Health Care Quality Improvement Program Research Articles

#5384 IMPROVEMENTS IN QUALITY OF LIFE (QOL) OF HEMODIALYSIS PATIENTS AFTER THE PANDEMIA; IT IS NOT WHAT IT SEEMS TO BE

Abstract Background and Aims Patients on hemodialysis (HD), are a clinically vulnerable population. We analyzed changes in the results of the KDQOL™-36 questionnaire carried out in 2019 vs 2021, during Covid-19 pandemic. We have related the results to demographic and analytical parameters, BCM, modality and dose of dialysis, in addition to having suffered a COVID-19 infection. Method This is a retrospective, observational analysis performed in 47 clinics from Fresenius Medical Care (FMC) Spain. As part of our Healthcare Quality Improvement Program, HRQoL measurements were assessed using the KDQOL™-36 questionnaire. This questionnaire evaluates Physical and Mental Composite Scores (PCS and MCS, respectively) and three disease-specific scales: Effects, Burden and Symptoms dimensions (EKD, BKD, SKD). We focused our analysis in 1000 patients who completed both surveys in 2019 and 2021 in order to analyze differences. We compared results of both surveys by Wilcoxon test. Improvement between 2019 and 2021 was calculated for each QoL Score. We categorized patients based on QoL evolution (improvement vs worsening) and analyzed the relationship between QoL improvement and different variables by univariate and multivariate logistic regression. Non-normal variables were categorized. Results The results are presented in detail in the figures section. Conclusion Except for the PCS, there were an improvement in QoL results in 2021 vs 2019. Women presented a worse evolution in EKD, MCS and SKD scores. In our study, having COVID-19 infection did not seem to be a factor associated with changes in quality-of-life in 2021. Patients on OL-HDF presented an improvement on the SKD scale compared to those treated with conventional therapy. Higher lean tissue index was related with improvement in PCS scale. Age was related with better EKD scale evolution as CCI above 5 was related with MSC Improvement. BKD scale evolution was related with HD vintage.

PCR159 The Clinical and Financial Impact of Blue Cross and Blue Shield of Louisiana Waiving Cost Share for the First Mental Health and Substance Use Disorder Follow-up Visit

Waiving cost share for the first Mental Health and Substance Use Disorder (MHSU) follow-up visit after MHSU hospitalization is a Blue Cross and Blue Shield of Louisiana health care quality improvement program designed to remove potential financial barriers that the follow-up visit must take place within seven days of discharge from an inpatient stay. A mental health provider must perform the follow-up visit. The purpose of this effort is to encourage patient compliance of completing follow-up visits within seven days of a MHSU inpatient discharge. Follow-up within seven days helps close the gap for the Follow-Up After Hospitalization for Mental Illness (FUH) HEDIS measure. This study evaluates the clinical and financial effect of this waived cost share.

HSD129 Managing Members with Complex Conditions: A Blue Cross and Blue Shield of Louisiana Program Evaluation

The Complex Case Management (CCM) program from Blue Cross and Blue Shield of Louisiana (BCBSLA) is a healthcare quality improvement program designed to incentivize providers through valued partnerships to improve quality and reduce costs for patients with complex health conditions. The CCM program assigns professional case managers to members to help assess, plan, and facilitate personal treatment options and care. The purpose of this study was to evaluate the effectiveness of the CCM program.

