Effectiveness Of Quality Improvement Strategies Research Articles

Quality improvement strategies enhance primary care dietetics: A systematic review and meta-analysis.

Quality improvement strategies have been widely applied in health care; however, little is known about their use in primary care dietetics. This review aims to describe and evaluate the effectiveness of quality improvement strategies that seek to improve patient outcomes by enhancing dietetic care compared to standard dietetic care. The study employed a systematic review and meta-analysis design following PRISMA guidelines and included studies up to March 2021. Studies were included if they used a randomised controlled trial (RCT) design to evaluate the effect of a quality improvement strategy applied to care delivered by a dietitian on patient outcomes. A meta-analysis was conducted where there were sufficient studies with homogeneous populations and outcome measures. Twelve RCTs (n = 1604) met the inclusion criteria for review and five studies (n = 511) were eligible for meta-analysis for glycated haemoglobin in patients with type 2 diabetes. The most frequently reported quality improvement strategies addressed disease management programs (58%), patient education (67%), group care (42%) and patient self-management (42%). A positive intervention effect was reported in 50% of the included studies. A low grade of evidence supported a positive intervention effect for quality improvement intervention by a dietitian for glycated haemoglobin (pooled mean difference = -0.39% with 95% confidence interval=-0.70 to -0.08, p = 0.01) in n = 511 patients with type 2 diabetes mellitus. Interventions aimed at enhancing quality in primary care dietetic practice support improvements in patient outcomes. Further research on quality improvement interventions for patient outcomes is required to strengthen the evidence base in this important topic.

Effectiveness of quality improvement strategies for type 1 diabetes in children and adolescents: a systematic review protocol

Introduction: Optimal glycaemic control is often a challenge in children and adolescents with type 1 diabetes (T1D). Implementation of patient, clinician or organisation-targeted quality improvement (QI) strategies has been proven to be beneficial in terms of improving glycaemic outcomes in adults living with diabetes. This review aims to assess the effectiveness of such QI interventions in improving glycaemic control, care delivery, and screening rates in children and adolescents with T1D. Methods and analysis: MEDLINE, EMBASE, CINAHL and Cochrane CENTRAL databases will be searched for relevant studies up to January 2021. Trial registries, ClinicalTrials.gov and ICTRP, will also be explored for any ongoing trials of relevance. We will include trials which examine QI strategies as defined by a modified version of the Cochrane Effective Practice and Organisation of Care 2015 Taxonomy in children (<18 years) with a diagnosis of T1D. The primary outcome to be assessed is glycated haemoglobin (HbA1c), although a range of secondary outcomes relating to clinical management, adverse events, healthcare engagement, screening rates and psychosocial parameters will also be assessed. Our primary intention is to generate a best-evidence narrative to summarise and synthesise the resulting studies. If a group of studies are deemed to be highly similar, then a meta-analysis using a random effects model will be considered. Cochrane Risk of Bias 1.0 tool will be applied for quality assessment. All screening, data extraction and quality assessment will be performed by two independent researchers. Dissemination: The results of this review will be disseminated through peer-reviewed publication in order to inform invested partners (e.g., Paediatric Endocrinologists) on the potential of QI strategies to improve glycaemic management and other related health outcomes in children with T1D, thereby guiding best practices in the outpatient management of the disorder. PROSPERO registration number: CRD42021233974 (28/02/2021).

Low-Burden Strategies to Promote Smoking Cessation Treatment Among Patients With Serious Mental Illness.

Patients with serious mental illness have high smoking prevalence and early mortality. Inadequate implementation of evidence-based smoking cessation treatment in community mental health centers (CMHCs) contributes to this disparity. This column describes a study of the effects of quality improvement strategies on treatment and cessation outcomes among patients with serious mental illness at four CMHCs. Two low-burden strategies, decision support and academic detailing with data-driven feedback, were implemented in the CMHCs' clinics from 2014 to 2016. Pre- and postimplementation data from pharmacy and medical records were analyzed. The percentage of patients receiving cessation medication increased from 5% to 18% (p≤.001), and smoking prevalence decreased from 57% to 54% (p≤.001). This quality improvement approach holds great potential for increasing the level of smoking cessation care for patients treated in CMHC settings. Decision support and academic detailing with feedback may be effective strategies to promote best practices.

