Health Care Quality Indicators Research Articles

Behavioral skills training for teaching safety skills to mental health service providers compared to training-as-usual: a pragmatic randomized control trial.

Violence in the healthcare workplace has been a global concern for over two decades, with a high prevalence of violence towards healthcare workers reported. Workplace violence has become a healthcare quality indicator and embedded in quality improvement initiatives of many healthcare organizations. The Centre for Addiction and Mental Health (CAMH), Canada's largest mental health hospital, provides all clinical staff with mandated staff safety training for self-protection and team-control skills. These skills are to be used as a last resort when a patient is at imminent risk of harm to self or others. The purpose of this study is to compare the effectiveness of two training methods of this mandated staff safety training for workplace violence in a large psychiatric hospital setting. Using a pragmatic randomized control trial design, this study compares two approaches to teaching safety skills CAMH's training-as-usual (TAU) using the 3D approach (description, demonstration and doing) and behavioural skills training (BST), from the field of applied behaviour analysis, using instruction, modeling, practice and feedback loop. Staff were assessed on three outcome measures (competency, mastery and confidence), across three time points: before training (baseline), immediately after training (post-training) and one month later (follow-up). This study was registered with the ISRCTN registry on 06/09/2023 (ISRCTN18133140). With a sample size of 99 new staff, results indicate that BST was significantly better than TAU in improving observed performance of self-protection and team-control skills. Both methods were associated with improved skills and confidence. However, there was a decrease in skill performance levels at the one-month follow-up for both methods, with BST remaining higher than TAU scores across all three time points. The impact of training improved staff confidence in both training methods and remained high across all three time points. The study findings suggest that BST is more effective than TAU in improving safety skills among healthcare workers. However, the retention of skills over time remains a concern, and therefore a single training session without on-the-job-feedback or booster sessions based on objective assessments of skill may not be sufficient. Further research is needed to confirm and expand upon these findings in different settings.

Obstetric risk profiles and causes of death: Estimating their association with cesarean sections among maternal deaths in Mexico.

Maternal mortality is a critical indicator of healthcare quality, and in Mexico, this has become increasingly concerning due to the stagnation in its decline, alongside a concurrent increase in cesarean section (C-section) rates. This study characterizes maternal deaths in Mexico, focusing on estimating the association between obstetric risk profiles, cause of death, and mode of delivery. Utilizing a retrospective observational design, 4,561 maternal deaths in Mexico from 2010-2014 were analyzed. Data were sourced from the Deliberate Search and Reclassification of Maternal Deaths database, alongside other national databases. An algorithm was developed to extract the Robson Ten Group Classification System from clinical summaries text, facilitating a nuanced analysis of C-section rates. Information on the reasons for the performance of a C-section was also obtained. Logistic regression and multinomial logistic regression models were used to estimate the relation between obstetric risk factors, mode of delivery and causes of maternal death, adjusting for covariates. Among maternal deaths in Mexico from 2010-2014, 47.1% underwent a C-section, with a significant history of previous C-sections observed in 31.4% of these cases, compared to 17.4% for vaginal deliveries (p<0.001). Early prenatal care in the first trimester was more common in C-section cases (46.8%) than in vaginal deliveries (38.3%, p<0.001). A stark contrast was noted in the place of death, with 82.4% of post-C-section deaths occurring in public institutions versus 69.1% following vaginal births. According to Robson's classification, the highest C-section rates were in Group 4 (67.2%, p<0.001) and Group 8 (66.9%, p<0.001). Logistic regression analysis revealed no significant difference in the odds of receiving a C-section in private versus other settings after adjusting for Robson criteria (OR: 1.21; 95% CI: 0.92, 1.60). A prior C-section significantly increased the likelihood of another (OR: 2.38; CI 95%: 2.01, 2.81). The analysis also indicated C-sections were significantly tied to deaths from hypertensive disorders (RRR = 1.25, 95% CI [1.12, 1.40]). In terms of indications, 6.3% of C-sections were performed under inadequate indications, while the indication was not identifiable in 33.1% of all C-sections. This study highlights a significant overuse of C-sections among maternal deaths in Mexico (2010-2014), revealed through the Robson classification and ana analysis of the reported indications for the procedure. It underscores the need for revising clinical decision-making to promote evidence-based guidelines and favor vaginal deliveries when possible. High C-section rates, especially noted disparities between private and public sectors, suggest economic and non-clinical factors may be at play. The importance of accurate data systems and further research with control groups to understand C-section practices' impact on maternal health is emphasized.

Examining Youth Flexible ACT Model Implementation in the Netherlands.

