Determinants of regulatory compliance in health and social care services: a systematic review

Background

The delivery of high quality health and social care services is a fundamental goal for health systems worldwide. Quality is variable in services and settings. One response to variation in quality is a regulatory framework that looks to set minimum standards that are enforced by an independent public authority. This systematic review seeks to identify and describe determinants of regulatory compliance in health and social care services.

Methods

Systematic searches were carried out on five electronic databases and grey literature sources. Titles and abstracts were screened by two reviewers independently. Determinants evaluated in studies were identified, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The included studies were quality appraised by two reviewers independently. The results were synthesised narratively under each CFIR domain.

Results

The search yielded 6,515 articles for screening, of which 148 were included. Most studies were quantitative designs focused on specific exposures (e.g. staffing levels, size, for-profit status). Qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance. Most of the determinants identified fit within the inner and outer setting domains of the CFIR, many with mixed findings in terms of an association with compliance. There were fewer determinants identified in the intervention characteristics, characteristics of individuals, and process domains of the CFIR.

Conclusions

The literature in this field focuses on the broader concept of quality and appears to neglect the more nuanced issues surrounding the successful implementation of regulatory standards i.e. compliance. A number of gaps, particularly in terms of qualitative work focussed on the mechanism involved in implementing regulations, remain in the literature and further research in this area is needed to provide a clearer picture.

Key messages

• No clear determinants of regulatory compliance were identified, suggesting it is complex and context specific.

• There are gaps in the literature around the underlying processes which contribute to the achievement of compliance that warrant research attention.

Are pressures sores in nursing homes related to nursing home size? A cross-sectional analysis

Background

Incidence of pressure sores are an indicator of quality of care provided. Pressure sores requiring hospitalisation are a very poor outcome and may indicate a chronic unmet need. Organisational factors of services are modifiable factors and may be associated with occurrence and severity of pressure sores. However, little investigation has been completed on this to date. The aim of this study was to assess the association of size of nursing homes and pressure sores requiring hospitalisation.

Methods

Using the Database of Statutory Notifications from Social Care in Ireland we identified from notifications received by the regulator in 2019, the number of pressure sores that required hospitalisation from nursing homes. Association of size of service (registered beds) and the percentage of pressure sores requiring hospital treatment was investigated, using negative binomial regression, unadjusted and adjusted for provider type (company, sole trader, statutory body, unincorporated body, partnership), staff to resident ratio and distance to hospital (km), and nurse to resident ratio as a proxy for resident complexity in a further model.

Results

598 Nursing homes were in operation in 2019. 1 was excluded for missing covariate data and 597 included for analysis. 447 submitted 2996 notifications of pressure sores, median (IQR): 3 (0 to 8). 255 pressure sores (8.51% of total) required hospitalisation. Pressure sores that required hospitalisation and size of service was positively associated, incidence rate ratio (95% confidence interval): 1.001 (1.000 to 1.002). This remained when adjusted for covariates, 1.003 (1.001 to 1.006) and additionally for nurse to staff ratio, 1.013 (1.011 to 1.016)

Conclusions

A small but significant higher number of pressures sores required hospitalisation from larger nursing homes. The reasons for this are unknown but may include cultural differences and ability to provide continuity of care between larger and smaller nursing homes.

Key messages

• Larger nursing homes are associated with higher incidents of pressure sores that require hospitalisation. This association remains when adjusted for covariates and nurse to staff ratio.

• Reasons larger nursing homes are associated with higher incidents of pressure sores that require hospitalisation are unknown but may be influenced by their ability to provide continuity of care.

What Types of Hospitals Do Adolescents and Young Adults With Complex Chronic Conditions Use?

BACKGROUND AND OBJECTIVE

Hospitalizations for children with complex chronic conditions (CCC) at pediatric hospitals have risen over time. Little is known about what hospital types, pediatric or adult, adolescents, and young adults (AYA) with CCCs use. We assessed the types of hospitals used by AYAs with CCCs.

METHODS

We performed a cross-sectional study of 856,120 hospitalizations for AYAs ages 15-to-30 years with ≥1 CCC in the 2017 National Inpatient Sample. We identified AYA with CCC by ICD-10-CM diagnosis codes using the pediatric CCC classification system version 2. Hospital types included pediatric hospitals (n = 70), adult hospitals with pediatric services (n = 277), and adult hospitals without pediatric services (n = 3975). We analyzed age trends by hospital type and CCC count in 1-year intervals and dichotomously (15-20 vs 21-30 years) with the Cochran-Armitage test.