Effectiveness of Quality Improvement Strategies for the Management of CKD: A Meta-Analysis.

Quality improvement interventions have enhanced care for other chronic illnesses, but their effectiveness for patients with CKD is unknown. We sought to determine the effects of quality improvement strategies on clinical outcomes in adult patients with nondialysis-requiring CKD. We conducted a systematic review of randomized trials, searching Medline and the Cochrane Effective Practice and Organization of Care database from January of 2003 to April of 2015. Eligible studies evaluated one or more of 11 prespecified quality improvement strategies, and prespecified study outcomes included at least one process of care measure, surrogate outcome, or hard clinical outcome. We used a random effects model to estimate the pooled risk ratio (RR; dichotomous data) or the mean difference (continuous data). We reviewed 15 patient-level randomized trials (n=3298 patients), and six cluster-randomized trials (n=30,042 patients). Quality improvement strategies reduced dialysis incidence (seven trials; RR, 0.85; 95% confidence interval [95% CI], 0.74 to 0.97) and LDL cholesterol concentrations (four trials; mean difference, -17.6 mg/dl; 95% CI, -28.7 to -6.5), and increased the likelihood that patients received renin-angiotensin-aldosterone system inhibitors (nine trials; RR, 1.16; 95% CI, 1.06 to 1.27). We did not observe statistically significant effects on mortality, cardiovascular events, eGFR, glycated hemoglobin, and systolic or diastolic BP. Quality improvement interventions yielded significant beneficial effects on three elements of CKD care. Estimates of the effectiveness of quality improvement strategies were limited by study number and adherence to quality improvement principles. This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_09_06_CJASNPodcast_17_10.mp3.

The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews.

BackgroundIt is now widely accepted that the mixed effect and success rates of strategies to improve quality and safety in health care are in part due to the different contexts in which the interventions are planned and implemented. The objectives of this study were to (i) describe the reporting of contextual factors in the literature on the effectiveness of quality improvement strategies, (ii) assess the relationship between effectiveness and contextual factors, and (iii) analyse the importance of contextual factors.MethodsWe conducted an umbrella review of systematic reviews searching the following databases: PubMed, Cochrane Database of Systematic Reviews, Embase and CINAHL. The search focused on quality improvement strategies included in the Cochrane Effective Practice and Organisation of Care Group taxonomy. We extracted data on quality improvement effectiveness and context factors. The latter were categorized according to the Model for Understanding Success in Quality tool.ResultsWe included 56 systematic reviews in this study of which only 35 described contextual factors related with the effectiveness of quality improvement interventions. The most frequently reported contextual factors were: quality improvement team (n = 12), quality improvement support and capacity (n = 11), organization (n = 9), micro-system (n = 8), and external environment (n = 4). Overall, context factors were poorly reported. Where they were reported, they seem to explain differences in quality improvement effectiveness; however, publication bias may contribute to the observed differences.ConclusionsContextual factors may influence the effectiveness of quality improvement interventions, in particular at the level of the clinical micro-system. Future research on the implementation and effectiveness of quality improvement interventions should emphasize formative evaluation to elicit information on context factors and report on them in a more systematic way in order to better appreciate their relative importance.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-0906-0) contains supplementary material, which is available to authorized users.

Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis.

Frequent users of health care services are a relatively small group of patients who account for a disproportionately large amount of health care utilization. We conducted a meta-analysis of the effectiveness of interventions to improve the coordination of care to reduce health care utilization in this patient group. We searched MEDLINE, Embase and the Cochrane Library from inception until May 2014 for randomized clinical trials (RCTs) assessing quality improvement strategies for the coordination of care of frequent users of the health care system. Articles were screened, and data abstracted and appraised for quality by 2 reviewers, independently. Random effects meta-analyses were conducted. We identified 36 RCTs and 14 companion reports (total 7494 patients). Significantly fewer patients in the intervention group than in the control group were admitted to hospital (relative risk [RR] 0.81, 95% confidence interval [CI] 0.72-0.91). In subgroup analyses, a similar effect was observed among patients with chronic medical conditions other than mental illness, but not among patients with mental illness. In addition, significantly fewer patients 65 years and older in the intervention group than in the control group visited emergency departments (RR 0.69, 95% CI 0.54-0.89). We found that quality improvement strategies for coordination of care reduced hospital admissions among patients with chronic conditions other than mental illness and reduced emergency department visits among older patients. Our results may help clinicians and policy-makers reduce utilization through the use of strategies that target the system (team changes, case management) and the patient (promotion of self-management).

