Core Quality Measures Research Articles

Click and learn: a longitudinal interprofessional case-based sepsis education curriculum

BackgroundSepsis is a global healthcare challenge and a leading cause of morbidity and mortality. In the USA, the Centers for Medicare & Medicaid Services has integrated the Severe Sepsis and...

Defining core quality measures for paediatric critical care using a multi-stakeholder, consensus driven process

Defining core quality measures for paediatric critical care using a multi-stakeholder, consensus driven process

Do prehospital sepsis alerts decrease time to complete CMS sepsis measures?

IntroductionIn an effort to improve sepsis outcomes the Centers for Medicare and Medicaid Services (CMS) established a time sensitive sepsis management bundle as a core quality measure that includes blood culture collection, serum lactate collection, initiation of intravenous fluid administration, and initiation of broad-spectrum antibiotics. Few studies examine the effects of a prehospital sepsis alert protocol on decreasing time to complete CMS sepsis core measures. MethodsThis study was a retrospective cohort study of patients transported via EMS from December 1, 2018 to December 1, 2019 who met the criteria of the Maryland Statewide EMS sepsis protocol and compared outcomes between patients who activated a prehospital sepsis alert and patients who did not activate a prehospital sepsis alert. The Maryland Institute for Emergency Medical Services Systems developed a sepsis protocol that instructs EMS providers to notify the nearest appropriate facility with a sepsis alert if a patient 18 years of age and older is suspected of having an infection and also presents with at least two of the following: temperature >38 °C or <35.5 °C, a heart rate >100 beats per minute, a respiratory rate >25 breaths per minute or end-tidal carbon dioxide less than or equal to 32 mmHg, a systolic blood pressure <90 mmHg, or a point of care lactate reading greater than or equal to 4 mmol/L. ResultsMedian time to achieve all four studied CMS sepsis core measures was 103 min [IQR 61–153] for patients who received a prehospital sepsis alert and 106.5 min [IQR 75–189] for patients who did not receive a prehospital sepsis alert (p-value 0.105). Median time to completion was shorter for serum lactate collection (28 min. vs 35 min., p-value 0.019), blood culture collection (28 min. vs 38 min., p-value <0.01), and intravenous fluid administration (54 min. vs 61 min., p-value 0.025) but was not significantly different for antibiotic administration (94 min. vs 103 min., p-value 0.12) among patients who triggered a sepsis alert. ConclusionThis study questions the effectiveness of prehospital sepsis alert protocols on decreasing time to complete CMS sepsis core measures. Future studies should address if these times can be impacted by having EMS providers independently administer antibiotics.

Hospital-Based Nursing Research: Clinical and Economic Outcomes.

We surveyed 181 nursing research leaders from Magnet® hospitals, using mixed methods with the online Hospital-Based Nursing Research Clinical and Economic Outcomes survey, to describe the clinical and economic outcomes of nursing research conducted in hospital settings. We used descriptive statistics to analyze the quantitative findings and a qualitative descriptive approach to study the open-ended responses. Most respondents reported that findings from their hospital-based studies were implemented on their units (88.2%), improved health care processes (88.2%), and reduced hospital costs (79%). Over 50% reported positive impacts on core quality measures, including improving patient/family satisfaction (76.8%), nurse satisfaction (65%), length of stay (59.1%), and infection rates (56.5%). Four themes were identified: study evaluation, improvements in care delivery/clinical outcomes, economic impact, and intrinsic and extrinsic rewards. Much of the research reported by respondents focused on quality measures with findings that resulted in improved clinical and economic outcomes.

Patient-centered oncology care: impact on utilization, patient experiences, and quality.

To determine whether implementation of patient-centered oncology standards in 5 medical oncology practices improved patient experiences and quality and reduced emergency department (ED) and hospital use. Retrospective, pre-post study design with a concurrent nonrandomized control group. We used insurance claims to calculate all-cause hospitalizations and ED visits and primary care and specialist office visits (n = 28,826 eligible patients during baseline and 30,843 during follow-up) and identify patients for a care experiences survey (n = 715 preintervention and 437 postintervention respondents). For utilization and patient experience outcomes, we compared pilot practices' performance with 18 comparison practices using difference-in-differences (DID) regression models accounting for practice-level clustering. We assessed pilot practice performance on 31 quality measures from the American Society of Clinical Oncology Quality Oncology Practice Initiative program. There were no statistically significant differences in hospital, ED, or primary care visits between the pilot and comparison groups over time, but there was a significant increase in specialty visits for the pilot group (adjusted DID of 0.07; 95% CI, 0.01-0.13; P = .03). For care experiences, pilot practices improved more on shared decision-making (4.03 DID composite score; P = .013), whereas the comparison group improved more on access (-6.36 DID composite score; P < .001) and exchanging information (-4.25 DID composite score; P = .013). On average, pilot practices improved performance on 65% of core quality measures from baseline to follow-up. This pilot of patient-centered oncology care showed improved quality but no impact on hospitalizations/ED use and mixed results for patient experiences. Findings are consistent with early evaluations of primary care patient-centered medical homes.

