Measuring Quality Of Care Research Articles

Optimizing Surgical Outcomes in Gastric Cancer: A Comparison of Laparoscopic and Open Total Gastrectomy.

The efficacy of the laparoscopic approach for total gastrectomy(TG) in Western countries remains under discussion. Recently, Textbook Outcome(TO) has gained recognition as a comprehensive measure of care quality in upper gastrointestinal surgery. Although predictive factors for TO after TG are well-documented, the influence of the surgical approach requires further analysis. This study aimed to compare the TO completion rate following total gastrectomy for gastric cancer between the open(OTG) and laparoscopic(LTG) approaches. TO was defined by ten criteria: (a)absence of intraoperative complications, (b)macroscopically complete resection, (c)R0 margin, (d)retrieval of ≥ 15 lymph nodes, (e)absence of postoperative complications with Clavien-Dindo grade ≥ 2, (f)no surgical reintervention within 30 days, (g)no unplanned ICU admission within 30 days, (h)no mortality within 30 days, (i)length of stay ≤ 21 days, and (j)no readmission within 30 days. Propensity score matching was used to adjust for potential selection bias. Predictive factors associated with TO were identified through univariate and multivariate analyses. Among the 188 patients, 34 underwent LTG. TO was achieved in 46.8% of cases, with no significant difference between OTG and LTG (45.5% vs 52.9%, p=0.43). After propensity score matching, similar outcomes were observed (44.1% vs 52.9%, p=0.47). However, LTG was associated with fewer postoperative complications of Clavien-Dindo grade ≥ 2 (p=0.049), particularly pulmonary complications(p=0.041). This study confirms the feasibility and safety of laparoscopic total gastrectomy for cancer. The laparoscopic approach yields a TO completion rate comparable to that of the open approach while reducing postoperative complications.

ASSOCIATION OF HEALTHCARE ACCESS AND DUAL ELIGIBILITY STATUS BASED ON ENROLLMENT IN MANAGED CARE

Abstract Dual-eligible beneficiaries (enrolled in both Medicare and Medicaid) remain a growing population with complex care needs. However, there are limited studies evaluating self-reported access to healthcare among these individuals. Using six key outcomes that describe the characteristics of beneficiaries’ usual source of care from the 2021 Medical Expenditure Panel Survey, we retrospectively analyzed self-assessment questionnaire data among individuals age 18 and older (N = 12,924) to evaluate the association between healthcare access and dual-eligibility status based on enrollment in managed care. A series of survey-weighted multivariable logistic regression models were estimated. After adjusting the models for demographic factors, socioeconomic factors, and interaction term between dual-eligible and managed care status, we calculated marginal effects of managed care and dual-eligibility on healthcare access outcomes and used analysis of variance contrast tests to estimate the difference in the probability of outcomes based on managed care and dual-eligibility status. The results demonstrate non-dual managed care beneficiaries were significantly less likely to seek care [4.1% versus 2.5%, p-value = 0.0338] and experienced greater delays in care [6.6% versus 4.9%, p-value = 0.0398] due to cost. We also noted no significant impact on established and regular care access independently based on dual-eligibility status or managed care status. These findings suggest managed care may not significantly influence dual-eligibles’ access to healthcare but should be analyzed further for associations with healthcare disparities before making policy recommendations. Future research should also examine associations between quality of care measures and dual-eligibility status to continue holistically evaluating healthcare equity.

Moral injury and mental health in healthcare workers are linked to organizational culture and modifiable workplace conditions: Results of a national, mixed-methods study conducted at Veterans Affairs (VA) medical centers during the COVID-19 pandemic