RESULTS

The largest change in pediatric hospitals used by AYA with CCCs occurred between 15 and 20 years with 39.7% versus 7.7% of discharges respectively (P< 0.001). For older AYA (21 to 30 years), 1.0% of discharges occurred at pediatric hospitals, compared with 65.6% at adult hospitals without pediatric services (P < 0.001). Older AYA at pediatric hospitals had more technology dependence (42.5%) versus younger AYA (27.6%, p < 0.001).

CONCLUSIONS

Most discharges for AYAs ≥21 years with CCCs were from adult hospitals without pediatric services. Higher prevalence of technology dependence and neuromuscular CCCs, as well as multiple CCCs, for AYA 21-to-30 years discharged from pediatric hospitals may be related to specific care needs only found in pediatric settings and challenges transferring into adult hospital care.

Reduced ER-mitochondria connectivity promotes neuroblastoma multidrug resistance

Most cancer deaths result from progression of therapy resistant disease, yet our understanding of this phenotype is limited. Cancer therapies generate stress signals that act upon mitochondria to initiate apoptosis. Mitochondria isolated from neuroblastoma cells were exposed to tBid or Bim, death effectors activated by therapeutic stress. Multidrug‐resistant tumor cells obtained from children at relapse had markedly attenuated Bak and Bax oligomerization and cytochrome c release (surrogates for apoptotic commitment) in comparison with patient‐matched tumor cells obtained at diagnosis. Electron microscopy identified reduced ER–mitochondria‐associated membranes (MAMs; ER–mitochondria contacts, ERMCs) in therapy‐resistant cells, and genetically or biochemically reducing MAMs in therapy‐sensitive tumors phenocopied resistance. MAMs serve as platforms to transfer Ca²⁺ and bioactive lipids to mitochondria. Reduced Ca²⁺ transfer was found in some but not all resistant cells, and inhibiting transfer did not attenuate apoptotic signaling. In contrast, reduced ceramide synthesis and transfer was common to resistant cells and its inhibition induced stress resistance. We identify ER–mitochondria‐associated membranes as physiologic regulators of apoptosis via ceramide transfer and uncover a previously unrecognized mechanism for cancer multidrug resistance.

Practice surrounding adverse events in residential care facilities in Ireland

Background

Part of regulation of residential care facilities (RCFs) is the statutory responsibility of RCFs to notify the regulator about adverse events (AEs). Notifications typically include a description of practice in the aftermath of AEs and are an information source that can inform quality and safety improvements. The herein aim therefore was to analyse narratives in notifications received by the Health Information and Quality Authority (HIQA) in Ireland, to identify practice surrounding AE management and reporting.

Methods

A sample (n = 447) of notifications received by HIQA in 2018 was drawn from the Database of Statutory Notifications from Social Care in Ireland, 2013-2019. Inductive thematic analysis was conducted. Analysis was structured using the a priori agreed themes of: practice in the aftermath of an AE, system vulnerabilities and reporting practices.

Results

Two overarching themes were identified. The first, a chronological theme contained three sub-themes: pre event, including existing measures and situations, response to the event and continued response. Measures that are resident focused and follow policies and protocols in RCFs to prevent or mitigate the seriousness of AEs, were evident in the response and continued response. From this chronological order emerged the cyclical theory where short and longer term actions become part of the pre-event of future similar or repeated AEs. The second overarching theme, regulatory input, encapsulated procedural notes, requests for further information and notes on repetitive patterns.

Conclusions

RCFs respond to AEs with short and longer term actions with resident health and wellbeing as the focus. These actions in turn become part of the pre-event of future AEs. This cycle can be leveraged for quality improvement initiatives. Input from inspectors was positive and constructive but highlighted some regulatory burden. Dissemination of these results as good practice guides may improve management and reporting of AEs.

Key messages

Residential care facilities respond to adverse events with short and long term measures which feed into the management of future AEs. This cycle can be leveraged for quality improvement initiatives. Improvement opportunities in reporting practices were found. The development of good practice guides for residential care facilities and inspectors could reduce regulatory burden.

Mortality in residential care services for people with disabilities in Ireland

Background

All-cause mortality is higher in people with disability than in people without disability. There is a need for descriptive epidemiological studies of deaths in people with disability to inform the development of public health interventions. All deaths in residential disability services in Ireland are notified to the Chief Inspector in the Health Information and Quality Authority (HIQA). These include notification of unexpected and expected deaths. The herein aim was to describe total, unexpected and expected deaths, and identify leading causes of death in residential disability services in Ireland.

Methods

Data on deaths in residential disability services in 2019 and 2020 were extracted from the Database of Statutory Notifications from Social Care in Ireland. The number of total deaths was calculated along with the percent and number of unexpected and expected deaths. The primary cause of death notified by services was coded using ICD-11 chapter headings.

