[Evaluation of the management and follow-up of diabetic patients in the prevention of diabetic retinopathy]

OBJECTIVE

Diabetes mellitus is a chronic disease with high morbidity and mortality, affecting 537 million adults worldwide. Spain is the second European country in prevalence, with 14.8% in the population aged twenty/seventy-nine years; with 11.6 cases per 1,000 people/year. Diabetic retinopathy (DR) is the fifth cause of vision loss worldwide and the seventh cause of blindness/visual impairment among members of the National Organization of the Blind in Spain (ONCE). Early detection of DR prevents blindness in diabetics and is conditioned by glycosylated hemoglobin. The aim of this paper was to analyze the management of diabetic patients in Aljarafe region (Seville) and identify opportunities for improvement in the coordination of their follow-up between the Primary Care physician and the ophthalmologist.

METHODS

A retrospective observational study (2016-2019) was carried out, with patients registered in the diabetic census of the twenty-eight municipalities of Aljarafe. The primary care and hospital health history, and telemedicine program were consulted. About statistical analysis, for qualitative variables, totals and percentages were calculated; for quantitative variables, mean and standard deviation (if normally distributed) and median and quartiles (if non-normally distributed).

RESULTS

There were 17,175 diabetics registered in Aljarafe (5.7% of the population); 14,440 patients (84.1%) had some determination of hemoglobin during the period, 9,228 (63.9%) had all of them in the appropriate range. Fundoscopic control was performed on 12,040 diabetics (70.1%), and of those who did not, 346 (10.6%) had all of them out of range. There were 1,878 (10.9%) patients without fundoscopic or metabolic control, 1,019 (54.3%) were women, 1,219 (64.9%) were under sixty-five years of age, 1,019 (54.3%) had severe comorbidity.

CONCLUSIONS

Most patients have adequate screening, and more than half have determinations within range. However, a significant percentage with no glycated hemoglobin within range lack fundoscopic control, and another smaller group lack fundoscopic or metabolic control, with inter-municipal variability. We propose to improve communication channels between levels.

Clinical pharmacy key performance indicators for hospital inpatient setting: a systematic review

BACKGROUND

Key performance indicators (KPIs) are quantifiable measures used to monitor the quality of health services. Implementation guidelines for clinical pharmacy services (CPS) do not specify KPIs.

AIM

To assess the quality of the studies that have developed KPIs for CPS in inpatient hospital settings.

METHOD

A systematic review was conducted by searching in Web of Science, Scopus, and PubMed, supplemented with citation analyses and grey literature searches, to retrieve studies addressing the development of KPIs in CPS for hospital inpatients. Exclusions comprised drug- or disease-specific studies and those not written in English, French, Portuguese, or Spanish. The Appraisal of Indicators through Research and Evaluation (AIRE) instrument assessed methodological quality. Domain scores and an overall score were calculated using an equal-weight principle. KPIs were classified into structure, process, and outcome categories. The protocol is available at https://doi.org/10.17605/OSF.IO/KS2G3 .

RESULTS

We included thirteen studies that collectively developed 225 KPIs. Merely five studies scored over 50% on the AIRE instrument, with domains #3 (scientific evidence) and #4 (formulation and usage) displaying low scores. Among the KPIs, 8.4% were classified as structure, 85.8% as process, and 5.8% as outcome indicators. The overall methodological quality did not exhibit a clear association with a major focus on outcomes. None of the studies provided benchmarking reference values.

CONCLUSION

The KPIs formulated for evaluating CPS in hospital settings primarily comprised process measures, predominantly suggested by pharmacists, with inadequate evidence support, lacked piloting or validation, and consequently, were devoid of benchmarking reference values.