959 Cirrhosis Patients Admitted With Ascites Have Longer Length of Stay and Higher 30-Day Readmission Rate

INTRODUCTION: Hospitalizations and readmissions in cirrhosis patients pose a significant economic burden to the health care system. Readmission rates are high for patients with decompensated cirrhosis; 30-day rates are as high as 30–40%. We aimed to identify the frequency and predictors of 30-day readmission rates in patients with decompensated cirrhosis admitted to two academic hospitals. METHODS: Using research informatics and validated ICD-10 codes, we identified cirrhosis patients admitted to the University of Miami Hospital (UMH) from 10/1/2017 to 10/1/2018. (Figure 1) After retrospective chart review, we excluded patients without cirrhosis or qualifying admissions. As patients from UMH are often admitted to Jackson Memorial Hospital, those records were also reviewed for admissions during the study period. Univariate analysis was conducted to describe demographics and disease-specific characteristics and identify variables associated with 30-day readmission rates. RESULTS: In our sample, 105 patients met inclusion criteria with 208 eligible admissions. Median age was 63 and 67.6% were male. During the index admission, the primary admission diagnosis was ascites in 36 patients, upper GI bleed in 15, and hepatic encephalopathy (HE) in 13. For 41 patients, the reason for admission is listed as other. (Table 1) The average length of stay (LOS) during the index admission was 7 days (±7.5). The readmission rate was 52.7%; the 30-day readmission rate was 25.8%. Twelve patients died during the index admission. Fifty patients had at least one readmission; range (1–8). A higher proportion of ascites patients were readmitted within 30 days, 35.3%, compared to 23.1% in those with GI bleed, 27.7% of HE patients and 17.1% of those with other diagnoses. Those with ascites also had the longest LOS, mean 7.67 days (±10). Noting the above results, we focused on the 47 patients with a primary or secondary diagnosis of ascites. Average time to paracentesis was 2 days. Only one patient with ascites (2.1%) was scheduled for paracentesis prior to discharge; 38 (81.8%) were discharged on diuretics. Fourteen patients (29.8%) were readmitted with a primary diagnosis of ascites (Table 2). CONCLUSION: Patients with decompensated cirrhosis are frequently readmitted in less than 30 days; ascites contributed to increased LOS and readmission rates. Additional study is needed to determine if Implementation of core quality measures decreases readmission rates and/or improves quality of life.

Implementation of the Core Quality Measures Collaborative (CQMC) Core Measure Sets by Public Payers: Successes and Opportunities

The present study reviews the accuracy of four methods (polls, prediction markets, expert judgment, and quantitative models) for forecasting the two German federal elections in 2013 and 2017. On average across both elections, polls and prediction markets were most accurate, while experts and quantitative models were least accurate. However, the accuracy of individual forecasts did not correlate across elections. That is, the methods that were most accurate in 2013 did not perform particularly well in 2017. A combined forecast, calculated by averaging forecasts within and across methods, was more accurate than three of the four component forecasts. The results conform to prior research on US presidential elections in showing that combining is effective in generating accurate forecasts and avoiding large errors.

Framing advance care planning in Parkinson disease: Patient and care partner perspectives.

Advance care planning (ACP) is a core quality measure in caring for individuals with Parkinson disease (PD) and there are no best practice standards for how to incorporate ACP into PD care. This study describes patient and care partner perspectives on ACP to inform a patient- and care partner-centered framework for clinical care. This is a qualitative descriptive study of 30 patients with PD and 30 care partners within a multisite, randomized clinical trial of neuropalliative care compared to standard care. Participants were individually interviewed about perspectives on ACP, including prior and current experiences, barriers to ACP, and suggestions for integration into care. Interviews were analyzed using theme analysis to identify key themes. Four themes illustrate how patients and care partners perceive ACP as part of clinical care: (1) personal definitions of ACP vary in the context of PD; (2) patient, relationship, and health care system barriers exist to engaging in ACP; (3) care partners play an active role in ACP; (4) a palliative care approach positively influences ACP. Taken together, the themes support clinician initiation of ACP discussions and interdisciplinary approaches to help patients and care partners overcome barriers to ACP. ACP in PD may be influenced by patient and care partner perceptions and misperceptions, symptoms of PD (e.g., apathy, cognitive dysfunction, disease severity), and models of clinical care. Optimal engagement of patients with PD and care partners in ACP should proactively address misperceptions of ACP and utilize clinic teams and workflow routines to incorporate ACP into regular care.