MO875: Correlation of Health-Related Quality of Life (HRQOL) Measures With Demographic and Clinical Variables and Covid-19 Incidence Rate in Haemodialysis Patients

BACKGROUND AND AIMSPatients with ESRD present high symptom burden and impaired health-related quality of life (HRQoL). While the maintenance of medical Key Performance Indicators (KPIs) within defined ranges has been traditionally the focus for dialysis patients' healthcare, there is now increasing evidence of how self-reported HRQoL data could also significantly impact their outcomes. The inclusion of these data, using Patient-Reported Outcomes Measurements (PROM), to the routine medical practice works in favor of providing personalized treatments and detecting new outcomes' predictive factors. In the present study, we aimed to evaluate possible correlations between demographic and clinical variables as well as the COVID-19 incidence rate with HRQoL scores in a haemodialysis patients' cohort.METHODThis is a retrospective, observational analysis performed in a total of 47 clinics from Fresenius Medical Care (FMC) Spain in the last quarter of 2021. Patients' demographic and clinical variables were obtained from EuCliD® (European Clinical database). As part of our Healthcare Quality Improvement Program, HRQoL measurements were assessed using the KDQOL™-36 questionnaire by an electronic device (ePROM). This questionnaire was developed specifically for patients affected by kidney disease and combines a generic assessment, which evaluates Physical and Mental Composite Scores (PCS and MCS, respectively) and three disease-specific scales where Effects, Burden and Symptoms dimensions are scored (EKD, BKD and SKD) [1]. For all clinics, we also collect data regarding their Spanish region, the presence or not of multidisciplinary teams in their staff and their number of active issues. This last parameter, part of FMC Balanced Scorecard, is calculated according to the number of KPIs below range, where a higher score indicates a higher number of active issues. Finally, the COVID-19 incidence rate adjusted per region was obtained from the Spanish Ministry of Health register.The mean (±SD) for quantitative variables and frequencies (%) for those categorical were calculated. We explored possible correlations between the HRQoL average scores and the different variables included in the study. All tests were performed using IBM® SPSS®Statistics V19 software and a P-value < 0.05 was considered statistically significant.RESULTSA total of 3480 ePROM were completed (patients' response rate = 82.4%, Figure 1). Descriptive parameters for demographic and clinical variables are shown in Table 1. The different KDQOL™-36 average scores were the following: PCS: 39.3 ± 2.3; MCS: 47 ± 3; EKD: 70 ± 7.4; BKD: 48.1 ± 8.9 and SKD: 81.2 ± 4.3. We found positive correlations between the presence of nutritionist staff with MCS and the quality of dialysis treatment (measured by OCM Kt/V) and the frequency of AVF as vascular access with EKD score. Unexpectedly, the Charlson Comorbidity Index (CCI) showed positively correlation with PCS. Regarding negative correlations, variables as the Spanish region, the proportion of women in the clinics, body composition parameters (ATM and FTM) and serum P concentration were all associated with PCS. We also observed that EKD scores could be affected in those clinics with a higher number of active issues. Moreover, high levels of CRP or Vitamin D may lead to worsening symptoms. Interestingly, we finally observed how a higher incidence rate of COVID-19 in the region could influence the BDK score in patients receiving haemodialysis treatment.FIGURE 1:Study flowchart.CONCLUSIONAlthough further analyses are needed, our study showed the correlation of HRQoL scores obtained by ePROM with factors of great impact in patients' outcomes. According to provide a higher healthcare quality and personalized treatments for ESRD patients, an integral approach considering their HRQoL data should be essential.Editable version available.

Predictive factors of diagnostic and therapeutic divergence in a nationwide cohort of patients seeking second medical opinion

ObjectivesThe aim of this study was to describe the profile of patients who sought a second medical opinion (SMO) on their therapeutic or diagnostic strategy using nationwide data from a French physician network dedicated to SMOs.MethodsAn observational cohort study was conducted and the study population consisted of patients residing in France or in the French overseas territories who submitted a request for an SMO through a dedicated platform between January 2016 and October 2020. Patient characteristics were compared between convergent and divergent SMOs. The divergent rate for all patients excluding those with mental diseases were described. Logistic regression was used to estimate the probability of a divergent SMO according to patient characteristics.Results and discussionIn total, 1,552 adult patients over several French regions were included. The divergence rate was 32.3 % (n = 502 patients). Gynecological [Odds Ratio (OR) and 95 % CI: 5.176 (3.154 to 8.494)], urological [OR 4.246 (2.053 to 8.782)] and respiratory diseases [OR 3.639 (1.357 to 9.758)] had the highest probability of a divergent SMO. Complex cases were also associated with a significantly higher risk of a divergent opinion [OR 2.78 (2.16 to 3.59)]. Age, sex, region and profession were not found to be predictive of a divergent second opinion.ConclusionsPolicymakers should encourage new research on patient outcomes such as mortality and hospitalization rates after a SMO. When proven effective, SMO networks will have the potential to benefit from specific public funding or even play a key role in national healthcare quality improvement programs.