Using mixed methods, we examined drivers of risk for moral injury, mental health symptoms, and burnout among frontline healthcare workers in high-risk Veterans Affairs (VA) clinical settings during the COVID-19 pandemic. Across 21 VA medical centers, 2,004 healthcare workers completed an online survey assessing potential risk factors for moral injury, posttraumatic stress, depression, and burnout. Assessed risk factors included: pandemic exposures; individual worker characteristics; aspects of workplace/organizational culture; and facility performance on standardized measures of care quality, patient satisfaction, and employee satisfaction (extracted from VA administrative data). Among surveyed workers, 39% were at risk for moral injury, 41% for posttraumatic stress, 27% for depression, and 25% for persistent burnout. In generalized linear mixed models, significant predictors of moral injury risk included perceived lack of management support for worker health/safety, supervisor support, coworker support, and empowerment to make job-related decisions—all modifiable workplace factors. Pandemic-related risk factors for moral injury included prolonged short-staffing, denying patient-family visits, and high work-family conflict. Predictors of posttraumatic stress, depression, and burnout were similar. Forty-six surveyed workers completed a follow-up qualitative interview about experiences of moral distress in the workplace, and interview themes aligned closely with survey findings. Rapid qualitative analysis identified protective factors that may reduce moral injury risk, including a collaborative workplace community, engaged leadership, empowerment to make changes in the workplace, and opportunity to process distressing events. We conclude with recommendations to mitigate moral injury risk in healthcare organizations. These include involving workers in discussions of high-stakes decisions that will affect them, creating consistent and clear channels of communication between the frontlines and leaders of the organization, practicing leadership rounding to improve leaders’ understanding of the daily work of frontline teams, and collaborating to understand how existing processes and policies may contribute to safety risks and moral conflict.

Advancing District Nursing Care Through a Learning Healthcare System: A Viewpoint on Key Requirements.

The increasing complexity of healthcare needs driven by an ageing population places pressure on district nursing care. Many vulnerable older adults prefer to remain at home, requiring care coordinated with general practitioners and other professionals. This demand for integrated care is further challenged by a shortage of nursing professionals and the lack of standardised approaches to measure care quality. This article identifies the key requirements for implementing a learning healthcare system in district nursing care, using patient outcome data to foster continuous improvement and create a more adaptive, evidence-based, and patient-centred approach. This paper synthesises findings from multiple studies conducted as part of a PhD thesis, utilising a multi-method approach. These methods include examining patient outcomes in district nursing care and evaluating necessary cultural, organisational, and financial changes. Four key requirements were identified: (1) standardising patient outcome measures; (2) fostering a data-driven culture and strengthening professional autonomy; (3) enhancing organisational support and integrated care; and (4) adopting financing models that incentivise continuous learning and quality improvement. Implementing a learning healthcare system with patient outcome data in district nursing care requires a transformative shift. Standardising outcome measures, investing in information systems, and promoting continuous learning are crucial. Aligning financial incentives with patient outcomes, strengthening professional autonomy, and enhancing organisational support can make district nursing more responsive and capable of meeting complex needs. The described requirements are essential for advancing district nursing care through a more adaptive, evidence-based, and patient-centred approach.

Pediatric Emergency Care Coordinator Presence and Pediatric Care Quality Measures

Higher pediatric readiness has been associated with improved quality and outcomes of care for children. Pediatric emergency care coordinators (PECCs) are a component of pediatric readiness, but the specific association between PECCs and quality-of-care measures is undefined. To examine the association between PECC presence and emergency department (ED) performance as reflected by quality-of-care measures. This cohort study of ED patients 18 years or younger used data across 8 states, combining the 2019 National Emergency Department Inventory-USA, 2019 State Emergency Department Database and State Inpatient Database, 2020 Supplemental National Emergency Department Inventory PECC Survey, and the 2021 National Pediatric Readiness Project Survey. This analysis was conducted from February 15, 2023, to July 9, 2024. Presence of a PECC. Hospitals were stratified by presence of pediatric resources (ie, pediatric intensive care and inpatient units), with exclusion of children's hospitals and comparison between pediatric-resourced and non-pediatric-resourced (unable to admit children, no pediatric intensive care unit) hospitals. The 7 measures chosen were length of stay longer than 1 day for discharged patients, left against medical advice or without completing treatment, death in the ED, return visits within 3 days, return visits with admission within 3 days, use of chest radiography in patients with asthma, and use of head computed tomography for patients with head trauma. For each stratum, multilevel generalized linear models were constructed to examine the association between PECC presence and process and utilization measure performance, adjusted for patient-level factors (age, sex, race and ethnicity, insurance, and complex chronic conditions) and ED-level factors (visit volume, patient census, and case mix [race and ethnicity, insurance, and complex chronic conditions]). There were 4 645 937 visits from pediatric patients (mean [SD] age, 7.8 [6.1] years; 51% male and 49% female) to 858 hospitals, including 849 non-freestanding pediatric hospitals, in the analytic sample. Highly resourced pediatric centers were most likely to have a PECC (52 of 59 [88%]) compared with moderately resourced (54 of 156 [35%]) and non-pediatric-resourced hospitals (66 of 519 [13%]). Among the 599 non-pediatric-resourced hospitals, PECC presence was associated with decreased rates of computed tomography in head trauma (adjusted odds ratio [AOR], 0.76; 95% CI, 0.66-0.87); in the pediatric-resourced hospitals, the AOR was 0.85 (95% CI, 0.73-1.00). For patients with asthma, PECC was associated with decreased chest radiography rates among pediatric-resourced hospitals (AOR, 0.77; 95% CI, 0.66-0.91) but not non-pediatric-resourced hospitals (AOR, 0.93; 95% CI, 0.78-1.12). The presence of a PECC was not consistently associated with quality-of-care measures. The presence of a PECC was variably associated with performance on imaging utilization measures, suggesting a potential influence of PECCs on clinical care processes. Additional studies are needed to understand the role of PECCs in driving adherence to clinical care guidelines and improving quality and patient outcomes.

