Healthcare consumer acceptability of routine use of the EQ-5D-5L in clinical care: a cross-sectional survey

PURPOSE

Patient reported outcome measures, such as the EQ-5D-5L, provide a measure of self-perceived health status or health-related quality of life. Understanding the consumer acceptability of a patient reported outcome measure can help to decide about its implementation across a healthcare organisation and possibly increase the likelihood of its use in clinical care. This study established the acceptability of the EQ-5D-5L from the perspective of clients receiving healthcare, and determined if acceptability varied by client sub-types.

METHODS

A cross-sectional survey explored clients' experience of the EQ-5D-5L. Eligible clients were aged ≥ 18 years and completed the EQ-5D-5L on admission and discharge to one of two multi-disciplinary community health services. Likert scale items explored acceptability, and open-ended questions determined if the EQ-5D-5L reflects experience of illness. Associations between acceptability and client characteristics were established using χ2 test. Open-ended questions were analysed using content analysis.

RESULTS

Most of the 304 clients (mean age 70 years, SD 16) agreed that the EQ-5D-5L: was easy to use/understand (n = 301, 99%) and useful (n = 289, 95%); improved communication with their therapist (n = 275, 90%); and made them feel more in control of their health (n = 276, 91%). Most clients also agreed that they wished to continue using the EQ-5D-5L (n = 285, 93%). Clients aged ≥ 60 years reported lower acceptability. Clients noted that the EQ-5D-5L did not capture experience of illness related to fatigue, balance/falls, cognition, and sleep.

CONCLUSION

The EQ-5D-5L is acceptable for use in care but does not capture all aspects of health relevant to clients, and acceptability varies by subgroup.

The Australian Health Care Homes trial: quality of care and patient outcomes. A propensity score-matched cohort study

OBJECTIVE

To assess the impact of the Health Care Homes (HCH) primary health care initiative on quality of care and patient outcomes.

DESIGN, SETTING

Quasi-experimental, matched cohort study; analysis of general practice data extracts and linked administrative data from ten Australian primary health networks, 1 October 2017 - 30 June 2021.

PARTICIPANTS

People with chronic health conditions (practice data extracts: 9811; linked administrative data: 10 682) enrolled in the HCH 1 October 2017 - 30 June 2019; comparison groups of patients receiving usual care (1:1 propensity score-matched).

INTERVENTION

Participants were involved in shared care planning, provided enhanced access to team care, and encouraged to seek chronic condition care at the HCH practice where they were enrolled. Participating practices received bundled payments based on clinical risk tier.

MAIN OUTCOME MEASURES

Access to care, processes of care, diabetes-related outcomes, hospital service use, risk of death.

RESULTS

During the first twelve months after enrolment, the mean numbers of general practitioner encounters (rate ratio, 1.14; 95% confidence interval [CI], 1.11-1.17) and Medicare Benefits Schedule claims for allied health services (rate ratio, 1.28; 95% CI, 1.24-1.33) were higher for the HCH than the usual care group. Annual influenza vaccinations (relative risk, 1.20; 95% CI, 1.17-1.22) and measurements of blood pressure (relative risk, 1.09; 95% CI, 1.08-1.11), blood lipids (relative risk, 1.19; 95% CI, 1.16-1.21), glycated haemoglobin (relative risk, 1.06; 95% CI, 1.03-1.08), and kidney function (relative risk, 1.13; 95% CI, 1.11-1.15) were more likely in the HCH than the usual care group during the twelve months after enrolment. Similar rate ratios and relative risks applied in the second year. The numbers of emergency department presentations (rate ratio, 1.09; 95% CI, 1.02-1.18) and emergency admissions (rate ratio, 1.13; 95% CI, 1.04-1.22) were higher for the HCH group during the first year; other differences in hospital use were not statistically significant. Differences in glycaemic and blood pressure control in people with diabetes in the second year were not statistically significant. By 30 June 2021, 689 people in the HCH group (6.5%) and 646 in the usual care group (6.1%) had died (hazard ratio, 1.07; 95% CI, 0.96-1.20).

CONCLUSIONS

The HCH program was associated with greater access to care and improved processes of care for people with chronic diseases, but not changes in diabetes-related outcomes, most measures of hospital use, or risk of death.

[Synthetic indicator of compliance with standards for Quality Units of health centers and multicenter prospective pilot study]

BACKGROUND AND OBJECTIVE

In Spain, Quality Units play a key and unique role in advising healthcare centers on the methodology of healthcare quality. The objectives of the study were to develop computer algorithms to obtain a synthetic indicator of standard compliance for Quality Units and to pilot its functioning in these units.

MATERIALS AND METHODS

The Excel program was used to establish evaluation algorithms, and quantitatively interrelate and weight various categories of standards, as a computer evaluation tool, to build a continuous improvement cycle system, and offer a global synthetic indicator of compliance. The tool was tested in a prospective multicenter pilot study, in which coordinators of Quality Units from different health centers and care settings participated, to evaluate the usefulness of the tool and compliance with the standards, in addition to analyzing the content validity of each standard.

RESULTS

The formulas for the structured computer algorithms were developed, consecutively, in a «PLAN-DO-CHECK-ACT» improvement cycle for the 9 categories of standards, resulting in a single synthetic indicator of compliance. Twenty-one Quality Units participated in the piloting. The overall average compliance rate for the synthetic indicator was 55.63% with differences between centers (P=.002) and between categories (P<.0001), but not by autonomous communities (P=.86) or by areas (P=.97). Content validity was ensured through the variable of «understanding» of the standards (P<.001), and through their «justification» with documentary evidence (P<.001).

CONCLUSIONS

The computer tool with the synthetic indicator have allowed for the evaluation of standard compliance in Quality Units of healthcare centers.

Developing a questionnaire to evaluate an automated audit & feedback intervention: a Rand-modified Delphi method

BACKGROUND

Audit and feedback (A&F) is a widely used implementation strategy to evaluate and improve medical practice. The optimal design of an A&F system is uncertain and structured process evaluations are currently lacking. This study aimed to develop and validate a questionnaire to evaluate the use of automated A&F systems.

METHODS

Based on the Clinical Performance Feedback Intervention Theory (CP-FIT) and the REFLECT-52 (REassessing audit & Feedback interventions: a tooL for Evaluating Compliance with suggested besT practices) evaluation tool a questionnaire was designed for the purpose of evaluating automated A&F systems. A Rand-modified Delphi method was used to develop the process evaluation and obtain validation. Fourteen experts from different domains in primary care consented to participate and individually scored the questions on a 9-point Likert scale. Afterwards, the questions were discussed in a consensus meeting. After approval, the final questionnaire was compiled.

RESULTS

A 34-question questionnaire composed of 57 items was developed and presented to the expert panel. The consensus meeting resulted in a selection of 31 questions, subdivided into 43 items. A final list of 30 questions consisting of 42 items was obtained.

CONCLUSION

A questionnaire consisting of 30 questions was drawn up for the assessment and improvement of automated A&F systems, based on CP-FIT and REFLECT-52 theory and approved by experts. Next steps will be piloting and implementation of the questionnaire.

[Maternal mortality due to Amniotic Fluid Embolism in France 2016-2018]

Amniotic embolism remains the 3rd leading cause of maternal death in France, with 21 maternal deaths over the 2016-2018 triennium. The women who died were more likely to be obese (25%), to benefit from induction of labor (71%) and be cared in a maternity hospital <1500 deliveries/year (45%), compared with the reference population (ENP 2016). The symptom occurred mainly during labor (95%) and the course was rapid, with a symptom-to-fatality interval of 4hours 45minutes (min: 25minutes - max: 8 days). Preventability was proposed for 35% of the deaths assessed, with areas for improvement identified in terms of technical skills (haemostasis procedures, management of polytransfusion), non-technical skills (communication) and health care organization (human resources, vital emergency plan, wide access to PSL). An autopsy was performed in 38% of deaths.

Quality of in-hospital care in traumatic spinal column and cord injuries (TSC/SCI) in I.R Iran

PURPOSE

This study aimed to implement the Quality of Care (QoC) Assessment Tool from the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to map the current state of in-hospital QoC of individuals with Traumatic Spinal Column and Cord Injuries (TSCCI).

METHODS

The QoC Assessment Tool, developed from a scoping review of the literature, was implemented in NSCIR-IR. We collected the required data from two primary sources. Questions regarding health system structures and care processes were completed by the registrar nurse reviewing the hospital records. Questions regarding patient outcomes were gathered through patient interviews.

RESULTS

We registered 2812 patients with TSCCI over six years from eight referral hospitals in NSCIR-IR. The median length of stay in the general hospital and intensive care unit was four and five days, respectively. During hospitalization 4.2% of patients developed pressure ulcers, 83.5% of patients reported satisfactory pain control and none had symptomatic urinary tract infections. 100%, 80%, and 90% of SCI registration centers had 24/7 access to CT scans, MRI scans, and operating rooms, respectively. Only 18.8% of patients who needed surgery underwent a surgical operation in the first 24 h after admission. In-hospital mortality rate for patients with SCI was 19.3%.

CONCLUSION

Our study showed that the current in-hospital care of our patients with TSCCI is acceptable in terms of pain control, structure and length of stay and poor regarding in-hospital mortality rate and timeliness. We must continue to work on lowering rates of pressure sores, as well as delays in decompression surgery and fatalities.