Implementation of Healthcare Quality Improvement Programs.

Implementation of Healthcare Quality Improvement Programs.

Survey-based Work System Assessment to Facilitate Large-scale Dissemination of Healthcare Quality Improvement Programs.

The dissemination of quality improvement (QI) interventions to a broader range of healthcare settings requires a proactive assessment of local work systems and processes. The objective of this study was to examine the feasibility of using a survey-based work system assessment (WSA) tool to facilitate the dissemination of a program for optimizing blood culture (BC) use. Informed by findings from an onsite, interview-based WSA at 2 hospitals, a 50-item WSA survey was devised and administrated to 15 hospitals participating in a QI collaborative. WSA survey data were summarized, shared, and discussed with individual hospitals to inform the adaptation and implementation of the BC program. Physician champions leading the local QI team assessed the use of the WSA survey by completing an 8-item survey. A total of 347 clinicians completed the WSA survey, and physician champions at 12 hospitals evaluated the use of the WSA survey. Both the WSA survey data and the evaluation of the WSA survey showed that the survey-based WSA tool could help participating hospitals understand their current BC ordering practices and identify potential barriers to implementing the program from the perspectives of different clinicians. We demonstrated how a survey-based tool could be used to facilitate WSA in the dissemination of a program for improving BC use to a multisite collaborative. A survey-based WSA tool can be used to facilitate future large-scale intervention dissemination efforts.

Family Health Support Center: health promotion, physical activity, and chronic diseases in Brazil - national PMAQ survey 2013.

to describe reported health promotion actions directed towards chronic non-communicable disease (CNCD) patients, the support of physical education professionals (PEP) and the implementation of actions to promote body practices and physical activity (BPPA) by the Family Health Support Center (FHSC) teams, according to Brazilian municipality context variables. this was a cross-sectional study, forming part of the 2013/2014 National Primary Health Care Access and Quality Improvement Program (PMAQ), by means of interviews with FHSC professionals. the action most reported by the teams was evaluation and rehabilitation of psychosocial conditions (90.8%); promotion of BPPA was the sixth most performed action, and was more prevalent in the Brazilian Southeast region (89.6%), in medium-sized municipalities (88.7%), with medium human development index (HDI) (86.7%); PEP provided support to 87% of the teams. FHSC were found to make an important contribution to BPPA.

Use of Human Factors and Ergonomics to Disseminate Health Care Quality Improvement Programs.

Use of Human Factors and Ergonomics to Disseminate Health Care Quality Improvement Programs.

Criticality of Maternal Complications During Childbirths.

