Quality Of Clinical Outcomes Research Articles

What is the relationship between hospital management practices and quality of care? A systematic review of the global evidence.

There is a widely held view that good management improves organisational performance. However, hospitals are complex organisations and the relationship between management practices and health service delivery is not straightforward. We conducted a global, systematic literature review of the quantitative evidence on the link between the adoption of management practices and quality of care in hospitals. We searched in PubMed, EMBASE, EconLit, Global Health and Web of Science on 16th October 2024, without language or country restrictions. We included empirical studies from January 1, 2000, onward, examining the quantitative association between hospital management practices and quality of care. Outcomes included structural quality (availability of resources such as drugs and equipment), clinical quality (adherence to guidelines), health outcomes and patient satisfaction or experience with care. In every study, each tested association was categorised as significantly positive (at the 5 percent level), null or significantly negative. The study was registered with PROSPERO (CRD42022301462). Of 11,731 articles, 25 studies met the inclusion criteria and had acceptable risk of bias. Studies were equally distributed between high-income and low- and middle-income countries, with 22 cross-sectional and three intervention studies. Of 111 associations, 55 (49.5%) were significantly positive, 1 (1%) was significantly negative, and 55 (49.5%) were null. Among associations tested, the majority were significantly positive for structural quality (79%), clinical quality (60%) and health outcomes (57%), while most associations between hospital management and patient satisfaction (80%) were null. The findings are mixed, with a similar proportion of positive and null associations between management practices and quality of care across studies. The evidence is limited by risk of bias introduced by non-randomised study designs. Evidence of positive associations in some settings warrants further investigation of the association through intervention studies or natural experiments. This could leverage methodological developments in quantitatively measuring management, highlighted by this review.

No Difference in Clinical and Hospital Quality Outcomes in Treatment of Reverse Obliquity Intertrochanteric Hip Fractures (AO/OTA 31.A3) Based on Cephalomedullary Nail Length

IntroductionThe purpose of this study was to evaluate outcomes following reverse obliquity (RO) intertrochanteric hip fractures based on the use of short cephalomedullary nails (CMNs) compared to long CMNs for fixation. MethodsAn IRB-approved prospectively collected hip fracture registry at an urban academic medical center was queried for all AO/OTA 31A3.1-3 reverse obliquity intertrochanteric (RO) fractures. One hundred and seventy patients with age > 55 years old and minimum 6-month follow-up were identified for analysis. Data was collected for patient demographics, injury details, intraoperative radiographic parameters, perioperative physiologic parameters, hospital quality measures, and outcomes including radiographic time to healing, need for reoperation, nonunion, and mortality. Comparative analyses were conducted between cohorts. Additional multivariable binary logistic and linear regression analyses were performed to evaluate for factors independently associated with short and long nail usage. ResultsThe mean age of the entire cohort was 80.91±10.09 years: 103 patients had a long CMN implanted, and 67 patients had a short CMN implanted. There were no demographic differences or differences in radiographic time to healing, rates of mortality, readmission, nonunion, and need for reoperation. Univariable analysis revealed that short CMN had lower intraoperative blood loss (111.19±83.97mL vs 176.72±161.45mL, p=0.002), decreased need for transfusion (37% vs. 55%, p=0.022), and shorter procedures (118.67±57.87min vs. 148.95±77.83min, p=0.002. Multivariable analysis revealed that short nail usage was associated with decreased intraoperative blood loss, decreased need for transfusion, and shorter operative times. ConclusionNail length does not affect healing or hospital quality outcomes in the treatment of RO hip fractures. The use of short CMNs for these fractures did correlate with lower intraoperative blood loss, operative time, and need for blood transfusion, with non-inferior outcomes and similar hospital quality measures when compared to long CMNs.

Post Hospitalization Clinical Quality Outcomes Among US Patients with Schizophrenia Treated with a Long-Acting Injectable or Switched to a New Oral Antipsychotic: A Retrospective Cohort Study.

