School of Health, Saxion University of Applied Sciences, Enschede, The Netherlands
| | | | - Marjo Maas
- IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Institute of Allied Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Thomas J Hoogeboom
- IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Paul Brand
- Medical Education, Isala Hospitals, Zwolle, The Netherlands
- Clinical Education, UMCG, Groningen, The Netherlands
| | - Philip van der Wees
- IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Tiwari D, O'Donnell A, Renaut R, Richardson T, Allen S. Reducing hospital mortality: Incremental change informed by structured mortality review is effective. Future Healthc J 2020; 7:143-148. [DOI: 10.7861/fhj.2019-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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5
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Khan MA, Soteriades ES, King J, Govender R, Hashim MJ, Masood-Husain S, Javaid SF, Debaib Mohammed Saeed Al Darei S, Dahi Al Sheryani S, Nauman J. Global Trends and Forecast of the Burden of Adverse Effects of Medical Treatment: Epidemiological Analysis Based on the Global Burden of Disease Study. Cureus 2020; 12:e7250. [PMID: 32195068 PMCID: PMC7071843 DOI: 10.7759/cureus.7250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Aim To quantify and update the years of life lost (YLL), years lived with disability (YLD) and disability-adjusted life years (DALY) due to the adverse effects of medical treatment (AEMT) between 1990 and 2017. Subject and methods We analyzed the latest dataset from the Global Burden of Disease (GBD) 2017 study. We described the burden of AEMT based on the number of DALY. We additionally evaluated the global age and sex-specific DALY and compared the age-standardized rates of DALY across the World Health Organization (WHO) regions from 1990 to 2017. Results Worldwide, the total DALYs due to AEMT were 84.93 [95% uncertainty interval (UI), 62.52 to 102.21] in 1990 and 62.79 (52.09 to 75.45) in 2017 per 100,000 population. The global percentage of change in DALY showed a negative trend of −26.06 % (−41.52 to −10.59) across all WHO regions between 1990 and 2017. The YLD has increased during the period from 1997 to 2017 by 29.47% (17.87 to 41.06). In 2017, men were affected more than women with a DALY of 66.78 in comparison to 58.91 DALY in women. DALY rates per 100,000 were highest across all the WHO regions in the first years of life. The predicted DALY rates were 59.92 (57.52 to 62.32) in the year 2020, 50.36 (32.03 to 68.70) in 2030, and 40.8 (−1.33 to 82.93) in 2040. Conclusion Using the GBD 2017 study data, we found a decrease in the DALY rate due to AEMT between 1990 and 2017 with a varying range of DALY between different WHO regions. DALY also differed by age and sex. The forecasting analyses showed a decrease in DALY due to AEMTs with a significant drop in the European region when compared to the African and American regions. However, the increasing trend for YLD signifies an increasing burden of people living with poor health due to AEMT. Our study proposes to identify disability due to AEMT as a significant public health crisis and calls for policymakers to create a robust revised policy.
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Affiliation(s)
- Moien Ab Khan
- Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, ARE
| | - Elpidoforos S Soteriades
- Epidemiology and Public Health, Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, ARE
| | - Jeff King
- Family Medicine, United Arab Emirates University, Al Ain, ARE
| | - Romona Govender
- Family Medicine, United Arab Emirates University, Al Ain, ARE
| | - Muhammad Jawad Hashim
- Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, ARE
| | | | - Syed Fahad Javaid
- Psychiatry and Behavioral Science, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, ARE
| | | | | | - Javaid Nauman
- Epidemiology and Public Health, Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, ARE
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Koenders N, van den Heuvel S, Bloemen S, van der Wees PJ, Hoogeboom TJ. Development of a longlist of healthcare quality indicators for physical activity of patients during hospital stay: a modified RAND Delphi study. BMJ Open 2019; 9:e032208. [PMID: 31712346 PMCID: PMC6858236 DOI: 10.1136/bmjopen-2019-032208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To develop a longlist of healthcare quality indicators for the care of hospitalised adults of all ages with (or at risk of) low physical activity during the hospital stay. DESIGN A modified RAND/UCLA Appropriateness Method Delphi study. SETTING AND PARTICIPANTS Participants were physical therapists, nurses and managers working in Dutch university medical centres. METHODS The current study consisted of three phases. Phase I was a systematic literature search for quality indicators and relevant domains. Phase II was a survey among healthcare professionals to collect additional data. Phase III consisted of three consensus rounds. In round 1, experts rated the relevance of the potential indicators online (Delphi). The second round was a face-to-face expert panel meeting managed by an experienced moderator. Acceptability, feasibility and validity of the quality indicators were discussed by the panel members. In round 3, the panel members rated the relevance of the potential indicators that were still under discussion. RESULTS The search retrieved 1556 studies of which 53 studies were assessed full text. Data from 17 studies were included in a first draft longlist of indicators. Eighteen nurses and one physical therapist responded to the survey and added data for a second draft of the longlist. Experts constructed the final longlist of 23 indicators in three consensus rounds. Seven domains were identified: 'Policy', 'Attitude and education', 'Equipment and support', 'Evaluation', 'Information', 'Patient-tailored physical activity plan' and 'Outcome measure'. CONCLUSION AND IMPLICATIONS The healthcare quality indicators developed in this study could help to grade, monitor and improve healthcare for hospitalised adults of all ages with (or at risk of) low physical activity during the hospital stay. Future research will focus on the psychometric quality of the indicators and selection of key performance indicators.
