Guide Quality Improvement Efforts Research Articles

Does Rounding Order Bias Discharge Efficiency? Predictors of Discharge Timing on an Academic Urology Service.

No previous works have analyzed whether the order in which surgical teams see patients on morning rounds affects discharge efficiency at teaching hospitals. We obtained perioperative urologic surgery timing data at our academic institution from 2014 to 2019. We limited the analysis to routine postoperative day 1 discharges. Univariate and multivariate analyses were performed to determine whether various hospital and patient factors were associated with discharge timing. We analyzed 1,494 patients. Average discharge order time was 11:22 a.m. and hospital discharge 1:24 p.m. Univariate regression revealed earlier discharge order time for patients seen later in rounds by 4 minutes per sequential room cluster (p = .013) and by 12 minutes per cluster when excluding short-stay patients. Multivariate analysis revealed discharge order placement did not vary significantly by rounding order. However, time of hospital discharge did (p < .001), likely due to speed of discharge in the designated short-stay units. Attending physician was the most consistent predictor in variations of discharge timing, with statistical significance across all measured outcomes. Patients seen later in rounding progression received earlier discharge orders, but this relationship does not remain in multivariate modeling or translate to earlier discharge. These findings have helped guide quality improvement efforts focused on discharge efficiency.

Benefit of linking hospital resource information and patient-level Stroke Registry data.

Variation in delivery of evidence-based care affects outcomes for patients with stroke. A range of hospital (organizational), patient and clinical factors can affect care delivery. Clinical registries are widely used to monitor stroke care and guide quality improvement efforts within hospitals. However, hospital features are rarely collected. We aimed to explore the influence of hospital resources for stroke, in metropolitan and regional/rural hospitals, on the provision of evidence-based patient care and outcomes. 2017 National Audit organizational survey (Australia) linked with patient-level data from the Australian Stroke Clinical Registry (AuSCR) (2016-2017 admissions). Regression models were used to assess the associations between hospital resources (based on the 2015 Australian National Acute Stroke Services Framework) and patient care (reflective of national guideline recommendations), as well as 90 to 180 day readmissions and health-related quality of life (HRQoL). Models were adjusted for patient factors, including severity of stroke. 52/127 hospitals with organizational survey data were merged with 22,832 AuSCR patients with first-ever stroke/transient ischemic attack (median age 75years; 55% male; 66% ischemic). In metropolitan hospitals (N=42, 20,977 patients; 1,701 thrombolyzed; 2,395 readmitted between 90 and 180 days post stroke), a faster median door-to-needle time for thrombolysis was associated with 500+ annual stroke admissions (-15.9min, 95%CI -27.2,-4.7), annual thrombolysis >20 patients (-20.2min, 95%CI -32.0,-8.3), and having specialist stroke staff (dedicated medical lead and stroke coordinator;-12.7min, 95%CI -25.0,-0.4). A reduced likelihood of all cause readmissions between 90 and 180 days was evident in metropolitan hospitals using care pathways for stroke management (OR 0.82, 95%CI 0.67, 0.99). In regional/rural hospitals (N=10, 1,855 patients), being discharged with a care plan was also associated with use of stroke clinical pathways (OR 3.58, 95%CI 1.45, 8.82). No specific hospital resources influenced 90 to 180-day HRQoL. Relevant to all international registries, integrating information about hospital resources with clinical registry data provides greater insights into factors that influence evidence-based care.

