The quality of care is related to death rates: hospital inpatient management of infants with acute gastroenteritis in Jamaica

Pentavalent rotavirus vaccine in developing countries: safety and health care resource utilization

OBJECTIVE

In the international, placebo-controlled, Rotavirus Efficacy and Safety Trial, the pentavalent rotavirus vaccine reduced the rate of rotavirus-attributable hospitalizations and emergency department visits by 95%. This study investigated the effect in Jamaica.

METHODS

The vaccine effect on rates of hospitalizations and emergency department visits in Jamaica was evaluated in both modified intention-to-treat and per-protocol analyses. Rates of serious adverse events, including intussusception, also were compared between groups.

RESULTS

A total of 1804 Jamaican infants, 6 to 12 weeks of age at entry and primarily from low/middle-income families of African heritage, received ≥1 dose. During the first year after dose 1, there were 2 and 11 hospitalizations or emergency department visits attributable to rotavirus gastroenteritis involving any serotype among 831 evaluable vaccine recipients and 809 evaluable placebo recipients, respectively (rate reduction: 82.2% [95% confidence interval: 15.1%-98.0%]). In the per-protocol analysis, all 8 G1 to G4 rotavirus-attributable events that occurred ≥2 weeks after dose 3 were in the placebo group (rate reduction: 100% [95% confidence interval: 40.9%-100%]). Of the 1802 subjects included in the safety analyses, intussusception was confirmed for 1 vaccine recipient (115 days after the third dose) and 3 placebo recipients. One vaccine recipient and 3 placebo recipients died during the follow-up period, but none of the deaths was considered to be vaccine-related.

CONCLUSIONS

In this posthoc subgroup analysis, the vaccine reduced health care resource utilization attributable to rotavirus gastroenteritis, without increased risk of intussusception or other serious adverse events, among infants in a resource-limited country.

Developing and introducing evidence based clinical practice guidelines for serious illness in Kenya

The under-5 mortality rate in most developing countries remains high yet many deaths could be averted if available knowledge was put into practice. For seriously ill children in hospital investigations in low-income countries commonly demonstrate incorrect diagnosis and treatment and frequent prescribing errors. To help improve hospital management of the major causes of inpatient childhood mortality we developed simple clinical guidelines for use in Kenya, a low-income setting. The participatory process we used to adapt existing WHO materials and further develop and build support for such guidelines is discussed. To facilitate use of the guidelines we also developed job-aides and a 5.5 days training programme for their dissemination and implementation. We attempted to base our training on modern theories around adult learning and deliberately attempted to train a ‘critical mass’ of health workers within each institution at low cost. Our experience suggests that with sustained effort it is possible to develop locally owned, appropriate clinical practice guidelines for emergency and initial hospital care for seriously ill children with involvement of pertinent stake holders throughout. Early experience suggests that the training developed to support the guidelines, despite the fact that it challenges many established practices, is well received, appropriate to the needs of front line health workers in Kenya and feasible. To our knowledge the process described in Kenya is among a handful of attempts globally to implement inpatient or referral care components of WHO / UNICEF’s Integrated Management of Childhood Illness approach. However, whether guideline dissemination and implementation result in improved quality of care in our environment remains to be seen.

What is the empirical evidence that hospitals with higher-risk adjusted mortality rates provide poorer quality care? A systematic review of the literature

Background

Despite increasing interest and publication of risk-adjusted hospital mortality rates, the relationship with underlying quality of care remains unclear. We undertook a systematic review to ascertain the extent to which variations in risk-adjusted mortality rates were associated with differences in quality of care.

Methods

We identified studies in which risk-adjusted mortality and quality of care had been reported in more than one hospital. We adopted an iterative search strategy using three databases – Medline, HealthSTAR and CINAHL from 1966, 1975 and 1982 respectively. We identified potentially relevant studies on the basis of the title or abstract. We obtained these papers and included those which met our inclusion criteria.

Results

From an initial yield of 6,456 papers, 36 studies met the inclusion criteria. Several of these studies considered more than one process-versus-risk-adjusted mortality relationship. In total we found 51 such relationships in a widen range of clinical conditions using a variety of methods. A positive correlation between better quality of care and risk-adjusted mortality was found in under half the relationships (26/51 51%) but the remainder showed no correlation (16/51 31%) or a paradoxical correlation (9/51 18%).

Conclusion

The general notion that hospitals with higher risk-adjusted mortality have poorer quality of care is neither consistent nor reliable.

Using vignettes to compare the quality of clinical care variation in economically divergent countries

OBJECTIVE

To determine whether clinical vignettes can measure variations in the quality of clinical care in two economically divergent countries.

DATA SOURCE/STUDY SETTING

Primary data collected between February 1997 and February 1998 at two Veterans Affairs facilities in the United States and four government-run outpatient facilities in Macedonia.

STUDY DESIGN

Randomly selected, eligible Macedonian and U.S. physicians (>97 percent participation rate) completed vignettes for four common outpatient conditions. Responses were judged against a master list of explicit quality criteria and scored as percent correct. DATA COLLECTION/ EXTRACTION: An ANOVA model and two-tailed t-tests were used to compare overall scores by case, study site, and country. Principal Findings. The mean score for U.S. physicians was 67 percent (+/-11 percent) compared to 48 percent (+/-11 percent) for Macedonian physicians. The quality of clinical practice, which emphasizes basic skills, varied greatly in both sites, but more so in Macedonia. However, the top Macedonian physicians in all sites approached or-in one case-exceeded the median score in the U.S. sites.

CONCLUSIONS

Vignettes are a useful method for making cross-national comparisons of the quality of care provided in very different settings. The vignette measurements revealed that some physicians in Macedonia performed at a standard comparable to that of their counterparts in the United States, despite the disparity of the two health systems. We infer that in poorer countries, policy that promotes improvements in the quality of clinical practice-not just structural inputs-could lead to rapid improvements in health.

Treatment of acute gastroenteritis: too much and too little care

This paper reviews the health services literature regarding care for gastroenteritis in children. United States health care utilization, use of oral rehydration therapy (ORT), and quality of care considerations are described. The literature suggests that some US children may receive too much care while others may not be getting enough and that physician practices continue to differ from expert recommendations.

Using mortality rates as a screening tool: the experience of the Department of Veterans Affairs

BACKGROUND

Despite widespread agreement that outcome analyses should be followed by in-depth review of the care provided by outlier providers, there are few, if any, reports in the literature describing the effectiveness of this approach to quality improvement. In 1991, the Department of Veterans Affairs (VA) completed a study to measure hospital-specific mortality rates for VA facilities and to use these rates as a screening tool for focused medical record reviews.

METHODS

The first phase of the project consisted of a comparison of fiscal year 1986 mortality rates for each VA medical center with aggregated VA data, using logistic regression analysis to adjust for patient characteristics related to mortality. In the second phase, medical record reviews of cases from hospitals with elevated levels of mortality were conducted.

RESULTS

The mortality rate analysis identified 44 facilities with rates that were significantly elevated overall or within specific patient categories. Both the mortality rate analysis and the medical record review suggested that quality concerns were more common in predominantly psychiatric medical centers than in other facilities.

CONCLUSION

The study uncovered important opportunities for improvement, particularly regarding the quality of medical care provided in VA psychiatric hospitals, suggesting there is value in performing intensive review of outlier providers in outcome analyses. However, serious questions remain concerning the validity of the use of administrative data-bases to assess hospitalwide mortality.