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Affiliation(s)
- Niek Koenders
- Department of Rehabilitation-Physical Therapy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stein van den Heuvel
- Department of Rehabilitation-Physical Therapy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Shanna Bloemen
- Department of Rehabilitation-Physical Therapy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Philip J van der Wees
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Thomas J Hoogeboom
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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7
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van Overveld LFJ, Takes RP, Vijn TW, Braspenning JCC, de Boer JP, Brouns JJA, Bun RJ, van Dijk BAC, Dortmans JAWF, Dronkers EAC, van Es RJJ, Hoebers FJP, Kropveld A, Langendijk JA, Langeveld TPM, Oosting SF, Verschuur HP, de Visscher JGAM, van Weert S, Merkx MAW, Smeele LE, Hermens RPMG. Feedback preferences of patients, professionals and health insurers in integrated head and neck cancer care. Health Expect 2017; 20:1275-1288. [PMID: 28618147 PMCID: PMC5689243 DOI: 10.1111/hex.12567] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2017] [Indexed: 12/31/2022] Open
Abstract
Background Audit and feedback on professional practice and health care outcomes are the most often used interventions to change behaviour of professionals and improve quality of health care. However, limited information is available regarding preferred feedback for patients, professionals and health insurers. Objective Investigate the (differences in) preferences of receiving feedback between stakeholders, using the Dutch Head and Neck Audit as an example. Methods A total of 37 patients, medical specialists, allied health professionals and health insurers were interviewed using semi‐structured interviews. Questions focussed on: “Why,” “On what aspects” and “How” do you prefer to receive feedback on professional practice and health care outcomes? Results All stakeholders mentioned that feedback can improve health care by creating awareness, enabling self‐reflection and reflection on peers or colleagues, and by benchmarking to others. Patients prefer feedback on the actual professional practice that matches the health care received, whereas medical specialists and health insurers are interested mainly in health care outcomes. All stakeholders largely prefer a bar graph. Patients prefer a pie chart for patient‐reported outcomes and experiences, while Kaplan‐Meier survival curves are preferred by medical specialists. Feedback should be simple with firstly an overview, and 1‐4 times a year sent by e‐mail. Finally, patients and health professionals are cautious with regard to transparency of audit data. Conclusions This exploratory study shows how feedback preferences differ between stakeholders. Therefore, tailored reports are recommended. Using this information, effects of audit and feedback can be improved by adapting the feedback format and contents to the preferences of stakeholders.
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Affiliation(s)
- Lydia F J van Overveld
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Nijmegen, The Netherlands
| | - Robert P Takes
- Department of Otolaryngology, Head and Neck surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Thomas W Vijn
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Nijmegen, The Netherlands
| | - Jozé C C Braspenning
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Nijmegen, The Netherlands.,The Netherlands Federation of University Medical Centres, NFU, Utrecht, The Netherlands
| | - Jan P de Boer
- Department of Medical Oncology, Antoni van Leeuwenhoek Nederlands Kanker Instituut, Amsterdam, The Netherlands
| | - John J A Brouns
- Department of Oral and Maxillofacial Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Rolf J Bun
- Department of Oral and Maxillofacial Surgery, Medical Centre Alkmaar, Alkmaar, The Netherlands
| | - Boukje A C van Dijk
- Department of Research, Comprehensive Cancer Organization the Netherlands (IKNL), Utrecht, The Netherlands.,Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Judith A W F Dortmans
- Department of Radiation Oncology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Emilie A C Dronkers
- Department of Otorhinolaryngology, Head and Neck surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Robert J J van Es
- Department of Head and Neck Surgical Oncology, UMC Utrecht Cancer Center, Utrecht, The Netherlands
| | - Frank J P Hoebers
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Arvid Kropveld
- Department of Otolaryngology, Head and Neck surgery, Elisabeth-TweeSteden ziekenhuis Tilburg, Tilburg, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Ton P M Langeveld
- Department of Otorhinolaryngology, Head and Neck surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sjoukje F Oosting
- Department of Medical Oncology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Hendrik P Verschuur
- Department of Otolaryngology, Head and Neck surgery, MC Haaglanden-Bronovo, The Hague, The Netherlands
| | - Jan G A M de Visscher
- Department of Oral and Maxillofacial Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Stijn van Weert
- Department of Otolaryngology, Head and Neck surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - Matthias A W Merkx
- Department of Oral and Maxillofacial Surgery, Radboud university Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Ludi E Smeele
- Department of Head and Neck Surgery and Oncology, Antoni van Leeuwenhoek Nederlands Kanker Instituut, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Academisch Medisch Centrum, Amsterdam Zuid-Oost, The Netherlands
| | - Rosella P M G Hermens
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Nijmegen, The Netherlands
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D'Lima DM, Moore J, Bottle A, Brett SJ, Arnold GM, Benn J. Developing effective feedback on quality of anaesthetic care: what are its most valuable characteristics from a clinical perspective? J Health Serv Res Policy 2016; 20:26-34. [PMID: 25472987 DOI: 10.1177/1355819614557299] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Research suggests that better feedback from quality and safety indicators leads to enhanced capability of clinicians and departments to improve care and change behaviour. The aim of the current study was to investigate the characteristics of feedback perceived by clinicians to be of most value. METHODS Data were collected using a survey designed as part of a wider evaluation of a data feedback initiative in anaesthesia. Eighty-nine consultant anaesthetists from two English NHS acute Trusts completed the survey. Multiple linear regression with hierarchical variable entry was used to investigate which characteristics of feedback predict its perceived usefulness for monitoring variation and improving care. RESULTS The final model demonstrated that the relevance of the quality indicators to the specific service area (β=0.64, p=0.01) and the credibility of the data as coming from a trustworthy, unbiased source (β=0.55, p=0.01) were the significant predictors, having controlled for all other covariates. CONCLUSION For clinicians to engage with effective quality monitoring and feedback, the perceived local relevance of indicators and trust in the credibility of the resulting data are paramount.