Cardiovascular Disease Prevention in Persons with Hemophilia

Background: Advances in the treatment of hemophilia have resulted in a nearly normal life expectancy for persons with hemophilia (PwH). As a result of this improved life expectancy the aging hemophilia population is now experiencing age-related complications including cardiovascular disease (CVD), which is the leading cause of death in the US general population. Several studies have shown that the CVD risk profile among PwH is less favorable than that in the general population (Fransen van de Putte et al., 2013; Sood et al., 2018). Despite higher rates of hypertension among PwH, rates of treatment are lower than in the general population (Sood et al., 2018). We also know that atherosclerosis develops at the same rate among PwH as in the general population (Biere-Rafi et al., 2012; Zwiers et al., 2012). When CVD occurs in PwH, the management is more complicated due to the requirement for clotting factor concentrates to offset anticoagulant and antiplatelet therapies and prevent serious bleeding complications (Martin & Key, 2016). Recent prospective data indicate that the incidence of cardiovascular endpoints in PwH is lower than would be predicted by the QRISK-2011 score, but the use of novel therapies was not analyzed in that study, and we do not know how widespread use of these therapies will impact the development of CVD among PwH (Van Der Valk et al., 2022). Primary prevention of CVD through risk factor management is essential to prevent cardiovascular complications in the era of novel therapies for hemophilia. Study Design and Methods: This multicenter observational cohort study will utilize quality improvement science informed by frequent data sampling to improve the management of hypertension and dyslipidemia in PwH. Ten large hemophilia treatment centers will contribute 100 PwH each and will be stratified by age such that 25% of the population will be age 18-29, 30-44, 45-59, and 60-89. PwH will be eligible for inclusion if they have hemophilia A or B of any severity, are age 18-89, have been seen in the last 2 years, and do not anticipate relocating in the next 3 years. Men and women with hemophilia will be included. Individual consent will not be required as the dataset will be completely deidentified and the quality improvement interventions will be applied broadly to the hemophilia population at each center. Data will be collected from routine clinical care records. The primary outcome will be the prevalence of diagnosed and undiagnosed hypertension in this cohort. Secondary outcomes will be prevalence of dyslipidemia and rates of treatment for hypertension and dyslipidemia. Exploratory and descriptive statistical analyses will be performed. Deidentified data will be entered into a database via electronic medical record integration. This will allow for collection of 5 years of retrospective data, and subsequent monthly prospective data collection for 3 years. The automated nature of the data collection is novel and will allow for rapid record collection with minimal manual data entry, which can introduce errors and delay analysis. As such, a substantial number of records and timepoints can be collected. Conventional manual data entry of this scale would not be feasible for many independent academic studies. Table 1 contains the most relevant variables that will be collected. Retrospective data will be analyzed to determine the prevalence of hypertension, dyslipidemia, and established CVD. Rates of hypertension and dyslipidemia meeting criteria for diagnosis, but without an official diagnosis will also be determined along with rates of treatment in those who have been diagnosed. Investigators will be trained on the latest guidelines from the American College of Cardiology for the management of hypertension and dyslipidemia as part of this initiative. A survey will be distributed to participating investigators to determine barriers to control of vascular risk factors. This data be used by a steering committee to guide quality improvement efforts at each site. Monthly reports will inform investigators on the progress of their quality improvement initiatives. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

A root cause analysis system to establish the most plausible explanation for post-endoscopy upper gastrointestinal cancer.

BACKGROUND : Missing upper gastrointestinal cancer (UGIC) at endoscopy may prevent curative treatment. We have developed a root cause analysis system for potentially missed UGICs at endoscopy (post-endoscopy UGIC [PEUGIC]) to establish the most plausible explanations. METHODS : The electronic records of patients with UGIC at two National Health Service providers were examined. PEUGICs were defined as UGICs diagnosed 6-36 months after an endoscopy that did not diagnose cancer. An algorithm based on the World Endoscopy Organization post-colonoscopy colorectal cancer algorithm was developed to categorize and identify potentially avoidable PEUGICs. RESULTS : Of 1327 UGICs studied, 89 (6.7 %) were PEUGICs (patient median [IQR] age at endoscopy 73.5 (63.5-81.0); 60.7 % men). Of the PEUGICs, 40 % were diagnosed in patients with Barrett's esophagus. PEUGICs were categorized as: A - lesion detected, adequate assessment and decision-making, but PEUGIC occurred (16.9 %); B - lesion detected, inadequate assessment or decision-making (34.8 %); C - possible missed lesion, endoscopy and decision-making adequate (8.9 %); D - possible missed lesion, endoscopy or decision-making inadequate (33.7 %); E - deviated from management pathway but appropriate (5.6 %); F - deviated inappropriately from management pathway (3.4 %). The majority of PEUGICs (71 %) were potentially avoidable and in 45 % the cancer outcome could have been different if it had been diagnosed on the initial endoscopy. There was a negative correlation between endoscopists' mean annual number of endoscopies and the technically attributable PEUGIC rate (correlation coefficient -0.57; P = 0.004). CONCLUSION : Missed opportunities to avoid PEUGIC were identified in 71 % of cases. Root cause analysis can standardize future investigation of PEUGIC and guide quality improvement efforts.

