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.
Patient care experience survey data might be useful for managing individual physician malpractice risk, but available evidence is limited. This study assesses whether patients' experiences with individual physicians, as measured by a validated survey, are associated with patient complaints and malpractice lawsuits.
Random samples of active patients in physicians' panels, with sample sizes adequate to provide highly reliable, stable information about patients' experiences with each physician (n = 19 202, average respondents per physician = 119) were used to assess the relation of patient survey measures to malpractice risk.
A large multi-specialty physician organization in eastern Massachusetts, USA.
Physicians providing care for at least 5 years in adult primary care and select high-risk specialty departments between January 1996 and December 2005 (n = 161).
Patient complaints (2001–05) and malpractice lawsuits (1996–2005).
Compared to primary care physicians, high-risk specialists had a lower patient complaint rate (0.34 vs. 1.36 complaints per patient care full time equivalent; P < 0.001), but a higher lawsuit rate (0.09 vs. 0.05 lawsuits per patient care full time equivalent; P = 0.02). Irrespective of physician specialty, the quality of physician–patient interactions (IRR = 0.61; P < 0.001) and care coordination (IRR = 0.65; P < 0.001) were inversely associated with patient complaints. Patient survey measures were not associated with malpractice lawsuits.
The results underscore the challenges organizations face when attempting to use patient survey data to manage individual physician medical malpractice risk. Because lawsuits are infrequent events, calibrating these validated patient survey measures to malpractice lawsuit risk will require large physician samples from diverse practices.
Accreditation usually requires that healthcare staff assess the quality of care delivered to patients in their own hospitals. It is unknown whether this assessment depends on the workplace rather than on the professional category of health personnel.
We aimed to identify major determinants of the perception of various categories of healthcare professionals concerning the quality of delivered information to inpatients in their ward, with a perspective to help the development of recommendations on how to compose self-assessment teams for the accreditation process.
A self-administered questionnaire survey was conducted in nine wards from five short-stay hospitals in Paris, France. Three hundred and fifteen healthcare professionals (physicians, nurses and nursing assistants) were included. The views of various categories of healthcare professionals regarding the compliance with a set of quality standards were compared by nonparametric statistical analyses. Determinants of the self-assessment of quality of care, including ward effect, were identified by fitting the data to a hierarchical model.
The participation rate was 86%, with 272 respondents (58 physicians, 149 nurses and 65 nursing assistants). Overall perceptions of various categories of healthcare professionals were not different. The final hierarchical model showed a strong ward effect (intracluster correlation coefficient=0.06, P<0.01) and a significant relationship between age of professionals and their opinion about quality of care.
We observed a ward cluster effect on healthcare staff perception of quality, but the category of healthcare professional was not a determinant. A satisfactory representativeness on age of professionals selected into the teams in charge of self-assessment during hospital accreditation is recommended.
Checklists are used in both medical and non-medical industries as cognitive aids to guide users through accurate task completion. Their development requires a systematic and comprehensive approach, particularly when implemented in high intensity fields such as medicine.
A narrative review of the literature was conducted to outline the methodology to designing and implementing clear and effective medical checklists.
We systematically searched for relevant English-language medical and non-medical literature both to describe where checklists have been demonstrated to improve delivery of care and also, how to develop valid checklists.
The MEDLINE search yielded 8303 citations of which 1042 abstracts were reviewed. On the basis of criteria for inclusion and subsequent full-manuscript review, 178 sources, including 17 non-medical publications, were included in the narrative review. This information was further supplemented by expert opinion in the area of checklist development and implementation. A small number of strategies for designing effective checklists were referenced in the literature, including utilization of pre-published guidelines, formation of expert panels and repeat pilot-testing of preliminary checklists.
Despite currently available evidence, a highly effective, standardized methodology for the development and design of medical-specific checklists has not previously been developed and validated, which has likely contributed to their inconsistent use in several key fields of medicine, despite evidence of their fundamental role in error management.
Nearly all hospital-specific comparative analyses, based on administrative data, are presented using cross-sectional displays. In this paper, we compare cross-sectional analyses with sequential monitoring using control charts.
Analysis of administrative data to compare cross-sectional funnel plots with one type of control chart: the risk-adjusted, expected-minus-observed plot.
Eighteen tertiary and base hospitals in Queensland, Australia, for the two financial years 2003–04 and 2004–05.