Development of Patient-Centered End-of-Life Care Quality Measures in China: A Modified Delphi Process.

Objective: Patient-centered care is widely recognized as a crucial component of high-quality end-of-life care. As this approach remains limited in China, this study sought to develop quality measures specifically tailored to end-of-life care within the country. Methods: Initial indicators were established through a comprehensive review of existing measures. Using the modified Delphi Method, a two-round survey with experts (n = 14) was applied to evaluate the importance of each item. Results: The authoritative coefficient of two rounds of expert consultation was 0.86 and 0.87, and the Kendall coefficient of concordance for the two rounds was 0.232 and 0.270 (P < 0.001), respectively, demonstrating an acceptable consensus among the experts. As a result, 31 key quality indicators were identified and deemed important. Conclusions: This study developed a scale for patient-centered end-of-life care quality measurement in China, consisting of six dimensions and 31 indicators. This scale lays a solid foundation for quality improvement initiatives and future development of patient-centered end-of-life care.

Accountable care organization changes in equity of ambulatory care quality by patient race and ethnicity, 2019-2022.

There is limited information about accountable care organization (ACO) variation in equity of ambulatory care quality. We examine whether equity of care changed for racial and ethnic minority patients from 2019 to 2022 and the extent to which equity of care performance varied for 11 ACOs in Massachusetts over time. We analyzed ACO-level changes in equity of care for 8 ambulatory care quality measures for Asian, Black, and Hispanic patients, measured as the percentage point difference between each group and the majority non-Hispanic White patient group. Cervical cancer screening (3.54 percentage point change, P < 0.001), colorectal cancer screening (3.54 percentage point change, P < 0.001), and eye exams for adults with diabetes (3.56 percentage point change, P = 0.008) had the largest performance declines. Equity of ambulatory care quality did not significantly change over time. The one exception was for breast cancer screening, where equity declined for Asian patients (3.52 percentage point change, P = 0.04). Although equity of care generally did not significantly change over time across ACOs, high variation in equity of care performance between ACOs highlights opportunities to identify and share the strategies that enable physician practices and healthcare systems to advance equity of care for racial and ethnic minority patients.

Impact of Socioeconomic Deprivation on Care Quality and Surgical Outcomes for Early-Stage Non-Small Cell Lung Cancer in United States Veterans.