Model adherence is a key indicator of mental health care quality. This study investigates the degree of model adherence, as well as content and staging of care, among the first Youth Flexible Assertive Community Treatment (ACT) teams in the Netherlands. Model fidelity was assessed in sixteen teams with the Youth Flexile ACT model fidelity scale (2014 version). Mental health workers completed a 'content of care questionnaire' to map the interventions applied in the teams. Model fidelity scores revealed that twelve teams adhered to the Youth Flexible ACT standard with 'optimal implementation' (≥ 4.1 on a 5 point scale) and four teams with 'adequate implementation'. Most disciplines were well integrated within the teams; however, several items regarding the involvement of specific disciplines and the availability of treatment interventions (peer support worker, employment and education specialist and programs, family interventions, integrated dual disorder treatment) scored below the optimum. Frequency of contact during ACT and the use of Routine Outcome Monitoring instruments scored below the optimum as well. The 'content of care' data showed that most clients received an individual psychological intervention, and nearly half of the client sample received scaled-up / intensified ACT care. The findings indicate a predominantly successful translation of care from the theoretical Flexible ACT framework into practice, covering both ACT and non-ACT functions. Further room for improvement lies in the incorporation of specialized disciplines in the personal and social recovery domains, including the peer support worker and employment and education specialist, as well as in specific protocolled interventions.

Missed nursing care and its relationship with nurses’ moral sensitivity: a descriptive-analytical study

BackgroundMissed care rates are an indicator of healthcare quality. Missed nursing care can reduce patient safety and lead to adverse events. Moral sensitivity enables nurses to interpret and respond to clients’ needs according to ethical principles. Despite the importance of moral sensitivity and its role in the quality of care, the relationship between nurses' moral sensitivity and missed nursing care has not been extensively studied. This raises the question of whether there is an association between nurses' moral sensitivity and missed care. This study was conducted to investigate the relationship between nurses’ moral sensitivity and missed nursing care in the medical and surgical departments of Imam Khomeini Hospital in Urmia, Iran.MethodsA cross-sectional study was conducted in 2022, on 202 nurses working in the medical and surgical departments of Imam Khomeini Medical Education Center, Urmia, Iran. Stratified random sampling was used to select the participants. A questionnaire on demographic characteristics, Kalisch's missed care questionnaire, and Lutzen's moral sensitivity questionnaire were used to collect data. Data were analyzed using the Pearson correlation test and linear regression analysis.ResultsMost participants (52.97%) showed moderate moral sensitivity. Nurses’ mean moral sensitivity and total missed care scores were 149.07 ± 21.60 and 59.45 ± 4.87, respectively. Pearson correlation test showed no significant correlation between moral sensitivity scores and the total missed care scores (r = 0.041, p = 0.152). However, in the regression analysis, moral sensitivity (β = 0.213, p < 0.001), age (β = 0.131, p < 0.001), working in rotating shifts (β = 0.183, p < 0.001), monthly income (β = 0.079, p = 0.004), work experience (β = 0.030, p = 0.010), and monthly work hours (β = 0.247, p = 0.010) influenced missed care. Approximately, 0.98% of the variance in the missed care was explained by these variables.ConclusionOur nurses reported moderate levels of moral sensitivity and a concerning level of missed care. Missed care can have detrimental effects on patient safety. Therefore, nursing managers must address this issue promptly.

Changes in Patient Safety Culture Attitudes Among Emergency, Intensive Care, and General Ward Nurses During the COVID-19 Pandemic

Patient safety culture is an indicator of healthcare quality and a topic of global importance in medical care. In this study, the attitudes towards patient safety culture of nursing staff working in the emergency, intensive care, and general wards are compared before and during the COVID-19 pandemic. A retrospective research design was utilized and an anonymous questionnaire survey conducted on the Taiwan Patient Safety Culture Survey web-based platform system was used to collect the data. The survey was administered in a regional hospital in northern Taiwan between 2018 and 2020. The 1,540 nursing personnel who participated in this study worked in the emergency, intensive care units, or general adult ward. The analysis focused on assessing participant attitudes towards patient safety culture in terms of both the overall score and sub-dimensions. The participants were mostly female and between 21 and 30 years old. A majority had completed a diploma or university education. The two analyses revealed the highest and lowest average scores were earned, respectively, in the "teamwork" and "resilience" dimensions of patient safety culture. In 2020, the average scores for all dimensions were lower than in 2018, and the average scores for the emergency and critical care group were lower than those for the general adult ward group. Sub-dimension analysis showed that the general adult ward group earned significantly higher scores in "teamwork" across all three sub-dimensions compared to the emergency and critical care groups. The general ward group exhibited the most significant score decline between the two surveys. Overall scores were found to have decreased during the COVID-19 pandemic period (2020). Notably, emergency and intensive care nurses earned consistently lower scores, likely due to the severity of patient conditions and increased pandemic-related workloads and stress. "Resilience" scores were the lowest among all nursing staff, with the most significant drop seen in general ward nurses. Enhancing nursing staff education and training as well as addressing their psychological well-being will be crucial to improving patient safety culture attitudes. Managers should provide infection control, resilience training, and psychological counseling to help nurses manage the challenges posed by infectious diseases effectively and enhance patient safety culture.