Measuring the diverse characteristics of county adult protective services programs

ABSTRACT Adult protective services (APS) programs vary markedly, yet few studies have quantified this diversity. In 2020, a survey of Ohio’s 85 county-administered APS programs incorporated subsequent feedback from staff and described the programs in a systematic manner. This process resulted in a 100% response rate and illustrated an efficient approach to measuring organizational characteristics (e.g., whether any staff are mostly dedicated to APS), resources (e.g., access to multidisciplinary teams), and practices (e.g., how often staff create a plan to meet client goals). The prevalence of many factors differed by the number of older adults the program served. For instance, 75% of programs in large counties had regular opportunities to share complex cases with a multidisciplinary team, compared to 28% of programs in small counties. Understanding the diverse characteristics of APS programs – and how to measure them – can help agencies guide quality improvement efforts and the dissemination of innovations.

Perspectives of Rural Primary Care Clinicians on Pediatric Attention-Deficit/Hyperactivity Disorder Care.

Despite efficacious treatments, evidence-based guidelines, and increased availability of integrated behavioral health care, youth coping with attention-deficit/hyperactivity disorder (ADHD) receive suboptimal care. More research is needed to understand and address care gaps, particularly within rural health systems that face unique challenges. We conducted a qualitative study within a predominantly rural health system with a pediatric-integrated behavioral health care program to address research gaps and prepare for quality improvement initiatives, including primary care clinician (PCC) trainings and clinical decision support tools in the electronic health record (EHR). Semistructured interviews were conducted with 26 PCCs representing clinics within the health system. Interview guides were based on the Practical Robust Implementation and Sustainability Model to elicit PCC views regarding determinants of current practices and suggestions to guide quality improvement efforts. We used thematic analysis to identify patterns of responding that were common across participants. PCCs identified several internal and external contextual factors as determinants of current practices. Of note, PCCs recommended increased access to continuing education trainings held in clinic over lunch and delivered in less than 30 minutes. Suggested improvements to the EHR included incorporating parent and teacher versions of the Vanderbilt Rating Scale into the EHR, documentation templates aligned with evidence-based guidelines, and alerts and suggestions to aid medication management during appointments. Future research to identify implementation strategies to help rural PCCs adopt innovations are needed given the increased responsibility for managing ADHD care and intractable gaps in access to behavioral health care in rural regions.

Insights for conducting large-scale surveys with veterans who have experienced homelessness

ABSTRACT Surveys of underserved patient populations are needed to guide quality improvement efforts but are challenging to implement. The goal of this study was to describe recruitment and response to a national survey of Veterans with homeless experience (VHE). We randomly selected 14,340 potential participants from 26 U. S. Department of Veterans Affairs (VA) facilities. A survey contract organization verified/updated addresses from VA administrative data with a commercial address database, then attempted to recruit VHE through 4 mailings, telephone follow-up, and a $10 incentive. We used mixed-effects logistic regressions to test for differences in survey response by patient characteristics. The response rate was 40.2% (n = 5766). Addresses from VA data elicited a higher response rate than addresses from commercial sources (46.9% vs 31.2%, p < .001). Residential addresses elicited a higher response rate than business addresses (43.8% vs 26.2%, p < .001). Compared to non-respondents, respondents were older, less likely to have mental health, drug, or alcohol conditions, and had fewer VA housing and emergency service visits. Collectively, our results indicated a national mailed survey approach is feasible and successful for reaching VA patients who have recently experienced homelessness. These findings offer insight into how health systems can obtain perspectives of socially disadvantaged groups. Abbreviations: H-PACTS: Homeless-Patient Aligned Care Teams; SHEP: Survey of Healthcare Experiences of Patients; SRG: Strategic Research Group; USPS: United States Postal Service; VA: U.S. Department of Veterans Affairs; VHE: veterans with homeless experience

“I need to have a fulfilling job”: A qualitative study of surgeon well-being and professional fulfillment

BackgroundBurnout, often regarded as an individual failing, rather than a systemic one, negatively impacts quality of care, patient safety and healthcare costs. Focusing on improving well-being can help mitigate burnout. This study examined protective factors that promote well-being and professional fulfillment in surgeons. MethodsUsing a purposive sample, 32 semi-structured 30-60-min interviews were conducted with surgeons of varying sub-specialties and rank. Abductive exploratory analysis was used to code and interpret interview transcripts and to build a conceptual model of surgeon well-being. ResultsEmergent protective factors were placed into one of three levels of implementation: individual, team-level, and institutional (figure). Individual factors for well-being included autonomy and adequate time to pursue non-clinical endeavors. Team-level factors consisted of adaptability, boundaries, and cohesion. Institutional factors related to diversifying performance evaluations and celebrating and recognizing individual value and contributions. ConclusionsThe conceptual model developed from the results of this study highlights factors important to surgeons’ professional well-being. This model can be used to guide quality improvement efforts.