Background: Socioeconomic deprivation has been associated with higher lung cancer risk and mortality in non-Veteran populations. However, the impact of socioeconomic deprivation on outcomes for non-small cell lung cancer (NSCLC) in an integrated and equal-access healthcare system, such as the Veterans Health Administration (VHA), remains unclear. Hence, we investigated the impact of area-level socioeconomic deprivation on access to care and postoperative outcomes for early-stage NSCLC in United States Veterans. Methods: We conducted a retrospective cohort study of patients with clinical stage I NSCLC receiving surgical treatment in the VHA between 1 October 2006 and 30 September 2016. A total of 9704 Veterans were included in the study and assigned an area deprivation index (ADI) score, a measure of socioeconomic deprivation incorporating multiple poverty, education, housing, and employment indicators. We used multivariable analyses to evaluate the relationship between ADI and postoperative outcomes as well as adherence to guideline-concordant care quality measures (QMs) for stage I NSCLC in the preoperative (positron emission tomography [PET] imaging, appropriate smoking management, pulmonary function testing [PFT], and timely surgery [≤12 weeks after diagnosis]) and postoperative periods (appropriate surveillance imaging, smoking management, and oncology referral). Results: Compared to Veterans with low socioeconomic deprivation (ADI ≤ 50), those residing in areas with high socioeconomic deprivation (ADI > 75) were less likely to have timely surgery (multivariable-adjusted odds ratio [aOR] 0.832, 95% confidence interval [CI] 0.732-0.945) and receive PET imaging (aOR 0.592, 95% CI 0.502-0.698) and PFT (aOR 0.816, 95% CI 0.694-0.959) prior to surgery. In the postoperative period, Veterans with high socioeconomic deprivation had an increased risk of 30-day readmission (aOR 1.380, 95% CI 1.103-1.726) and decreased odds of meeting all postoperative care QMs (aOR 0.856, 95% CI 0.750-0.978) compared to those with low socioeconomic deprivation. There was no association between ADI and overall survival (adjusted hazard ratio [aHR] 0.984, 95% CI 0.911-1.062) or cumulative incidence of cancer recurrence (aHR 1.047, 95% CI 0.930-1.179). Conclusions: Our results suggest that Veterans with high socioeconomic deprivation have suboptimal adherence to care QMs for stage I NSCLC yet do not have inferior long-term outcomes after curative-intent resection. Collectively, these findings demonstrate the efficacy of an integrated, equal-access healthcare system in mitigating disparities in lung cancer survival that are frequently present in other populations. Future VHA policies should continue to target increasing adherence to QMs and reducing postoperative readmission for socioeconomically disadvantaged Veterans with early-stage NSCLC.

Leverage machine learning to identify key measures in hospital operations management: a retrospective study to explore feasibility and performance of four common algorithms

BackgroundMeasures in operations management are pivotal for monitoring and assessing various aspects of hospital performance. Existing literature highlights the importance of regularly updating key management measures to reflect changing trends and organizational goals. Advancements in machine learning (ML) have presented promising opportunities for enhancing the process of updating operations management measures. However, their specific application and performance remain relatively unexplored. We aimed to investigate the feasibility and effectiveness of using common ML techniques to identify and update key measures in hospital operations management.MethodsHistorical data on 43 measures on financial balance and quality of care under 4 categories were retrieved from the BI system of a regional health system in Central China. The dataset included 17 surgical and 15 non-surgical departments over 48 months. Four common ML techniques, linear models (LM), random forest (RF), partial least squares (PLS), and neural networks (NN), were used to identify the most important measures. Ordinary least square was employed to investigate the impact of the top 10 measures. A ground truth validation compared the ML-identified key measures against the humanly decided strategic measures from annual meeting minutes.ResultsFor financial balancing, inpatient treatment revenue was an important measure in 3/4 years, followed by equipment depreciation costs. The measures identified using the same technique differed between years, though RF and PLS yielded relatively consistent results. For quality of care, none of the ML-identified measures repeated over the years. Those consistently important over four years differed almost entirely among four techniques. On ground truth validation, the 2016–2019 ML-identified measures were among the humanly identified measures, with the exception of equipment depreciation from the 2019 dataset. All the ML-identified measures for quality of care failed to coincide with the humanly decided measures.ConclusionsUsing ML to identify key hospital operational measures is viable but performance of ML techniques vary considerably. RF performs best among the four techniques in identifying key measures in financial balance. None of the ML techniques seem effective for identifying quality of care measures. ML is suggested as a decision support tool to remind and inspire decision-makers in certain aspects of hospital operations management.

