Taiwan's health-care system allows patients to utilize specialty services without referrals by primary care providers. This discontinuity of care may lead to increases in future hospitalizations. This study aims to determine whether the discontinuity of care is associated with the risk of hospitalization.
A secondary data analysis based on a claim data of a nationally representative random sample of diabetic patients in Taiwan. A usual provider continuity (UPC) index was developed—a ratio of the visits to the physician that subjects most usually see relevant to diabetes care to the total physician visits relevant to diabetes care—to investigate its association with the risk of hospitalization.
Taiwan's National Health Insurance scheme from 1997 through 2002.
Totally 6476 diabetic patients.
None.
Diabetes-related short-term and long-term ambulatory care sensitive condition (ACSC) admissions.
Patients with ACSC admissions had significantly lower UPC scores compared with those without ACSC admissions. Using a Cox regression model that controlling for age, sex, severity of diabetes and the number of total visits, patients with low to medium continuity of care (UPC <0.75) were found to be significantly associated with increased risk of hospitalization as compared with patients with high continuity of care, especially for long-term ACSC admissions (relative risk: 1.336 [1.019–1.751]).
Higher continuity of care with usual providers for diabetic care is significantly associated with lower risk of future hospitalization for long-term diabetic complication admissions. To avoid future hospitalization, health policy stakeholders are encouraged to improve the continuity of care through strengthening the provider–patient relationships.
To determine the incidence of potential medical adverse events among patients undergoing forensic autopsy, and to present the characteristics of potential medical adverse events.
Retrospective review of consecutive autopsy records.
Department of Forensic Medicine, the Jikei University School of Medicine, Tokyo, Japan.
A total of 3355 forensic autopsy cases between 1983 and 2006.
Incidence of potential medical adverse events identified in decedents undergoing forensic autopsy, classified by actual occurrence as ‘confirmed’, ‘equivocal’ and ‘negative’ cases; proportion of potential diagnostic, performance and system errors among potential medical adverse events.
Of 291 autopsies (8.7%) with potential medical adverse events, 66 cases (22.7%) were confirmed, 42 cases (14.4%) were negative and 183 cases (62.9%) were equivocal. Confirmed cases consisted of potential diagnostic errors in 49 cases (74.2%) and performance errors in 17 cases (25.8%). Equivocal cases included 99 cases associated with potential diagnostic errors (54.1%) and 60 cases associated with potential system errors (32.8%). In 38 of the confirmed cases (57.5%), serious exacerbation of patient condition occurred outside the medical facility.
Potential medical adverse events are not uncommon in decedents undergoing forensic autopsy. They are particularly associated with potential diagnostic errors. Forensic autopsy may provide information that could be used to improve care and reduce deaths due to potential medical adverse events.
Ample research has examined physicians' evidence-based medicine (EBM) knowledge and skills; however, previous research has not linked EBM knowledge to objective measures of process of care.
A cross-sectional study of quality of care measures extracted from electronic medical records and EBM knowledge assessed via a validated questionnaire.
One region of the largest Health Maintenance Organization in Israel.
Seventy-four physicians and their 8334 diabetic patients, 7092 coronary heart disease patients and 17 132 hypertensive patients.
Outcome measures were four diabetes quality of care indicators (LDL tests, microalbumin tests, hemoglobin A1C tests, eye examination referrals), and two drug prescription indicators (statin prescription for coronary heart disease patients, and thiazide prescription for hypertensive patients). Independent variables were total EBM knowledge and its components: critical appraisal and information retrieval.
Total EBM knowledge was independently and significantly associated with LDL testing (b = 0.13; P = 0.036), microalbumin testing (b = 0.33; P = 0.001), hemoglobin A1C testing (b = 0.17; P = 0.036), eye examination referrals (b = 0.16; P = 0.021) and statin prescriptions (b = 0.18; P = 0.025). Critical appraisal was independently associated with microalbumin tests (b = 0.46; P = 0.002) and eye examination referrals (b = 0.20; P = 0.048). Information retrieval was only independently associated with hemoglobin A1C testing (b = 0.43; P = 0.004). Thiazide prescription was not associated with EBM knowledge scores.
Physicians' higher total EBM knowledge primarily correlates with better quality of care; however, correlations were modest and explained only a small portion in the variance of clinical performance. Results indicate that there might be a need to focus on teaching all the components of EBM rather than EBM microskills.