Adherence to antipsychotic medication and care discontinuity remain a challenge to healthcare practitioners providing care to patients with schizophrenia. This study used real-world data from a US hospital-based, all-payer database to examine clinical quality measures among patients with schizophrenia initiated on a long-acting injectable (LAI) or switched to a new oral antipsychotic medication (OAP) following a hospitalization. A retrospective cohort study using the PINC AI™ Healthcare Database compared two cohorts of patients with schizophrenia on post-index hospitalization clinical quality and care continuity endpoints. Patients initiated on an LAI (n = 7292) or switched to a new OAP (n = 31,956) during an index hospitalization between April 2017 and April 2020 were included. Propensity score weighting addressed differences in patient, hospital, and clinical characteristics between the two cohorts. Patients who initiated an LAI experienced significantly greater adjusted 30-day antipsychotic medication continuation to index therapy, higher rate of 30-day outpatient follow-up care, longer mean time to discontinuation of index therapy, and lower risk of discontinuing their index treatment compared to patients who switched to a new OAP (all p values < 0.001). Probability of 30-day antipsychotic medication continuation was significantly higher for LAI initiators than for patients who switched to a new OAP, even after controlling for patient, clinical, and hospital characteristics (adjusted odds ratio = 1.2, 95% CI 1.1-1.3, p < 0.001). Patients who initiated an LAI in a hospital setting experienced better clinical quality and care continuity outcomes compared to patients who were switched to a new OAP. These findings may be useful in identifying solutions to help improve the quality of medication management post-hospital discharge among patients with schizophrenia.

Will your insurance type influence clinical quality outcomes? An investigation of contributing factors, underlying mechanism, and consequences

Although past studies have found differences in clinical quality outcomes based on patients' insurance type, the extent of these discrepancies, the underlying mechanisms supporting this relationship, and factors that can moderate this effect have not yet been addressed. We seek to fill this gap by studying the relationship between insurance type and clinical quality outcomes using the level of care received, that is, treatment intensity, as a mediator. Using agency theory, we argue that underinsured patients (patients insured by Medicaid) will experience more adverse clinical quality outcomes due to lower treatment intensity compared to privately insured patients. We then explore whether two contextual factors—patient complexity and resource utilization—influence the relationship between insurance type and treatment intensity, and in turn clinical quality outcomes. We use 2010–2016 data from California to test these relationships. The insurance types used for comparison are private and Medi‐Cal (California's equivalent of Medicaid, representing underinsured patients). A patient's 30‐day readmission rate is used as a measure of clinical quality and the log of charges normalized by wage index and inflation (called treatment intensity) is used as a proxy for the level of care they received. We use within‐hospital coarsened exact score matching to create a comparable group of patients using private and Medi‐Cal insurance followed by a hospital fixed effects regression with errors clustered by hospital to test these relationships. Results indicate that treatment intensity mediates the relationship between insurance type and clinical quality outcomes. Further, the difference in treatment intensity based on insurance type is reduced as patient complexity increases, while higher utilization at a hospital lowers its incentive to provide equitable care to underinsured patients.

Introducing robotic oesophagectomy into an Australian practice: an assessment of the early procedural outcomes and learning curve

Robotic oesophagectomy (RAMIO) is a novel procedure in Australia and New Zealand. We aimed to report the early operative and clinical outcomes achieved during the introduction of RAMIO into the practice of a single Australian surgeon and benchmark these against outcomes of patients receiving conventional minimally invasive oesophagectomy (MIO) by the same surgeon. Data on all patients undergoing RAMIO, performed by a single high-volume Australian surgeon, were collected from a prospectively maintained database. Operative, clinical and surgical quality outcomes were benchmarked on a univariable basis against those of patients receiving MIO. Learning curves were computed using quadratic and linear regression of operating times on case-numbers and compared using Cox regression modelling. 290 patients (237 MIO, 53 RAMIO (47% Ivor-Lewis, 53% McKeon oesophagectomy)) were included. Compared with MIO, the median thoracic operating time was 20 min longer for RAMIO (P = 0.03). Following RAMIO, there was less blood loss (P < 0.01) and a shorter length of stay (P < 0.01).There were no differences in morbidity and quality of surgery following RAMIO compared with MIO. There were no deaths following RAMIO. Having progressed from MIO, the operating times for RAMIO improved after 22 cases compared with MIO (110 cases) (HR 0.70 (0.51-0.93), P = 0.01). With careful implementation, RAMIO may be safely performed within the Australian setting and is associated with a modest increase in procedure duration, but less blood loss and shorter length of stay compared with conventional MIO.