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Affiliation(s)
- Danielle M D'Lima
- Research Psychologist, Imperial Patient Safety Translational Research Centre, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, UK
| | - Joanna Moore
- Researcher, Imperial Patient Safety Translational Research Centre, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, UK
| | - Alex Bottle
- Senior Lecturer, School of Public Health, Imperial College London, UK
| | - Stephen J Brett
- Consultant Intensivist, Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, UK
| | - Glenn M Arnold
- Consultant Anaesthetist, Department of Anaesthesia, Imperial College Healthcare NHS Trust, UK
| | - Jonathan Benn
- Lecturer, Imperial Patient Safety Translational Research Centre, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, UK
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Herepath A, Kitchener M, Waring J. A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03400] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BackgroundHospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.ObjectivesThis study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.DesignWe used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.SettingWelsh Government and NHS Wales.ParticipantsInterviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.Main outcome measuresIdentification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.ResultsAn innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.ConclusionsHeightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Andrea Herepath
- Sir Roland Smith Centre for Strategic Management, Department of Entrepreneurship, Strategy and Innovation, Lancaster University Management School, Lancaster University, Lancaster, UK
- Cardiff Business School, Cardiff University, Cardiff, UK
| | | | - Justin Waring
- Nottingham University Business School, University of Nottingham, Nottingham, UK
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10
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Benn J, Arnold G, D’Lima D, Wei I, Moore J, Aleva F, Smith A, Bottle A, Brett S. Evaluation of a continuous monitoring and feedback initiative to improve quality of anaesthetic care: a mixed-methods quasi-experimental study. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03320] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BackgroundThis study evaluated the impact of a continuous quality monitoring and feedback initiative in anaesthesia.ObjectivesTo conduct a quasi-experimental evaluation of the feedback initiative and its effect on quality of anaesthetic care and perioperative efficiency. To understand the longitudinal effects of passive and active feedback and investigate the mechanisms and interactions underpinning those effects.DesignMixed-methods evaluation with analysis and synthesis of data from longitudinal qualitative interviews, longitudinal evaluative surveys and an interrupted time series study.InterventionContinuous measurement of a range of anaesthetic quality indicators was undertaken in a London teaching hospital alongside monthly personal feedback from case summary data to a cohort of anaesthetists, with follow-up roll-out to the whole NHS trust. Basic feedback consisted of the provision of passive monthly personalised feedback reports containing summary case data. In the enhanced phase, data feedback consisted of more sophisticated statistical breakdown of data, comparative and longitudinal views, and was paired with an active programme of dissemination and professional engagement.MethodsBaseline data collection began in March 2010. Implementation of basic feedback took place in October 2010, followed by implementation of the enhanced feedback protocol in July 2012. Weekly aggregated quality indicator data, coupled with surgical site infection and mortality rates, was modelled using interrupted time series analyses. The study anaesthetist cohort comprised 50,235 cases, performed by 44 anaesthetists over the course of the study, with 22,670 cases performed at the primary site. Anaesthetist responses to the surveys were collected pre and post implementation of feedback at all three sites in parallel with qualitative investigation. Seventy anaesthetists completed the survey at one or more time points and 35 health-care professionals, including 24 anaesthetists, were interviewed across two time points.ResultsResults from the time series analysis of longitudinal variation in perioperative indicators did not support the hypothesis that implementation of basic feedback improved quality of anaesthetic care. The implementation of enhanced feedback was found to have a significant positive impact on two postoperative pain measures, nurse-recorded freedom from nausea, mean patient temperature on arrival in recovery and Quality of Recovery Scale scores. Analysis of survey data demonstrated that anaesthetists value perceived credibility of data and local relevance of quality indicators above other criteria when assessing utility of feedback. A significant improvement in the perceived value of quality indicators, feedback, data use and overall effectiveness was observed between baseline and implementation of feedback at the primary site, a finding replicated at the two secondary sites. Findings from the qualitative research elucidated processes of interaction between context, intervention and user, demonstrating a positive response by clinicians to this type of initiative and willingness to interact with a sustained and comprehensive feedback protocol to understand variations in care.ConclusionsThe results support the potential of quality monitoring and feedback interventions as quality improvement mechanisms and provide insight into the positive response of clinicians to this type of initiative, including documentation of the experiences of anaesthetists that participated as users and codesigners of the feedback. Future work in this area might usefully investigate how this type of intervention may be transferred to other areas of clinical practice and further explore interactions between local context and the successful implementation of quality monitoring and feedback systems.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Jonathan Benn
- Imperial Patient Safety Translational Research Centre, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Glenn Arnold
- Department of Anaesthesia, Imperial College Healthcare NHS Trust, London, UK
| | - Danielle D’Lima
- Imperial Patient Safety Translational Research Centre, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Igor Wei
- Imperial Patient Safety Translational Research Centre, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Joanna Moore
- Imperial Patient Safety Translational Research Centre, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Floor Aleva
- IQ Scientific Institute for Quality of Healthcare, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Andrew Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - Alex Bottle
- School of Public Health, Imperial College London, London, UK
| | - Stephen Brett
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
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Education for cardiac arrest--Treatment or prevention? Resuscitation 2015; 92:59-62. [PMID: 25921543 DOI: 10.1016/j.resuscitation.2015.04.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/01/2015] [Accepted: 04/17/2015] [Indexed: 11/23/2022]
Abstract
In-hospital cardiac arrests (IHCA) occur infrequently and individual staff members working on general wards may only rarely encounter one. Mortality following IHCA is high and the evidence for the benefits of many advanced life support (ALS) interventions is scarce. Nevertheless, regular, often frequent, ALS training is mandatory for many hospital medical staff and nurses. The incidence of pre-cardiac arrest deterioration is much higher than that of cardiac arrests, and there is evidence that intervention prior to cardiac arrest can reduce the incidence of IHCA. This article discusses a proposal to reduce the emphasis on widespread ALS training and to increase education in the recognition and response to pre-arrest clinical deterioration.