The incidence of severe maternal morbidity is increasing in the United Sates. To improve maternal outcomes, three maternal complications have been selected for priority intervention based on their proportionate mortality and preventability: obstetric hemorrhage, severe hypertension, and venous thromboembolism. This approach excludes complications that are not associated with high mortality but significantly contribute to maternal morbidity. The aim of this study was to provide an alternative ranking of maternal complications requiring interventions using cost-based criticality analysis. Discharge records indicating delivery hospitalizations, and 17 maternal complications were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes in the 2012 National Inpatient Sample, a 20% national representative sample of hospital discharge records from community hospitals. For each complication, criticality was calculated as the product of its incidence and severity. Severity was estimated using excess cost, the difference between the mean costs of discharges with and without the complication. Costs were calculated as the product of hospital charges and a cost-to-charge ratio and adjusted with a linear regression model. Complications were ranked based on criticality. The study sample included 734,865 delivery hospitalizations. At least one complication was recorded in 80,657 discharges (11.0%, 95% confidence interval = 10.9-11.1). The four highest-ranked critical complications were pre-eclampsia/eclampsia (criticality: $93), postpartum hemorrhage ($47), gestational hypertension ($34), and anesthesia-related complications ($5). In addition to postpartum hemorrhage and severe hypertension, anesthesia-related complications and gestational hypertension may be new priority targets for interventions during delivery hospitalizations. Criticality analysis seems to be an alternative or complimentary approach for planning healthcare quality improvement programs.

Utilization of Breast Cancer Screening in Brazil: An External Assessment of Primary Health Care Access and Quality Improvement Program

Breast cancer is the most frequent type of cancer in women and the second leading cause of cancer death after lung cancer in more developed countries and the leading cause of death in developing countries. The aim of this study was to analyze the association between three sets of variables and the utilization of breast cancer screening among women attending primary health care centers participating in the Primary Care Access and Quality Improvement Program in Brazil. A survey of 65,391 women was conducted across Brazil in 2012. The primary outcomes were percentage of women who never had a clinical breast examination and percentage of women who never had a mammography. Crude and adjusted analyses performed using Poisson regression assessed the association of these outcomes with service organization variables, as well as with socioeconomic and demographic variables. Results showed that 37.7% of women never had a clinical breast examination and 30.3% never had a mammography. Never having had both screening procedures decreased as the Human Development Index increased. Never having had a clinical breast examination increased with increasing population size and increasing municipal family health strategy coverage. The proportion of women never having had a clinical breast examination was highest in the northern region. White women and those who had a partner had greater utilization of screening. Women who had paid work and lived in families with higher per capita income had greater utilization of clinical breast examination. The proportion of women who never had a mammography was highest for women living in households with six or more people and receiving the Bolsa Família benefit. Women with lower per capita family income had higher utilization of mammography. Appropriate structures and work processes were associated with greater utilization of mammography. Investments in primary health care structure and teamworking processes are essential to improve the utilization of screening, prevention, and early diagnosis of breast cancer in Brazil.

A network perspective on patient experiences and health status: the Medical Expenditure Panel Survey 2004 to 2011

BackgroundThere is a growing emphasis on the need to engage patients in order to improve the quality of health care and improve health outcomes. However, we are still lacking a comprehensive understanding on how different measures of patient experiences interact with one another or relate to health status. This study takes a network perspective to 1) study the associations between patient characteristics and patient experience in health care and 2) identify factors that could be prioritized to improve health status.MethodsThis study uses data from the two-year panels from the Medical Expenditure Panel Survey (MEPS) initiated between 2004 and 2011 in the United States. The 88 variables regarding patient health and experience with health care were identified through the MEPS documentation. Sex, age, race/ethnicity, and years of education were also included for analysis. The bnlearn package within R (v3.20) was used to 1) identify the structure of the network of variables, 2) assess the model fit of candidate algorithms, 3) cross-validate the network, and 4) fit conditional probabilities with the given structure.ResultsThere were 51,023 MEPS interviewees aged 18 to 85 years (mean = 44, 95% CI = 43.9 to 44.2), with years of education ranging from 1 to 19 (mean = 7.4, 95% CI = 7.40 to 7.46). Among all, 55% and 74% were female and white, respectively. There were nine networks identified and 17 variables not linked to others, including death in the second years, sex, entry years to the MEPS, and relations of proxies. The health status in the second years was directly linked to that in the first years. The health care ratings were associated with how often professionals listened to them and whether professionals’ explanation was understandable.ConclusionsIt is feasible to construct Bayesian networks with information on patient characteristics and experiences in health care. Network models help to identify significant predictors of health care quality ratings. With temporal relationships established, the structure of the variables can be meaningful for health policy researchers, who search for one or a few key priorities to initiate interventions or health care quality improvement programs.