[Maternal mortality and health care organization in France 2016-2018]

Organization of care is one of the elements examined when assessing cases. Organization of care is a factor, which is considered in addition to the content of care when assessing mortality cases. The factors related to the organization of care concern the suitability of the place of care, the completion of a necessary transfer, the adequacy of human and material resources, and the communication between caregivers. For the 2016-2018 triennium these preventability factors are the subject of a dedicated chapter. Overall, one or more preventability factors linked to the organization of care were reported in 51 cases, i.e. 24% of all assessed cases. The field of communication was the most frequently reported (32/51), followed by inappropriate place of care (20/51), insufficient human resources (13/51), transfers not performed or performed late (11/51) and insufficient material resources (9/51). An overall analysis can be made along two dimensions: organization within the maternity unit, and coordination with other sectors or outpatient medicine. Areas for improvement within the maternity unit relate to the ability to deal with life-threatening emergencies, to organize the call for specialized and/or trained human reinforcements, to organize intensive monitoring of patients in the event of organ failure, and to facilitate good communication between caregivers. Regarding coordination with other units, it is proposed to improve collaboration between the maternity unit's emergency department and the general emergency department, and to improve the transfer of information required by all those involved, including primary care physicians, in the pre-, per- and postpartum period. Finally, the place of care for patients presenting with a psychiatric and somatic pathology is a situation that requires careful consultation.

Development of the China's list of ambulatory care sensitive conditions (ACSCs): a study protocol

BACKGROUND

The hospitalization rate of ambulatory care sensitive conditions (ACSCs) has been recognized as an essential indicator reflective of the overall performance of healthcare system. At present, ACSCs has been widely used in practice and research to evaluate health service quality and efficiency worldwide. The definition of ACSCs varies across countries due to different challenges posed on healthcare systems. However, China does not have its own list of ACSCs. The study aims to develop a list to meet health system monitoring, reporting and evaluation needs in China.

METHODS

To develop the list, we will combine the best methodological evidence available with real-world evidence, adopt a systematic and rigorous process and absorb multidisciplinary expertise. Specific steps include: (1) establishment of working groups; (2) generations of the initial list (review of already published lists, semi-structured interviews, calculations of hospitalization rate); (3) optimization of the list (evidence evaluation, Delphi consensus survey); and (4) approval of a final version of China's ACSCs list. Within each step of the process, we will calculate frequencies and proportions, use descriptive analysis to summarize and draw conclusions, discuss the results, draft a report, and refine the list.

DISCUSSION

Once completed, China's list of ACSCs can be used to comprehensively evaluate the current situation and performance of health services, identify flaws and deficiencies embedded in the healthcare system to provide evidence-based implications to inform decision-makings towards the optimization of China's healthcare system. The experiences might be broadly applicable and serve the purpose of being a prime example for nations with similar conditions.

Human rights and support groups to improve quality of life, self-care and disability in epilepsy: [Rights and support groups for epilepsy]

BACKGROUND

People with epilepsy have multiple barriers to recovering their quality of life. The objective of the present study was to determine the impact of a community group intervention focused on the components of mutual aid and human rights, to improve the quality of life in people with epilepsy.

METHODS

Prospective quasi-experimental study, incorporating pre- and post-intervention evaluations. There were 102 people who underwent an intervention focused on the central components of mutual aid groups (Active agency, Coping strategies, Emotion recognition and management, Problem solving, Supportive interaction, Identity construction, Trust, and Social networks) and in the QualityRights strategy. As evaluation instruments, scales were used to determine quality of life (QOLIE-10), treatment adherence (Morisky Test), self-care behaviors, perception of disability and quality in the provision of health services.

RESULTS

Correlations were shown between the variables proposed for quality of life. The intervention showed an improvement in all variables and a moderate to large effect in the self-care domain. There was a significant effect size in the self-care and quality of life variables with the intervention. Pharmacological adherence showed a moderate effect size in young people, adults and older adults. Regarding the perception of disability, the effect size was found only in adults. The pharmacological adherence variable also had a moderate effect size. This does specify the age groups, but not in the general sample.

CONCLUSION

Seizure-free time constitutes a fundamental element in recovery. However, psychosocial conditions constitute key elements to achieve a better quality of life in people with epilepsy.

Comparing risk-adjusted inpatient fall rates internationally: validation of a risk-adjustment model using multicentre cross-sectional data from hospitals in Switzerland and Austria

BACKGROUND

Inpatient falls in hospitals are an acknowledged indicator of quality of care. International comparisons could highlight quality improvement potential and enable cross-national learning. Key to fair cross-national comparison is the availability of a risk adjustment model validated in an international context. This study aimed to 1) ascertain that the variables of the inpatient fall risk adjustment model do not interact with country and thus can be used for risk adjustment, 2) compare the risk of falling in hospitals between Switzerland and Austria after risk adjustment.

METHODS

The data on inpatient falls from Swiss and Austrian acute care hospitals were collected on a single measurement day in 2017, 2018 and 2019 as part of an international multicentre cross-sectional study. Multilevel logistic regression models were used to screen for interaction effects between the patient-related fall risk factors and the countries. The risks of falling in hospital in Switzerland and in Austria were compared after applying the risk-adjustment model.

RESULTS

Data from 176 hospitals and 43,984 patients revealed an inpatient fall rate of 3.4% in Switzerland and 3.9% in Austria. Two of 15 patient-related fall risk variables showed an interaction effect with country: Patients who had fallen in the last 12 months (OR 1.49, 95% CI 1.10-2.01, p = 0.009) or had taken sedatives/psychotropic medication (OR 1.40, 95% CI 1.05-1.87, p = 0.022) had higher odds of falling in Austrian hospitals. Significantly higher odds of falling were observed in Austrian (OR 1.38, 95% CI 1.13-1.68, p = 0.002) compared to Swiss hospitals after applying the risk-adjustment model.

CONCLUSIONS

Almost all patient-related fall risk factors in the model are suitable for a risk-adjusted cross-country comparison, as they do not interact with the countries. Further model validation with additional countries is warranted, particularly to assess the interaction of risk factors "fall in the last 12 months" and "sedatives/psychotropic medication intake" with country variable. The study underscores the crucial role of an appropriate risk-adjustment model in ensuring fair international comparisons of inpatient falls, as the risk-adjusted, as opposed to the non-risk-adjusted country comparison, indicated significantly higher odds of falling in Austrian compared to Swiss hospitals.

The FlaQuM-Quickscan: A starting point to include primary care professionals' perspectives in the evaluation of hospital quality priorities

INTRODUCTION

Today, primary care professionals' (PCPs) perspectives on hospital quality are unknown when evaluating hospital quality priorities. The aims of the present study were to identify key healthcare quality attributes from PCPs' perspective, to validate an instrument that measures PCPs' experiences of healthcare quality multidimensionally and to define hospital quality priorities based on PCPs' experiences.

MATERIAL AND METHODS

Focus groups with PCPs were conducted to identify quality attributes through a qualitative in-depth analysis. A multicentre study of 18 hospitals was used to quantitatively assess construct, discriminant and criterion validity of the FlaQuM-Quickscan, an instrument that measures 'Healthcare quality for patients and kin' (part 1) and 'Healthcare quality for professionals' (part 2). To set quality priorities, scores on quality domains were analyzed descriptively and between-hospital variation was examined by evaluating differences in hospitals' mean scores on the quality domains using one-way Analysis of Variance (ANOVA).

RESULTS

Identified key attributes largely corresponded with Lachman's multidimensional quality model. Including 'Communication' as a new quality domain was recommended. The FlaQuM-Quickscan was completed by 550 PCPs. Confirmatory factor analyses showed reasonable to good fit, except for the Root Mean Square Error of Approximation (RMSEA) in part 2. The 'Equity' domain scored the highest in parts 1 and 2. Domains 'Kin-centred care' and 'Accessibility and timeliness' scored the lowest in part 1 and 'Resilience' and 'Partnership and co-production' in part 2. Significant variation in hospitals' mean scores was observed for eleven domains in part 1 and sixteen domains in part 2.

CONCLUSIONS

The results gained a better understanding of PCPs' perspective on quality. The FlaQuM-Quickscan is a valid instrument to measure PCPs' experiences of hospital quality. Identified priorities indicate that hospital management should focus on multifaceted quality strategies, including technical domains, person-and kin-centredness, core values and catalysts.

Development and acceptability of PETS-Now, an electronic point-of-care tool to monitor treatment burden in patients with multiple chronic conditions: a multi-method study

BACKGROUND

The aim of this study was to develop a web-based tool for patients with multiple chronic conditions (MCC) to communicate concerns about treatment burden to their healthcare providers.

METHODS

Patients and providers from primary-care clinics participated. We conducted focus groups to identify content for a prototype clinical tool to screen for treatment burden by reviewing domains and items from a previously validated measure, the Patient Experience with Treatment and Self-management (PETS). Following review of the prototype, a quasi-experimental pilot study determined acceptability of using the tool in clinical practice. The study protocol was modified to accommodate limitations due to the Covid-19 pandemic.