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Kristoffersen DT, Helgeland J, Waage HP, Thalamus J, Clemens D, Lindman AS, Rygh LH, Tjomsland O. Survival curves to support quality improvement in hospitals with excess 30-day mortality after acute myocardial infarction, cerebral stroke and hip fracture: a before-after study. BMJ Open 2015; 5:e006741. [PMID: 25808167 PMCID: PMC4386226 DOI: 10.1136/bmjopen-2014-006741] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To evaluate survival curves (Kaplan-Meier) as a means of identifying areas in the clinical pathway amenable to quality improvement. DESIGN Observational before-after study. SETTING In Norway, annual public reporting of nationwide 30-day in-and-out-of-hospital mortality (30D) for three medical conditions started in 2011: first time acute myocardial infarction (AMI), stroke and hip fracture; reported for 2009. 12 of 61 hospitals had statistically significant lower/higher mortality compared with the hospital mean. PARTICIPANTS Three hospitals with significantly higher mortality requested detailed analyses for quality improvement purposes: Telemark Hospital Trust Skien (AMI and stroke), Østfold Hospital Trust Fredrikstad (stroke), Innlandet Hospital Trust Gjøvik (hip fracture). OUTCOME MEASURES Survival curves, crude and risk-adjusted 30D before (2008-2009) and after (2012-2013). INTERVENTIONS Unadjusted survival curves for the outlier hospitals were compared to curves based on pooled data from the other hospitals for the 30-day period 2008-2009. For patients admitted with AMI (Skien), stroke (Fredrikstad) and hip fracture (Gjøvik), the curves suggested increased mortality from the initial part of the clinical pathway. For stroke (Skien), increased mortality appeared after about 8 days. The curve profiles were thought to reflect suboptimal care in various phases in the clinical pathway. This informed improvement efforts. RESULTS For 2008-2009, hospital-specific curves differed from other hospitals: borderline significant for AMI (p=0.064), highly significant (p≤0.005) for the remainder. After intervention, no difference was found (p>0.188). Before-after comparison of the curves within each hospital revealed a significant change for Fredrikstad (p=0.006). For the three hospitals, crude 30D declined and they were non-outliers for risk-adjusted 30D for 2013. CONCLUSIONS Survival curves as a supplement to 30D may be useful for identifying suboptimal care in the clinical pathway, and thus informing design of quality improvement projects.
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Affiliation(s)
| | - Jon Helgeland
- Quality Measurement Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | | | | | - Dirk Clemens
- Innlandet Hospital Trust Gjøvik, Brumunddal, Norway
| | - Anja Schou Lindman
- Quality Measurement Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | - Liv Helen Rygh
- Quality Measurement Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | - Ole Tjomsland
- Quality Measurement Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway
- South-Eastern Norway Regional Health Authority, Hamar, Norway
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13
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The MET 5-min mile: Measuring performance of medical emergency teams. Resuscitation 2014; 85:973-4. [DOI: 10.1016/j.resuscitation.2014.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 05/07/2014] [Indexed: 11/22/2022]
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Fowler AJ, Agha RA, Sevdalis N. Surveillance and quality improvement in the United Kingdom: Is there a meeting point? Surgeon 2014; 12:177-80. [DOI: 10.1016/j.surge.2014.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/09/2014] [Accepted: 03/13/2014] [Indexed: 11/25/2022]
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Lee EJ, Hwang SH, Lee JA, Kim Y. Variations in the hospital standardized mortality ratios in Korea. J Prev Med Public Health 2014; 47:206-15. [PMID: 25139167 PMCID: PMC4162118 DOI: 10.3961/jpmph.2014.47.4.206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 07/05/2014] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES The hospital standardized mortality ratio (HSMR) has been widely used because it allows for robust risk adjustment using administrative data and is important for improving the quality of patient care. METHODS All inpatients discharged from hospitals with more than 700 beds (66 hospitals) in 2008 were eligible for inclusion. Using the claims data, 29 most responsible diagnosis (MRDx), accounting for 80% of all inpatient deaths among these hospitals, were identified, and inpatients with those MRDx were selected. The final study population included 703 571 inpatients including 27 718 (3.9% of all inpatients) in-hospital deaths. Using logistic regression, risk-adjusted models for predicting in-hospital mortality were created for each MRDx. The HSMR of individual hospitals was calculated for each MRDx using the model coefficients. The models included age, gender, income level, urgency of admission, diagnosis codes, disease-specific risk factors, and comorbidities. The Elixhauser comorbidity index was used to adjust for comorbidities. RESULTS For 26 out of 29 MRDx, the c-statistics of these mortality prediction models were higher than 0.8 indicating excellent discriminative power. The HSMR greatly varied across hospitals and disease groups. The academic status of the hospital was the only factor significantly associated with the HSMR. CONCLUSIONS We found a large variation in HSMR among hospitals; therefore, efforts to reduce these variations including continuous monitoring and regular disclosure of the HSMR are required. OBJECTIVES The hospital standardized mortality ratio (HSMR) has been widely used because it allows for robust risk adjustment using administrative data and is important for improving the quality of patient care. METHODS All inpatients discharged from hospitals with more than 700 beds (66 hospitals) in 2008 were eligible for inclusion. Using the claims data, 29 most responsible diagnosis (MRDx), accounting for 80% of all inpatient deaths among these hospitals, were identified, and inpatients with those MRDx were selected. The final study population included 703 571 inpatients including 27 718 (3.9% of all inpatients) in-hospital deaths. Using logistic regression, risk-adjusted models for predicting in-hospital mortality were created for each MRDx. The HSMR of individual hospitals was calculated for each MRDx using the model coefficients. The models included age, gender, income level, urgency of admission, diagnosis codes, disease-specific risk factors, and comorbidities. The Elixhauser comorbidity index was used to adjust for comorbidities. RESULTS For 26 out of 29 MRDx, the c-statistics of these mortality prediction models were higher than 0.8 indicating excellent discriminative power. The HSMR greatly varied across hospitals and disease groups. The academic status of the hospital was the only factor significantly associated with the HSMR. CONCLUSIONS We found a large variation in HSMR among hospitals; therefore, efforts to reduce these variations including continuous monitoring and regular disclosure of the HSMR are required.