Core Quality and Outcome Measures for Pediatric Health

Core Quality and Outcome Measures for Pediatric Health

Evaluating the Effectiveness of Concurrent Review: Does It Improve Stroke Measure Results?

Concurrent review is a quality improvement strategy in which patients are tracked from admission to discharge, and messages are communicated to the responsible physician when quality stroke measures have not been met. There is little research regarding interventions that might influence clinical practice patterns and improvement in compliance with core quality measures. This study sought to evaluate whether concurrent review implementation was associated with change in performance on stroke measure outcome data. Randomly selected charts from 2 hospitals (A and B) during 3 time periods were reviewed. In period 1, neither hospital had a process for concurrent review. In period 2, hospital A, where concurrent review was implemented, was compared with hospital B without this process. In period 3, both hospitals had the process of concurrent review. Information on baseline demographics, insurance status, and length of stay was collected, as well as stroke performance measures. A total of 620 medical records were reviewed during the 3 time periods. Although the number of beds and annual stroke volume were higher at hospital B, patient characteristics were similar. During period 2, when hospital A implemented concurrent review and hospital B had not, a statistically significant higher compliance with performance in 7 stroke measures occurred in hospital A than in hospital B. In period 3, when both hospitals utilized concurrent review, no statistical significant differences occurred in 7 of the 10 stroke measures. Concurrent review is a quality improvement intervention that increases performance with stroke performance measures.

New "Core Quality Measures": Only a Beginning.

A plethora of quality measures are used in health care for quality improvement, accountability (including reimbursement), and research. The Core Quality Measures Collaborative, with input from the American Association of Family Physicians, recently released several groups of reduced core measure sets, including one for primary care. The proposed measures are less helpful for the increasing proportion patients with multiple morbidities or advancing illness. Going forward, the development of quality measures that assess multidimensional patient experiences and how closely the health care patients receive matches their goals in the face of multiple morbidities and advancing illness should be the focus.

Collaborative Care on the Stroke Unit: A Cross-Sectional Outcomes Study.

The aim of this study was to evaluate the economic and quality outcomes associated with a collaborative advanced practice nurse and hospitalist physician model of care on the inpatient stroke unit as compared with usual hospitalist physician-led care. High functioning collaborative teams are anticipated to be essential under value-based reimbursement. Hospitalist nurse practitioners were assigned to the stroke unit in collaboration with hospitalist physicians to implement daily hospital management for patients with stroke and transient ischemic attack. To evaluate outcomes associated with the care model, a retrospective cross-sectional design was used with 100 patients in the collaborative advanced practice nurse and hospitalist physician care group and 100 patients in the usual hospitalist physician-led care group. Primary outcome measures were length of stay, 30-day readmissions, stroke core measure documentation, and patient experiences of care. Analysis of demographic characteristics assured that the samples were similar. The collaborative care group performed better on one of five stroke core quality measures and on two of three patient experiences of care measures. Mean length of stay and hospital readmissions were similar between groups. Five patients left the stroke unit against medical advice in the usual hospitalist physician-led care group, whereas there were no discharges against medical advice in the collaborative care group. Advanced practice nurse and hospitalist physician collaboration is a promising model for healthcare quality improvement during inpatient stroke care; results are likely generalizable to other adult medicine populations.

Implementing a Hospitalist Program in a Critical Access Hospital.