Application of the multiple dependent state sampling strategy to late adolescent suicide rates

A multiple dependent state sampling plan (MDSSP) is designed when the lifetimes of the variables follow New Lomax Rayleigh Distribution (NLRD). The decision to accept or reject a lot in the proposed methodology is based on the quality of the given present or previous lots. A binomial model-based operating characteristic curve (OC curve) for continuous lots of variables under similar settings in healthcare is used in finding the probability of acceptance, acceptance number, rejection number, and the number of preceding (succeeding) lots to consider. Time truncated life test based on the specified median of the NLRD is used in designing the current acceptance sampling plan. For specified values of the parameters of NLRD, quantile ratios, consumer's risk and producer's risk, average sampling number (ASN) and probability of acceptance of a lot are reported in tables. Real data on worldwide suicide rates of 15-19 years in the year 2019 from the World Health Organization (WHO) website is considered to illustrate this methodology. The minimum sample size required from the selected data to comment on worldwide suicide rates in late adolescents is explained with MDSSP. The results of the proposed acceptance sampling method are compared with the single-stage sampling plan.

Ideal cardiovascular health metrics and the risk of nonalcoholic fatty liver disease in Korean adults

BACKGROUND

The association between cardiovascular risk factors and nonalcoholic fatty liver disease (NAFLD) is well established, but whether cardiovascular health (CVH) metrics is associated with NAFLD had not been fully studied. Thus, we examined the association between CVH metrics and NAFLD in the middle-aged Korean population.

METHODS

We used data of 2,928 (851 men and 2,077 women) participants aged 30-64 years from the Cardiovascular and Metabolic Disease Etiology Research Center study. CVH metrics were measured using a modified version of Life's Simple 7 by the American Heart Association. NAFLD diagnosis was based on the fatty liver index or liver-to-spleen ratio on computed tomography. A multiple logistic regression model was used to investigate the cross-sectional and longitudinal associations between CVH metrics and NAFLD.

RESULTS

In the cross-sectional analysis, the odds ratio for NAFLD was lower in participants with ideal CVH (odds ratio [OR], 0.13; 95% confidence interval [CI], 0.08-0.18), while it was higher in individuals with poor CVH (OR, 2.87; 95% CI, 2.13-3.86). Similarly, the risk of new-onset NAFLD was lower in participants with ideal CVH (OR, 0.28; 95% CI, 0.11-0.74), and higher in individuals with poor CVH (OR, 2.20; 95% CI, 0.50-9.72) in the longitudinal analysis of a subgroup.

CONCLUSIONS

Ideal CVH was associated with a lower risk of NAFLD while poor CVH was associated with a higher risk of NAFLD. These findings suggest that making efforts to encourage people to manage their CVH to the ideal level may prevent and manage NAFLD.

Challenges using electronic nursing routine data for outcome analyses: A mixed methods study

OBJECTIVES

To explore the challenges of secondary use of routinely collected data for analyzing nursing-sensitive outcomes in Austrian acute care hospitals.

METHOD

A convergent parallel mixed methods design was performed. We conducted a quantitative representative survey with nursing managers from 32 Austrian general acute care hospitals and 11 qualitative semi-structured interviews with nursing quality management experts. Both results were first analyzed independently and afterward merged in the discussion.

RESULTS

On average, 76% of nursing documentation is already electronically supported in the surveyed Austrian hospitals. However, existing nursing data is seldom used for secondary purposes such as nursing-sensitive outcome analyses. This is due to four major reasons: First, hospitals often do not have a data strategy for the secondary use of routine data. Second, hospitals partly lack the use of standardized and uniform nursing terminologies, especially for nursing evaluation. Third, routine nursing data is often not documented correctly and completely. Fourth, data on nursing-sensitive outcomes is usually collected in specific documentation forms not integrated into routine documentation.

CONCLUSION

The awareness of the possibilities for secondary use of nursing data for nursing-sensitive outcome analyses in Austrian hospitals is still in its infancy. Therefore, nursing staff and nursing management must be trained to understand how to collect and process nursing data for nursing-sensitive outcome analyses. Further studies would be interesting in order to determine the factors that influence the decision-making processes for the secondary use of nursing data for outcome analyses.