Results

During 2019 and 2020, on average 9,115 people resided in residential disability services. Of these, 395 died, of which 45% (n = 178) were notified as unexpected. The leading causes of unexpected deaths were respiratory system diseases (35%, n = 62) and circulatory system diseases (18%, n = 32). The leading causes of expected death were respiratory system diseases (41%, n = 89) and cancers (31%, n = 67).

Conclusions

Almost half of deaths in residential disability services were notified as unexpected. Respiratory disease was the leading cause of both expected and unexpected death in people with disability residing in residential services in Ireland; three-fold the general Irish population (10.7%). Public health interventions aimed at reducing respiratory disease may reduce deaths in this group.

Key messages

In 2019 and 2020, nearly half of deaths of people with a disability residing in residential services were notified as unexpected. Death from respiratory diseases was substantially higher in people with disability living in residential services in Ireland than in the general population and warrants public health intervention.

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center

BACKGROUND

Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality.

RESULTS

Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race.

CONCLUSIONS

Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.

Hospital Readmission of Adolescents and Young Adults With Complex Chronic Disease

IMPORTANCE

Adolescents and young adults (AYA) who have complex chronic disease (CCD) are a growing population that requires hospitalization to treat severe, acute health problems. These patients may have increased risk of readmission as demands on their self-management increase and as they transfer care from pediatric to adult health care practitioners.

OBJECTIVE

To assess variation across CCDs in the likelihood of readmission for AYA with increasing age.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective 1-year cross-sectional study of the 2014 Agency for Healthcare Research and Quality Nationwide Readmissions Database for all US hospitals. Participants were 215 580 hospitalized individuals aged 15 to 30 years with cystic fibrosis (n = 15 213), type 1 diabetes (n = 86 853), inflammatory bowel disease (n = 48 073), spina bifida (n = 7819), and sickle cell anemia (n = 57 622) from January 1, 2014, to December 1, 2014.

EXPOSURES

Increasing age at index admission.

MAIN OUTCOMES AND MEASURES

Unplanned 30-day hospital readmission. Readmission odds were compared by patients' ages in 2-year epochs (with age 15-16 years as the reference) using logistic regression, accounting for confounding patient characteristics and data clustering by hospital.

RESULTS

Of 215 580 participants, 115 982 (53.8%) were female; the median (interquartile range) age was 24 (20-27) years. Across CCDs, multimorbidity was common; the percentages of index hospitalizations with 4 or more coexisting conditions ranged from to 33.4% for inflammatory bowel disease to 74.2% for spina bifida. Thirty-day hospital readmission rates varied significantly across CCDs: 20.2% (cystic fibrosis), 19.8% (inflammatory bowel disease), 20.4% (spina bifida), 22.5% (type 1 diabetes), and 34.6% (sickle cell anemia). As age increased from 15 to 30 years, unadjusted, 30-day, unplanned hospital readmission rates increased significantly for all 5 CCD cohorts. In multivariable analysis, age trends in the adjusted odds of readmission varied across CCDs. For example, for AYA who had cystic fibrosis, the adjusted odds of readmission increased to 1.9 (95% CI, 1.5-2.3) by age 21 years and remained elevated through age 30 years. For AYA who had type 1 diabetes, the adjusted odds of readmission peaked at ages 23 to 24 years (odds ratio, 2.3; 95% CI, 2.1-2.6) and then declined through age 30 years.

CONCLUSIONS AND RELEVANCE

These findings suggest that hospitalized AYA who have CCDs have high rates of multimorbidity and 30-day readmission. The adjusted odds of readmission for AYA varied significantly across CCDs with increasing age. Further attention is needed to hospital discharge care, self-management, and prevention of readmission in AYA with CCD.

IL-2 withdrawal from human CD8+ T cell expansion in the presence of IL-7 enables retention of favorable functional and phenotypic characteristics for adoptive immunotherapy (165.2)

Viral infection and reactivation of latent viruses are major causes of mortality and morbidity following haematopoietic stem cell transplantation. Adoptive immunotherapy with CD8+ T cells has proven efficacy in preventing or treating post-transplant viral infection, including therapy with resting T cells that undergo homeostatic expansion in vivo that follows transplantation. However T cells continuously expanded in vitro in IL-2 lose many characteristics associated with efficacy in vivo, and most IL-2-expanded cells die soon after infusion. Here we describe an alternative expansion protocol for human CD8+ T cells that only exposes the cells briefly to IL-2. Survival of the cells after IL-2 withdrawal relies on the continuous presence of IL-7, and the cells eventually come to rest in the cultures. In this system, timed exposure of naïve CD8+ T cells to IL-12 and IL-21 generates memory cells with competent effector functions upon rechallenge, specifically strong production of IFNγ, TNFα and IL-2. The memory cells generated also have acquired a favourable phenotype associated with early differentiation status by both cell surface markers (CCR7, CD62L, CD27 and CD28) and transcription factors (eg Tcf-1). Although our system has been piloted on the expansion of naïve CD8+ T cells, we propose that this alternative protocol could be used to generate resting antigen-specific memory cells with improved efficacy in preventing or treating viral disease in immunocompromised patients.