The hospitalist model of inpatient care has rapidly expanded, but little is known about hospitalist care in critical access hospitals (CAHs). We aimed to determine the impact of a hospitalist model of care on staff satisfaction, patient volumes, patient satisfaction, length of stay, and care quality in a CAH. We initiated a hybrid rotating hospitalist program in September 2008 at Winneshiek Medical Center (Decorah, Iowa), a 25-bed rural CAH. We reviewed patient volumes, Centers for Medicare and Medicaid Services core quality measures, acute length of stay, and staff satisfaction for primary care-hospitalist physicians and inpatient and clinic nurses. Patient volume and length of stay were compared with CAH data reported by the Iowa Hospital Association. Patient volumes (acute, skilled, and observation) increased by 15% compared with a 17% decrease for statewide CAHs. Length of stay decreased from 2.88 to 2.75 days and remained lower than the average stay for Iowa CAHs (3.05 days). In the year after implementation, we observed no deterioration in core quality measures (range, 93%-100%) or patient satisfaction (86th percentile). Inpatient nurse satisfaction and primary care-hospitalist satisfaction improved. Early clinic nurse skepticism showed improved satisfaction at the 5-year review. Hospitalist care contributed to ongoing delivery of high-quality care and satisfactory patient experiences while supporting the mission of a CAH in rural Iowa. Implementation required careful consideration of its effects on the outpatient practice. Broader implementation of this model in CAHs may be warranted.

Temporal trends and variability of colonoscopy performance in a gastroenterology practice.

Quality measures for colonoscopy are operator dependent and vary. It is unclear whether quality measures change over time. In this study, time-dependent variation in colonoscopy performance was examined in a gastroenterology practice. Colonoscopy and histopathology records that were collected at three hospitals (one university and two non-university hospitals) over three time periods (2007, 2010, and 2013) were reviewed. Data from colonoscopists performing at least 100 procedures per year were analyzed. Inter-colonoscopist variation in performance (i. e. adjusted cecal intubation rate [aCIR], adenoma detection rate [ADR], advanced ADR, mean adenomas per procedure [MAP], proximal ADR, nonpolypoid ADR, and serrated polyp detection rate) were examined using coefficients of variation. Logistic regression analyses were also performed, adjusting for covariates. A total of 23 colonoscopists performing 6400 procedures were included. Overall, the mean aCIR, ADR, MAP, and proximal ADR improved significantly over time, from 91.9 %, 22.5 %, 0.37, and 10.2 % in 2007 to 95.3 %, 25.8 %, 0.45, and 13.4 %, respectively, in 2013 (P < 0.05). The inter-colonoscopist variation in ADR decreased from 37 % in 2007 to 15 % in 2013 (P < 0.05). In the non-university hospitals, mean values for quality measures increased significantly over time, whereas they remained stable in the university hospital. Variability in performance among colonoscopists decreased significantly within the gastroenterology clinical practice. Core quality measures improved over time, mainly through improvement of the lower performers. Measurement of inter-colonoscopist variation in performance helps to identify factors that stimulate or hinder performance, and forms the basis for interventions. http://www.trialregister.nl.

Unwarranted Pneumococcal Vaccination in an Acute Care Hospital Related to Core Quality Measure Initiatives

Unwarranted Pneumococcal Vaccination in an Acute Care Hospital Related to Core Quality Measure Initiatives

Unwarranted Pneumococcal Vaccination in an Acute Care Hospital Related to Core Quality Measure Initiatives

Unwarranted Pneumococcal Vaccination in an Acute Care Hospital Related to Core Quality Measure Initiatives

A new shield from the double-edged sword of reperfusion in STEMI

This editorial refers to ‘Cardioprotection by combined intrahospital remote ischaemic perconditioning and postconditioning in ST-elevation myocardial infarction: the randomized LIPSIA CONDITIONING trial’[†][1], by I. Eitel et al ., on page 3049. Beginning with the ‘open artery theory’ in the 1970s, the field of ST-segment elevation myocardial infarction (STEMI) management has been dominated by the fundamental principle that ‘time is muscle’, reflecting that prolonged coronary occlusion leads to myocardial injury.1 For this reason, contemporary management of STEMI focuses on rapid coronary reperfusion via balloon angioplasty and stenting to limit myocardial damage. The metric for success in STEMI therapy is a door to balloon (DTB) time of <90 min, which is defined as the interval from the first ECG showing STEMI to mechanical reperfusion of the occluded coronary artery. The DTB time is a standard part of ACC/AHA/ESC guidelines and a core quality measure of hospital and operator performance. However, recent data suggest that there may not be an incremental mortality benefit to a DTB time of <90 min in the setting of an anterior STEMI or cardiogenic shock.2 Furthermore, despite timely reperfusion, nearly 10% of acute myocardial infarction (AMI) patients die during their index hospitalization and two-thirds of survivors progress to develop chronic heart failure.3 These findings suggest that a re-examination of therapeutic priorities in the setting of AMI may be necessary. While coronary reperfusion to restore myocardial oxygen supply is ultimately necessary, the next generation of interventionalists will need to focus on alternative approaches both to improve survival and to reduce the burden of ischaemic heart failure. Described best by Braunwald and Kloner in 1985, myocardial reperfusion is a ‘double-edged … [1]: #fn-2

Fifteen years' experience of a College of American Pathologists program for continuous monitoring and improvement.