Enhancing Prehospital Outcomes for Cardiac Arrest (EPOC) study: sequential mixed-methods study protocol in Michigan, USA

IntroductionOut-of-hospital cardiac arrest (OHCA) is a common, life-threatening event encountered routinely by first responders, including police, fire and emergency medical services (EMS). Current literature suggests that there is significant regional...

Emergency department utilisation and critical readmission in patients with Fontan circulation.

We aimed to conduct a multi-centre study characterising emergency department utilisation and critical readmissions experienced by children with Fontan circulation. We conducted a retrospective review of children who underwent the Fontan operation at three institutions (i.e., centres A, B, and C) between 2009 and 2014, with follow-up through December 2015. Multi-variable analyses were performed to determine factors associated for emergency department utilisation within 1 year of surgery, emergency department utilisation at any time following surgery, or critical readmission (defined as admission to ICU, operating room, or cardiac catheterisation). We reviewed 297 patients, of which 147 patients (49%) had 607 emergency department encounters. Forty-six patients (15%) required 71 critical readmissions. Multi-variable analyses revealed centre C (p = 0.02) and post-operative hospitalisation ≥ 14 days (p = 0.03) to be significantly associated with emergency department utilisation within 1 year, whereas centre B (p < 0.001), post-operative hospitalisation ≥ 14 days (p = 0.002), and African-American/Black race (p = 0.04) were significantly associated with critical readmission. In this multi-centre study, nearly half of patients with Fontan circulation received emergency department care, often presenting with high disease acuity requiring readmission. Emergency department utilisation and need for critical readmission were independently influenced by the centre at which surgery was performed, prolonged post-operative hospitalisation, and racial background. These data could help guide quality improvement efforts aimed at reducing morbidity in this unique patient population.

Identifying Quality Gaps in Preventive Care for Outpatients With Cirrhosis Within a Large, Academic Health Care System.

We sought to identify specific gaps in preventive care provided to outpatients with cirrhosis and to determine factors associated with high quality of care (QOC), to guide quality improvement efforts. Outpatients with cirrhosis who received care at a large, academic tertiary health care system in the United States were included. Twelve quality indicators (QIs), including preventive care processes for ascites, esophageal varices, hepatic encephalopathy, hepatocellular carcinoma (HCC), and general cirrhosis care, were measured. QI pass rates were calculated as the proportion of patients eligible for a QI who received that QI during the study period. We performed logistic regression to determine predictors of high QOC (≥ 75% of eligible QIs) and receipt of HCC surveillance. Of the 439 patients, the median age was 63years, 59% were male, and 19% were Hispanic. The median Model for End-Stage Liver Disease-Sodium score was 11, 64% were compensated, and 32% had hepatitis C virus. QI pass rates varied by individual QIs, but were overall low. For example, 24% received appropriate HCC surveillance, 32% received an index endoscopy for varices screening, and 21% received secondary prophylaxis for spontaneous bacterial peritonitis. In multivariable analyses, Asian race (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 1.3-10.2) was associated with higher QOC, and both Asian race (OR: 3.3, 95% CI: 1.2-9.0) and decompensated status (OR: 2.1, 95% CI: 1.1-4.2) were associated with receipt of HCC surveillance. A greater number of specialty care visits was not associated with higher QOC. Conclusion: Receipt of outpatient preventive cirrhosis QIs was variable and overall low in a diverse cohort of patients with cirrhosis. Variation in care by race/ethnicity and illness trajectory should prompt further inquiry into identifying modifiable factors to standardize care delivery and to improve QOC.