RESULTS

Fifteen patients with MCC and 18 providers participated in focus groups to review existing PETS content. The pilot tool (named PETS-Now) consisted of eight domains (Living Healthy, Health Costs, Monitoring Health, Medicine, Personal Relationships, Getting Healthcare, Health Information, and Medical Equipment) with each domain represented by a checklist of potential concerns. Administrative burden was minimized by limiting patients to selection of one domain. To test acceptability, 17 primary-care providers first saw 92 patients under standard care (control) conditions followed by another 90 patients using the PETS-Now tool (intervention). Each treatment burden domain was selected at least once by patients in the intervention. No significant differences were observed in overall care quality between patients in the control and intervention conditions with mean care quality rated high in both groups (9.3 and 9.2, respectively, out of 10). There were no differences in provider impressions of patient encounters under the two conditions with providers reporting that patient concerns were addressed in 95% of the visits in both conditions. Most intervention group patients (94%) found that the PETS-Now was easy to use and helped focus the conversation with the provider on their biggest concern (98%). Most providers (81%) felt they had learned something new about the patient from the PETS-Now.

CONCLUSION

The PETS-Now holds promise for quickly screening and monitoring treatment burden in people with MCC and may provide information for care planning. While acceptable to patients and clinicians, integration of information into the electronic medical record should be prioritized.

Clinical care standards for the management of low back pain: a scoping review

The objective of this study is to compare and contrast the quality statements and quality indicators across clinical care standards for low back pain. Searches were performed in Medline, guideline databases, and Google searches to identify clinical care standards for the management of low back pain targeting a multidisciplinary audience. Two independent reviewers reviewed the search results and extracted relevant information from the clinical care standards. We compared the quality statements and indicators of the clinical care standards to identify the consistent messages and the discrepancies between them. Three national clinical care standards from Australia, Canada, and the United Kingdom were included. They provided from 6 to 8 quality statements and from 12 to 18 quality indicators. The three standards provide consistent recommendations in the quality statements related to imaging, and patient education/advice and self-management. In addition, the Canadian and Australian standards also provide consistent recommendations regarding comprehensive assessment, psychological support, and review and patient referral. However, the three clinical care standards differ in the statements related to psychological assessment, opioid analgesics, non-opioid analgesics, and non-pharmacological therapies. The three national clinical care standards provide consistent recommendations on imaging and patient education/advice, self-management of the condition, and two standards (Canadian and Australian) agree on recommendations regarding comprehensive assessment, psychological support, and review and patient referral. The standards differ in the quality statements related to psychological assessment, opioid prescription, non-opioid analgesics, and non-pharmacological therapies.

Evaluating Primary Healthcare Quality from Migrants and Refugees' Viewpoint

Background

The likelihood of poor health outcomes for refugees is increased due to a variety of complicated causes. Lack of access to high-quality care during resettlement is frequently cited by migrants. Therefore, this study was carried out to assess the quality of primary care services from the perspective of refugees and migrants.

Methods

This cross-sectional study was conducted in three health networks affiliated with Iran University of Medical Sciences in 2021. Data were collected by using a self-administrative questionnaire, the validity and reliability of which were checked and confirmed. The questionnaires were randomly completed by 280 migrants and refugees. Data were analyzed by using Kruskal-Wallis, Mann-Whitney U, Spearman correlation, exploratory factor analysis, and Cronbach's α with SPSS 22.

Results

According to the results, the overall service quality was 3.86 out of 5. The highest and lowest mean scores were related to efficiency (4.12 ±0.64) and tangibility (3.28 ±0.39). Furthermore, there was a significant relationship between the perception of service quality and gender, education, residence area, and the rate of center visits (P < 0.05).

Conclusion

The quality of services was generally rated favorably by the refugees. Managers and decision-makers are recommended to allocate enough funds to equip and upgrade the amenities at health centers to increase the quality of services.

Socioeconomic inequalities in patient-reported outcome measures of Dutch primary hip and knee arthroplasty patients for osteoarthritis

OBJECTIVE

To study socio-economic inequalities in patient-reported outcomes in primary hip and knee arthroplasty (THA/TKA) patients for osteoarthritis, using two analytical techniques.

METHODS

We obtained data from 44,732 THA and 30,756 TKA patients with preoperative and 12-month follow-up PROMs between 2014 and 2020 from the Dutch Arthroplasty Registry. A deprivation indicator based on neighborhood income, unemployment rate, and education level was linked and categorized into quintiles. The primary outcome measures were the EQ-5D-3L index and Oxford Hip/Knee Score (OHS/OKS) preoperative, at 12-month follow-up, and the calculated change score between these measurements. We contrasted the most and least deprived quintiles using multivariable linear regression, adjusting for patient characteristics. Concurrently, we calculated concentration indices as a non-arbitrary tool to quantify inequalities.

RESULTS

Compared to the least deprived, the most deprived THA patients had poorer preoperative (EQ-5D -0.03 (95%CI -0.02, -0.04), OHS -1.26 (-0.99, -1.52)) and 12-month follow-up health (EQ-5D -0.02 (-0.01, -0.02), OHS -0.42 (-0.19, -0.65)), yet higher mean change (EQ-5D 0.02 (0.01, 0.03), OHS 0.84 (0.52, 1.16)). The most deprived TKA patients had similar results. The higher mean change among the deprived resulted from lower preoperative health in this group (confounding). After accounting for this, the most deprived patients had a lower mean change. The concentration indices showed similar inequality effects and provided information on the magnitude of inequalities over the entire socio-economic range.

CONCLUSION

The most deprived THA and TKA patients have worse preoperative health, which persisted after surgery. The concentration indices allow comparison of inequalities across different outcomes (e.g., revision risk).

[Continuation of implementation processes in residential long-term care : Sustainability of the expert standard "Relationship management in the care of people with dementia"]

BACKGROUND

Nursing institutions are facing many challenges due to evidence-based requirements. For example, they are required to introduce new interventions such as expert standards and thus adapt routine practices to new findings; however, if new interventions are continuously implemented in the facilities their sustainability is questionable.

OBJECTIVE

The aim was to find out how sustainably the expert standard "Relationship management in the care of people with dementia" is implemented in residential long-term care institutions.

MATERIAL AND METHODS

Qualitative, guideline-based interviews were conducted with persons from residential long-term care, oriented to the procedure of the problem-centered interview. The interviewees were involved in the model implementation of the expert standard "Relationship management in the care of people with dementia"'. The data were then analyzed using qualitative content analysis.

RESULTS

The participants assessed the sustainable implementation in different ways. Some rated the sustainability of the expert standard in their institution as successful, while others see potential for improvement. According to the participants, the sustainability of continuation of implementation processes is influenced by various factors. These relate to the institution, the external context, the intervention, the implementation process, and the people involved in the implementation.

CONCLUSION

On the basis of the factors identified, key needs can be derived for nursing practice, for science and research as well as for politics and legislation, so that the sustainability of expert standards and other evidence-based interventions can be ensured and, if necessary, optimized.

The relationship between nursing home staffing and resident safety outcomes: A systematic review of reviews

BACKGROUND

Resident safety is an important topic for nursing home practice with up to 33 % of residents subjected to an adverse event. In spite of a large evidence base examining the relationship between nursing home staffing and resident outcomes, the findings of several systematic reviews remain inconclusive and contradicting, possibly due to methodological shortcomings.

OBJECTIVE

The main aim of this review was to provide a comprehensive overview of the literature on nursing home staffing and its relationship with resident safety outcomes.

DESIGN

We undertook a systematic review of reviews. We searched Medline, CINAHL and Embase by the end of November 2022. Reviews were included if they assessed the relationship between nursing home staffing and resident safety outcomes using objective measures and data at resident level. Quality appraisal was conducted using the SIGN-checklist, but we did not exclude any reviews based on quality assessment. We used a narrative approach, tables and figures to summarize the findings.

RESULTS

We included 13 systematic reviews published between 2006 and 2022 building on primary evidence from 1977 to 2022. Twelve reviews investigated the relationship between nurse staffing and resident safety outcomes (187 unique primary studies), and one review focused on allied health professionals (28 primary studies). Five reviews originated as work to inform governmental recommendations on staffing. We found diverse approaches used to investigate the staffing-outcome relationship with regard to design, timeframe, operationalization, data-source and theoretical rationales guiding the studies. The most prominently reported resident safety outcomes were pressure ulcers and urinary tract infections. Commonly reported staffing measures included number and level of education of nursing home staff. Based on narrative summaries, staffing seems to have a favorable relationship with resident safety outcomes, but logic models explaining the mechanisms of this relationship were sparsely reported.

CONCLUSIONS

The existing literature shows methodological limitations that demand a change in research on the staffing-outcome relationship in the nursing home setting. Our work highlights the need for carefully designed primary studies that address the pertinent shortcomings by design, timeframe, operationalization, data-source and theoretical rationales. These future studies will allow to carefully examine the causal relationship between selected staffing measures and resident safety outcomes in further detail and serve as legitimate evidence bases to inform action plans for clinical practice and to evaluate staffing policies.

Acute care pathway assessed through performance indicators during the COVID-19 pandemic in OECD countries (2020-2021): a scoping review

BACKGROUND

The COVID-19 pandemic severely impacted care for non-COVID patients. Performance indicators to monitor acute care, timely reported and internationally accepted, lacked during the pandemic in OECD countries. This study aims to summarize the performance indicators available in the literature to monitor changes in the quality of acute care in OECD countries during the first year and a half of the pandemic (2020-July 2021) and to assess their trends.