A Quality Improvement Initiative for Inpatient Advance Care Planning

The Centers for Medicare & Medicaid Services (CMS) implemented advance care planning (ACP) billing codes in 2016 to encourage practitioners to conduct and document ACP conversations, and included ACP as a quality metric in the CMS Bundled Payments for Care Improvement Initiative in 2018. Use of this billing code in the inpatient setting has not been studied. To determine whether a quality improvement intervention to increase inpatient ACP is effective in increasing ACP billing rates or changing hospital treatment plans or patient outcomes. This nationwide cohort study and difference-in-differences analyses compared changes in ACP billing, treatment, and outcomes in Medicare fee-for-service beneficiaries aged 65 years and older who were hospitalized and cared for by 3 different groups: practitioners employed by a national acute care staffing organization who underwent an ACP quality improvement intervention, nonintervention practitioners at the same hospital, and control group practitioners from other hospitals. Using data from the Master Beneficiary Summary File, acute care hospital stays for nonsurgical conditions were linked to Medicare enrollment, claims, and vital status data from 1-year preadmission to 1-year postadmission from 2015 to 2019. The ACP billing rates for each group were assessed for associations with 6 inpatient treatments and 4 outcomes. Data analyses were performed from January 2022 to December 2024. Billed ACP conversations, receipt of intensive care and life support (intensive care unit admission, gastrostomy tube placement, mechanical ventilation, tracheostomy), treatment limitations (newly initiated do-not-resuscitate orders) and outcomes (discharge to hospice, inpatient death, 30-day postadmission death, and 1-year postadmission death). The total study sample included 109 intervention hospitals, 1691 control hospitals, nearly 12 million Medicare fee-for-service beneficiaries aged 65 years and older, and 738 309 practitioners associated with admissions from 2016 to 2018. ACP billing rates increased more for the intervention (1.3% in preintervention to 14.0% in postintervention; P < .001) than for the nonintervention (same hospitals) and control groups (odds ratio [OR], 2.6; 95% CI, 1.7-4.1 intervention vs control). Increased ACP billing rates were significantly associated with decreased rates of inpatient death in the intervention group (OR, 0.95; 95% CI, 0.90-1.00) compared to the nonintervention (OR, 1.10; 95% CI, 1.04-1.17) and control groups (reference). All other associations were nonsignificant. This nationwide cohort study suggests that while the ACP quality initiative increased ACP billing, changes in clinical outcomes were inconsistent with the hypotheses. Further study is needed to address questions regarding confounding by unobserved measures of care quality.

Association between Unmet Social Need and Ambulatory Quality of Care for US Children

ObjectivesChildren who experience socioeconomic adversity often have worse health; however, less is known about their quality of care. We sought to evaluate the association between parent/caregiver-reported socioeconomic adversity and quality of pediatric primary, acute, and chronic ambulatory care on a national level. MethodsThis was a retrospective cohort study of 5368 representative US children (1–17 years) in the 2021 Medical Expenditure Panel Survey. Socioeconomic adversity was defined as parent/caregiver-reported food, housing, transportation, or utility insecurity in the past 12 months. Outcomes included 10 quality measures of primary, acute, and chronic care, and experience of care measured through parent/caregiver survey. We described variation in socioeconomic adversity and used multivariable regression to examine associations with quality outcomes. ResultsOne-third of parent/caregivers reported socioeconomic adversity. Food insecurity (23.6%) was most common followed by utility (19.5%), housing (15.0%), and transportation (4.7%) insecurity. Black (53.2%) and Hispanic (46.9%) parent/caregivers experienced the highest rates of socioeconomic adversity. Children with socioeconomic adversity received lower quality of care for four quality measures, including more frequent Emergency Department visits (Odds Ratio (OR)= 1.69 [95% Confidence Interval (CI): 1.28–2.23]), less favorable asthma medication ratio (OR=0.04 [95% CI: 0.01–0.31]), and less frequent well child (OR=0.73 [95% CI: 0.59–0.90]) and dental care (OR=0.76 [95% CI: 0.63–0.94], P < .05 for all). There were no statistically significant differences in experience of care. ConclusionsSocioeconomic adversity is common among US children with disproportionate impact on Black and Hispanic families. There are significant disparities in pediatric primary, acute, and chronic care quality, based on parent/caregiver-reported socioeconomic adversity, highlighting the need for systems-level interventions.