The Emergency Department Trigger Tool: Validation and Testing to Optimize Yield

Recognized as a premier approach for adverse event (AE) detection, trigger tools have been developed for multiple clinical settings outside the emergency department (ED). We recently derived and tested an ED trigger tool (EDTT) with enhanced features for high-yield detection of harm, consisting of 30 triggers associated with AEs. In this study, we validate the EDTT in an independent sample and compare record selection approaches to optimize yield for quality improvement. This is a retrospective observational study using data from 13months of visits to an urban, academic ED by patients aged ≥ 18years (92,859 records). We conducted standard two-tiered trigger tool reviews on an independent validation sample of 3,724 records with at least one of the 30 triggers found associated with AEs in our previous derivation sample (N=1,786). We also tested three new candidate triggers and reviewed 72 records with no triggers for comparison purposes. We compare derivation and validation samples on: 1) triggers showing persistent associations with AEs, 2) AE yield (AEs detected/records reviewed), and 3) representativeness of AE types detected. We use bivariate associations of triggers with AEs as the basis for trigger selection. We then use multivariable modeling in the combined derivation and validation samples to determine AE risk scores using trigger weights. This allows us to predict occurrence of AEs and derive population prevalence estimates. Finally, we compare yield for detection of AEs under three record selection strategies (random selection, trigger counts, weighted trigger counts). Twenty-four of the 30 triggers were confirmed to be associated with AEs on bivariate testing. Three previously marginal triggers and two of three new candidate triggers were also found to be associated with AEs. The presence of any of these 29 triggers was associated with an AE rate of 10% in our selected sample (compared to 1.1% for none, p<0.001). The risk of an AE increased with number of triggers. Combining data from both phases, we identified 461 AEs in 429 unique visits in 5,582 records reviewed. Our multivariable model (which emphasized parsimony) retained 12 triggers with a ROC AUC of 82% in both samples. Selecting records for review based on number of triggers improves yield to 14% for 4+ triggers (top 10% of visits) and to 28% for 8+ (top 1%). A weighted trigger count has corresponding yields of 18 and 38%. The method for selecting records for review did not appear to affect event-type representativeness, with similar distributions of event types and severities detected. In this single-site study of the EDTT we observed high levels of validity in trigger selection, yield, and representativeness of AEs, with yields that are superior to estimates for traditional approaches to AE detection. Record selection using weighted triggers outperforms a trigger count threshold approach and far outperforms random sampling from records with at least one trigger. The EDTT is a promising efficient and high-yield approach for detecting all-cause harm to guide quality improvement efforts in the ED.

Closing the gap in implementation of HIV clinical guidelines in a low resource setting using electronic medical records

BackgroundUniversal health coverage promises equity in access to and quality of health services. However, there is variability in the quality of the care (QoC) delivered at health facilities in low and middle-income countries (LMICs). Detecting gaps in implementation of clinical guidelines is key to prioritizing the efforts to improve quality of care. The aim of this study was to present statistical methods that maximize the use of existing electronic medical records (EMR) to monitor compliance with evidence-based care guidelines in LMICs.MethodsWe used iSanté, Haiti’s largest EMR to assess adherence to treatment guidelines and retention on treatment of HIV patients across Haitian HIV care facilities. We selected three processes of care – (1) implementation of a ‘test and start’ approach to antiretroviral therapy (ART), (2) implementation of HIV viral load testing, and (3) uptake of multi-month scripting for ART, and three continuity of care indicators – (4) timely ART pick-up, (5) 6-month ART retention of pregnant women and (6) 6-month ART retention of non-pregnant adults. We estimated these six indicators using a model-based approach to account for their volatility and measurement error. We added a case-mix adjustment for continuity of care indicators to account for the effect of factors other than medical care (biological, socio-economic). We combined the six indicators in a composite measure of appropriate care based on adherence to treatment guidelines.ResultsWe analyzed data from 65,472 patients seen in 89 health facilities between June 2016 and March 2018. Adoption of treatment guidelines differed greatly between facilities; several facilities displayed 100% compliance failure, suggesting implementation issues. Risk-adjusted continuity of care indicators showed less variability, although several facilities had patient retention rates that deviated significantly from the national average. Based on the composite measure, we identified two facilities with consistently poor performance and two star performers.ConclusionsOur work demonstrates the potential of EMRs to detect gaps in appropriate care processes, and thereby to guide quality improvement efforts. Closing quality gaps will be pivotal in achieving equitable access to quality care in LMICs.

Predictors of Emergency Visits Within 14 Days of Outpatient Endoscopy at A Safety-Net Hospital: A Case-Control Study