METHODS

Scoping review. Search in Embase and MEDLINE (07-07-2022). Acute care performance indicators and indicators related to acute general surgery were collected and collated following a care pathway approach. Indicators assessing identical clinical measures were grouped under a common indicator title. The trends from each group of indicators were collated (increase/decrease/stable).

RESULTS

A total of 152 studies were included. 2354 indicators regarding general acute care and 301 indicators related to acute general surgery were included. Indicators focusing on pre-hospital services reported a decreasing trend in the volume of patients: from 225 indicators, 110 (49%) reported a decrease. An increasing trend in pre-hospital treatment times was reported by most of the indicators (n = 41;70%) and a decreasing trend in survival rates of out-of-hospital cardiac arrest (n = 61;75%). Concerning care provided in the emergency department, most of the indicators (n = 752;71%) showed a decreasing trend in admissions across all levels of urgency. Concerning the mortality rate after admission, most of the indicators (n = 23;53%) reported an increasing trend. The subset of indicators assessing acute general surgery showed a decreasing trend in the volume of patients (n = 50;49%), stability in clinical severity at admission (n = 36;53%), and in the volume of surgeries (n = 14;47%). Most of the indicators (n = 28;65%) reported no change in treatment approach and stable mortality rate (n = 11,69%).

CONCLUSION

This review signals relevant disruptions across the acute care pathway. A subset of general surgery performance indicators showed stability in most of the phases of the care pathway. These results highlight the relevance of assessing this care pathway more regularly and systematically across different clinical entities to monitor disruptions and to improve the resilience of emergency services during a crisis.

Longer-term quality of care, effectiveness, and cost-effectiveness of implementing a model of care for osteoarthritis: A cluster-randomized controlled trial

OBJECTIVE

To assess the quality of care, effectiveness, and cost-effectiveness over 12 months after implementing a structured model of care for hip and knee osteoarthritis (OA) in primary healthcare as compared to usual care.

DESIGN

In this pragmatic cluster-randomized, controlled trial with a stepped-wedge cohort design, we recruited 40 general practitioners (GPs), 37 physiotherapists (PTs), and 393 patients with symptomatic hip or knee OA from six municipalities (clusters) in Norway. The model included the delivery of a 3-hour patient education and 8-12 weeks individually tailored exercise programs, and interactive workshops for GPs and PTs. At 12 months, the patient-reported quality of care was assessed by the OsteoArthritis Quality Indicator questionnaire (16 items, pass rate 0-100%, 100%=best). Costs were obtained from patient-reported and national register data. Cost-effectiveness at the healthcare perspective was evaluated using incremental net monetary benefit (INMB).

RESULTS

Of 393 patients, 109 were recruited during the control periods (control group) and 284 were recruited during interventions periods (intervention group). At 12 months the intervention group reported statistically significant higher quality of care compared to the control group (59% vs. 40%; mean difference: 17.6 (95% confidence interval [CI] 11.1, 24.0)). Cost-effectiveness analyses showed that the model of care resulted in quality-adjusted life-years gained and cost-savings compared to usual care with mean INMB €2020 (95% CI 611, 3492) over 12 months.

CONCLUSIONS

This study showed that implementing the model of care for OA in primary healthcare, improved quality of care and showed cost-effectiveness over 12 months compared to usual care.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT02333656.

Goals of the Morbidity and Mortality meeting in acute care: A scoping review

OBJECTIVE

The objective of this study was to describe what is known about understandings of the goals of the Morbidity and Mortality meeting.

REVIEW METHODS USED

The study utilised scoping review methodology.

DATA SOURCES

Papers in English presenting empirical data published in academic journals with Morbidity and Mortality meetings as the central concept of study. Included papers presented data about the perception of stakeholders about goals of the Morbidity and Mortality meeting. Medline, Embase, and CINAHL databases were search conducted from earliest record - October 20th 2021. A manual search of the reference lists of all included papers identified further eligible papers.

REVIEW METHODS

Data about the location, participant type, and methods/ methodology were extracted and entered onto a database. Content analysis of the results and discussion sections of qualitative papers yielded broad categories of meeting goal. This provided a framework for the organisation of the quantitative findings, which were subsequently extracted and charted under these categories.

RESULTS

Twenty-five papers were included in the review, and six main categories were identified in the qualitative synthesis of findings. These included meeting goals related to quality and safety, education, legal and reputational risk management, professional culture, family/caregivers, and peer support.

CONCLUSIONS

There are heterogeneous understandings of key terminologies used to describe Morbidity and Mortality meeting goals, particularly evident within understandings of educational and quality and safety meeting goals. This paper defines and unravels this complexity in a way that researchers and clinicians can define, compare and evaluate their own department's meeting goals.

The impact of a multidisciplinary goals-of-care program on unplanned readmission rates at a comprehensive cancer center

PURPOSE

This study examined the 30-day unplanned readmission rate in the medical oncology population before and after the implementation of an institution-wide multicomponent interdisciplinary goals of care (myGOC) program.

METHODS

This retrospective study compared the 30-day unplanned readmission rates in consecutive medical patients during the pre-implementation period (May 1, 2019, to December 31, 2019) and the post-implementation period (May 1, 2020, to December 31, 2020). Secondary outcomes included 7-day unplanned readmission rates, inpatient do-not-resuscitate (DNR) orders, and palliative care consults. We randomly selected a hospitalization encounter for each unique patient during each study period for statistical analysis. A multivariate analysis model was used to examine the association between 30-day unplanned readmission rates and implementation of the myGOC program.

RESULTS

There were 7028 and 5982 unique medical patients during the pre- and post-implementation period, respectively. The overall 30-day unplanned readmission rate decreased from 24.0 to 21.3% after implementation of the myGOC program. After adjusting for covariates, the myGOC program implementation remained significantly associated with a reduction in 30-day unplanned readmission rates (OR [95% CI] 0.85 [0.77, 0.95], p = 0.003). Other factors significantly associated with a decreased likelihood of a 30-day unplanned readmission were an inpatient DNR order, advanced care planning documentation, and an emergent admission type. We also observed a significant decrease in 7-day unplanned readmission rates (OR [95% CI] 0.75 [0.64, 0.89]) after implementation of the myGOC program.

CONCLUSION

The 30-day and 7-day unplanned readmission rates decreased in our hospital after implementation of a system-wide multicomponent GOC intervention.

Completeness of medication information in admission notes from emergency departments

BACKGROUND

Medication lists prepared in the emergency department (ED) form the basis for diagnosing and treating patients during hospitalization. Since incomplete medication information may lead to patient harm, it is crucial to obtain a correct and complete medication list at hospital admission. In this cross-sectional retrospective study we wanted to explore medication information completeness in admission notes from Norwegian EDs and investigate which factors were associated with level of completeness.

METHODS

Medication information was assessed for completeness by applying five evaluation criteria; generic name, formulation, dose, frequency, and indication for use. A medication completeness score in percent was calculated per medication, per admission note and per criterion. Quantile regression analysis was applied to investigate which variables were associated with medication information completeness.

RESULTS

Admission notes for patients admitted between October 2018 and September 2019 and using at least one medication were included. A total of 1,080 admission notes, containing 8,604 medication orders, were assessed. The individual medications had a mean medication completeness score of 88.1% (SD 16.4), while admission notes had a mean medication completeness score of 86.3% (SD 16.2). Over 90% of all individual medications had information about generic name, formulation, dose and frequency stated, while indication for use was only present in 60%. The use of an electronic tool to prepare medication information had a significantly strong positive association with completeness. Hospital visit within the last 30 days, the patient's living situation, number of medications in use, and which hospital the patient was admitted to, were also associated with information completeness.

CONCLUSIONS

Medication information completeness in admission notes was high, but potential for improvement regarding documentation of indication for use was identified. Applying an electronic tool when preparing admission notes in EDs seems crucial to safeguard completeness of medication information.

Interventions to promote cost-effectiveness in adult intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study

BACKGROUND

There is limited evidence to guide interventions that promote cost-effectiveness in adult intensive care units (ICU). The aim of this consensus statement is to identify globally applicable interventions for best ICU practice and provide guidance for judicious use of resources.

METHODS

A three-round modified online Delphi process, using a web-based platform, sought consensus from 61 multidisciplinary ICU experts (physicians, nurses, allied health, administrators) from 21 countries. Round 1 was qualitative to ascertain opinions on cost-effectiveness criteria based on four key domains of high-value healthcare (foundational elements; infrastructure fundamentals; care delivery priorities; reliability and feedback). Round 2 was qualitative and quantitative, while round 3 was quantitative to reiterate and establish criteria. Both rounds 2 and 3 utilized a five-point Likert scale for voting. Consensus was considered when > 70% of the experts voted for a proposed intervention. Thereafter, the steering committee endorsed interventions that were identified as 'critical' by more than 50% of steering committee members. These interventions and experts' comments were summarized as final considerations for best practice.

RESULTS

At the conclusion of round 3, consensus was obtained on 50 best practice considerations for cost-effectiveness in adult ICU. Finally, the steering committee endorsed 9 'critical' best practice considerations. This included adoption of a multidisciplinary ICU model of care, focus on staff training and competency assessment, ongoing quality audits, thus ensuring high quality of critical care services whether within or outside the four walls of ICUs, implementation of a dynamic staff roster, multidisciplinary approach to implementing end-of-life care, early mobilization and promoting international consensus efforts on the Green ICU concept.