Quality improvement strategies for diabetes management decrease HbA1c, cholesterol and blood pressure, and increase screening for disease complications

Commentary on: Tricco AC, Ivers NM, Grimshaw JM, et al. Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis. Lancet 2012; 379: 225–2 61.[OpenUrl][1]...

Effectiveness of quality improvement strategies on the management of diabetes

Effectiveness of quality improvement strategies on the management of diabetes

Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis

The effectiveness of quality improvement (QI) strategies on diabetes care remains unclear. We aimed to assess the effects of QI strategies on glycated haemoglobin (HbA(1c)), vascular risk management, microvascular complication monitoring, and smoking cessation in patients with diabetes. We identified studies through Medline, the Cochrane Effective Practice and Organisation of Care database (from inception to July 2010), and references of included randomised clinical trials. We included trials assessing 11 predefined QI strategies or financial incentives targeting health systems, health-care professionals, or patients to improve management of adult outpatients with diabetes. Two reviewers independently abstracted data and appraised risk of bias. We reviewed 48 cluster randomised controlled trials, including 2538 clusters and 84,865 patients, and 94 patient randomised controlled trials, including 38,664 patients. In random effects meta-analysis, the QI strategies reduced HbA(1c) by a mean difference of 0·37% (95% CI 0·28-0·45; 120 trials), LDL cholesterol by 0·10 mmol/L (0·05-0.14; 47 trials), systolic blood pressure by 3·13 mm Hg (2·19-4·06, 65 trials), and diastolic blood pressure by 1·55 mm Hg (0·95-2·15, 61 trials) versus usual care. We noted larger effects when baseline concentrations were greater than 8·0% for HbA(1c), 2·59 mmol/L for LDL cholesterol, and 80 mm Hg for diastolic and 140 mm Hg for systolic blood pressure. The effectiveness of QI strategies varied depending on baseline HbA(1c) control. QI strategies increased the likelihood that patients received aspirin (11 trials; relative risk [RR] 1·33, 95% CI 1·21-1·45), antihypertensive drugs (ten trials; RR 1·17, 1·01-1·37), and screening for retinopathy (23 trials; RR 1·22, 1·13-1·32), renal function (14 trials; RR 128, 1·13-1·44), and foot abnormalities (22 trials; RR 1·27, 1·16-1·39). However, statin use (ten trials; RR 1·12, 0·99-1·28), hypertension control (18 trials; RR 1·01, 0·96-1·07), and smoking cessation (13 trials; RR 1·13, 0·99-1·29) were not significantly increased. Many trials of QI strategies showed improvements in diabetes care. Interventions targeting the system of chronic disease management along with patient-mediated QI strategies should be an important component of interventions aimed at improving diabetes management. Interventions solely targeting health-care professionals seem to be beneficial only if baseline HbA(1c) control is poor. Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research (now Alberta Innovates--Health Solutions).

Exploring the black box of change in improving test-ordering routines

The effects of quality improvement strategies are sometimes limited in spite of a systematic development approach. What elements play a role in the change process is not yet fully understood. To explore this 'black box' of change, by analysing the barriers and facilitators GPs perceive during the change process. Qualitative study among GPs who participated in the quality improvement strategy arm of a randomized clinical trial on blood test ordering for unexplained complaints (UCs). The strategy was based on a national guideline that advocates delayed test ordering in patients presenting with UCs. Each GP's change process was assessed by means of a semi-structured interview about barriers to and facilitators of change. Twenty-four interviews were analysed. Important themes identified in the interviews were lack of problem awareness, the time and effort it takes to change, influence of patients and the pros and cons of the changed behaviour. The themes can be summarized into one comprehensive issue: the GPs lack a sense of urgency to change. An important explanation seems to be that two questions from the problem analysis prior to the development of the strategy had not been adequately answered: "Is the GPs' current behaviour a problem and does the problem have consequences for patients?" and if so, "What is the extent of the problem?." As a result, insufficient attention was given to applicability issues, such as time investment, costs and patient and practitioner satisfaction and anxiety.