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Affiliation(s)
| | - Soo-Hee Hwang
- Health Insurance Review & Assessment Research Institute, Health Insurance Review and Assessment Service, Seoul, Korea
| | - Jung-A Lee
- Institute of Health Policy and Management, Medical Research Center, Seoul National University, Seoul, Korea
| | - Yoon Kim
- Institute of Health Policy and Management, Medical Research Center, Seoul National University, Seoul, Korea ; Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
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From data to decisions? Exploring how healthcare payers respond to the NHS Atlas of Variation in Healthcare in England. Health Policy 2013; 114:79-87. [PMID: 23702086 DOI: 10.1016/j.healthpol.2013.04.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 04/08/2013] [Accepted: 04/19/2013] [Indexed: 11/23/2022]
Abstract
PURPOSE Although information on variations in health service performance is now more widely available, relatively little is known about how healthcare payers use this information to improve resource allocation. We explore to what extent and how Primary Care Trusts (PCTs) in England have used the NHS Atlas of Variation in Healthcare, which has highlighted small area variation in rates of expenditure, activity and outcome. METHODS Data collection involved an email survey among PCT Chief Executives and a telephone follow-up to reach non-respondents (total response: 53 of 151 of PCTs, 35%). 45 senior to mid-level staff were interviewed to probe themes emerging from the survey. The data were analysed using a matrix-based Framework approach. FINDINGS Just under half of the respondents (25 of 53 PCTs) reported not using the Atlas, either because they had not been aware of it, lacked staff capacity to analyse it, or did not perceive it as applicable to local decision-making. Among the 28 users, the Atlas served as a prompt to understand variations and as a visual tool to facilitate communication with clinicians. Achieving clarity on which variations are unwarranted and agreeing on responsibilities for action appeared to be important factors in moving beyond initial information gathering towards decisions about resource allocation and behaviour change. CONCLUSIONS Many payers were unable to use information on small area variations in expenditure, activity and outcome. To change this what is additionally required are appropriate tools to understand causes of unexplained variation, in particular unwarranted variation, and enable remedial actions to be prioritised in terms of their contribution to population health.
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Sorinola OO, Weerasinghe C, Brown R. Preventable hospital mortality: learning from retrospective case record review. JRSM SHORT REPORTS 2012; 3:77. [PMID: 23323195 PMCID: PMC3545333 DOI: 10.1258/shorts.2012.012077] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objective To determine the proportion of hospital deaths associated with preventable problems in care and how they can be reduced. Design A two phase before and after evaluation of a hospital mortality reduction programme. Setting A district general hospital in Warwickshire, England. Participants In Phase 1, 400 patients who died in 2009 at South Warwickshire NHS Foundation Trust had their case notes reviewed. In Phase 2, Trust wide measures were introduced across the whole Trust population to bring about quality improvements. Main outcome measures To reduce the crude mortality and in effect the risk adjusted mortality index (RAMI) by 45 in the three years following the start of the programme, from 145 in 2009 to 100 or less in 2012. Results In total, 34 (8.5%) patients experienced a problem in their care that contributed to death. The principal problems were lack of senior medical input (24%), poor clinical monitoring or management (24%), diagnostic errors (15%) and infections (15%). In total, 41% (14) of these were judged to have been preventable (3.5% of all deaths). Following the quality improvement programme, crude mortality fell from 1.95% (2009) to 1.56% (2012) while RAMI dropped from 145 (2009) to 87 (2012). Conclusion A quality improvement strategy based on good local evidence is effective in improving the quality of care sufficiently to reduce mortality.
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Affiliation(s)
- Olanrewaju O Sorinola
- South Warwickshire Foundation NHS Trust , Warwick CV34 5BW , UK ; University of Warwick , Coventry CV4 7AL , UK
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Minne L, Eslami S, de Keizer N, de Jonge E, de Rooij SE, Abu-Hanna A. Statistical process control for monitoring standardized mortality ratios of a classification tree model. Methods Inf Med 2012; 51:353-8. [PMID: 22773038 DOI: 10.3414/me11-02-0044] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 05/04/2012] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The ratio of observed to expected mortality (standardized mortality ratio, SMR), is a key indicator of quality of care. We use PreControl Charts to investigate SMR behavior over time of an existing tree-model for predicting mortality in intensive care units (ICUs) and its implications for hospital ranking. We compare the results to those of a logistic regression model. METHODS We calculated SMRs of 30 equally-sized consecutive subsets from a total of 12,143 ICU patients aged 80 years or older and plotted them on a PreControl Chart. We calculated individual hospital SMRs in 2009, with and without repeated recalibration of the models on earlier data. RESULTS The overall SMR of the tree-model was stable over time, in contrast to logistic regression. Both models were stable after repeated recalibration. The overall SMR of the tree on the whole validation set was statistically significantly different (SMR 1.00 ± 0.012 vs. 0.94 ± 0.01) and worse in performance than the logistic regression model (AUC 0.76 ± 0.005 vs. 0.79 ± 0.004; Brier score 0.17 ± 0.012 vs. 0.16 ± 0.010). The individual SMRs' range in 2009 was 0.53-1.31 for the tree and 0.64-1.27 for logistic regression. The proportion of individual hospitals with SMR >1, hinting at poor quality of care, reduced from 38% to 29% after recalibration for the tree, and increased from 15% to 35% for logistic regression. CONCLUSIONS Although the tree-model has seemingly a longer shelf life than the logistic regression model, its SMR may be less useful for quality of care assessment as it insufficiently responds to changes in the population over time.