Patients admitted with acute myocardial infarction.
Risk-adjusted, 30-day, in-hospital, mortality rates.
There were no outliers on the cross-sectional funnel plots for either of the 2 years using three-sigma limits and three low-outliers and one high-outlier using two-sigma limits. One reasonable interpretation of these plots is that most of the variations are due to statistical noise and there is little to be learnt by seeking to understand the reasons for variation across hospitals. In contrast, for the control charts, 28% of hospitals signalled for a relative increase of 75% above that for all hospitals combined.
If the aim of clinical indicators based on administrative data is to provide a starting point for learning, then control charting provides potentially more useful information than the more commonly used cross-sectional analyses. Control charts provide an understandable and up-to-date overview that allows early detection of runs of good or bad outcomes that can help hospitals identify areas for more in-depth self-monitoring and learning.
To identify whether patients in lower socioeconomic groups had worse pain and functional levels prior to total knee arthroplasty and then establish whether these patients had poorer post-operative outcomes following total knee arthroplasty.
Data was obtained from a prospective observational study of 974 patients undergoing primary total knee arthroplasty for osteoarthritis. The study was undertaken in 13 centers in 4 countries. Pre-operative data was collected and patients were followed for 2 years post-operatively. Pre-operative details of the patients' demographics; socioeconomic status (SES) (education and income); height; weight and co-morbid conditions were obtained. The WOMAC scores were obtained preoperatively and during follow-up.
Using multivariate linear regression analysis, patients with a lower income had a significantly worse pre-operative WOMAC Pain (P = 0.021) and function score (P = 0.039) than those with higher incomes. However, income did not have a significant impact on outcome at final follow-up after adjusting for other significant covariates. Level of education did not correlate with pre-operative scores or with outcome at any time during follow-up.
Across all four countries, patients with lower incomes appeared to have a greater need for total knee arthroplasty. However, level of income and educational status did not appear to affect the final outcome following total knee arthroplasty. Patients with lower incomes appeared able to compensate for their worse pre-operative score and obtain similar outcomes post-operatively. These findings are in contrast to studies on other medical conditions and surgical interventions, in which a lower SES has been found to have a negative impact on patient outcomes.
To compare the conceptualization of performance underlying different accreditation manuals.
Accreditation manuals were selected from the 2003 WHO report titled ‘Quality and Accreditation in Healthcare Services’. We used manuals from WHO-listed countries that most influenced the standards: Canada, France, the USA and Australia. The fifth manual is published by the Pan American Health Organization (PAHO).
Standards from each manual were classified by two independent reviewers. The coding grid, which was based on a Parsonian-based integrative framework on performance, was composed of performance dimensions and their interlinks/alignments.
The four dimensions of quality, goal-attainment, adaptation to the external environment and values, along with their alignments, were given differing levels of importance in the five manuals. The Australian manual emphasizes all four dimensions and their alignments. The PAHO accreditation focuses mainly on quality. The manuals from Canada, France and the USA fall somewhere between the two accreditation extremes of complete versus one-dimensional. Finally, we present a taxonomy of the conceptualization of performance in accreditation manuals that distinguishes between quality-oriented and alignment-oriented accreditation manuals.
Specific conceptualizations of performance underlying accreditation manuals may not be neutral. Perhaps, more normative accreditation manuals are associated with authoritative management styles, or more balanced accreditation manuals with comprehensive management styles. Our comparative analysis is a first step toward better understanding the relationship between the conceptualization of performance and the management style adopted in a particular healthcare organization. This relationship could help explain the variation observed in healthcare organization performance.
To provide a targeted portrait of socioeconomic disparities in health care quality in four countries and how those disparities have changed over time.
Within each country, comparisons between the highest and lowest quintiles of socioeconomic status were made to determine if disparities exist and if any observed disparities have been decreasing over a 5-year period.
Small geographic areas in Canada, England, New Zealand and the United States.
Data were obtained by working with national health statistics agencies in each country.
There were socioeconomic disparities in health care quality and health status for most of the indicators studied in all four countries. The analysis included nine quality indicators in four countries, for a total of thirty-six observations. Twenty-six observations had a ratio of highest to lowest socioeconomic quintile of <0.95 or >1.05. These disparities generally persisted over time. The relative difference between the highest and lowest quintile decreased over time in eight of the twenty-one observations with time-series data available.