Implementation of health care quality indicators for out-of-hospital emergencies: a systematic review

Although many health care quality indicators have been defined for establishing a common, homogeneous, and reliable system for assessing emergency department care, less information is available on the use of indicators of quality in attending emergencies outside the hospital. We aimed to identify and analyze quality indicators that have appeared in the literature on out-of-hospital emergencies. This systematic review of the literature followed the ations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We developed protocols for searching 5 databases to locate studies using quality indicators to evaluate care in out-of-hospital emergencies. Studies were published between July 2017 and July 2018 in either English or Spanish. We identified 22 studies naming 333 quality indicators in out-of-hospital emergencies. The indicators were classified as clinical or nonclinical; within each of these 2 sets, we also identified domains, or subcategories. As nonclinical quality identifiers were more numerous in the literature, it seems that they are the ones most often used to assess out-of-hospital emergency care at this time. This finding leaves the door open to designing and implementing new indicators able to measure quality of care in this clinical setting.

Association Between Hospitals' Risk-Adjusted Emergency Department Visits and Survival and Costs in Kidney Cancer Patients Undergoing Nephrectomy

PURPOSE

To estimate the association between a hospital's risk-adjusted emergency department (ED) visit rate and its risk-adjusted mortality rate and costs among kidney cancer patients undergoing initial nephrectomy.

PATIENTS AND METHODS

Using 2007-2012 Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we used logistic regression to model ED visit occurrence within 30 and 365 days for all kidney cancer patients receiving initial surgery. Our model controlled for demographics, stage, histology, systemic targeted therapy, and comorbidities. Based on model predictions, we created a ratio of actual versus predicted ED visits for hospitals to identify hospitals with higher and lower than predicted ED visit rates. We estimated the association between the hospitals' ED visit ratio and hospitals' risk-adjusted 365-day mortality rates, and 6- and 12-month total costs and total costs (less ED visits).

RESULTS

In our sample of 6078 patients, 15.5% had an ED visit within 30 days of surgery and 43.5% within 365 days. For hospitals with ≥ 11 patients, we found no statistically significant association between 30-day or 365-day risk-adjusted ED visit rate and their 365-day risk-adjusted mortality rate. Hospitals' 30-day ED visit rates were not significantly associated with either 6- or 12-month costs. However, hospitals' 365-day ED visit rates were significantly associated with 12-month costs, even when excluding the cost of the ED visit.

CONCLUSION

Our results suggest hospitals' risk-adjusted ED visit rates capture a qualitatively different measure of quality than the more commonly reported mortality rates. Longer term ED visit rates are significantly associated with increased costs while 30-day ED visits are not.

A composite indicator to assess the quality of care in the management of patients with rheumatoid arthritis in outpatient rheumatology clinics

OBJECTIVE

The current guidelines in the treatment of rheumatoid arthritis (RA) include the early diagnosis and early use of disease modifying drugs to achieve remission or low disease activity level, known as "Treat to Target" (T2T). The objective of this study is to develop a composite indicator (CI) to evaluate the quality of care in the management of patients with RA, according to the T2T strategy and other general recommendations concerning the management of these patients.

MATERIAL AND METHOD

The phases of the construction of the CI were: 1) selection of quality criteria through expert judgment; 2) prioritization of the criteria, according to relevance and feasibility, applying the Delphi methodology (two rounds) involving 20 experts; 3) design of quality indicators; and 4) calculation of the weighted CI, using the mean value in relevance and feasibility granted by the experts. The source of information for the calculation of the CI are the medical records of patients with RA.

RESULTS

Twelve criteria out of 37 required a second Delphi round. Thirty-one criteria were prioritized. These criteria presented a median in relevance and feasibility greater than or equal to 7.5, with an interquartile range of less than 3.5, and a level of agreement (score greater than or equal to 8) greater than or equal to 80%.

