For many complex cardiovascular procedures the well-established link between volume and outcome has rested on the underlying assumption that experience leads to more reliable implementation of the processes of care which have been associated with better clinical outcomes. This study tested that assumption by examining the relationship between cardiovascular case volumes and the implementation of twelve basic evidence-based processes of cardiovascular care.
Observational analysis of over 3000 US hospitals submitting cardiovascular performance indicator data to The Joint Commission on during 2005. Hospitals were grouped together based upon their annual case volumes and indicator rates were calculated for twelve standardized indicators of evidence-based processes of cardiovascular care (eight of which assessed evidenced-based processes for patients with acute myocardial infarction and four of which evaluated evidenced-based processes for heart failure patients). As case volume increased so did indicator rates, up to a statistical cut-point that was unique to each indicator (ranging from 12 to 287 annual cases). t-Test analyses and generalized linear mixed effects logistic regression were used to compare the performance of hospitals with case volumes above or below the statistical cut-point. Hospitals with case volumes that were above the cut-point had indicator rates that were, on an average, 10 percentage points higher than hospitals with case volumes below the cut-point (P < 0.05).
Hospitals treating fewer cardiovascular cases were significantly less likely to apply evidence-based processes of care than hospitals with larger case volumes, but only up to a statistically identifiable cut-point unique to each indicator.
Clinical practice in Russia is set out in a series of centralized guidelines. However, many of these guidelines are not supported by evidence and, despite their existence, there is considerable unexplained variation in practice. This study examines the decision to recommend a Caesarean section, an intervention for which there is a solid evidence base, but whose use varies considerably among facilities in Russia.
To identify the factors that Russian obstetricians take into account when recommending a Caesarean section.
Conjoint analysis. Ninety-two obstetricians from three regions were asked to state whether they would recommend a Caesarean section in each of 30 vignettes (including three for validation) combining 10 medical, social and organizational factors previously identified as contributing to the decision to intervene, including some absolute indications to intervene or not to, on the basis of international evidence.
Checks for consistency within ratings by individuals gave no cause for concern. However, there was a wide variation in the probability of intervening among obstetricians, with six recommending intervention in only one scenario and one in 27 scenarios. Some factors were consistent with evidence but others were not, such as myopia or previous abortions. Intervention was more likely at 11 p.m. than at noon. Male obstetricians were more likely to intervene than females.
This study highlights the importance of understanding clinical decision-making in Russia as a prelude to changing it.
To compare patient reports about hospital care between western New York State and southern Ontario using a random intercept model.
Cross-sectional survey of 3923 patients who received medical or surgical care between August and October 2004 at 28 hospitals (14 hospitals per jurisdiction). Thirty-five questions were combined to calculate eight indicators with scores ranging from 0 to 100 (best care experience). For each indicator, a model was built where the region (western New York vs. southern Ontario) was included as a fixed effect with hospital as random within region. A number of patient characteristics were also included as fixed effects.
The effect of the region was statistically significant (P < 0.05) only for the models predicting the ‘continuity and transition’, ‘involvement of family’ and ‘physical comfort’ indicator scores. The differences were 10.66, 4.05 and –3.23 points, respectively. In all three models, the random intercepts were not statistically significant, indicating that the differences above did not vary by hospitals. The model predicting ‘overall impression’ scores, however, showed a random intercept statistically significant (P = 0.026). The individual-level explained proportion of variance ranged from 5.68 to 11.22%, and the hospital-within-region-level explained proportion of variance ranged from 2.19 to 52.28%.
The difference observed on the ‘continuity and transition’ indicator might be the only one somewhat meaningful, and might be explained by health maintenance organization reimbursements' mechanisms and hospital quality improvement initiatives available in western New York, as well as by the fact that occupancy rates in western New York border the 60% compared with the 95% in southern Ontario.
To evaluate the association of characteristics of patients and general practices with patient assessment of quality of care.
Cross-sectional multi-practice study using the general practice assessment survey.
General practices in Australia.
Ninety-six general practices and 7505 chronic illness patients aged ≥18 years.
Access of care and patient-centredness.
Two factors were identified in factor analysis: ‘Access of care’ and ‘Patient-centredness’. Multilevel regression analysis showed significant associations between patients' assessments and patient and practice characteristics. Patients from smaller practices (one to three general practitioners) reported better access to care compared with larger practices. Patients from urban areas were more satisfied with patient-centredness than those from rural areas. Self-reported health status and age had a positive and home ownership, employment and education, and patients from non-English-speaking countries a negative relationship with both scores. Females were more satisfied with patient-centredness.
Patient assessments of quality of care and patient-centredness were strongly associated with practice and patient characteristics. This has important implications for interpreting assessments of the quality of primary care, and for policy and practice measures designed to improve this.
(i) To compare public perceptions of the frequency, responsibility, causes and solutions for preventable medical errors for persons who report and do not report having experienced a preventable medical error while receiving healthcare services in Alberta, Canada. (ii) To describe public opinion about confidentiality and disclosure of preventable medical error. (iii) To examine the relationship between reporting preventable medical error and perceived quality of the healthcare system.
Population-based telephone survey. Households selected by random digit dialing and individual in household selected by most recent birthday. Province of Alberta, Canada. Representative sample of adult Albertans (N = 1500). Public perceptions of the frequency, responsibility, causes and solutions for preventable medical error; opinions about confidentiality and disclosure; perceived quality of the healthcare system.