The fact that disparities in a variety of indicators exist in four very different health systems underscores the importance of factors common to the four systems or factors outside the health system. Some successful strategies for reducing disparities could potentially be learned from the few examples of success in these countries.
To investigate the socio-economic differentials in the quality (clinical and interpersonal) of antenatal care and also the correlation between differentials in the quality and utilization of antenatal care.
The study uses cross-sectional, nationally representative data from National Family Health Survey (1998–99).
Four south Indian states (Andhra Pradesh, Karnataka, Kerala and Tamil Nadu) and four north Indian states (Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh).
More than four antenatal care visits for utilization, and index of clinical, information and interpersonal quality of care.
Lower than desired quality of antenatal care was observed in both north and south Indian states, though the quality was significantly better in south India compared with north India, especially among the disadvantaged women. Significant socio-economic differentials in the quality of care were evident in both north and south India, but were more glaring in north India. A significantly positive relationship was observed between the quality and utilization of antenatal care in the rural areas from village-level multivariate analysis.
Poor quality of antenatal care is likely to reduce its utilization. Policy and program interventions to improve the quality of care of antenatal care, especially for the poor and other disadvantaged population groups, more so in north India, are essential to improve maternal health outcomes. The India's National Rural Health Mission (NRHM), launched in 2005, should lay greater emphasis on improving the quality of antenatal care, among other things, to increase utilization of antenatal care and achieve better maternal health outcomes.
Although an active role of the patient is often stressed in diabetes care, it is not easily implemented in daily practice. The aim of the study was to measure the effects of introducing a diabetes passport to patients after embedding the passport in the organization of care.
Randomized controlled trial.
Forty general practice in The Netherlands.
Pre- and post-intervention data were obtained from 993 patients with type 2 diabetes mellitus. Patients treated in secondary care and patients over 80 years of age were excluded.
The intervention consisted of clarifying the diabetes care tasks for all practice staff and embedding the diabetes passports in the structured care.
Main outcome measure. Self-reported use of the diabetes passport.
Diabetes passports were issued to 87% of the patients. After 15 months, 76% of the patients reported that the passport was being used during clinic visits. The process indicators of care improved by 10% on average in the intervention group. However, there were no changes in the outcome measures.
Diabetes passports can be introduced successfully in structured primary care and they lead to improved effect measures for medical behaviour.
Although agreement about the need for quality improvement in health care is almost universal, the means of achieving effective improvement in overall care is not well understood. Avedis Donabedian developed the structure–process–outcome framework in which to think about quality-improvement efforts.
There is now a robust evidence-base in the quality-improvement literature on process and outcomes, but structure has received considerably less attention. The health-care field would benefit from expanding the current interpretation of structure to include broader perspectives on organizational attributes as primary determinants of process change and quality improvement.
We highlight and discuss the following key elements of organizational attributes from a management perspective: (i) executive management, including senior leadership and board responsibilities (ii) culture, (iii) organizational design, (iv) incentive structures and (v) information management and technology. We discuss the relevant contributions from the business and medical literature for each element, and provide this framework as a roadmap for future research in an effort to develop the optimal definition of ‘structure’ for transforming quality-improvement initiatives.
Qualitative research explores complex phenomena encountered by clinicians, health care providers, policy makers and consumers. Although partial checklists are available, no consolidated reporting framework exists for any type of qualitative design.
To develop a checklist for explicit and comprehensive reporting of qualitative studies (indepth interviews and focus groups).
We performed a comprehensive search in Cochrane and Campbell Protocols, Medline, CINAHL, systematic reviews of qualitative studies, author or reviewer guidelines of major medical journals and reference lists of relevant publications for existing checklists used to assess qualitative studies. Seventy-six items from 22 checklists were compiled into a comprehensive list. All items were grouped into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting. Duplicate items and those that were ambiguous, too broadly defined and impractical to assess were removed.
Items most frequently included in the checklists related to sampling method, setting for data collection, method of data collection, respondent validation of findings, method of recording data, description of the derivation of themes and inclusion of supporting quotations. We grouped all items into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting.
The criteria included in COREQ, a 32-item checklist, can help researchers to report important aspects of the research team, study methods, context of the study, findings, analysis and interpretations.
To quantify the impact of different guideline implementation interventions to improve treatment of community-acquired pneumonia (CAP) in a hospital setting.