The Q-Tracks program, created in 1999, is a quality monitoring subscription service offered by the College of American Pathologists. To establish benchmarks in quality metrics, monitor changes in performance over time, and identify practice characteristics associated with better performance. The Q-Tracks program provides ongoing study of multiple metrics offered in most laboratory disciplines. The design enables measuring the effects of process changes and comparisons with other participating laboratories. Each laboratory Q-Tracks monitor has a primary quality indicator and additional secondary indicators. To date, 19 Q-Tracks monitors have been offered, with 12 currently active monitors. Q-Tracks are primarily conducted in hospital-based laboratories in the United States, Canada, and 21 other countries. Common to most Q-Tracks monitors is a demonstration of performance improvement by subscribers with long-term participation. This finding was seen in preanalytic, turnaround time, and postanalytic measures. Q-Tracks monitors contribute to the overall demonstration and improvement of laboratory and hospital quality because they address core quality measures for the College of American Pathologists Laboratory Accreditation Program and multiple Joint Commission National Patient Safety Goals. The Q-Tracks program has established multiple benchmarks in most disciplines of the laboratory and has demonstrated significant performance improvement in benchmarks and individual laboratories over time.

Integrating Two Measures of Quality Practice into Clinical and Practical Legal Education Assessment: Good client interviewing and effective community legal education

&lt;p&gt;This paper will examine, through two case studies (an undergraduate clinical program and a Practical Legal Education (PLE) advice clinic) the scope for indicators developed by Curran to assess the outcomes, effectiveness and quality of legal assistance service in Australia to be used in clinical assessment. This article will explore how two particular indicators evaluated as fundamental in that research might be utilised to assess students so as to enhance the quality of their clinical participation.&lt;/p&gt;&lt;p&gt;Clinical Legal Education is seen by its adherents as ‘a premier method of learning and teaching. Its intensive, one-on-one or small group nature can allow students to apply legal theory and develop their lawyering skills to solve client legal problems. Its teaching pedagogy is distinguished by a system of self-critique and supervisory feedback enabling law students to learn how to learn from their experiences’. In many senses it is a form of experiential learning through engagement with the practice of law.It aims to contextualise the study of law and draw on student learning in other courses to guide and support them in identifying, developing and applying ethical legal practice skills. But its scope is much wider than simply ‘skills’, it also aims to develop students’ critical understanding of approaches to legal practice, to their understanding of the roles of lawyers in relation to individual clients and social justice issues and to encourage and as a means to validate student aspirations to promote access to justice and equality through the law.&lt;/p&gt;&lt;p&gt;We suggest ways to assess the quality of such engagement by clinical students, focusing on Curran’s core quality measures of ‘a good client interview’ and ‘quality community legal education’. The value of utilising these two indicators to assess the quality of student engagement is that they themselves are core to the activities in which students are involved in clinic.&lt;/p&gt;

The impact of the distance from the interventional cardiologist's home to the hospital during off hours

The impact of the distance from the interventional cardiologist's home to the hospital and door to balloon time (DTBT) BACKGROUND: The importance of DTBT is highlighted by its inclusion as one of the core quality measures collected by the center for Medicare and Medicaid services and by the Joint commission on Accreditation of Healthcare organizations. We investigated the effect of time of day on the DTBT in patients having primary percutaneous coronary intervention (pPCI) and the impact of distance of the on call interventional cardiologist from the hospital on the DTBT and major adverse cardiac events (MACE) in patients undergoing pPCI during the off hours Patients enrolled in the study presented with STEMI either in the field or to the emergency department (ED) and underwent pPCI from October 2007 to July 2009 RESULTS: Significant predictors of DTBT included a history of prior MI (P = 0.001), prior percutaneous coronary intervention (P = 0.021), prior coronary artery bypass grafting (P < 0.001), and history of diabetes mellitus (P = 0.004). The strongest predictor of DTBT was on versus off hours. Mean DTB was 18.5 min greater during off hours (72 min) compared to on-hours (53.5 min). The distance from the cardiologist's home to the hospital was not associated with DTBT on multivariable analysis (P = 0.20) CONCLUSION: When pPCI is performed in a highly organized STEMI center with broad staff support and expertise in cardiac care, the increase in the DTBT during off hours was not associated with increase MACE rates.