Gaining consensus on clinical quality outcomes for eating disorders: Framework for the development of an Australian national minimum dataset

ObjectivesEating disorders (EDs) are complex psychiatric illnesses requiring multidisciplinary care across both mental and medical healthcare settings. Currently, no nationally comprehensive, consistent, agreed on or mandated data set or data...

Drug Targeting Approaches and Use of Drug Delivery Systems in Management of Cancer.

Mutations and their manifestations in the form of various diseases and disorders result in cancer which is a major cause of human death worldwide. A considerable amount of information is available at the cellular, molecular and genetic levels regarding the occurrence and spread of precarious cancer; yet, there is no cure. The traditional methods of treatment such as chemotherapy, radiotherapy and surgical intervention have shown to be moderately effective and to keep some types of cancer under control, but each modality has its own advantages and disadvantages. In recent years, more advanced methods such as targeted therapies, immunotherapy, and precision medicine are shown to be promising, and these fields continue to expand rapidly along with the conventional methods. This review focuses on the reports of advanced methods of treatment from a scientific standpoint to recognize many new and modern approaches. Selective targeting of the tumour cells by nanoparticle-based novel drug delivery approaches includes the latest innovations in their preparation strategies and applications. The concept of precision medicine and its impact on treatment are highlighted here with the hope of individualised therapy with minimum side effects as a part of ever-expanding treatment strategies. Additional challenges related to cancer treatment like multi-drug resistance and toxicity are also deliberated in brief. Based on the available reports and scientific evidence, better targeted approaches with better quality clinical outcomes and more precise drug delivery to fit individual treatment needs are anticipated in the near future to control this deadly disease.

Impact of Acid, Weakly Acid and Alkaline Laryngopharyngeal Reflux on Voice Quality

To analyze pre to posttreatment voice changes regarding the type of reflux in patients with acid, weakly acid or alkaline laryngopharyngeal reflux (LPR). Patients with LPR, diagnosed using hypopharyngeal-esophageal multichannel intraluminal impedance pH-monitoring (HEMII-pH), were prospectively recruited from three University Hospitals. Patients were treated with a combination of diet, proton pump inhibitors, magaldrate and alginate for 3 months. The following clinical and voice quality outcomes were studied pre to posttreatment according to the type of reflux (acid, weakly acid, nonacid): HEMII-pH, gastrointestinal endoscopy features, reflux symptom score (RSS), reflux sign assessment (RSA), voice handicap index (VHI), perceptual voice assessment (grade of dysphonia and roughness), aerodynamic and acoustic measurements. From December 2018 to March 2021, 160 patients completed the evaluations, accounting for 60 acid, 52 weakly acid, and 48 alkaline cases of LPR. There were no baseline differences in clinical and voice quality outcomes between groups. RSS and RSA significantly improved from pre to posttreatment in the entire cohort and in all patient groups. VHI, dysphonia and roughness, maximum phonation time, Jitter, Shimmer and noise to harmonic ratio significantly improved from pre to posttreatment. Individuals with alkaline reflux reported better voice quality improvements as compared to acid and weakly acid reflux patients. Patients with acid and alkaline reflux reported better posttreatment voice quality outcomes as compared to weakly acid reflux patients. Future basic science and clinical studies are needed to better understand the histological changes of the vocal folds due to reflux of varying pH types and gastroduodenal enzyme content.

The effect of row number on clinical and life quality outcomes of patients who underwent arthroscopic rotator cuff repair

Objective: Shoulder pain and disability are mostly seen following rotator cuff rupture. Arthroscopic rotator cuff repair becomes a gold standard treatment for rotator cuff rupture when conservative treatment fails. Comparing functional results, retear rates and reoperation rates of arthroscopic rotator cuff repair in terms of single-row versus double row techniques is our aim in this study. &#x0D; Material and Method: Overall, 174 arthroscopic rotator cuff surgery patients were specified into 2 groups. Group 1 consists of 81 patients underwent single-row repair and group 2 consists of 93 patients consisted of transosseos equivalent technique double row. We evaluated demographic data and American Shoulder and Elbow Surgeons, Constant Murley, Visual analogue scale and 36-item Short Form subscale scores.&#x0D; Results: Mean follow-up time was 14.08±4.77 months. ASES, CM and VAS following ARCR were similar between two groups. Some of SF-36 subscale score improvements after operation are significantly better in group 2; role limitations due to physical health (p = 0.041), energy/fatigue (p = 0.026), emotional well-being (p = 0.017), pain (p = 0.010), general health (p = 0.037). Re-rupture rates were significantly different. In group 1 re-rupture rate was 13.6% and for group 2 it was 1.1% (p = 0.001).&#x0D; Conclusion: Lower re-rupture rates, and improved quality of life outcomes at short-term follow-up can be obtained by arthroscopic double-row repair. We suggest that the double-row technique can be considered for patients who have medium to large rotator cuff tears for lower re-rupture rates and some quality of life outcomes.