Pubmed, the Cochrane Library, the Cochrane Effective Practice and Organization of Care specialized register, EMBASE and CINAHL.
Hospital-based trials studying the effect of guidelines on compliance with care processes, clinical and/or economic outcomes in the treatment of CAP together with a description of their implementation interventions.
Two independent reviewers extracted and categorized utilized implementation interventions, assessed intensity of use and calculated changes for process of care variables, clinical and economical outcomes. Correlations between interventions and improvement of outcomes were assessed by means of Spearman's rho-test and Mann–Whitney U-test.
In 27 included studies, educational meetings (21/27) and distribution of written material (14/27) were the two most used interventions. Most individual studies show positive overall results, but taken together, no significant relation between number or type of implementation interventions and improvement of outcomes could be detected. Only audit and feedback showed a significant negative influence on the improvement rate of length of stay (p = 0.003; n = 20).
Other hospital-specific factors are likely to have a higher impact on the rate of improvement than the implementation interventions alone. Describing which interventions are most successful is unlikely to be correct without taking these hospital-specific factors into account. Future research should focus on how to identify and define these factors and how to adapt the intervention to hospital-specific factors.
Health-care systems need actionable information on amputation rates in order to improve foot-care delivery.
To evaluate regional variation in total, major, and minor amputation rates using individual-level data.
This was a retrospective cohort study of Veterans Health Administration users with diabetes who were Medicare enrolled between fiscal years 1998 and 2000 (10/1/1997–9/30/2000). The outcome was outlier status, based upon observed-to-expected ratios, for total, major, and minor amputations of 22 regional networks in fiscal year 2000.
331,806 patients incurred a total of 4,037 (12.2 per 1000; range 9.3–16.7 across networks) amputations in fiscal year 2000: 2,271 major amputations (6.8 per 1000; 4.7–9.1) and 1,766 minor amputations (5.3 per 1000; 3.9–7.6). All network outliers based upon the total amputation observed-to-expected ratio were also outliers based on major amputation observed-to-expected ratio. However, two of the five non-outliers based on total amputations were outliers based on major amputations. Simultaneous evaluation of major and minor amputation observed-to-expected ratios demonstrated four patterns of dual outlier status among networks: two networks had lower than expected minor and major amputation rates; two had higher than expected minor and major amputation rates; one network was lower than expected by major but higher by minor amputation rate; one was higher than expected by major but lower by minor amputation rate.
Simultaneous evaluation of major and minor amputation rates identifies different patterns of regional outlier status compared to total or major amputation rates alone. This strategy may facilitate targeted evaluations of health-care processes and structures.
Metastatic spinal cord compression is a dreaded complication of cancer affecting 5–10% of patients requiring urgent treatment. A clinical practice improvement project was carried out to review and fine tune the clinical pathway for the acute management of patients with metastatic spinal cord compression.
To improve the quality of care for metastatic spinal cord compression over 6 months by ensuring that >90% of patients receive definitive treatment within 24 h of radiological diagnosis.
Using clinical practice improvement project methodology, the clinical pathway of 17 patients treated with radiotherapy for metastatic spinal cord compression within the last 6 months were reviewed to identify gaps and delays in the system. Interventions to form a multidisciplinary acute spinal cord crisis team, fine tune clinical referral processes and formulate a standardized treatment protocol were then implemented. Post-intervention of 22 subsequent patients were monitored for time to start steroids and radiation therapy, length of stay and hospitalization bill.
With the interventions implemented, the mean response time to start steroidal therapy was reduced from 8.4 to 2.6 days and radiotherapy from 9.9 to 3.9 days. These translated into shorter mean length of stay from 23.8 to 14.7 days and smaller hospitalization bill size from Singapore$13 723 to 8808.
A clinical practice improvement project, to improve the quality of care for patients with metastatic spinal cord compression, can shorten response time to start steroidal therapy and definitive radiotherapy resulting in shorter length of stay and smaller hospitalization bill.
Patient age is the main socio-demographic factor influencing patient satisfaction with care but the nature of the relationship between age and patient satisfaction is controversial.
This study aims to clarify whether the association of age with satisfaction is linear or shows some other configuration.