CONCLUSIONS

This Delphi study with international experts resulted in 9 consensus statements and best practice considerations promoting cost-effectiveness in adult ICUs. Stakeholders (government bodies, professional societies) must lead the efforts to identify locally applicable specifics while working within these best practice considerations with the available resources.

Audit and feedback to reduce unwarranted clinical variation at scale: a realist study of implementation strategy mechanisms

BACKGROUND

Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation.

METHODS

Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff.

RESULTS

The program's audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy.

CONCLUSIONS

Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.

Cross-cultural adaptation of the Moroccan Arabic dialect version of the Primary Care Assessment Tool

OBJECTIVE

To adapt the Primary Primary Care Assessment Tool-Adult Edition into the Moroccan Arabic dialect and to assess its reliability and validity from the perspective of Moroccan adult patients.

METHOD

A committee of experts carried out the cross-cultural adaptation of the Primary Care Assessment Tool. The adapted questionnaire was subject to forward and backward translation and a pilot study. Exploratory factor analysis assessed the internal consistency, reliability, and construct validity of items and scales. Finally, descriptive statistics were performed on the final factor structure.

RESULTS

A 43-item Moroccan Arabic dialect version of the Primary Care Assessment Tool-Adult Edition was developed. It consisted of six multi-item scales that represented the four main dimensions of primary care: first contact, continuity, comprehensiveness, and coordination. Four derived dimensions were included: cultural competence, communication, advice, and community orientation. All six scales demonstrated robust internal consistency, item-total solid correlations, and construct validity. The calculated Cronbach's alpha coefficients ranged from 0.78 to 0.90.

CONCLUSIONS

Comprehensive metric analyses supported the reliability and validity of the Moroccan Arabic dialect version of the Primary Care Assessment Tool-Adult Edition in assessing core primary care domains from the patients' experience. This tool could be used for future research on primary care in Morocco.

Dyadic coping strategies and quality of care experience: An original study of patients living with multiple sclerosis and their caregivers

BACKGROUND AND OBJECTIVE

Multiple sclerosis has a major impact on the lives of patients and their caregivers. Measuring their experience is essential for improving the quality of care. Based on a sample of patient-informal caregiver dyads we examine whether coping strategies they implemented influenced their self-experience of quality of care.

METHODS

One hundred and eighty three dyads were involved in this cross-sectional study. Self reported data included experience with the quality of care (Musicare) and coping strategies (Brief Cope) for patients and their caregivers. An actor-partner interdependence model (APIM) analysis was performed to assess the dyadic effects of coping strategies on experience of quality of care.

RESULTS

Positive coping strategies were the most used by patients and caregivers alike. They were associated with a better experience of relationships with healthcare professionals, information about the disease and patient reception at the sites providing care. APIM analyses confirmed most of these results and identified one "partner" effect.

CONCLUSION

The experience of the quality of the care of patients living with MS is related to the use of positive coping strategies.

Alert-Grouping: Smart Personalization of Monitoring System Thresholds to Help Healthcare Teams Struggle with Alarm Fatigue in Intensive Care

In Intensive Care Units (ICUs), patients are monitored using various devices that generate alerts when specific metrics, such as heart rate and oxygen saturation, exceed predetermined thresholds. However, these alerts can be inaccurate and lead to alert fatigue, resulting in errors and inaccurate diagnoses. We propose Alert grouping, a "Smart Personalization of Monitoring System Thresholds to Help Healthcare Teams Struggle Alarm Fatigue in Intensive Care" model. The alert grouping looks at patients at the individual and cluster levels, and healthcare-related constraints to assist medical and nursing teams in setting personalized alert thresholds of vital parameters. By simulating the function of ICU patient bed devices, we demonstrate that the proposed alert grouping model effectively reduces the number of alarms overall, improving the alert system's validity and reducing alarm fatigue. Implementing this personalized alert model in ICUs boosts medical and nursing teams' confidence in the alert system, leading to better care for ICU patients by significantly reducing alarm fatigue, thereby improving the quality of care for ICU patients.

Hearing the voices of adolescents: Evaluating the quality of care for young adults with chronic illnesses in the UAE

BACKGROUND

Quality care for adolescents and young adults with chronic illnesses has been under-explored in the United Arab Emirates (UAE) and internationally, especially from patients' perspectives. Most available international studies focused on quality of life and the transition to adulthood rather than service quality.

AIM

This research assesses care quality for adolescents with chronic illnesses in the UAE, aiming to understand their perspectives, appraise current practices, and identify service gaps.

METHODS

A cross-sectional survey employed a validated questionnaire examining 33 essential care components. Participants comprised 576 adolescents and young adults with chronic conditions from five UAE Emirates.

RESULTS

Participant's reports indicated that none of the 33 care elements were received consistently. Most participants (80.6%) reported crucial care aspects were absent, and across most investigated items, 19.4%-46.5% of participants reported receiving the services they were supposed to receive only some or many of the times, indicating significant areas for improvement.

CONCLUSIONS

Findings demonstrate significant care quality gaps for UAE's adolescents and young adults with chronic illnesses. These may critically affect their ability to manage their conditions and ensure holistic growth. These insights can guide healthcare enhancements tailored to this demographic.

PRACTICE IMPLICATIONS

There is an urgency for enhanced patient-centered care in UAE healthcare, emphasizing clinicians' roles in supporting adolescents with chronic illnesses, especially during transitions. Healthcare managers should prioritize standardized care policies, improved communication, and training that emphasizes consistent patient feedback and transition readiness. Further research into care gaps and tailored interventions within the region's distinct sociocultural setting is essential.

Transitioning from the "Three Delays" to a focus on continuity of care: a qualitative analysis of maternal deaths in rural Pakistan and Mozambique

BACKGROUND

The Three Delays Framework was instrumental in the reduction of maternal mortality leading up to, and during the Millennium Development Goals. However, this paper suggests the original framework might be reconsidered, now that most mothers give birth in facilities, the quality and continuity of the clinical care is of growing importance.

METHODS

The paper explores the factors that contributed to maternal deaths in rural Pakistan and Mozambique, using 76 verbal autopsy narratives from the Community Level Interventions for Pre-eclampsia (CLIP) Trial.

RESULTS

Qualitative analysis of these maternal death narratives in both countries reveals an interplay of various influences, such as, underlying risks and comorbidities, temporary improvements after seeking care, gaps in quality care in emergencies, convoluted referral systems, and arrival at the final facility in critical condition. Evaluation of these narratives helps to reframe the pathways of maternal mortality beyond a single journey of care-seeking, to update the categories of seeking, reaching and receiving care.

CONCLUSIONS

There is a need to supplement the pioneering "Three Delays Framework" to include focusing on continuity of care and the "Four Critical Connection Points": (1) between the stages of pregnancy, (2) between families and health care workers, (3) between health care facilities and (4) between multiple care-seeking journeys.

TRIAL REGISTRATION

NCT01911494, Date Registered 30/07/2013.

Multinational patterns of second line antihyperglycaemic drug initiation across cardiovascular risk groups: federated pharmacoepidemiological evaluation in LEGEND-T2DM

Objective

To assess the uptake of second line antihyperglycaemic drugs among patients with type 2 diabetes mellitus who are receiving metformin.

Design

Federated pharmacoepidemiological evaluation in LEGEND-T2DM.

Setting

10 US and seven non-US electronic health record and administrative claims databases in the Observational Health Data Sciences and Informatics network in eight countries from 2011 to the end of 2021.

Participants

4.8 million patients (≥18 years) across US and non-US based databases with type 2 diabetes mellitus who had received metformin monotherapy and had initiated second line treatments.

Exposure

The exposure used to evaluate each database was calendar year trends, with the years in the study that were specific to each cohort.

Main outcomes measures

The outcome was the incidence of second line antihyperglycaemic drug use (ie, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter-2 inhibitors, dipeptidyl peptidase-4 inhibitors, and sulfonylureas) among individuals who were already receiving treatment with metformin. The relative drug class level uptake across cardiovascular risk groups was also evaluated.

Results

4.6 million patients were identified in US databases, 61 382 from Spain, 32 442 from Germany, 25 173 from the UK, 13 270 from France, 5580 from Scotland, 4614 from Hong Kong, and 2322 from Australia. During 2011-21, the combined proportional initiation of the cardioprotective antihyperglycaemic drugs (glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors) increased across all data sources, with the combined initiation of these drugs as second line drugs in 2021 ranging from 35.2% to 68.2% in the US databases, 15.4% in France, 34.7% in Spain, 50.1% in Germany, and 54.8% in Scotland. From 2016 to 2021, in some US and non-US databases, uptake of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors increased more significantly among populations with no cardiovascular disease compared with patients with established cardiovascular disease. No data source provided evidence of a greater increase in the uptake of these two drug classes in populations with cardiovascular disease compared with no cardiovascular disease.

Conclusions

Despite the increase in overall uptake of cardioprotective antihyperglycaemic drugs as second line treatments for type 2 diabetes mellitus, their uptake was lower in patients with cardiovascular disease than in people with no cardiovascular disease over the past decade. A strategy is needed to ensure that medication use is concordant with guideline recommendations to improve outcomes of patients with type 2 diabetes mellitus.