University COVID -19 Surveillance Testing Center: Challenges and Opportunities for Schools of Nursing.

As the impact of the COVID-19 pandemic became clear, it was evident that higher education schools and Universities, including schools of nursing were facing enormous challenges to create a safe environment for educational instruction to continue. Clinical education in particular was affected as clinical sites were increasingly unable to accommodate student clinical rotations due to crushing volumes and overwhelming care needs of COVID patients. This article outlines the innovative efforts of one university that set up a robust surveillance testing program that required and provided weekly COVID-19 testing of all students, faculty and staff that were on-campus. The testing center is nurse led and nurse managed, providing a clinical experience for over 50 nursing students each semester, allowing them to accrue community clinical hours so that they can progress through their nursing program. Clinical quality and patient experience outcomes are shared, and lessons learned described.

Are Online Patient Reviews Associated With Health Care Outcomes? A Systematic Review of the Literature

Although online patient reviews (OPRs) are ubiquitous, there has been debate about whether OPRs are associated with measures of health care outcomes. The majority of patients search for online information about a hospital or provider before scheduling an encounter, therefore, the extent to which OPRs are valid information is important. We conducted a systematic review of the literature to examine the extent to which OPRs are associated with measures of patient experience, clinical quality, and other outcomes. We searched Medline, CINAHL, Web of Science, and PsycInfo, which yielded 32 studies. There were consistent positive correlations between OPRs and patient experience at both the organization and individual provider levels of analysis. However, associations between OPRs and quality measures were mixed. Organizational level OPRs may be more reliable than individual provider OPRs. In addition, the strength of association could be affected by the type of encounter setting, specialty, and specific measures.

Mapping geographical disparities in population-level patient-reported quality of life following prostate cancer management.

e18531 Background: Prostate cancer patients generally have good survival outcomes, but some survivors have poor functional outcomes with persisting symptoms and poor quality of life (QoL). Socio-economic status (SES), access to specialist care and place of residence (including rural, remote areas) are associated with poor survival. These variables may also impact survivorship outcomes, including QoL. This study aimed to identify and visualise geographical disparities in QoL outcomes for prostate cancer survivors. Methods: We extracted complete data for 7690 patients, including patient-reported EPIC-26 QoL questionnaire results (12 months post-treatment), from the Prostate Cancer Outcomes Registry–Victoria (PCOR-VIC), a population-based clinical quality outcomes registry. Patient-matched geographic coordinates were obtained through the Victorian Cancer Registry. Scores from each of the 5 EPIC-26 functional domains were visualised using geospatial maps and correlated to the Index of Relative Socio-economic Advantage and Disadvantage (IRSAD) and geographical remoteness. A composite score condensing all 5 domains into a single number (range 5 – 20) was created for succinct visualisation of functional outcomes. We analysed hotspots using the Getis-Ord Gi* statistic. Results: Scores in all 5 functional domains were positively correlated to IRSAD, which remained an independent predictor of low functional score when controlling for age, disease stage, treatment modality and geographical remoteness (p &lt; 0.001 for all). Geographical remoteness predicted low functional score in all domains (p &lt; 0.05) except Urinary Irritative but was not statistically significant when adjusted for IRSAD. The constructed composite score was significantly correlated to IRSAD and remoteness in a univariate model (p &lt; 0.001). In a multivariate model, remoteness was not an independent predictor of outcome, but the composite score rose by 0.13 for each IRSAD decile (p &lt; 0.001), with patients in the bottom decile of IRSAD more likely to have composite scores below median ( &lt; 14) than those in the top decile (OR 1.8 CI 1.4-2.2 p &lt; 0.001). The composite score allowed visualisation of functional outcomes in a single figure and identification of geographic hotspots with poor outcome. Conclusions: Systematic collection of long-term patient-reported outcomes is feasible. Geographical disparities in QoL outcome following prostate cancer treatment correlated with SES and remoteness, and we note the relative importance of SES over remoteness. A single composite score for EPIC-26 showed face-validity. Our results will allow targeted efforts to further understand the drivers of these findings and improve equity in survivorship outcomes for prostate cancer survivors. The methods developed in this study can be extended and re-deployed to evaluate outcomes in other jurisdictions and cancer types.