AIMS: Gastrointestinal endoscopic procedures are commonly performed outpatient procedures associated with adverse events that may lead to emergency department visits. Establishing risk factor for post-endoscopy emergency department visits may guide quality improvement efforts. MATERIALS AND METHODS: Matched case control study of patients over the age of 18 presenting to the emergency department of a safety-net hospital within two weeks of any outpatient endoscopic procedure between July 1, 2013 and December 31, 2014. Controls were matched to cases by age, sex, procedure type, date, and day of week procedure was performed. Univariable and multivariable analysis were performed to identify predictors of emergency visits after endoscopy. REULTS: We identified 143 cases from a total of 6,601 outpatient procedures during the study period. 64 (44.8%) of the visits were attributed to the procedure yielding a visit rate of 0.97%. Compared to controls, cases were more likely to have MediCal (Medicaid) insurance (75.7% vs 59.2%, p = 0.003), prior ED visits (2.5 vs 0.5, p < 0.001), multiple primary care visits (4.9 vs 3.3, p < 0.001), trainee involvement (62.9% vs 44.4%, p = 0.002), and speak English (67.1% vs 54.9%, p = 0.04). On multivariable analysis of cases with visits attributable to the procedure, antiplatelet/anticoagulant use (OR 2.81, CI 1.07-7.34, p = 0.04), MediCal insurance (OR 2.55, CI 1.02-6.40, p = 0.05), multiple ED visits per year (OR 3.31, CI 2.22-4.94, p < 0.001), number of endoscopic interventions (OR 1.22, CI 1.06-1.40, p = 0.006), and trainee involvement (OR 2.55, CI 1.09-5.97, p = 0.03) were all risk factors for post-procedure visits. CONCLUSION: In a safety-net system, medically complex patients, greater number of endoscopic interventions, and lower socioeconomic status may influence emergency department utilization after endoscopy. This information may inform future quality improvement efforts.

Quality Measures, All-Cause Mortality, and Health Care Use in a National Cohort of Veterans With Cirrhosis.

Decompensated cirrhosis is associated with high morbidity and mortality. However, no standardized quality measures (QMs) have yet been adopted widely. The Veterans Affairs (VA) Advanced Liver Disease Technical Advisory Group recently developed a set of six internal QMs to guide quality improvement efforts in cirrhosis in the domains of access to care, hepatocellular carcinoma surveillance, variceal surveillance, quality of inpatient care for upper gastrointestinal bleeding, and cirrhosis-related rehospitalizations. We aimed to (1) quantify adherence to cirrhosis QMs and (2) determine whether adherence was associated with all-cause mortality and health care use within a large national cohort of veterans with cirrhosis. We performed a retrospective study using data from the Veterans Outcomes and Costs Asociated with Liver Disease cohort of 121,129 patients newly diagnosed with cirrhosis from January 1, 2008, to December 31, 2016, at 128 VA facilities. The mean follow-up time was 2.7years (interquartile range, 1.1-5.1years). Adherence to outpatient access to specialty care was 71%, variceal surveillance was 32%, and early postdischarge care was 54%. In adjusted analyses, outpatient access to specialty care (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.78-0.82), hepatocellular carcinoma surveillance (HR, 0.92; 95% CI, 0.90-0.95), variceal surveillance (HR, 0.93; 95% CI, 0.89-0.99), and early postdischarge care (HR, 0.57; 95% CI, 0.54-0.60) were associated with lower all-cause mortality. Readmissions after 30days (HR, 1.53; 1.46-1.60) and 90days (HR, 1.88; 95% CI, 1.54-1.70) were associated with higher all-cause mortality. Higher adherence to QMs was also associated with lower inpatient health care use. Conclusion: Five of the six proposed VA cirrhosis QMs were measurable using existing data sources, associated with mortality and health care use, and may be used to guide future quality improvement efforts in cirrhosis.

The burden of severe maternal outcomes and indicators of quality of maternal care in Nigerian hospitals: a secondary analysis comparing two large facility-based surveys.

To compare severe maternal outcomes (SMOs) from two multi-centre surveys in Nigerian hospitals, and to evaluate how the SMO burden affects quality of secondary and tertiary hospital care. Two facility-based surveys of women experiencing SMO (maternal near-miss or maternal deaths). Sixteen secondary and five tertiary facilities in Nigeria [WHO Multi-Country Survey on Maternal and Newborn Health (WHOMCS)] and 42 public tertiary facilities in Nigeria (Nigeria Near-Miss and Maternal Death Survey). 371 women in WHOMCS-Nigeria and 2449 women in Nigeria Near-Miss and Maternal Death Survey who experienced SMO. Secondary analysis and comparison of SMO data from two surveys, stratified by facility level. Maternal mortality ratio (MMR) per 100000 livebirths (LB), maternal near-miss (MNM) ratio per 1000 LB, SMO ratio per 1000 LB and mortality index (deaths/SMO). Maternal mortality ratio and mortality indices were highest in tertiary facilities of the WHOMCS-Nigeria (706 per 100000; 26.7%) and the Nigeria Near-Miss and Maternal Death Survey (1088 per 100000; 40.8%), and lower in secondary facilities of the WHOMCS-Nigeria (593 per 100000; 17.9%). The MNM ratio and SMO ratio were highest in secondary WHOMCS-Nigeria facilities (27.2 per 1000 LB; 33.1 per 1000 LB). Tertiary-level facilities in Nigeria experience unacceptably high maternal mortality rates, but secondary-level facilities had a proportionately higher burden of severe maternal outcomes. Common conditions with a high mortality index (postpartum haemorrhage, eclampsia, and infectious morbidities) should be prioritised for action. Surveillance using SMO indicators can guide quality improvement efforts and assess changes over time. 2820 Nigerian women with severe maternal outcomes: high mortality in tertiary level hospitals, higher burden in secondary level.