Accreditation of nutrition support teams: A new initiative by the Turkish Society of Clinical Enteral & Parenteral Nutrition

OBJECTIVES

Accreditation is a process to evaluate compliance of an institution or organization with predetermined performance standards, focusing on achieving continuous improvement strategies and optimal quality standards and motivating the accredited organization to do so. There is no established accreditation program for nutrition support teams (NSTs) at national and international levels. In order to increase the standards of NSTs, developing an accreditation program is being planned by the Turkish Society of Clinical Enteral & Parenteral Nutrition (KEPAN).

METHODS

Accreditation standards were developed by a study group under the organization of KEPAN. Minimum standards for composition, qualifications, physical requirements, workflow charts, medical records, and both patient and health care providers' safety measures in NSTs were specified. These standards were uploaded to a computer program, and the necessary infrastructure for a web-based management of accreditation processes was developed.

RESULTS

An organization applying for accreditation should fill in the application form on KEPAN website electronically. Eligibility criteria for accreditation include number of NST members, physical environment, patient monitoring requirements, research, and training. A total of 22 standards are surveyed under 13 sections. These standards contain 61 criteria. To be accredited, each of 22 standards must score >70 and each of 13 sections must score >80.

CONCLUSIONS

In order to increase the quality of nutritional care and improve patient outcomes, an accreditation program has been developed. This program principally sets the basic standards, organizational scheme, and responsibilities of NSTs.

Patient participation in end-stage kidney disease care: variation over time and effects of staff-directed interventions - a quasi-experimental study

BACKGROUND

Among those elements establishing decent quality of care from a patient perspective, opportunities to participate in accord with one's individual needs and preferences are central. To date, little is known the extent of preference-based patient participation in kidney care, and what facilitates optimal conditions. This study investigated i) preference-based patient participation in kidney care over time, and ii) the effects of interventions designed to enhance person-centred patient participation.

METHODS

A quasi-experimental study was conducted across nine kidney care sites in southeast Sweden. A cohort of 358 patients with stage IV chronic kidney disease (eGRF 15-19 ml/min) or V (eGRF < 15 mL/min) entered the study. Of these, 245 patients (with kidney replacement therapy or intermittent outpatient visits only) completed a survey on patient participation at four time points: every six months from August 2019 to May 2021, patients reported their preferences for and experiences of participation using the validated Patient Preferences for Patient Participation tool, the 4Ps. Between the first and second data collection points, interventions were provided for designated staff to facilitate person-centred participation, using two strategies for two subgroups at three sites each: the managers receiving a bundle of information via e-mail on patient participation in a standard dissemination procedure (three sites), or an additional half-year support program for implementation offered to 1-2 staff per site (three sites), with no intervention for a control group (three sites). The differences in 4Ps data between groups were analysed using multilevel ordinal regression.

RESULTS

Over time and across all sites, most patients' experiences of participation fully or almost fully matched their engagement preferences (57%-90%). Still, up to 12% of patient reports indicated that their preferences and experiences were insufficiently matched: in these cases, the patients had preferred to be more involved than they had experienced, for example, in making healthcare plans and setting health-related goals. The interventions did not affect the levels of preference-based participation, but patients in the control group sites had slightly more consistent matches.

CONCLUSIONS

Living with kidney failure necessitates patient engagement, but opportunities to participate in accordance with one's preferences are not fully provided for all patients. Additional efforts to support a common understanding and to ensure person-centred patient participation is still needed.

Monitoring the performance of a dedicated weaning unit using risk-adjusted control charts for the weaning rate in prolonged mechanical ventilation

BACKGROUND

Weaning rate is an important quality indicator of care for patients with prolonged mechanical ventilation (PMV). However, diverse clinical characteristics often affect the measured rate. A risk-adjusted control chart may be beneficial for assessing the quality of care.

METHODS

We analyzed patients with PMV who were discharged between 2018 and 2020 from a dedicated weaning unit at a medical center. We generated a formula to estimate monthly weaning rates using multivariate logistic regression for the clinical, laboratory, and physiologic characteristics upon weaning unit admission in the first two years (Phase I). We then applied both multiplicative and additive models for adjusted p-charts, displayed in both non-segmented and segmented formats, to assess whether special cause variation existed.

RESULTS

A total of 737 patients were analyzed, including 503 in Phase I and 234 in Phase II, with average weaning rates of 59.4% and 60.3%, respectively. The p-chart of crude weaning rates did not show special cause variation. Ten variables from the regression analysis were selected for the formula to predict individual weaning probability and generate estimated weaning rates in Phases I and II. For risk-adjusted p-charts, both multiplicative and additive models showed similar findings and no special cause variation.

CONCLUSION

Risk-adjusted control charts generated using a combination of multivariate logistic regression and control chart-adjustment models may provide a feasible method to assess the quality of care in the setting of PMV with standard care protocols.

[Implications for improving health care quality and patient safety of palliative residents in nursing homes: A qualitative study]

INTRODUCTION

Despite the increasing importance of palliative care, the implementation of professional and ethical quality standards appears to be challenging for nursing homes, leading to different levels of palliative care between facilities. This study aims to examine the concrete problem areas of palliative care in everyday practice and to discover what is needed to improve health care quality and patient safety of palliative residents in nursing homes from different perspectives.

METHODS

Semi-structured interviews with 14 employees and managers of two nursing homes in urban and rural areas in North Rhine-Westphalia were conducted and analyzed according to Mayring's qualitative content analysis. Additionally, characteristics of ideal-typical palliative care in nursing homes were identified from different perspectives through interdisciplinary focus groups of various involved professions.

RESULTS

Due to a lack of structural and organizational guidelines, processes of palliative care are based on subjective actions of the staff, which leads to uncertainties and differences in the management of palliative care for nursing home residents. Besides limited time resources for care and support of residents at their end of life, this represents a major stress factor for employees. In the focus groups, characteristics of ideal-typical palliative care in the everyday practice of palliative care were identified. In terms of potential for optimization, palliative care pathways are seen as one way to contribute to creating a framework for palliative processes which at the same time leaves room for professional decisions in individual cases.

DISCUSSION

It seems likely that inconsistencies in the management of palliative care processes can also be found in other nursing homes. Indications of this include the low proportion of residents with identified palliative care needs and the lack of use of assessments to identify palliative needs and to monitor typical palliative symptoms. At the same time, it must be taken into account that the last phase of life is characterised by individuality, which cannot and should not be standardised. In palliative care practice, professional perceptions and empirical knowledge are well needed. Nevertheless, in terms of quality of care, these should not be the sole basis for palliative action.

CONCLUSION

Different levels of palliative care and employees' uncertainties indicate that palliative care practice in nursing homes requires a framework that helps staff to act more confidently and yet leaves room for professional action and decision-making in individual cases.

Improving the Management and Follow-up of Atopic Dermatitis: A Delphi Process Report of Consensus Between Hospital Dermatologists and Pharmacists

Managing atopic dermatitis, one of the most common dermatologic conditions, is often challenging. To establish consensus on recommendations for responding to various situations that arise when treating atopic dermatitis, a group of hospital pharmacists and dermatologists used the Delphi process. A scientific committee developed a Delphi survey with 2 blocks of questions to explore the group's views on 1) evaluating response to treatment in the patient with atopic dermatitis and 2) cooperation between the dermatology department and the hospital pharmacy service. The experts achieved an overall rate of consensus of 86% during the process. Conclusions were that dermatologists and hospital pharmacists must maintain good communication and coordinate their interventions to optimize the management of atopic dermatitis and patients' responses to treatment.

The quality of prison primary care: cross-sectional cluster-level analyses of prison healthcare data in the North of England

Background

Prisoners have significant health needs, are relatively high users of healthcare, and often die prematurely. Strong primary care systems are associated with better population health outcomes. We investigated the quality of primary care delivered to prisoners.

Methods

We assessed achievement against 30 quality indicators spanning different domains of care in 13 prisons in the North of England. We conducted repeated cross-sectional analyses of routinely recorded data from electronic health records over 2017-20. Multi-level mixed effects logistic regression models explored associations between indicator achievement and prison and prisoner characteristics.

Findings

Achievement varied markedly between indicators, prisons and over time. Achieved processes of care ranged from 1% for annual epilepsy reviews to 94% for blood pressure checks in diabetes. Intermediate outcomes of care ranged from only 0.2% of people with epilepsy being seizure-free in the preceding year to 34% with diabetes having sufficient blood pressure control. Achievement improved over three years for 11 indicators and worsened for six, including declining antipsychotic monitoring and rising opioid prescribing. Achievement varied between prisons, e.g., 1.93-fold for gabapentinoid prescribing without coded neuropathic pain (odds ratio [OR] range 0.67-1.29) and 169-fold for dried blood spot testing (OR range 0.05-8.45). Shorter lengths of stay were frequently associated with lower achievement. Ethnicity was associated with some indicators achievement, although the associations differed (both positive and negative) with indicators.

Interpretation

We found substantial scope for improvement and marked variations in quality, which were largely unaltered after adjustment for prison and prisoner characteristics.

Funding

National Institute for Health and Care Research Health and Social Care and Delivery Research Programme: 17/05/26.