Impact of a primary healthcare quality improvement program on diabetes in Canada: evaluation of the Quality Improvement and Innovation Partnership (QIIP)

ObjectivePrimary healthcare (PHC) quality improvement (QI) initiatives are designed to improve patient care and health outcomes. We evaluated the Quality Improvement and Innovation Partnership (QIIP), an Ontario-wide PHC QI program...

Is There Evidence That Performance Measurement in Stroke Has Influenced Health Policy and Changes to Health Systems?

Is There Evidence That Performance Measurement in Stroke Has Influenced Health Policy and Changes to Health Systems?

Use of Antithrombotic Medications Among Elderly Ischemic Stroke Patients

The use of antithrombotic medications after ischemic stroke is recommended for deep vein thrombosis prophylaxis and secondary stroke prevention. We assessed the rate of receipt of these therapies among eligible ischemic stroke patients age ≥65 years and determined the effects of age and other patient characteristics on treatment. The analysis included Medicare fee-for-service beneficiaries discharged with ischemic stroke (ICD 433.x1, 434.x1, 436) randomly selected for inclusion in the Medicare Health Care Quality Improvement Program's National Stroke Project 1998 to 1999, 2000 to 2001. Patients discharged from nonacute facilities, transferred, or terminally ill were excluded. Receipt of in-hospital pharmacological deep vein thrombosis prophylaxis, antiplatelet medication, anticoagulants for atrial fibrillation, and antithrombotic medications at discharge were assessed in eligible patients, stratified by age (65 to 74, 75 to 84, and 85+ years). Descriptive models identified characteristics associated with treatment. Among 31 554 patients, 14.9% of those eligible received pharmacological deep vein thrombosis prophylaxis, 83.9% antiplatelet drugs, 82.8% anticoagulants for atrial fibrillation, and 74.2% were discharged on an antithrombotic medication. Rates of treatment decreased with age and were lowest for patients ages 85 years or older. Admission from a skilled nursing facility and functional dependence were associated with lower treatment rates. There was substantial underutilization of antithrombotic therapies among elderly ischemic stroke patients, particularly among the very elderly, those admitted from skilled nursing facilities, and patients with functional dependence. The reasons for low use of antithrombotic therapies, including the apparent underutilization of deep vein thrombosis prophylaxis in otherwise eligible patients, require further investigation.

Toward More Sustainable Health Care Quality Improvement in Developing Countries

Resource constraints are often identified as a hurdle to the sustainability of large-scale (national and regional) health care quality improvement (QI) programs in developing countries. However, poor fit of a QI model with a given country's context may present the greater challenge. To explore contextual factors influencing the sustainability of large-scale QI initiatives in developing countries, we performed a systematic literature review. Large-scale initiatives appear to have received significant attention only recently in these settings, as priority was traditionally given to extending service coverage. Further, these initiatives often relied on QI models originating from developed country settings, which differed significantly from the systems, resource structures, culture, and values found in the target country. The QI programs frequently focused on high-impact/immediate change rather than on program sustainability. Barriers to sustainability were identified during the planning, start-up, and continuation phases. On the basis of our review, greater attention to sustainable methods for large-scale QI in developing countries is needed. We suggest a "Little Steps" approach that begins by defining QI concepts, goals, and processes in a manner congruent with the target setting and that builds upon existing systems, structures, and values. Despite immediate short-term needs, an approach emphasizing incremental QI achievements may be more effective in yielding sustainable improvements in health care quality at the national or regional level.