Data were obtained from two different satisfaction studies conducted in 27 short-stay teaching hospitals. Study 1 included 1547 inpatients, who completed the EQS-H questionnaire at the time of discharge. Study 2 included 7624 inpatients interviewed by phone at home after discharge, who answered the SAPHORA questionnaire. On the basis of the results of the exploratory analysis, three models for adjustment of age on satisfaction were compared: a simple linear model, a five-group step function and a linear model with a change in slope.
The most suitable model for adjusting patient age to satisfaction scores for quality of medical and nursing care, whether for the EQS-H or the SAPHORA scale, was not a linear relationship: patient age was linearly and positively correlated to satisfaction before 65 years and negatively thereafter. Adjustment of patient age to accommodation and premises satisfaction scores proved to be different, closer to a linear relationship.
These results suggest considering the patient age variable as a non-linear factor for adjusting satisfaction scores, in particular in relation to care. Further studies are needed to confirm the evidence of a threshold around 65 years beyond which satisfaction scores for the quality of medical and nursing care decrease.
Methods used to generate items for complex measurement scales are heterogeneous and probably produce heterogeneous data, yet nothing is known about the advantages of one method over another.
We aimed to compare methods of generating items for tools designed to measure quality-of-life for patients.
We used five methods to develop a quality-of-life instrument for patients with lower-limb osteoarthritis: individual interviews with patients involving two different techniques (semi-structured and cognitive), individual interviews with health professionals, and focus groups of patients and health professionals. The process generated 80 items, of which 37 were excluded after content and psychometric analysis. With the final 43-item scale used as a ‘reference standard’, we estimated the contribution of each method.
For health professionals, the focus group and individual interviews produced 35 and 81% of the items, respectively. For patients, the focus groups produced 74% of the items and both interview techniques 100% of the items. Health professionals provided a narrower picture of the effects of the disease on quality-of-life. Focus groups contributed less to social domains than did individual interviews. The two patient interview techniques highlighted different themes.
In developing a complex measurement scale for patients, we found individual interviews with patients the best method for formulating items; other methods such as physician interviews and focus groups contributed no additional information. Reports of instrument generation should include details of the item-generation step, the methods used to develop items and the number of people involved.
To assess the impact of variables related to setting, study design and definition on adverse outcome occurrence and mortality in hospitalized patients.
Pubmed and Embase.
Articles in English from 1980 onwards, in non-selected patients or surgical patients only.
Data were extracted independently by two authors using a predefined form. Included study methodology variables were general variables such as setting, patient variables like age, study variables like number of reviewers and definition and the resulting adverse outcome occurrence and mortality.
Eleven studies reporting on 76 617 non-selected patients and 18 studies representing 136 292 surgical patients were included. Adverse outcomes were estimated to occur in 16% (12–19%) of non-selected patients and in 18% (14–22%) of surgical patients, taking into account the heterogeneity between studies. The study methodology variables were not statistically significant in explaining variation in adverse outcome occurrence, but the individual studies, when used as a random effect variable, were significant. Conversely, the study variable was not significant to explain variation in mortality rates, whereas the study methodology variables were: having more than one reviewer increased mortality by 30–80%, older study populations resulted in higher mortality and including a cause in the definition halved the mortality rate.
Study methodology variables do not explain differences in adverse outcome occurrence between studies. Other inter-study differences are more important. However, study methodology is an important predictor for mortality differences and should be taken into account when interpreting differences between studies.
The importance of emergency systems accessible by telephone for the early attention of patients with ischemic cardiopathy is well known. In Andalusia, this service is provided by calling 061. However, studies show an insufficient use of the existing emergency system in this type of patient.
To identify explanations related to the decision regarding the method of transport to health-care systems, by private means of transport or 061 services, for people with ischemic cardiopathy from the onset of symptoms until their arrival at the Emergency Department.
Eleven focal groups were held with subjects diagnosed with ischemic cardiopathy. The discussions were related to the method of transport (using 061 or their own means of transport to a major hospital or to a nearby health facility for onward transfer), depending on the existence of previous experience and distance to the hospital.
The method of transport is related to the degree of ignorance about what is happening, perceptions regarding the fastest way to reach the hospital, people available around the patient when the event takes place, vehicle availability and possible stressful situations.
This study provides information about the reasons for using or not using the emergency transport systems for these patients and understanding how decisions were made. The study's importance lies in the possibility of improving individuals' access to health care systems through education-based actions and a strategic information and training plan that targets patients, families and health professionals.