Antenatal Predictors of NICU Admission at a High-Risk Perinatal Center [16B

INTRODUCTION: The purpose of this study was to identify antenatal predictors of NICU admission at 34 weeks gestation and beyond at a high-risk perinatal center. METHODS: An IRB approved, quality improvement database was created containing clinical and sociodemographic data from 8,858 deliveries at 34+ weeks from January 2011 to May 2018. All data was obtained from the University of Virginia Clinical Data Repository. Relationships between NICU admission and potential antenatal predictors were stratified by gestational age (GA) and assessed using Pearson chi-square or logistic regression. RESULTS: Out of 8,858 births, 1,313 infants (14.8%) were admitted to the NICU with a mean length of stay of 13.2 days. Mean length of stay was longest for 35 week deliveries (15.5 days, 95% CI 12.48-16.3) and was shortest for 42 week deliveries (3.4 days, 95% CI 1.27-4.30). Most term NICU admissions occurred at 39 weeks (20.7%, P<.001). Of NICU admissions, 764 (58.2%) were male and 549 (41.2%) were female, yet gender was only associated with NICU admission at 39 weeks (P=.01). Cesarean delivery (P=0.00-0.02) and neonatal abstinence syndrome (P=.00-.01) were significantly correlated with NICU admission in all GA groups except 34 and 42 weeks. Risk factors associated with NICU admission varied by GA at delivery. CONCLUSION: NICU admission average length of stay exceeds usual maternal stays. Common obstetric complications were associated with NICU admission. Analysis of local data can guide quality improvement efforts to address risk factors for NICU admission. This could have future implications for development of programs that decrease identified risks and NICU admissions.

An integrated primary care approach for frail community-dwelling older persons: a step forward in improving the quality of care

BackgroundHigh-quality care delivery for frail older persons, many of whom have multiple complex needs, is among the greatest challenges faced by healthcare systems today. The Chronic Care Model (CCM) may guide quality improvement efforts for primary care delivery to frail older populations. Objectives of this study were to assess the implementation of interventions in CCM dimensions, and to investigate the quality of primary care as perceived by healthcare professionals, in practices following the Finding and Follow-up of Frail older persons (FFF) integrated care approach and those providing usual care.MethodsStructured interviews were conducted with general practitioners (GPs) from 11 intervention practices and 4 control practices to assess the implementation of interventions. A longitudinal survey (12-month period, 2 measurement timepoints) was conducted to assess the quality of primary care as perceived by healthcare professionals (intervention and control GP practices) using the Assessment of Chronic Illness Care Short version (ACIC-S). Independent-samples t-tests were used to assess differences in ACIC-S scores between groups. Interviews were conducted with GPs from the intervention practices to gain a deeper understanding of their experiences with the FFF approach.ResultsIntervention practices implemented significantly more interventions congruent with (dimensions of) the CCM compared with control GP practices. With respect to the quality of primary care as perceived by healthcare professionals, mean ACIC-S scores for all CCM dimensions and overall mean ACIC-S scores were significantly higher in the intervention group than in the control group at the follow-up timepoint. The number of implemented interventions was associated positively with perceived quality of primary care (ACIC-S scores) at follow-up. Important motives of GPs to implement the FFF approach were the aging of the population and transformations in the primary care sector. Proactive care delivery and multidisciplinary collaboration were considered to be essential. Major challenges to the implementation and embedding of the FFF approach were structural financing and manpower, and the availability of a facilitating information and communication technology system.ConclusionsOur study showed that proactive, integrated care that is based on (elements of) the CCM may be a step forward in improving quality of care for frail older persons.