Effects of Quality Improvement Strategies for Type 2 Diabetes in Bronx,N.Y.

Improving care of people with diabetes has become a major goal for many institutions. This is particularly important in the Bronx because we deal with a large underserved population of ethnic/racial minorities that is susceptible to more diabetes and further complications. Montefiore Medical Center already has in place many resources, such as multidisciplinary diabetes workgroups committed to implementing quality improvement (QI) projects. To carry on such endeavors, a complex and well-designed administrative support system is required from the executive office. The QI committees rely on step-by-step methodologies to define a series of factors that occur systematically and result in improved care. The large population with diabetes is cared for mainly by primary care physicians (PCPs) that are part of a large sophisticated health care system. Because of both the complexity and diversity of the population, several programs are tailored to the needs of specific subgroups. The implementation of different interventions and their effectiveness and cost must be properly assessed. Thus, QI projects are necessary to provide meaningful information that can be used for improving these health care systems and the patient care they provide. In this article, we describe the population of the Bronx, the structure and programs that are dedicated to diabetes at Montefiore, and our information technology (IT) system and how it can be used for QI programs. We also provide an example of how the system is being used. Although the Bronx is only one borough in New York City, its population is larger than all but five U.S. cities. This is a vibrant and younger population of diverse racial/ethnic backgrounds. Data from the U.S. Census Bureau, year 2000, illustrate how the Bronx statistics compare to national statistics. Average population age in the Bronx is 33.27 years versus 36.22 years nationally (71% are < 44 years of …

The quality dilemma

In the language and logic of the free market, providers of health care will have to demonstrate the quality of their work. However, in this setting quality is only interpreted in quantitative ways and consequently does not necessarily do justice to good physicians. Moreover, both outcome measures and process measures have serious drawbacks. An emphasis on outcome measures will disadvantage physicians working in deprived areas and doctors managing more complicated cases. Although process measures give the most direct information on the physician's performance, their evidence base is not always as straightforward as commonly supposed. Finally, measurement of quality indicators is complicated and time consuming. Physicians should be aware of the drawbacks of quality measurement and of the poor effects of quality improvement strategies on patient outcomes.

Better adherence to the guidelines during cardiopulmonary resuscitation through the provision of audio-prompts

Objective: Quality assurance to optimize clinical resuscitation performance is important. The aims of the present study were to identify the deficiencies in the clinical practice of resuscitation by motion analysis of video-recorded cardiopulmonary resuscitation (CPR), and to evaluate the effectiveness of quality improvement strategies based on audio-prompt methods. Materials and methods: A two-stage prospective trial was conducted. The first stage (observation group) was designed to identify any major clinical nonconformity to current resuscitation guidelines by videotaped CPR sessions. The second stage (intervention group) was designed to evaluate the effectiveness of audio prompts in ameliorating the problems identified at the first stage. The demographic data of patients and CPR variables between the two groups were analysed. Results: A total of 30 resuscitation attempts were recorded during study period: 17 patients were in the observation group and 13 patients in the intervention group. Inadequate number of chest compressions per minute, lack of re-oxygenation during prolonged intubation attempts and unnecessary hands-off periods were identified as the three most important deficiencies in CPR practice. Compared to the observation group, the intervention group showed a significant improvement in the hands-off period per minute during CPR (12.7 ± 5.3 s versus16.9 ± 7.9 s, P < 0.05), the total hands-off time during CPR (164 ± 94 s versus 273 ± 153 s, P < 0.05), the proportion of intubation attempts taking under 20 s (56.3% versus 10%, P < 0.05). Conclusions: Audio-prompts can improve the adherence to current CPR guidelines in the clinical setting significantly. The quality improvement measures described in this study are helpful in translating CPR knowledge into clinical practice.