The Contribution of Case Mix, Skill Mix and Care Processes to the Outcomes of Community Hospitals: A Population-Based Observational Study

Development and usability of a hospital standardized ADL ratio (HSAR) for elderly patients with cerebral infarction: a retrospective observational study using administrative claim data from 2012 to 2019 in Japan

BACKGROUND

Maintenance of activities of daily living (ADL) during acute hospitalization is an important treatment goal, especially for elderly inpatients with diseases that often leave disabilities, such as cerebral infarction. However, studies assessing risk-adjusted ADL changes are limited. In this study, we developed and calculated a hospital standardized ADL ratio (HSAR) using Japanese administrative claims data to measure the quality of hospitalization care for patients with cerebral infarction.

METHODS

This study was designed as a retrospective observational study using the Japanese administrative claim data from 2012 to 2019. The data of all hospital admissions with a primary diagnosis of cerebral infarction (ICD-10, I63) were used. The HSAR was defined as the ratio of the observed number of ADL maintenance patients to the expected number of ADL maintenance patients multiplied by 100, and ratio of ADL maintenance patients was risk-adjusted using multivariable logistic regression analyses. The c-statistic was used to evaluate the predictive accuracy of the logistic models. Changes in HSARs in each consecutive period were assessed using Spearman's correlation coefficient.

RESULTS

A total of 36,401 patients from 22 hospitals were included in this study. All variables used in the analyses were associated with ADL maintenance, and evaluations using the HSAR model showed predictive ability with c-statistics (area under the curve, 0.89; 95% confidence interval, 0.88-0.89).

CONCLUSIONS

The findings indicated a need to support hospitals with a low HSAR because hospitals with high/low HSAR were likely to produce the same results in the subsequent periods. HSAR can be used as a new quality indicator of in-hospital care and may contribute to the assessment and improvement of the quality of care.

Regional practice variation in pelvic organ prolapse surgery in Tuscany, Italy: a retrospective cohort study on administrative health data

OBJECTIVES

To explore determinants of practice variation in both access, and quality and efficiency of surgical care for pelvic organ prolapse (POP).

DESIGN AND SETTING

A retrospective cohort study employing administrative health data from the Tuscany region, Italy.

PARTICIPANTS

All women over 40 years hospitalised for apical/multicompartmental POP reconstructive surgery (excluding anterior/posterior colporrhaphy without concomitant hysterectomy) from January 2017 to December 2019.

OUTCOMES

We first computed treatment rates just for women residing in Tuscany (n=2819) and calculated the Systematic Component of Variation (SCV) to explore variation in access to care among health districts. Then, using the full cohort (n=2959), we ran multilevel models for the average length of stay and reoperations, readmissions and complications, and computed the intraclass correlation coefficient to assess the individual and hospital determinants of efficiency and quality of care provided by hospitals.

RESULTS

The 5.4-fold variation between the lowest-rate (56/100 000 inhabitants) and the highest-rate (302/100 000) districts and the SCV over 10% confirmed high systematic variation in the access to care. Higher treatment rates were driven by greater provisions of robotic and/or laparoscopic interventions, which showed highly variable usage rates. Both individual and hospital factors influenced quality and efficiency provided by hospitals, but just low proportions of variation were explained by hospital and patient characteristics.

CONCLUSIONS

We found high and systematic variation in the access to POP surgical care in Tuscany and in quality and efficiency provided by hospitals. Such a variation may be mainly explained by user and provider preferences, which should be further explored. Also, supply-side factors may be involved, suggesting that wider and more uniform dissemination of robotic/laparoscopic procedures may reduce variation.

Evaluating the Hospital Standardized Home-Transition Ratios for Cerebral Infarction in Japan: A Retrospective Observational Study from 2016 through 2020

Discharge to home is considered appropriate as a treatment goal for diseases that often leave disabilities such as cerebral infarction. Previous studies showed differences in risk-adjusted in-hospital mortality and readmission rates; however, studies assessing the rate of hospital-to-home transition are limited. We developed and calculated the hospital standardized home-transition ratio (HSHR) using Japanese administrative claims data from 2016–2020 to measure the quality of in-hospital care for cerebral infarction. Overall, 24,529 inpatients at 35 hospitals were included. All variables used in the analyses were associated with transition to another hospital or facility for inpatients, and evaluation of the HSHR model showed good predictive ability with c-statistics (area under curve, 0.73 standard deviation; 95% confidence interval, 0.72–0.73). All HSHRs of each consecutive year were significantly correlated. HSHRs for cerebral infarction can be calculated using Japanese administrative claims data. It was found that there is a need for support for low HSHR hospitals because hospitals with high/low HSHR were likely to produce the same results in the following year. HSHRs can be used as a new quality indicator of in-hospital care and may contribute to assessing and improving the quality of care.