Prepare, plan, practice

Prepare, plan, practice

Williamson's ABNA revisited

Purpose – The purpose of this viewpoint article is to acquaint those engaged in health care quality improvement and patient safety programs with an effective, well‐documented but overlooked method. As described in a 1978 article, “Achievable Benefit Not Achieved” (ABNA) is a formal, efficient, transdisciplinary, evidence‐based method to identify and prioritize quality improvement project topics.Design/methodology/approach – Narrative review of personal experience and pertinent literature.Findings – While the ABNA method succeeds in serving its purpose when applied, and no evidence could be found to discredit it, ABNA appears to have been abandoned and forgotten for reasons of political expediency.Research limitations/implications – A strength and weakness of this research is its reliance upon personal narratives from the limited number of individuals still available who have first‐hand knowledge of past events. Convergence of those narratives along common themes, and their consistency with published recor...

Impacts of a Government-Sponsored Outpatient-Based Disease Management Program for Patients with Asthma: A Preliminary Analysis of National Data from Taiwan

In response to the high prevalence rates, mortality rates, and rising medical cost of asthma, the Bureau of National Health Insurance (BNHI) initiated a Healthcare Quality Improvement Program (HQIP) for people with asthma. The aim of this study was to investigate a preliminary analysis of the impact of a government-sponsored, outpatient-based disease management programs for people with asthma on the economic outcomes, the physician's and the patient's satisfaction. Using a retrospective design, a 1:4 (intervention vs. control group) matched cohort study design was used. Comparison of 1-year pre/post tests of utilizations of healthcare resources were conducted for 854 already diagnosed cases of patients with asthma. Comparison of independent tests between the intervention group and control group were performed for already diagnosed cases (n = 854) and newly-diagnosed cases (n = 231). Valid surveys were received from 212 physicians who participated the program, for a response rate of 46.0%, and 642 patients who enrolled in the program, for a response rate of 27.70%. Results indicated that the intervention group of already diagnosed cases had 39.94% fewer ED visits, 46.31% fewer inpatient visits, and 51.74% shorter length of stay, at a significant level. Though the HQIP program for people with asthma appeared to reduce medical care resource utilization for the intervention group, the control groups showed similar reductions but in different magnitude. For the newly diagnosed group, the intervention group had 197.43% more outpatient visits and 61.19% fewer ED visits of than those of the control group at a significant level. A majority of physicians (70%-85%) had positive opinions toward the HQIP program, but they admitted that the HQIP program prolonged the consultation time in outpatient visits (79.1%), and only 29.7% physicians did not feel interfered with while carrying out the HQIP. More than 80% of the patients showed positive feedback to the HQIP. The majority of the patients substantially adhered to physicians' suggestions, and had more accurate knowledge of and better self-care skills concerning asthma. These results have significance for the design of future programs aimed at improving the care of people with asthma and other chronic diseases in BNHI, Taiwan.

Improved diabetes care by primary care physicians: results of a group-randomized evaluation of the Medicare Health Care Quality Improvement Program (HCQIP)

Background and Objective Glycosylated hemoglobin (HbA1C) measurements in patients with diabetes mellitus contribute to glycemic control, and, therefore to lower diabetic complication rates. Determine if an intervention that includes claims-based feedback about patterns of HbA1C measurement results in more frequent monitoring of HbA1C in diabetic Medicare beneficiaries. Subjects Primary care physicians in a single Southern state treating Medicare beneficiaries with diabetes mellitus. Methods A group-randomized evaluation of an intervention that included claims-based feedback about patterns of HbA1C measurement, educational materials, and practice aids. Results Rates for each quality indicator increased from 1996 to 1998 for both the intervention and comparison groups, although increases were larger for intervention counties. HbA1C testing rates increased in intervention counties 16.8% compared to 13.0% in the comparison counties, an absolute difference of 4.0% (95% CI, 0.7 to 7.3). Differences for other indicators were small, although positive and favoring the intervention, and lacked statistical significance. Conclusions Physician interventions that included practice-level feedback about monitoring of glycemic control successfully led to improved care of diabetic Medicare beneficiaries.