CONCLUSIONS

The constructed CI allows us to evaluate the quality of care of patients with RA following the T2T strategy in the rheumatology units of Spanish hospitals, offering a valid and easily interpretable summary measure.

[Impact of an emergency department short-stay unit on clinical management and quality of hospital care indicators]

OBJECTIVES

The primary aim was to study the impact that creating a short-stay unit (SSU) had on clinical management and quality of care indicators of a hospital overall and its conventional wards. The secondary aim was to establish values for those indicators and determine the level of satisfaction of patients admitted to the SSU.

MATERIAL AND METHODS

Quasi-experimental before-after study of the impact of establishing a SSU in a tertiary care teaching hospital. The first period (without the SSU) was in 2012, the second (with the SSU) was from 2013 through 2015. To meet the first objective we selected cases in 2012 in which patients were hospitalized for problems related to the 5 diagnosis-related groups most often admitted to the SSU in the second period. To meet the second objective, we studied all patients admitted to the SSU in the second period Data related to quality of care and clinical management were analyzed retrospectively. and asked them to complete a questionnaire on patient satisfaction.

RESULTS

A total of 76 241 admissions were included: 19 090 in the first period and 57 151 in the second (2705 admissions were to the SSU). The mean hospital stay decreased in the second period (incidence rate ratio [IRR], 0.93; 95% CI, 0.91-0.95); the mean stay also decreased on medical wards (IRR, 0.94; 95% CI, 0.92-0.96) with no impact on adverse outcomes. The mean stay in the SSU was under 3 days in spite of an increase in the weighted mean (IRR,1.08; 95% CI, 1.05-1.11). A total of 320 questionnaires were received (11.8% response rate); all aspects were assessed very highly.

CONCLUSION

Our experience suggests that opening a SSU could improve clinical management and quality of care indicators for a hospital overall and for its conventional wards in the context of the GRDs that most frequently lead to admissions.

Lower extremity amputation rates in people with diabetes as an indicator of health systems performance. A critical appraisal of the data collection 2000-2011 by the Organization for Economic Cooperation and Development (OECD)

AIMS

Critical appraisal of secondary data made available by the OECD for the time frame 2000-2011.

METHODS

Comparison of trends and variation of amputations in people with diabetes across OECD countries. Generalized estimating equations to test the statistical significance of the annual change adjusting for major potential confounders.

RESULTS

A total of 26 OECD countries contributed to the OECD data collection for at least 1 year in the reference time frame, showing a decline in rates of over 40 %, from a mean of 13.2 (median 9.4, range 5.1-28.1) to 7.8 amputations per 100,000 in the general population (9.9, 1.0-18.4). The multivariate model showed an average decrease equal to -0.27 per 100,000 per year (p = 0.015), adjusted by structural characteristics of health systems, showing lower amputation rates for health systems financed by public taxation (-4.55 per 100,000 compared to insurance based, p = 0.002) and non-ICD coding mechanisms (-7.04 per 100,000 compared to ICD-derived, p = 0.001). Twelve-year decrease was stronger among insurance-based financing systems (tax based: -0.16 per 100,000, p = 0.064; insurance based: -0.36 per 100,000; p = 0.046).

CONCLUSIONS

In OECD countries, amputation rates in diabetes continuously decreased over 12 years. Still, in 2011, one amputation every 7 min could be directly attributed to diabetes. Although interesting, these results should be taken with extreme caution, until common definitions are improved and data quality issues, e.g., a different ability in capturing diabetes diagnoses, are fully resolved.

Adherence with national guidelines in hospitalized patients with community-acquired pneumonia: results from the CAPO study in Venezuela

INTRODUCTION

The Community-Acquired Pneumonia Organization (CAPO) is an international observational study in 130 hospitals, with a total of 31 countries, to assess the current management of hospitalized patients with community-acquired pneumonia (CAP). 2 Using the centralized database of CAPO was decided to conduct this study with the aim of evaluate the level of adherence with national guidelines in Venezuela, to define in which areas an intervention may be necessary to improve the quality of care of hospitalized patients with CAP.