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Affiliation(s)
- Lilian Minne
- Academic Medical Center, Department of Medical Informatics, Amsterdam, The Netherlands.
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Assessment of variation in live donor kidney transplantation across transplant centers in the United States. Transplantation 2011; 91:1357-63. [PMID: 21562451 DOI: 10.1097/tp.0b013e31821bf138] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transplant centers vary in the proportion of kidney transplants performed using live donors. Clinical innovations that facilitate live donation may drive this variation. METHODS We assembled a cohort of renal transplant candidates at 194 US centers using registry data from 1999 to 2005. We measured magnitude of live donor kidney transplantation (LDKTx) through development of a standardized live donor transplantation ratio (SLDTR) at each center that accounted for center population differences. We examined associations between center characteristics and the likelihood that individual transplant candidates underwent LDKTx. To identify practices through which centers increase LDKTx, we also examined center characteristics associated with consistently being in the upper three quartiles of SLDTR. RESULTS The cohort comprised 148,168 patients, among whom 34,593 (23.3%) underwent LDKTx. In multivariable logistic regression, candidates had an increased likelihood of undergoing LDKTx at centers with greater use of "unrelated donors" (defined as nonspouses and nonfirst-degree family members of the recipient; odds ratio [OR] 1.31 for highest vs. lowest use; P=0.02) and at centers with programs to overcome donor-recipient incompatibility (OR 1.33; P=0.01). Centers consistently in the upper three SLDTR quartiles were also more likely to use "unrelated" donors (OR 8.30 per tertile of higher use; P<0.01), to have incompatibility programs (OR 4.79, P<0.01), and to use laparoscopic nephrectomy (OR 2.53 per tertile of higher use; P=0.02). CONCLUSION Differences in center population do not fully account for differences in the use of LDKTx. To maximize opportunities for LDKTx, centers may accept more unrelated donors and adopt programs to overcome biological incompatibility.
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Kapur N, Clements C, Bateman N, Foëx B, Mackway-Jones K, Hawton K, Gunnell D. Self-poisoning suicide deaths in England: could improved medical management contribute to suicide prevention? QJM 2010; 103:765-75. [PMID: 20685840 DOI: 10.1093/qjmed/hcq128] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Suicide by self-poisoning is a major cause of death worldwide. Few studies have investigated the medical management of fatal self-poisoning. AIM To describe the characteristics and management of a national sample of individuals who died by intentional self-poisoning in hospital and assess the quality of care that they received. DESIGN National population-based descriptive study and confidential inquiry. METHODS Adults (aged ≥ 16 years) who had died by self-poisoning in English hospitals in 2005 and received a coroner's verdict of suicide or undetermined death at inquest were included. Socio-demographic and clinical data were collected through detailed questionnaires sent to clinicians at the treating hospitals. A panel of three expert assessors rated each case with respect to quality of care and likely contribution to the fatal outcome. RESULTS We obtained information on 121 cases (response rate for questionnaires 77%). Expert assessors rated 41/104 cases [39% (95% CI 30-49%)] as having received inadequate care; in the majority (38/41-93%) of these, this poor care was felt to have potentially contributed to the patient's death. The most common reason for a rating of inadequate care was poor airway management (recorded in over half of inadequate care cases). In three cases, the receipt of inadequate care was associated with the presence of some form of advance directive. CONCLUSION In as many as 39% of in-hospital self-poisoning fatalities, the care received may be in some way sub-optimal. The challenge for clinical services is to ensure that optimal management strategies are implemented in practice.
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Affiliation(s)
- N Kapur
- Centre for Suicide Prevention, School of Community Based Medicine, University of Manchester, Manchester M13 9PL, UK.
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21
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Education is what remains after medical emergency teams are trained. Crit Care Med 2010; 38:1610. [DOI: 10.1097/ccm.0b013e3181da4cf1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Slonim AD, Khandelwal S, He J, Hall M, Stockwell DC, Turenne WM, Shah SS. Characteristics associated with pediatric inpatient death. Pediatrics 2010; 125:1208-16. [PMID: 20457682 PMCID: PMC3033561 DOI: 10.1542/peds.2009-1451] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The primary objective of this study was to obtain a broad understanding of inpatient deaths across academic children's hospitals. METHODS A nonconcurrent cohort study of children hospitalized in 37 academic children's hospitals in 2005 was performed. The primary outcome was death. Patient characteristics including age, gender, race, diagnostic grouping, and insurance status and epidemiological measures including standardized mortality rate and standardized mortality ratios (SMRs) were used. RESULTS A total of 427 615 patients were discharged during the study period, of whom 4529 (1.1%) died. Neonates had the highest mortality rate (4.03%; odds ratio: 8.66; P < .001), followed by patients >18 years of age (1.4%; odds ratio: 2.86; P < .001). The SMRs ranged from 0.46 (all patient-refined, diagnosis-related group 663, other anemias and disorders of blood) to 30.0 (all patient-refined, diagnosis-related group 383, cellulitis and other bacterial skin infections). When deaths were compared according to institution, there was considerable variability in both the number of children who died and the SMRs at those institutions. CONCLUSIONS Patient characteristics, such as age, severity, and diagnosis, were all substantive factors associated with the death of children. Opportunities to improve the environment of care by reducing variability within and between hospitals may improve mortality rates for hospitalized children.