Electronic alert outpatient protocol improves the quality of care for the risk of postcontrast acute kidney injury following computed tomography

BACKGROUND

Prevention and diagnosis of postcontrast acute kidney injury (AKI) after contrast-enhanced computed tomography is burdensome in outpatient department. We investigated whether an electronic alert system could improve prevention and diagnosis of postcontrast AKI.

METHODS

In March 2018, we launched an electronic alert system that automatically identifies patients with a baseline estimated glomerular filtration rate of <45 mL/min/1.73 m2, provides a prescription of fluid regimen, and recommends a follow-up for serum creatinine measurement. Participants prescribed contrast-enhanced computed tomography at outpatient department before and after the launch of the system were categorized as historical and alert group, respectively. Propensity for the surveillance of postcontrast AKI was compared using logistic regression. Risks of AKI, admission, mortality, and renal replacement therapy were analyzed.

RESULTS

The historical and alert groups included 289 and 309 participants, respectively. The alert group was more likely to be men and take diuretics. The most frequent volume of prophylactic fluid in historical and alert group was 1,000 and 750 mL, respectively. Follow-up for AKI was more common in the alert group (adjusted odds ratio, 6.00; p < 0.001). Among them, incidence of postcontrast AKI was not statistically different. The two groups did not differ in risks of admission, mortality, or renal replacement therapy.

CONCLUSION

The electronic alert system could assist in the detection of high-risk patients, prevention with reduced fluid volume, and proper diagnosis of postcontrast AKI, while limiting the prescribing clinicians' burden. Whether the system can improve long-term outcomes remains unclear.

Effectiveness of nonpharmacological interventions to prevent adverse events in the intensive care unit: A review of systematic reviews

BACKGROUND

Different types of interventions have been assessed for the prevention of adverse events. However, determining which patient-safety practice is most effective can be challenging when there is no systematised evidence synthesis. An overview following the best methodological standards can provide the best reliable integrative evidence.

OBJECTIVES

The objective of this study was to provide an overview of effectiveness nonpharmacological interventions aimed at preventing adverse events in the intensive care unit.

METHODS

A review of systematic reviews (SRs) was conducted according to the Cochrane Handbook and PRISMA recommendations. PubMed, CINAHL, and Cochrane Library were searched for SRs published until March 2022. Two reviewers independently assessed the study's quality, using AMSTAR-2, and extracted data on intervention characteristics and effect on prevention of adverse events.

RESULTS

Thirty-seven SRs were included, and 27 nonpharmacological interventions were identified to prevent 11 adverse events. Most of the reviews had critically low methodological quality. Among all the identified interventions, subglottic secretion drainage, semirecumbent position, and kinetic bed therapy were effective in preventing ventilator-associated pneumonia; the use of earplugs, early mobilisation, family participation, and music in reducing delirium; physical rehabilitation in improving muscle strength; use of respiratory support in preventing reintubation; the use of a computerised physician order entry system in reducing risk of medication errors; and the use of heated water humidifier was effective in reducing artificial airway occlusion.

CONCLUSIONS

Some nonpharmacological interventions reduced adverse events in the intensive care setting. These findings should be interpreted carefully due to the low methodological quality. SRs on preventing adverse events in the intensive care unit should adhere to quality assessment tools so that best evidence can be used in decision-making.

Care coordination in homecare and its relationship with quality of care: A national multicenter cross-sectional study

INTRODUCTION

As health care complexity increases, skilled care coordination is becoming increasingly necessary. This is especially true in homecare settings, where services tend to be highly interprofessional. Poor coordination can result in services being provided twice, at the wrong time, unnecessarily or not at all. In addition to risking harm to the client, such confusion leads to unnecessary costs. From the patient's perspective, then, professional coordination should help both to remove barriers limiting quality of care and to minimize costs. To date, though, studies examining the relationship between care coordination and care quality have faced multiple challenges, leading to mixed results. And in homecare contexts, where the clients are highly vulnerable and diverse care interfaces make coordination especially challenging, such studies are rare.

OBJECTIVES

Therefore, the aim of this study was to explore the relationship, from the perspectives of clients and of homecare professionals, between coordination and quality of care. For both groups, we hypothesized that better coordination would correlate with higher ratings of quality of care. For the clients, we predicted that higher coordination ratings would lead to lower incidence of unplanned health care use, i.e., emergency department (ED) visits, unscheduled urgent medical visits and hospitalizations.

DESIGN AND METHODS

This study is part of a national multi-center cross-sectional study in the Swiss homecare setting. We recruited 88 homecare agencies and collected data between January and September 2021 through written questionnaires for agencies' managers, employees (n = 3223) and clients (n = 1509). To test our hypotheses, we conducted multilevel analyses.

RESULTS

Employee-perceived care coordination ratings correlated positively with employee-rated quality of care (OR = 2.78, p < .001); client-perceived care coordination problems correlated inversely with client-reported quality of care (β = -0.55, p < .001). Client-perceived coordination problems also correlated positively with hospitalizations (IRR = 1.20, p < .05) and unscheduled urgent medical visits (IRR = 1.18, p < .05), but not significantly with ED visits. No associations were discernible between employee-perceived coordination quality and either health care service use or client quality-of-care ratings.

DISCUSSION

While results indicate relationships between coordination and diverse aspects of care quality, various coordination gaps (e.g., poor information flow) also became apparent. The measurement of both care coordination and quality of care remains a challenge. Further research should focus on developing and validating a coordination questionnaire that measures care coordination.

[Translated article] Improving the Management and Follow-up of Atopic Dermatitis: A Delphi Process Report of Consensus Between Hospital Dermatologists and Pharmacists

Managing atopic dermatitis, one of the most common dermatologic conditions, is often challenging. To establish consensus on recommendations for responding to various situations that arise when treating atopic dermatitis, a group of hospital pharmacists and dermatologists used the Delphi process. A scientific committee developed a Delphi survey with two blocks of questions to explore the group's views on (1) evaluating response to treatment in the patient with atopic dermatitis and (2) cooperation between the dermatology department and the hospital pharmacy service. The experts achieved an overall rate of consensus of 86% during the process. Conclusions were that dermatologists and hospital pharmacists must maintain good communication and coordinate their interventions to optimize the management of atopic dermatitis and patients' responses to treatment.

Body objectified? Phenomenological perspective on patient objectification in teleconsultation

The global crisis of COVID-19 pandemic has considerably accelerated the use of teleconsultation (consultation between the patient and the doctor via video platforms). While it has some obvious benefits and drawbacks for both the patient and the doctor, it is important to consider-how teleconsultation impacts the quality of the patient-doctor relationship? I will approach this question through the lens of phenomenology of the body, focusing on the question-what happens to the patient objectification in teleconsultation? To answer this question I will adopt a phenomenological approach combining both insights drawn from the phenomenological tradition, i.e., the concepts of the lived body and the object body, and the results from the phenomenologically informed qualitative research study on the patient experience of teleconsultation. The theoretical background against which I have developed this study comprises discussions within the field of phenomenology of medicine regarding the different sources of patient objectification within clinical encounter and the arguments concerning the negative impact that objectification has on the quality of care. I will argue that a factor that has frequently been identified within phenomenology of medicine as the main source of patient objectification in clinical encounters, namely, the internalized gaze of the clinician, is diminished during teleconsultation, increasing patient's sense of agency, decreasing her sense of alienation and opening up the possibility for a closer relationship between the patient and the health care provider, all of which lead to the transformation of the hierarchical patient-health care professional relationship.

[Focus on semi-residential care - Development of science-based impulses for the design of day care for the elderly]

BACKGROUND

Despite its important role in the elderly care system, day care in Germany has so far rather little attention paid to it. Keeping their patients' health and self-reliance and facilitating relief and support for family caregivers are central tasks of day care, regulated by law. Nevertheless, there is not only a lack of findings about the working methods and effects of day care, but also of orientation in terms of how to configure high-quality care on a structural, process-related and conceptual level. The aim of the TpQ project ("Weiterentwicklung und Qualitätsverbesserung von Tagespflege in Nordrhein-Westfalen", "further development of and quality improvement in day care facilities in Northrhine-Westphalia") was to close this gap and to offer the institutions a catalogue of impulses that contains current national and international research findings as well as the perspectives of every stakeholder associated with day care.

METHOD

In an explorative sequential mixed-method design, we conducted a search for and a synthesis of the literature in the form of a scoping review, qualitative interviews with guests, relatives, non-users, employees and managers of day care, association representatives, nursing scientists and business consultants, a quantitative paper-based survey among guests, relatives, employees and managers of day care and an expert conference for result validation. The sample received study information either directly by mail or through the staff of the recruited adult day care facilities. The survey-area is the federal state of North Rhine-Westphalia. The analysis of the qualitative data was conducted according to the qualitative content analysis and was used for the development of the quantitative surveys. The quantitative data analysis was descriptive. Based on the comparison with literature analysis and qualitative findings, the impulses for the design of day care were finally formulated and validated during an expert workshop.

RESULTS

From the literature (N=49) and the interviews (N=85), different expectations and wishes with regard to day care were generated. These included staff and structural requirements as well as concrete ideas of the conceptual orientation of day care. The quantitative survey (N=392) showed considerable agreement with the content-related and organizational requirements of the qualitative survey and allowed us to identify the relevant quality aspects from the point of view of guests, relatives and staff of day care facilities. In summary, 15 dimensions for the design of day care (conception/basic principles, quality management, nursing care, transport/driving service, opening hours, equipment, networking, staff, introduction of new guests, activity offers, health promotion and prevention, promotion of social participation, support of relatives, public work, counseling) were defined as relevant quality areas and explained with 81 impulses.