METHODS

In this observational retrospective study quality indicators were used to evaluate the management of hospitalized patients with CAP in 8 Venezuelan's centers. The care of the patients was evaluated in the areas of: hospitalization, oxygen therapy, empiric antibiotic therapy, switch therapy, etiological studies, blood cultures indication, and prevention. The compliance was rated as good (>90%), intermediate (60% to 90%), or low (<60%).

RESULTS

A total of 454 patients with CAP were enrolled. The empiric treatment administered within 8 hours of the patient arrival to the hospital was good (96%), but the rest of the indicators showed a low level of adherence (<60%).

CONCLUSION

We can say that there are many areas in the management of CAP in Venezuela that are not performed according to the national guidelines of SOVETHORAX.1 In any quality improvement process the first step is to evaluate the difference between what is recommended and what is done in clinical practice. While this study meets this first step, the challenge for the future is to implement the processes necessary to improve the management of CAP in Venezuela.

[Quality of care indicators for the care of human immunodeficiency virus-infected individuals, adapted to the pediatric age]

INTRODUCTION

Since infection with human immunodeficiency virus (HIV) was first described, there have been many advances in its diagnosis, monitoring and treatment. However, few contributions are related to the area of health care quality. In this sense, the Spanish Study Group on AIDS (GESIDA) has developed a set of quality care indicators for adult patients living with HIV infection that includes a total of 66 indicators, 22 of which are considered to be relevant. Standards were calculated for each of them in order to reflect the level of the quality of care offered to these patients. Similar documents for pediatric patients are currently lacking.

METHODS

Preparation of a set of quality care indicators applicable to pediatric patients based on the GESIDA document and the Spanish Guidelines for monitoring of pediatric patients infected with HIV. Each indicator was analysed with respect to the required standards in all patients under 18 years of age followed-up in our Unit, with the aim of evaluating the quality of care provided.

RESULTS

A total of 61 indicators were collected (51 from the GESIDA document and 10 from currently available pediatric guidelines), 30 of which were considered to be relevant. An overall compliance of 81%-83% was obtained when assessing the relevant indicators.

CONCLUSION

The availability of health care quality standards is essential for the care of pediatric HIV-infected patients. The assessment of these indicators in our Unit yielded satisfactory results.

Creation of a synthetic indicator of quality of care as a clinical management standard in primary care

Introduction

The development of electronic medical records has allowed the creation of new quality indicators in healthcare. Among them, synthetic indicators facilitate global interpretation of results and comparisons between professionals.

Methods

A healthcare quality standard (EQA, the Catalan acronym for Estàndard de Qualitat Assistencial) was constructed to serve as a synthetic indicator to measure the quality of care provided by primary care professionals in Catalonia (Spain). The project phases were to establish the reference population; select health problems to be included; define, select and deliberate about subindicators; and construct and publish the EQA.

Results

Construction of the EQA involved 107 healthcare professionals, and 91 health problems were included. In addition, 133 experts were consulted, who proposed a total of 339 indicators. After systematic paired comparison, 61 indicators were selected to create the synthetic indicator. The EQA is now calculated on a monthly basis for more than 8000 healthcare professionals using an automated process that extracts data from electronic medical records; results are published on a follow-up website. Along with the use of the online EQA results tool, there has been an ongoing improvement in most of the quality of care indicators.

Conclusions

Creation of the EQA has proven to be useful for the measurement of the quality of care of primary care services. Also an improvement trend over 5 years is shown across most of the measured indicators.

Electronic supplementary material

The online version of this article (doi:10.1186/2193-1801-2-51) contains supplementary material, which is available to authorized users.