To assess changes in the quality of care following the introduction of a new postnatal package.
Using a pre-test, post test design to observe client–provider interactions with women 0–6 weeks postpartum.
Four health facilities in a rural district, eastern Kenya.
Health providers and postpartum women.
Introduction of comprehensive postnatal package of care, with three targeted assessments within 48 h of birth, 1–2 weeks and 6 weeks, to providers working in maternity and maternal and child health clinics.
Improved quality of postnatal counselling.
Increased mean scores for counselling on danger signs in the newborn (0.24–1.39) and infant feeding (1.33–2.19) were noted. The total quality of care index for the newborn increased overall but remained lower than desired (from 3.37 to 6.45 out of 11). Essential maternal care index improved (3.4–8.72 out of 23). More women accepted a family planning method at 6 weeks (35–63%).
The introduction of new comprehensive postnatal care package improved performance of providers in counselling in maternal and newborn complications, infant feeding and family planning. Additional studies looking at the postpartum family planning needs for women living with HIV would also be useful. However, providers would benefit from additional clinical skills for managing maternal and newborn complications during the critical period following childbirth.
To evaluate the appropriateness of phacoemulsification procedures performed in four Spanish regions, applying criteria developed by means of RAND/UCLA methodology.
Prospective observational study.
Seventeen public teaching hospitals in four regions of Spain.
Patients on waiting list to undergo cataract extraction by phacoemulsification.
Cataract surgery by phacoemulsification.
Level of appropriateness of each intervention, according to criteria developed by means of the RAND/UCLA appropriateness methodology.
Among the 5442 analysed patients the indication of phacoemulsification was appropriate in 69.6%, inappropriate in 7.3% and uncertain in 23.0%. Presence of ocular comorbidity, lack of cataract-induced visual function limitation, anticipated postoperative visual acuity of <0.5, preoperative visual acuity of >0.1 and high surgical complexity were associated with inappropriateness.
Some clinical characteristics, when present, make it especially important to obtain a careful assessment of the risks and benefits of surgery. Consideration of these characteristics may improve the appropriateness of phacoemulsification.
The vast majority of health system capacity-building efforts have focused on enhancing medical and public health skills; less attention has been directed at developing hospital managers despite their central role in improving the functioning and quality of health-care systems.
Initial assessment of hospital management systems demonstrated weak functioning in several management areas. In response, we developed with the Ethiopian Ministry of Health (MoH) a novel Master of Hospital Administration (MHA) program, reflecting a collaborative effort of the MoH, the Clinton HIV/AIDS Initiative, Jimma University and Yale University. The MHA is a 2-year executive style educational program to develop a new cadre of hospital leaders, comprising 5% classroom learning and 85% executive practice.
The MHA has been implemented with 55 hospital leaders in the position of chief executive officer within the MoH, with courses taught in collaboration by faculty of the North and the South universities.
The program has enrolled two cohorts of hospital leaders and is working in more than half of the government hospitals in Ethiopia. Lessons learned include the need to: (i) balance education in applied, technical skills with more abstract thinking and problem solving, (ii) recognize the interplay between management education and policy reform, (iii) remain flexible as policy changes have direct impact on the project, (iv) be realistic about resource constraints in low-income settings, particularly information technology limitations, and (v) manage the transfer of knowledge for longer term sustainability.
To perform a systematic review, supplemented by a targeted grey literature scan, for performance measurement and improvement frameworks within and across the health, education and social service systems. The intended outcome was the creation of a foundation of evidence to inform the development of cross-sectoral quality improvement frameworks.
MEDLINE, CINAHL, PsycINFO, ERIC, EMBASE, Social Services Abstracts, Social Work Abstracts and Education Index Full Text were searched up to April/May 2007. In addition, 26 governmental and 27 organizational websites were searched.
English language material with a publication date of 1986 or more recent that described a health, education or social services multidimensional framework for performance measurement and improvement.
The framework name; administrative sector; level of application; setting; population of interest; categories of quality described within the framework; country of application; and citations to other performance measurement and improvement frameworks were extracted from each article.
In total, 111 frameworks were identified. Most frameworks (n = 97) were developed in or for the health sector. A concept sorting exercise identified 16 quality concepts applicable across many settings, sectors and levels of application.
This systematic review of quality domains will be relevant and useful to those who are developing and using performance measurement and improvement frameworks for adult and child populations within or across the health, social service or education sectors.