Quality of integrated primary care and coproduction of care with community-living frail older persons

Introduction: The Chronic Care Model (CCM) was developed to guide quality improvement efforts in primary care and identifies important elements that promote high-quality integrated care and foster coproduction. We aimed to increase our knowledge on the CCM in the primary care setting for community-dwelling frail older persons in the Netherlands. The objective was therefore to assess congruency of care with (elements of) the CCM, professionals’ perceptions of quality of care and coproduction of care. Methods: A longitudinal study was conducted with a control group (4 GP practices delivering usual primary care) and an intervention group. The intervention group consisted of 11 GP practices that implemented a proactive, integrated care approach for frail older persons, which is called ‘Finding and Follow-up of Frail older persons’ (FFF). The FFF approach combines interrelated components of integrated primary care (e.g. case management, self-management support, multidisciplinary teams) that are assumed to promote high-quality primary care and coproduction of care. We assessed coproduction of care (relational coproduction instrument) and perceived quality of care (Assessment of Chronic Illness Care Short version; ACIC-S) among 75 healthcare professionals. Data were collected at baseline (T0) and 12 months after (T1) and were analyzed by chi-square tests, McNemar test, t-tests and regression analysis. To assess congruency of (integrated) primary care with the CCM, we conducted structured interviews with the 15 GPs. The interview format comprised 64 interventions across six CCM dimensions, i.e. community linkages, healthcare organization, self-management support, delivery system design, decision support, and clinical information systems. We assessed which interventions were implemented successfully in the intervention and control GP practices and we collected additional qualitative data. Results: Each GP practice implemented (various) interventions within each of the six dimensions of the CCM. Intervention GP practices implemented more interventions that are congruent with (dimensions of) the CCM than control GP practices (respectively 33 and 23 interventions on average). At baseline, ACIC-S scores on the CCM dimensions ‘healthcare organization’ and ‘delivery system design’ were significantly higher in the intervention group compared with the control group. Over time, quality of care improved significantly in the intervention group while there were no significant changes in quality of care in the control group. At T1, ACIC-S scores on all dimensions of the CCM were significantly higher in the intervention group compared with the control group. Furthermore, quality of care at baseline and improvements therein positively influenced coproduction of care with frail older persons in the intervention group. Discussion and conclusion: Overall, our study showed that the integrated care approach FFF successfully improved quality of care as perceived by professionals. This conclusion is in line with the finding that intervention GP practices implemented more interventions that are congruent with the CCM. Moreover, (improvements in) quality of care positively influenced coproduction of care with community-living frail older persons. Lessons learned: Redesigning primary healthcare systems and implementing integrated care based on (elements of) the CCM may contribute to improved quality of care and coproduction of care. Limitations: A limitation of our study was the small number of healthcare professionals in the control group. Suggestions for future research: Although the presence of a control group strengthened our findings, we recommend involving a larger sample of professionals providing usual care.

Noncompliance to a Postoperative Algorithm Using Feeding Readiness Assessments Prolonged Length of Stay at a Pediatric Heart Institute.

Introduction:Variable compliance to postoperative feeding algorithms after pediatric cardiac surgery may be associated with suboptimal growth, decreased parental satisfaction, and prolonged hospital length of stay (LOS). Our heart center performed an audit of compliance to a previously introduced postoperative feeding algorithm to guide quality improvement efforts. We hypothesized that algorithm noncompliance would be associated with increased LOS.Methods:We retrospectively identified children ≤ 3 months admitted for their first cardiac surgery between January 1, 2015 and December 31, 2016. The algorithm uses objective oral feeding readiness assessments (FRA). At the end of a predefined evaluation period, a “sentinel” FRA score is assigned. The sentinel FRA and FRA trend guide decisions to pursue gastrostomy tube (GT) or oral-only feeds. Among those who reached the sentinel FRA, we defined compliance as ≤ 3 days before pursuing GT or oral-only feeds once indicated by the algorithm.Results:Sixty-nine patients were included. Forty-nine complied with the algorithm (71%), and 45 received GT (65.2%). Noncompliers had significantly longer LOS (34 versus 25 days; P = 0.01). Among GT recipients, noncompliers waited 6 additional days for a GT compared with compliers (P ≤ 0.001). Subjective decisions to extend oral feeding trials or await results of a swallow study were associated with algorithm noncompliance.Conclusions:This audit of compliance to a feeding algorithm after pediatric cardiac surgery highlighted variability of practice, including relying on subjective appraisals of feeding skills over objective FRAs. This variability was associated with increased LOS and can be hypothesis-generating for future quality improvement efforts.