Wildfire exposures and in-hospital length of stay following lung cancer surgery.

311 Background: Wildfires pose substantial health and safety threats to patients recovering from lung cancer surgery. Without specific disaster preparedness guidelines, oncologists might resort to improvisational strategies, such as increasing the length of stay (LOS), a federal care quality measure with financial implication for hospitals, to better protect the health and safety of this medically vulnerable population. Methods: Individuals aged ≥18 years who received curative-intent lobectomy or pneumonectomy for stage I-III NSCLC between 2004 and 2021 were selected from the National Cancer Database. Exposure was defined as a Federal Emergency Management Agency (FEMA) Presidential Disaster Declaration in the county of the treatment facility between date of surgery and date of discharge from the hospital. Differences in the cumulative distribution function of LOS, defined as days between date of surgery and date of discharge from the hospital, were evaluated between exposed and propensity score matched unexposed patients, who were treated at the same facility but at a time when no disasters occurred, using the product-limit method and log-rank test. In sensitivity analysis, patients with discharge date equal to date of death (in-hospital mortality) were excluded, and the association was evaluated stratified by stage. Results: Patients exposed to a wildfire disaster declaration in the county of the treating facility had longer LOS (p&lt;0.001) than unexposed patients (9.4days compared to 7.5 days, respectively) overall and for each of the stages (I-III) for which surgery is the recommended treatment modality. In sensitivity analysis, there were no in-hospital mortality difference between exposed and unexposed patients (10.8% and 10.5%, respectively, p=0.76). Excluding patients who died in the hospital did not change the main results. Conclusions: Patients whose facility is impacted by a wildfire disaster during recovery from lung cancer surgery have longer length of stay than similar patients treated at the same facility but at times when no disaster occurred. Future studies should evaluate whether extended hospital stay improves safety and quality of surgical care. Moreover, these findings should be considered for disaster preparedness guidelines tailored to vulnerable patient population.

Automated Identification of HeartFailureWith Reduced Ejection Fraction Using Deep Learning-Based Natural Language Processing.

The lack of automated tools for measuring care quality limits the implementation of a national program to assess guideline-directed care in heart failure with reduced ejection fraction (HFrEF). The authors aimed to automate the identification of patients with HFrEF at hospital discharge, an opportunity to evaluate and improve the quality of care. The authors developed a novel deep-learning language model for identifying patients with HFrEF from discharge summaries of hospitalizations with heart failure at Yale New Haven Hospital during 2015 to 2019. HFrEF was defined by left ventricular ejection fraction<40% on antecedent echocardiography. The authors externally validated the model at Northwestern Medicine, community hospitals of Yale, and the MIMIC-III (Medical Information Mart for Intensive Care III) database. A total of 13,251 notes from 5,392 unique individuals (age 73 ± 14 years, 48% women), including 2,487 patients with HFrEF (46.1%), were used for model development (train/held-out: 70%/30%). The model achieved an area under receiver-operating characteristic curve (AUROC) of 0.97 and area under precision recall curve (AUPRC) of 0.97 in detecting HFrEF on the held-out set. The model had high performance in identifying HFrEF with AUROC=0.94 and AUPRC=0.91 on 19,242 notes from Northwestern Medicine, AUROC=0.95 and AUPRC=0.96 on 139 manually abstracted notes from Yale community hospitals, and AUROC=0.91 and AUPRC=0.92 on 146 manually reviewed notes from MIMIC-III. Model-based predictions of HFrEF corresponded to a net reclassification improvement of 60.2 ± 1.9% compared with diagnosis codes (P< 0.001). The authors developed a language model that identifies HFrEF from clinical notes with high precision and accuracy, representing a key element in automating quality assessment for individuals with HFrEF.