Five hundred and fifty-nine (37.3%; 95% CI 34.8–39.8%) of 1500 respondents reported that they or a family member had ever experienced a preventable medical error while receiving health care in Alberta, Canada. Respondents who reported a preventable medical error were more likely to believe that preventable medical errors occur with greater frequency, were less likely to think that their doctor would tell them if a preventable medical error was made in their care, and tended to rate the quality of the healthcare system less favourably.
This paper provides healthcare managers and policymakers with insight into the public's perceptions of preventable medical error and may facilitate the development of strategies to improve patient safety, public confidence and public satisfaction with the healthcare system.
Many healthcare organizations have implemented adverse event reporting systems in the hope of learning from experience to prevent adverse events and medical errors. However, a number of these applications have failed or not been implemented as predicted.
This study presents an extended technology acceptance model that integrates variables connoting trust and management support into the model to investigate what determines acceptance of adverse event reporting systems by healthcare professionals.
The proposed model was empirically tested using data collected from a survey in the hospital environment. A confirmatory factor analysis was performed to examine the reliability and validity of the measurement model, and a structural equation modeling technique was used to evaluate the causal model.
The results indicated that perceived usefulness, perceived ease of use, subjective norm, and trust had a significant effect on a professional's intention to use an adverse event reporting system. Among them, subjective norm had the most contribution (total effect). Perceived ease of use and subjective norm also had a direct effect on perceived usefulness and trust, respectively. Management support had a direct effect on perceived usefulness, perceived ease of use, and subjective norm.
The proposed model provides a means to understand what factors determine the behavioral intention of healthcare professionals to use an adverse event reporting system and how this may affect future use. In addition, understanding the factors contributing to behavioral intent may potentially be used in advance of system development to predict reporting systems acceptance.
Home care is the most rapidly growing segment of the Canadian healthcare system. Overwhelmingly, research on patient safety has been conducted within institutional settings, resulting in a significant knowledge gap about safety in homecare. Given the dramatic increase in the amount, acuity and complexity of health care being provided in the home and community, it is essential to develop our understanding of safety in this sector.
The objective of this paper is to describe the landscape of safety in home care in Canada.
This pan-Canadian initiative included three phases: a literature review, 20 key informant interviews and an invitational roundtable. Data were synthesized using a content analysis approach.
Patient safety is a failure of systems rather than of humans; there are many change processes required to create safe environments; organizational culture and workplace factors are critical. Patients have a key role to play in their care and thus must be part of the patient safety discourse. Themes central to safety in home care are: the inextricably linked relationships and communication among clients/families and caregivers/providers; unregulated and uncontrolled settings, autonomy and isolation; the multidimensionality of safety (physical, emotional, social, functional); a diminishing focus on prevention, health promotion and chronic care; challenges of human resources and maintenance of competence.
Addressing safety in home care and mitigating the risks presents unique challenges and requires a major rethink of underlying institutionally oriented assumptions and guiding frameworks.
Medication documentation is a critical aspect of quality patient care. The current study examined whether electronic medical records provide medication documentation that is more complete and faster to retrieve than traditional paper records.
This study involves a comparison of archived paper medical records to recent electronic medical records through chart review. A convenient sample of three large community mental health centers in Indiana was used. Medical charts for 180 patients with schizophrenia were rated on a checklist composed of 16 items that was adapted from a national project. Documentation that existed before implementation of the electronic medical record system was compared with that after implementation at each of the three centers. The main outcome measures were completeness and retrieval time of medication documentation.
Electronic medical records provided medication documentation that was more complete and faster to retrieve than paper records across all centers and within each center. On average, electronic medical records were 40% more complete and 20% faster to retrieve.
Electronic records have potential to improve medication management for patients in mental health centers over traditional records. However, medication documentation for patients diagnosed with schizophrenia was found to be deficient in many areas, regardless of documentation format.
The aim was to assess and discuss the utility of a complication registry for determining outcome and delivered care in surgery.
All patients with Laparoscopic Cholecystectomy between 1998 and 2006 were analysed. Complications were prospectively documented and evaluated according to outcome measures mentioned in literature (bile duct injury, morbidity, mortality and conversion rate) for Laparoscopic Cholecystectomy. In addition, all patient files were evaluated for possible risk factors and non-registered complications.
One thousand two hundred fifty four Laparoscopic Cholecystectomies were performed, with 207 complications in 152 (12%) patients. Eighteen (9%) events were additionally found after evaluating all medical files. Thirteen (1%) bile duct injuries occurred, 7% (n = 91) morbidity, no mortality and 18% (n = 226) conversion rate. The probability of complications was significantly higher in patients diagnosed with complicated gallstone disease, ASA 3/4, > 70 years, acute and converted procedures. Thirty % (n = 63) of all documented adverse events reflected issues other than traditionally mentioned outcome measures, categorised as hospital-provider errors or miscellaneous.
Ninety % of all complications in laparoscopic cholecystectomy were documented in our registry. Factors associated with a high probability of complications were identified and 30% of all events reflected issues other than traditionally mentioned outcome measures for Laparoscopic Cholecystectomy. The registry can be used for outcome measurement, however differences in case mix and data collection methods should be taken into account.