DISCUSSION AND CONCLUSION

Addressing the perspective of users, family caregivers and other persons involved in adult day care reveals complex requirements and opportunities for the design of adult day care. In contrast to existing quality inspection guidelines, the impulses can be used to independently assess adult day care with the goal of contributing to the further development and sharpening of the profile of adult day care.

Effects of star ratings bonus payments on disparities in medication utilization issues

Background

Previous literature suggested that the consequences of inappropriate medication use may be borne disproportionately by racial/ethnic minorities. It is, therefore, essential to examine if quality improvement initiatives, such as Medicare Part D Star Ratings (Star Ratings), can improve these disparities.

Objective

To assess the impact of Star Ratings bonus payments to Medicare Advantage prescription drug plans (MAPDs) implemented in 2012 on racial/ethnic disparities in medication utilization issues (MUIs).

Methods

This study mainly used secondary data from Medicare administrative data linked to Area Health Resources Files for years before (2010-2011) and after MAPD bonus payment implementation (2016-2017). Patients in MAPDs were treated as the intervention group, and those in independent prescription drug plans (PDPs) were used as the comparison group because PDPs were ineligible for bonuses. MUIs targeted and not targeted in Star Ratings were both examined to determine spillover effects. A difference-in-differences approach was applied by including in a logistic regression a 3-way interaction term for dummy variables for racial/ethnic minorities, later period of 2016-2017, and MAPD plan.

Results

Racial/ethnic minorities experienced more MUIs: e.g., the odds of MUIs targeted in Star Ratings among MAPD enrollees were 83% higher (odds ratio [OR] = 1.83; 95% confidence interval [CI] = 1.71-1.96) for Black than White patients. Black-White disparities in MUIs targeted in Star Ratings decreased 16% more (OR = 0.84; 95% = CI 0.78-0.91) over time among MAPD enrollees than those in PDPs. This pattern was not found for non-Star Ratings measures. Changes in Hispanic-White disparities were similar between MAPD and PDP enrollees for MUIs targeted and not-targeted by Star Ratings. Asian-White and Other-White disparities in MUIs did not experience a higher reduction among MAPD enrollees than PDP enrollees.

Conclusions

Part D bonus payments are associated with lower Black-White disparities in MUIs targeted by Star Ratings. However, Part D bonus payments may not have reduced Hispanic-White or Asian-White disparities. Future research should explore the causes of the bonus payments' heterogeneous effects across racial/ethnic groups.

[Patient-reported outcome measures for assessing health-related quality of life in patients with voice and swallowing disorders]

Standardized and validated patient surveys in the form of questionnaires are becoming increasingly important in otorhinolaryngology. Subjective symptoms and functional limitations but also health-related quality of life are assessed with so-called patient-reported outcome measures (PROMs). Besides patient history and objective findings, these questionnaires can be applied as another important source for ensuring the quality of patient-centered care. In German-speaking countries there are now several PROMs that specifically ask for the patient perspective on voice and swallowing disorders. For patients with voice disorders the following questionnaires based on the Voice Handicap Index (VHI), which are also used internationally, are mainly applied: VHI-30, VHI-12i, and VHI-9i. In the field of oropharyngeal dysphagia, the German versions of the Eating Assessment Tool-10 (EAT-10), des Sydney Swallow Questionnaire SSQ‑G, the Swallowing Quality of Life Questionnaire (SWAL-QoL), and the MD Anderson Dysphagia Inventory (MDADI) are currently mostly used.

Patterns of care for people with small cell lung cancer in Victoria, 2011-19: a retrospective, population-based registry data study

OBJECTIVES

To report stage-specific patterns of treatment and the influence of management and treatment type on survival rates for people newly diagnosed with small cell lung cancer (SCLC).

DESIGN

Cross-sectional patterns of care study; analysis of data prospectively collected for the Victorian Lung Cancer Registry (VLCR).

SETTING, PARTICIPANTS

All people diagnosed with SCLC in Victoria during 1 April 2011 - 18 December 2019.

MAIN OUTCOME MEASURES

Stage-specific management and treatment of people with SCLC; median survival time.

RESULTS

During 2011-19, 1006 people were diagnosed with SCLC (10.5% of all lung cancer diagnoses in Victoria); their median age was 69 years (interquartile range [IQR], 62-77 years), 429 were women (43%), and 921 were current or former smokers (92%). Clinical stage was defined for 896 people (89%; TNM stages I-III, 268 [30%]; TNM stage IV, 628 [70%]) and ECOG performance status at diagnosis for 663 (66%; 0 or 1, 489 [49%]; 2-4, 174 [17%]). The cases of 552 patients had been discussed at multidisciplinary meetings (55%), 377 people had received supportive care screening (37%), and 388 had been referred for palliative care (39%). Active treatment was received by 891 people (89%): chemotherapy, 843 (84%); radiotherapy, 460 (46%); chemotherapy and radiotherapy, 419 (42%); surgery, 23 (2%). Treatment had commenced within fourteen days of diagnosis for 632 of 875 patients (72%). Overall median survival time from diagnosis was 8.9 months (IQR, 4.2-16 months; stage I-III: 16.3 [IQR, 9.3-30] months; stage IV: 7.2 [IQR, 3.3-12] months). Multidisciplinary meeting presentation (hazard ratio [HR], 0.66; 95% CI, 0.58-0.77), multimodality treatment (HR, 0.42; 95% CI, 0.36-0.49), and chemotherapy within fourteen days of diagnosis (HR, 0.68; 95% CI, 0.48-0.94) were each associated with lower mortality during follow-up.

CONCLUSION

Rates of supportive care screening, multidisciplinary meeting evaluation, and palliative care referral for people with SCLC could be improved. A national registry of SCLC-specific management and outcomes data could improve the quality and safety of care.

Views of healthcare professionals on gender roles: A qualitative study

PROBLEM

Gender equality is one of the most important determinants of health. Discriminatory interventions, values, beliefs, and prejudices of healthcare professionals during their service affect health adversely.

BACKGROUND

There is not adequate information about the views of healthcare professionals on gender roles.

AIM

This study was conducted to understand and define the views of healthcare professionals involved in the health system on gender roles.

METHODS

This study was performed using the "phenomenological method," one of the qualitative research methods. A total of 28 healthcare professionals - 10 midwives, 12 nurses, and 6 doctors - were included in the research. Individual in-depth interviews were held with the healthcare professionals included in the study.

FINDINGS

As a result of the descriptive analysis performed after the individual interviews about the views of healthcare professionals on gender roles, 6 main themes were determined. These themes are (1) the neglect of women by society, (2) using force on women, (3) seeing women as sexual objects, (4) having a say in society, (5) glorified masculinity and femininity roles, and (6) gender equality.

DISCUSSION

In this study, healthcare professionals expressed that women were neglected by societies since gender roles were determined by patriarchal societies. This situation adversely influences the health of individuals. Importance should be attached to equality between women and men to improve health. Healthcare professionals who support equality will improve the quality of care.

CONCLUSION

Healthcare professionals should provide equitable services without discrimination. This equitable care they provide will positively affect the health of individuals.

Key aspects of psychosocial needs in palliative care - a qualitative analysis within the setting of a palliative care unit in comparison with specialised palliative home care

BACKGROUND

The number of palliative care patients with complex needs is increasing in developed countries. In addition to physical aspects and symptom control, psychosocial aspects are of great importance for palliative care patients. The aim of this study was to understand which psychosocial aspects are important to patients, relatives and health professionals within the setting of a palliative care unit in comparison with specialised palliative home-care (SPHC).

METHODS

We used a qualitative design based on semistructured interviews, which were coded via qualitative content analysis. The study took place in the state of Hesse, Germany, and data collection was conducted in 2017 (interviews from the ELSAH study, which was conducted in a SPHC) and 2018 (supplementary interviews conducted in a palliative care unit). The results from both settings were compared.

RESULTS

In the palliative care unit, 10 health professionals, 11 patients and 8 relatives were interviewed. In the outpatient setting, we interviewed 30 health professionals, 14 patients and 14 relatives. We identified four key psychosocial issues related to palliative care that were relevant in both the inpatient and outpatient settings: care planning, patient-centred care, a protected environment with feelings of safety, and psychological well-being. In addition, immediate availability of medical staff, greater relief of the relatives and better accessibility of psychological care were more important in the inpatient setting than in the specialised palliative home care setting.

CONCLUSIONS

Knowledge and application of the identified key issues may improve patient-centred palliative care. Accessibility of psychological care and immediate availability of medical staff may be important factors for enhancing psychological well-being in the inpatient palliative care setting. Consideration of the identified key issues may help to develop more collaborative transitions between the palliative care unit and the SPHC and may help to provide palliative care patients and their families with care that is appropriate and feasible for them.

TRIAL REGISTRATION

The underlying comparative study of the outpatient setting of specialised palliative home-care (ELSAH) was registered within the German Clinical Trials Register DRKS-ID: DRKS00012421, ( https://drks.de/search/de/trial/DRKS00012421 ) on 19th May 2017.