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Affiliation(s)
- Anthony D. Slonim
- Childrens National Medical Center, Division of Critical Care Medicine, Washington, DC 20010. Associate Professor, Internal Medicine, Pediatrics and Public Health, The George Washington University School of Medicine, Washington DC
| | | | - Jianping He
- Children’s National Medical Center, Washington, DC 20010
| | - Matthew Hall
- Child Health Corporation of America, Shawnee Mission, KS
| | | | | | - Samir S. Shah
- Divisions of General Pediatrics and Inf. Diseases, The Childrens Hospital of Philadelphia, Departments of Pediatrics and Epidemiology, And the Center for Clinical Epid. and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pa
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Pulver LK, Tett SE, Coombes J. The Queensland experience of participation in a national drug use evaluation project, Community-Acquired Pneumonia Towards Improving Outcomes Nationally (CAPTION). BMC Pulm Med 2009; 9:38. [PMID: 19646287 PMCID: PMC2731033 DOI: 10.1186/1471-2466-9-38] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 08/03/2009] [Indexed: 11/10/2022] Open
Abstract
Background Multicentre drug use evaluations are described in the literature infrequently and usually publish only the results. The purpose of this paper is to describe the experience of Queensland hospitals participating in the Community-Acquired Pneumonia Towards Improving Outcomes Nationally (CAPTION) project, specifically evaluating the implementation of this project, detailing benefits and drawbacks of involvement in a national drug use evaluation program. Methods Emergency departments from nine hospitals in Queensland, Australia, participated in CAPTION, a national quality improvement project, conducted in 37 Australian hospitals. CAPTION was aimed at optimising prescribing in the management of Community-Acquired Pneumonia according to the recommendations of the Australian Therapeutic Guidelines: Antibiotic 12th edition. The project involved data collection, and evaluation, feedback of results and a suite of targeted educational interventions including audit and feedback, group presentations and academic detailing. A baseline audit and two drug use evaluation cycles were conducted during the 2-year project. The implementation of the project was evaluated using feedback forms after each phase of the project (audit or intervention). At completion a group meeting with the hospital coordinators identified positive and negative elements of the project. Results Evaluation by hospitals of their participation in CAPTION demonstrated both benefits and drawbacks. The benefits were grouped into the impact on the hospital dynamic such as; improved interdisciplinary working relationships (e.g. between pharmacist and doctor), recognition of the educational/academic role of the pharmacist, creation of ED Pharmacist positions and enhanced involvement with the National Prescribing Service, and personal benefits. Personal benefits included academic detailing training for participants, improved communication skills and opportunities to present at conferences. The principal drawback of participation was the extra burden on already busy staff members. Conclusion A national multicentre drug use evaluation project such as CAPTION allows hospitals which would otherwise not undertake such projects the opportunity to participate. The Queensland arm of CAPTION demonstrated benefits to both the individual participants and their hospitals, highlighting the additional value of participating in a multicentre project of this type.
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Affiliation(s)
- Lisa K Pulver
- School of Pharmacy, Steele Building, University of Queensland, Queensland, Australia.
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Wouters MWJM, Karim-Kos HE, le Cessie S, Wijnhoven BPL, Stassen LPS, Steup WH, Tilanus HW, Tollenaar RAEM. Centralization of esophageal cancer surgery: does it improve clinical outcome? Ann Surg Oncol 2009; 16:1789-98. [PMID: 19370377 PMCID: PMC2695873 DOI: 10.1245/s10434-009-0458-9] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2007] [Revised: 01/27/2009] [Accepted: 01/27/2009] [Indexed: 12/22/2022]
Abstract
Background The volume–outcome relationship for complex surgical procedures has been extensively studied. Most studies are based on administrative data and use in-hospital mortality as the sole outcome measure. It is still unknown if concentration of these procedures leads to improvement of clinical outcome. The aim of our study was to audit the process and effect of centralizing oesophageal resections for cancer by using detailed clinical data. Methods From January 1990 until December 2004, 555 esophagectomies for cancer were performed in 11 hospitals in the region of the Comprehensive Cancer Center West (CCCW); 342 patients were operated on before and 213 patients after the introduction of a centralization project. In this project patients were referred to the hospitals which showed superior outcomes in a regional audit. In this audit patient, tumor, and operative details as well as clinical outcome were compared between hospitals. The outcome of both cohorts, patients operated on before and after the start of the project, were evaluated. Results Despite the more severe comorbidity of the patient group, outcome improved after centralizing esophageal resections. Along with a reduction in postoperative morbidity and length of stay, mortality fell from 12% to 4% and survival improved significantly (P = 0.001). The hospitals with the highest procedural volume showed the biggest improvement in outcome. Conclusion Volume is an important determinant of quality of care in esophageal cancer surgery. Referral of patients with esophageal cancer to surgical units with adequate experience and superior outcomes (outcome-based referral) improves quality of care.