Organizational Costs and Benefits of a Health System Quality Improvement Intervention to Increase Aspirin Use for Primary Prevention of Heart Attack and Stroke.

Performance improvement on clinical quality outcomes typically requires significant effort by personnel in health care organizations. Understanding the cost of quality improvement is important given diffusion of value-based contracting. This study investigates the organizational costs and benefits associated with planning and implementing the Ask about Aspirin intervention to increase use of low-dose aspirin in clinically recommended patient populations. Data from 4 health systems in Minnesota were used to estimate personnel effort and labor resource costs as well as corresponding benefits, measured as the change in aspirin use among eligible candidates during the study period. Overall personnel effort across the 4 systems was approximately 3900 hours with corresponding resource costs estimated to be $214,385. Aspirin use increased 4.7% overall, corresponding to roughly 1530 new users in the aspirin candidate population. Significant variation was observed by system in total hours reported, distribution of effort by activity type, and in benefits realized from the intervention.

A client-centered approach in home care for older persons – an integrative review

Objective To describe and synthesize client-centered care and service in home care for older persons. Methods The study was an integrative review using the guidelines for literature reviews by the Joanna Briggs Institute. The research process followed the Whittemore and Knafl framework and PRISMA toolkit in the selection of eligible articles. The CINAHL, Medline, Scopus, Web of Science and Social Sciences abstracts were searched for articles published between January 2007 and May 2020 according to previously designed search strategies. In total, 24 articles were deemed relevant for an analysis using a thematic analysis. Results The analysis resulted in four themes with sub-themes which revealed that client-centered care and service in home care consist of: 1) Clients’ involvement in their own care; self-care, decision-making, satisfactory daily life, 2) Family members’ and care partners’ participation in care; family members’ and care partners’ commitment to care, family members’ and care partners’ competence in care, 3) Communication and co-operation; communication models, empowerment, partnership, and 4) Evidence-based service competence; delivery and organization of services, implementation of services, versatile clinical skills, quality outcomes and personnel wellbeing. Conclusions According to the results, achieving client-centered care and service in home care requires the realization of all of the above aspects. The practice of nursing must better identify all dimensions of client-centered care and take these into account in the delivery of home care services. KEY POINTS Client-centeredness is a fundamental value and the basis of nursing and care in home care provided for older persons This paper: deepens and structures the concept of client-centered care in the context of home care. assists professionals to understand the factors behind client-centered care within the home care environment. provides deeper understanding of the roles of the older person, family members, and the service system in developing client-centered services in home care for older persons.

The Conduct of Sponsored Trials Has No Association with Dialysis Facility Clinical Quality Outcomes

The Conduct of Sponsored Trials Has No Association with Dialysis Facility Clinical Quality Outcomes

Mental health nursing in the 1960s remembered.

WHAT IS KNOWN ON THIS SUBJECT?: A growing literature is revealing the historical roles of nurses, their work and the various treatments with which they were involved. Remarkably little, however, has been written by nurses themselves about the culture in which they worked and the beliefs and values they held. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: In providing a personal account of psychiatric nurse training in the 1960s, this paper seeks to show the ways in which hospital culture and clinical practices shaped nursing identities and the attitudes of nurses towards their work. WHAT ARE IMPLICATIONS FOR PRACTICE?: This paper contributes to understanding the influence of cultural, managerial and attitudinal factors in shaping the work of mental health nurses and the quality of clinical outcomes they can achieve. ABSTRACT: For more than a century, mental hospitals were bedevilled by political disinterest, under-resourcing, patient neglect and over reliance on medication and ECT to ensure compliance. Labelling mental health problems as illnesses silenced patients while empowering doctors. In the 1960s, social revolution brought about major changes for mental health care including a reduction in hospital beds, the growth of community services, improved pharmacological and psychological interventions and the rise of patient activism. Tensions between biomedical and psychological models of mental illness arose which persists to the present day. Although historians have studied this period from different perspectives, relatively little has been written by nurses. This is a personal account of nursing in a large psychiatric hospital between 1962 and 1965.