Electronic Health Record Nudges and Health Care Quality and Outcomes in Primary Care

Nudges have been increasingly studied as a tool for facilitating behavior change and may represent a novel way to modify the electronic health record (EHR) to encourage evidence-based care. To evaluate the association between EHR nudges and health care outcomes in primary care settings and describe implementation facilitators and barriers. On June 9, 2023, an electronic search was performed in PubMed, Embase, PsycINFO, CINAHL, and Web of Science for all articles about clinician-facing EHR nudges. After reviewing titles, abstracts, and full texts, the present review was restricted to articles that used a randomized clinical trial (RCT) design, focused on primary care settings, and evaluated the association between EHR nudges and health care quality and patient outcome measures. Two reviewers abstracted the following elements: country, targeted clinician types, medical conditions studied, length of evaluation period, study design, sample size, intervention conditions, nudge mechanisms, implementation facilitators and barriers encountered, and major findings. The findings were qualitatively reported by type of health care quality and patient outcome and type of primary care condition targeted. The Risk of Bias 2.0 tool was adapted to evaluate the studies based on RCT design (cluster, parallel, crossover). Studies were scored from 0 to 5 points, with higher scores indicating lower risk of bias. Fifty-four studies met the inclusion criteria. Overall, most studies (79.6%) were assessed to have a moderate risk of bias. Most or all descriptive (eg, documentation patterns) (30 of 38) or patient-centeredness measures (4 of 4) had positive associations with EHR nudges. As for other measures of health care quality and patient outcomes, few had positive associations between EHR nudges and patient safety (4 of 12), effectiveness (19 of 48), efficiency (0 of 4), patient-reported outcomes (0 of 3), patient adherence (1 of 2), or clinical outcome measures (1 of 7). This systematic review found low- and moderate-quality evidence that suggested that EHR nudges were associated with improved descriptive measures (eg, documentation patterns). Meanwhile, it was unclear whether EHR nudges were associated with improvements in other areas of health care quality, such as effectiveness and patient safety outcomes. Future research is needed using longer evaluation periods, a broader range of primary care conditions, and in deimplementation contexts.

Inequalities in Ambulatory Care Sensitive Conditions: An International Comparison of High-Income Countries

ObjectiveTo examine the differences in inequalities in Ambulatory Care Sensitive Conditions (ACSC) hospitalizations relative to socioeconomic status across nine countries, namely Australia, Canada, England, Finland, France, New Zealand, Spain, Switzerland, and the United States (US). ApproachThe International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) research collaborative developed national data sets with hospitalization and sociodemographic data aggregated to small-area levels and pooled across countries using a common data model. Inequalities were assessed using both the slope index of inequality and the relative index of inequality. ResultsThis study developed a common definition and set of codes for ACSC hospitalizations that proved to be comparable across countries and regions. Consistent socioeconomic gradients were observed in all countries with higher ACSC hospitalization rates for individuals in most disadvantaged areas. The greatest difference in hospitalizations between the highest and lowest income quintiles were observed in New Zealand (1603 per 100,000), Finland (1802 per 100,000) and England (1955 per 100,000). ConclusionsThe high-income countries included in this study displayed many commonalities in inequalities in ACSC hospitalizations. As a proxy measure of primary care access and quality, the observed inequalities may implicate disparities in health care quality and access for the lowest socioeconomic status groups. ImplicationsBarriers to health care access in low socioeconomic groups remain a complex and multifaceted issue. Future research should investigate the underlying contributing factors to the observed ACSC hospitalization equity gradients, including primary care delivery model, remuneration approach, and population structure.

The maternal and newborn health eCohort to track longitudinal care quality: study protocol and survey development.

The MNH eCohort was developed to fill gaps in maternal and newborn health (MNH) care quality measurement. In this paper, we describe the survey development process, recruitment strategy, data collection procedures, survey content and plans for analysis of the data generated by the study. We also compare the survey content to that of existing multi-country tools on MNH care quality. The eCohort is a longitudinal mixed-mode (in-person and phone) survey that will recruit women in health facilities at their first antenatal care (ANC) visit. Women will be followed via phone survey until 10-12 weeks postpartum. User-reported information will be complemented with data from physical health assessments at baseline and endline, extraction from MNH cards, and a brief facility survey. The final MNH eCohort instrument is centered around six key domains of high-quality health systems including competent care (content of ANC, delivery, and postnatal care for the mother and newborn), competent systems (prevention and detection, timely care, continuity, integration), user experience, health outcomes, confidence in the health system, and economic outcomes. The eCohort combines the maternal and newborn experience and, due to its longitudinal nature, will allow for quality assessment according to specific risks that evolve throughout the pregnancy and postpartum period. Detailed information on medical and obstetric history and current health status of respondents and newborns will allow us to determine whether women and newborns at risk are receiving needed care. The MNH eCohort will answer novel questions to guide health system improvements and to fill data gaps in implementing countries.