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Affiliation(s)
- M W J M Wouters
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
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de Vos M, Graafmans W, Kooistra M, Meijboom B, Van Der Voort P, Westert G. Using quality indicators to improve hospital care: a review of the literature. Int J Qual Health Care 2009; 21:119-29. [PMID: 19155288 DOI: 10.1093/intqhc/mzn059] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE To review the literature concerning strategies for implementing quality indicators in hospital care, and their effectiveness in improving the quality of care. DATA SOURCES A systematic literature study was carried out using MEDLINE and the Cochrane Library (January 1994 to January 2008). STUDY SELECTION Hospital-based trials studying the effects of using quality indicators as a tool to improve quality of care. DATA EXTRACTION Two reviewers independently assessed studies for inclusion, and extracted information from the studies included regarding the health care setting, type of implementation strategy and their effectiveness as a tool to improve quality of hospital care. RESULTS A total of 21 studies were included. The most frequently used implementation strategies were audit and feedback. The majority of these studies focused on care processes rather than patient outcomes. Six studies evaluated the effects of the implementation of quality indicators on patient outcomes. In four studies, quality indicator implementation was found to be ineffective, in one partially effective and in one it was found to be effective. Twenty studies focused on care processes, and most reported significant improvement with respect to part of the measured process indicators. The implementation of quality indicators in hospitals is most effective if feedback reports are given in combination with an educational implementation strategy and/or the development of a quality improvement plan. CONCLUSION Effective strategies to implement quality indicators in daily practice in order to improve hospital care do exist, but there is considerable variation in the methods used and the level of change achieved. Feedback reports combined with another implementation strategy seem to be most effective.
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Affiliation(s)
- Maartje de Vos
- Department of Tranzo, University of Tilburg, Tilburg, the Netherlands.
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Shojania KG, Forster AJ. Hospital mortality: when failure is not a good measure of success. CMAJ 2008; 179:153-7. [PMID: 18625987 DOI: 10.1503/cmaj.080010] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Crump B. Should we use large scale healthcare interventions without clear evidence that benefits outweigh costs and harms? Yes. BMJ 2008; 336:1276. [PMID: 18535068 PMCID: PMC2413344 DOI: 10.1136/bmj.a145] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Obtaining definitive evidence on the effects of large scale interventions can be difficult. Bernard Crump believes that implementation with careful monitoring is justified but Seth Landefeld and colleagues (doi: 10.1136/bmj.a144) argue that acting without proof of net benefit is both costly and potentially damaging to health
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Affiliation(s)
- Bernard Crump
- NHS Institute for Innovation and Improvement, Coventry CV4 7AL.
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Heijink R, Koolman X, Pieter D, van der Veen A, Jarman B, Westert G. Measuring and explaining mortality in Dutch hospitals; the hospital standardized mortality rate between 2003 and 2005. BMC Health Serv Res 2008; 8:73. [PMID: 18384695 PMCID: PMC2362116 DOI: 10.1186/1472-6963-8-73] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Accepted: 04/03/2008] [Indexed: 11/16/2022] Open
Abstract
Background Indicators of hospital quality, such as hospital standardized mortality ratios (HSMR), have been used increasingly to assess and improve hospital quality. Our aim has been to describe and explain variation in new HSMRs for the Netherlands. Methods HSMRs were estimated using data from the complete population of discharged patients during 2003 to 2005. We used binary logistic regression to indirectly standardize for differences in case-mix. Out of a total of 101 hospitals 89 hospitals remained in our explanatory analysis. In this analysis we explored the association between HSMRs and determinants that can and cannot be influenced by hospitals. For this analysis we used a two-level hierarchical linear regression model to explain variation in yearly HSMRs. Results The average HSMR decreased yearly with more than eight percent. The highest HSMR was about twice as high as the lowest HSMR in all years. More than 2/3 of the variation stemmed from between-hospital variation. Year (-), local number of general practitioners (-) and hospital type were significantly associated with the HSMR in all tested models. Conclusion HSMR scores vary substantially between hospitals, while rankings appear stable over time. We find no evidence that the HSMR cannot be used as an indicator to monitor and compare hospital quality. Because the standardization method is indirect, the comparisons are most relevant from a societal perspective but less so from an individual perspective. We find evidence of comparatively higher HSMRs in academic hospitals. This may result from (good quality) high-risk procedures, low quality of care or inadequate case-mix correction.
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Affiliation(s)
- Richard Heijink
- National Institute for Public Health and the Environment, Bilthoven, The Netherlands.
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Abstract
OBJECTIVE To use statistical process control charts to monitor in-hospital outcomes at the hospital level for a wide range of procedures and diagnoses. DATA SOURCES Routine English hospital admissions data. STUDY DESIGN Retrospective analysis using risk-adjusted log-likelihood cumulative sum (CUSUM) charts, comparing each hospital with the national average and its peers for in-hospital mortality, length of stay, and emergency readmission within 28 days. DATA COLLECTION Data were derived from the Department of Health administrative hospital admissions database, with monthly uploads from the clearing service. PRINCIPAL FINDINGS The tool is currently being used by nearly 100 hospitals and also a number of primary care trusts responsible for purchasing hospital care. It monitors around 80 percent of admissions and in-hospital deaths. Case-mix adjustment gives values for the area under the receiver operating characteristic curve between 0.60 and 0.86 for mortality, but the values were poorer for readmission. CONCLUSIONS CUSUMs are a promising management tool for managers and clinicians for driving improvement in hospital performance for a range of outcomes, and interactive presentation via a web-based front end has been well received by users. Our methods act as a focus for intelligently directed clinical audit with the real potential to improve outcomes, but wider availability and prospective monitoring are required to fully assess the method's utility.
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Affiliation(s)
- Alex Bottle
- Dr. Foster Unit at Imperial College, Department of Primary Care and Social Medicine, Imperial College London, First floor, Jarvis House, 12 Smithfield Street, London EC1A 9LA, U.K
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