Value-Based Care: An Executive Briefing

In today’s challenging health care environment, the paradigm shift from volume to value requires nurse leaders to develop enhanced skills to transform health care in 2020. Key drivers for success include: igniting innovation and change; embracing data and analytics; and launching new care delivery models that soar beyond organizational boundaries. Value-based care is here to stay, and nursing must be the catalyst for change. Equipped with new skills and the knowledge of CMS Pay for Performance programs, nurse leaders will design the future health care landscape.

MON-LB301 Application of Lean Six-Sigma DMAIC Tool for Improvement and Sustainability of Diabetes Management in Outpatient Clinics

DMAIC: Define, Measure, Analyze, Improve, Control. LSL: Lower specified limit. USL: Upper specified limit.Lean Six Sigma DMAIC is quality improvement methodology used for strategic business management. Frequent applications of this methodology in healthcare include improvement of patient satisfaction, reduction of emergency department waiting times, prescription error reduction and monetary recovery by reducing waste.Patients with a HgbA1c testing frequency of >6 months have poorer glycemic control. The American Diabetes Association recommends HgbA1c test quarterly in patients whose therapy has changed or who are not meeting glycemic goals and at least two times a year in patients who are meeting treatment goals.We hypothesized that the Lean Six-Sigma DMAIC tools can be used in the outpatient clinic setting to improve frequency of HgbA1c testing in patients with diabetes mellitus.At baseline, 19% of our patients with diabetes mellitus had HgbA1c tested infrequently, defined as more than 6 months. This high percentage is a concern as it could lead to poor diabetes control. The aim was to increase percentage of patients having an HgbA1c tested between 3 to 6 months before an appointment in our clinic, to a goal of 90%. Target population included all patients with diabetes mellitus seen in outpatient endocrinology clinic.A baseline analysis of existing processes was done through brainstorming with the clinic staff using a fish bone diagram. Lack of follow up and HgbA1c testing orders were some of the modifiable factors identified. The new processes implemented include nurse driven standing medical orders for HgbA1c testing and pre-visit planning. Control phase included regular audits to sustain the improvements.The percentage of patients with a HgbA1c testing within 3-6 months of appointment improved from a baseline of 76.7% (LSL:70%, USL:94%) to 92.2% (LSL:88%, USL:93.7%). The improvement was noticeable within 1 month of new process implementation and continues to sustain. The mean had an absolute improvement of 15.5%. The variation from the mean decreased from 25% at baseline to 6% at the end of the control phase. The reduction in variation made our future results more predictable.The use of Lean Six-Sigma DMAIC quality improvement tools are an effective method to improve quality of care in the outpatient setting. These strategies can be replicated for other clinical quality outcomes.

Using Lean Performance Improvement for Patient-Centered Medical Home Transformation at an Academic Public Hospital.

Although Lean performance improvement (PI) has been used in health care for more than 15 years, little is known about how Lean has been used in Patient-Centered Medical Home (PCMH) transformation. We describe our experience implementing Lean in our safety-net, primary care teaching clinic. To advance high value care, a culture of systematic, sustainable PI methods needed to be integrated into primary care and taught to resident physicians. Clinic leadership were trained in Lean methods, protected time was dedicated to PI for a stable, interdisciplinary team, then visual management was introduced, and resident physicians were integrated into the clinic's PI initiatives. Self-assessment using the PCMH Assessment tool demonstrated improvement in core features of the PCMH model. Process outcomes also revealed successful, sustainable integration of Lean into our primary care clinic and resident training, and early findings show improvements in clinical quality outcomes. Patient survey outcomes demonstrate improvement in patient experience. Lean can be used successfully to promote PCMH transformation and create a culture of continuous PI in an academic, safety-net primary care setting.

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