Skill-mix change and outcomes in primary care: Longitudinal analysis of general practices in England 2015-2019

BACKGROUND

Increasing the employment of staff with new clinical roles in primary care has been proposed as a solution to the shortages of GPs and nurses. However, evidence of the impacts this has on practice outcomes is limited. We examine how outcomes changed following changes in skill-mix in general practices in England.

METHODS

We obtained annual data on staff in 6,296 English general practices between 2015 and 2019 and grouped professionals into four categories: GPs, Nurses, Health Professionals, and Healthcare Associate Professionals. We linked 10 indicators of quality of care covering the dimensions of accessibility, clinical effectiveness, user experiences and health system costs. We used both fixed-effect and first-differences regressions to model changes in staff composition and outcomes, adjusting for practice and population factors.

RESULTS

Employment increased over time for all four staff groups, with largest increases for Healthcare Professionals (from 0.04 FTE per practice in 2015 to 0.28 in 2019) and smallest for Nurses who experienced a 3.5 percent growth. Increases in numbers of GPs and Nurses were positively associated with changes in practice activity and outcomes. The introduction of new roles was negatively associated with patient satisfaction: a one FTE increase in Health Professionals was associated with decreases of 0.126 [-0.175, -0.078] and 0.116 [-0.161, -0.071] standard deviations in overall patient satisfaction and satisfaction with making an appointment. Pharmacists improved medicine prescribing outcomes. All staff categories were associated with higher health system costs. There was little evidence of direct complementarity or substitution between different staff groups.

CONCLUSIONS

Introduction of new roles to support GPs does not have straightforward effects on quality or patient satisfaction. Problems can arise from the complex adaptation required to adjust practice organisation and from the novelty of these roles to patients. These findings suggest caution over the implementation of policies encouraging more employment of different professionals in primary care.

Self-Psychological Control and Creativity of Music Creation in Multimusic Environment

This study aimed to solve the difficulties in the research of self-psychology, three executive controls, and creativity in multimusic environment. In today's teaching and performance, the study of piano adaptation has practical significance in broadening artistic vision, improving performance technology, and training symphonic music thinking. A research method of self-psychological three executive controls and creativity generation for creation in multimusic environment is proposed. A computer composition algorithm is based on the hidden Markov model and interactive genetic algorithm. By integrating melody elements and rhythm into the traditional Markov model with only notes or rhythm as the unit, a new hidden Markov music prediction model is established, and the interactive genetic algorithm is used to optimize the music segments. Simulation results show that the algorithm can use a small dataset to quickly create music clips with certain melody logic and in line with users' personality. It is proved that the method based on the hidden Markov model and interactive genetic algorithm can meet the research needs of self-psychological three execution control and creativity generation in multimusic environment.

Designing and Governing Responsive Local Care Systems - Insights from a Scoping Review of Paramedics in Integrated Models of Care

Introduction

Programs that fill gaps in fractured health and social services in response to local needs can provide insight on enacting integrated care. Grassroots programs and the changing roles of paramedics within them were analyzed to explore how the health workforce, organizations and governance could support integrated care.

Methods

A study was conducted following Arksey and O'Malley's method for scoping reviews, using Valentijn's Rainbow Model of Integrated Care as an organizing framework. Qualitative content analysis was done on clinical, professional, organizational, system, functional and normative aspects of integration. Common patterns, challenges and gaps were documented.

Results

After literature search and screening, 137 documents with 108 unique programs were analysed. Paramedics bridge reactive and preventative care for a spectrum of population needs through partnerships with hospitals, social services, primary care and public health. Programs encountered challenges with role delineation, segregated organizations, regulation and tensions in professional norms.

Discussion

Five concepts were identified for fostering integrated care in local systems: single point-of-entry care pathways; flexible and mobile workforce; geographically-based cross-cutting organizations; permissive regulation; and assessing system-level value.

Conclusion

Integrated care may be supported by a generalist health workforce, through cross-cutting organizations that work across silos, and legislation that balances standardization with flexibility.