Comparing methods for assessing the reliability of health care quality measures.

Quality measurement plays an increasing role in U.S. health care. Measures inform quality improvement efforts, public reporting of variations in quality of care across providers and hospitals, and high-stakes financial decisions. To be meaningful in these contexts, measures should be reliable and not heavily impacted by chance variations in sampling or measurement. Several different methods are used in practice by measure developers and endorsers to evaluate reliability; however, there is uncertainty and debate over differences between these methods and their interpretations. We review methods currently used in practice, pointing out differences that can lead to disparate reliability estimates. We compare estimates from 14 different methods in the case of two sets of mental health quality measures within a large health system. We find that estimates can differ substantially and that these discrepancies widen when sample size is reduced.

Evidence on the effectiveness of value-based payment schemes implemented in a hospital setting: A systematic review.

Value-based payment is among payment models rewarding health care providers for achieving pre-defined targets of quality or efficiency measures of care. This paper aims to identify the evidence of the effectiveness of value-based payment schemes implemented in hospital settings. A systematic review of databases for studies published from 2000 to 2022 that evaluated VBP programs was conducted. We searched four databases including PubMed, Scopus, Embase, and Web of Sciences in July 2023. Studies were screened and assessed for eligibility. A thematic analysis approach was used to synthesize and summarize the findings. Overall, 29 articles looking into the VBP programs have been included. Most articles describe the effects on the outcome of care (n = 18). The findings of a great deal of evidence in this field show that VBP is not correlated with some outcome measures including hospital-acquired conditions, 30-day mortality, mortality trends, as well as mortality among patients with acute myocardial infarction or heart failure. Only three of 12 studies have revealed a positive relationship between a P4P program and efficiency. Seven studies from the United States (US) found no evidence or mixed findings on the effects of P4P on efficiency. The magnitude of the effects of VBP on healthcare quality, patient experience, and costs has often been small and non-significant. The unintended negative impact of incentives in value-based payment on hospitals should be tackled when adopting policies and decisions.

Conceptual and methodological recommendations for assessing the empirical validity of process measures of health care quality.

Conceptual and methodological recommendations for assessing the empirical validity of process measures of health care quality.

Suboptimal monitoring and management in patients with unrecorded stage 3 chronic kidney disease in real-world settings: Insights from REVEAL-CKD.

Clinical practice guidelines for patients with chronic kidney disease (CKD) recommend regular monitoring and management of kidney function and CKD risk factors. However, the majority of patients with stage 3 CKD lack a diagnosis code, and data on the implementation of these recommendations in the real world are limited. To assess the implementation of guideline-directed monitoring and management practices in the real world in patients with stage 3 CKD without a recorded diagnosis code. REVEAL-CKD (NCT04847531) is a multinational, observational study of patients with stage 3 CKD. Eligible patients had ≥2 consecutive estimated glomerular filtration rate (eGFR) measurements indicative of stage 3 CKD recorded >90 and ≤730 days apart, lacked an International Classification of Diseases 9/10 diagnosis code corresponding to CKD any time before and up to 6 months after the second eGFR measurement. Testing of key measures of care quality were assessed. The study included 435,971 patients from 9 countries. In all countries, the prevalence of urinary albumin-creatinine ratio and albuminuria testing was low. Angiotensin-converting enzyme inhibitor, angiotensin receptor blocker and statin prescriptions were highly variable, and sodium-glucose cotransporter-2 inhibitor prescriptions remained below 21%. Blood pressure measurements were recorded in 20.2%-89.9% of patients. Overall, a large proportion of patients with evidence of stage 3 CKD did not receive recommended, guideline-directed monitoring and management. The variability in standard of care among countries demonstrates a clear opportunity to improve monitoring and management of these patients, most likely improving long-term outcomes.