Key concepts for estimating the burden of surgical conditions and the unmet need for surgical care

Background

Surgical care is emerging as a crucial issue in global public health. Methodology is needed to assess the impact of surgical care from a public health perspective.

Methods

A consensus opinion of a group of surgeons, anesthesiologists, and public health experts was established regarding the methodology for estimating the burden of surgical conditions and the unmet need for surgical care.

Results

For purposes of analysis, we define surgical conditions as any disease state requiring the expertise of a surgically trained provider. Abnormalities resulting from a surgical condition or its treatment are termed surgical sequelae. Surgical care is defined as any measure that reduces the rates of physical disability or premature death associated with a surgical condition. To measure the burden of surgical conditions and unmet need for surgical care we propose using cumulative disability-adjusted life-year (DALY) curves generated from age-specific population-based data. This conceptual framework is based on the premise that surgically associated disability and death is determined by the incidence of surgical conditions and the quantity and quality of surgical care. The burden of surgical conditions is defined as the total disability and premature deaths that would occur in a population should there be no surgical care; the unmet need for surgical care is defined as the potentially treatable disability and premature deaths due to surgical conditions. Burden of surgical conditions should be expressed as DALYs and unmet need as potential DALYs avertable.

Conclusions

Methodology is described for estimating the burden of surgical conditions and unmet need for surgical care. Using this approach it will be feasible to estimate the global burden of surgical conditions and help clarify where surgery fits among other global health priorities. These methods need to be validated using population-based data.

Rapid, sensitive bioluminescent reporter technology for naphthalene exposure and biodegradation

A bioluminescent reporter plasmid for naphthalene catabolism (pUTK21) was developed by transposon (Tn4431) insertion of the lux gene cassette from Vibrio fischeri into a naphthalene catabolic plasmid in Pseudomonas fluorescens. The insertion site of the lux transposon was the nahG gene encoding for salicylate hydroxylase. Luciferasemediated light production from P. fluorescens strains harboring this plasmid was induced on exposure to naphthalene or the regulatory inducer metabolite, salicylate. In continuous culture, light induction was rapid (15 minutes) and was highly responsive to dynamic changes in naphthalene exposure. Strains harboring pUTK21 were responsive to aromatic hydrocarbon contamination in Manufactured Gas Plant soils and produced sufficient light to serve as biosensors of naphthalene exposure and reporters of naphthalene biodegradative activity. The robust and sensitive nature of the bioluminescent reporter technology suggests that new sensing methods can be developed for on-line process monitoring and control in complex environmental matrices.

Use of Bioluminescence Markers To Detect Pseudomonas spp. in the Rhizosphere

The use of bioluminescence as a sensitive marker for detection of Pseudomonas spp. in the rhizosphere was investigated. Continuous expression of the luxCDABE genes, required for bioluminescence, was not detectable in the rhizosphere. However, when either a naphthalene-inducible luxCDABE construct or a constitutive luxAB construct (coding only for the luciferase) was introduced into the Pseudomonas cells, light emission could be initiated just prior to measurement by the addition of naphthalene or the substrate for luciferase, n-decyl aldehyde, respectively. These Pseudomonas cells could successfully be detected in the rhizosphere by using autophotography or optical fiber light measurement techniques. Detection required the presence of 10 to 10 CFU/cm of root, showing that the bioluminescence technique is at least 1,000-fold more sensitive than beta-galactosidase-based systems.

A facet-based system for computer-assisted instruction in pain management for elderly patients

DIANA2, a web-based interactive tutor for pain management (see www.talariainc.com), was more effective than conventional methods of learning (such as reading articles that contain the same type of information) in making the principles of pain management for the elderly more easily accessible to learners. DIANA2 was similarly effective for different types of health care providers (students, nurses, and residents), and the study participants were excited by their experience with a different mode of learning. DIANA is based on interactive facet-based learning principles that guide learners to reflect on their understanding of the situation and to modify and augment their understanding in response to real-time facet-specific feedback.