STUDY OF RATE, CAUSE AND PATTERN OF HOSPITAL READMISSIONS IN EMERGENCY MEDICINE OF A TERTIARY CARE HOSPITAL IN NORTH INDIA

Introduction: Hospital readmission rates serve as crucial indicators of healthcare quality, with significant implications for patient outcomes and financial costs. This study aims to investigate the rates, causes, and patterns of hospital readmissions in the emergency medicine department of a tertiary care hospital in North India. Methodology: A prospective study spanning one year was conducted, involving 4116 patients admitted through emergency medicine. The study analyzed readmission rates at different intervals (7 days, 30 days, 90 days, and 1 year) and considered demographic factors, primary diagnoses, and comorbidities. Data were collected through systematic random sampling and reinforced with semi-structured interviews and administrative records. Results &amp; Observations: The study revealed varying readmission rates across different time intervals and diagnoses. Gastrointestinal disorders and respiratory diseases consistently exhibited elevated readmission rates. Age, gender, and Charlson Comorbidity Index were identified as significant factors influencing readmission patterns. Patients aged 50-59 years and males demonstrated higher readmission rates. The severity of comorbidities, as measuredbytheCharlson Comorbidity Index, was positivelycorrelated with increased readmission rates. Discussion: The findings underscore the importance of targeted post-discharge care, disease-specific interventions, and tailored strategies for specific demographics. The study emphasizes the need for enhanced monitoring and interventions, especially in the later stages post-discharge. Patient-centric insights highlight the role of discharge readiness and patient perceptions in influencing readmission dynamics. Conclusion: This study provides comprehensive insights into the complex factors influencing hospital readmissions in the emergency medicine setting. It emphasizes the necessity for focused interventions, customized care strategies, and all-encompassing approaches to reduce readmission risks. Healthcare institutions are encouraged to prioritize transitional care, interdisciplinary collaboration, evidence-based interventions, and patient-centered care models to optimize patient outcomes and alleviate the economic burden associated with avoidable readmissions.

OECD’s work on health care quality and outcomes indicators: Implications for the Croatian healthcare system in the light of the ongoing accession process

OECD’s work on health care quality and outcomes indicators: Implications for the Croatian healthcare system in the light of the ongoing accession process

Incidence of hypertensive disorders of pregnancy and causes of maternal deaths due to hypertensive disorders of pregnancy: A Restrospective cohort study

Abstract Background: Maternal mortality is one of the prime health-care level and quality indicators of a country. The causal changing trends of maternal mortality demand a fair and constant revision of facilities provided to new mothers. We need an in-detail analysis of the recent trends and causes and the entire spectrum of it. Objective: The objective is to study the incidence of hypertensive disorders of pregnancy (HDP) and the causes of maternal deaths due to HDP. Materials and Methods: A retrospective cohort study was carried out over 3 years. Maternal death and hypertensive disorder of pregnancy were defined as per standard guidelines. The obstetric and demographic variables were recorded. The risk ratio with its 95% confidence interval was calculated. Results: The incidence of HDP was 33.8% in a total of 29,125 deliveries that took place in 3-year period. Total maternal deaths were 222 (0.76%), and among these, 78 cases (35.1%) had HDP. HDP had a significant effect on intrauterine deaths and hospital stays. The most common form of HDP was preeclampsia in 57.7%. The most common complication that occurred in HDP maternal deaths was pulmonary edema in 21.5% of the cases. Conclusion: The incidence of HDP was high in the present study center. The deaths due to HDP are also high owing to the maximum number of patients being referred from other places in late stages. Regular antenatal care, educating the society, early diagnosis of risk factors, and early referral forms are the important factors to be considered to prevent maternal death.

Outcomes of early hospital readmission after kidney transplantation: Perspectives from a Canadian transplant centre.

Early hospital readmissions (EHRs) after kidney transplantation range in incidence from 18%-47% and are important and substantial healthcare quality indicators. EHR can adversely impact clinical outcomes such as graft function and patient mortality as well as healthcare costs. EHRs have been extensively studied in American healthcare systems, but these associations have not been explored within a Canadian setting. Due to significant differences in the delivery of healthcare and patient outcomes, results from American studies cannot be readily applicable to Canadian populations. A better understanding of EHR can facilitate improved discharge planning and long-term outpatient management post kidney transplant. To explore the burden of EHR on kidney transplant recipients (KTRs) and the Canadian healthcare system in a large transplant centre. This single centre cohort study included 1564 KTRs recruited from January 1, 2009 to December 31, 2017, with a 1-year follow-up. We defined EHR as hospitalizations within 30 d or 90 d of transplant discharge, excluding elective procedures. Multivariable Cox and linear regression models were used to examine EHR, late hospital readmissions (defined as hospitalizations within 31-365 d for 30-d EHR and within 91-365 d for 90-d EHR), and outcomes including graft function and patient mortality. In this study, 307 (22.4%) and 394 (29.6%) KTRs had 30-d and 90-d EHRs, respectively. Factors such as having previous cases of rejection, being transplanted in more recent years, having a longer duration of dialysis pretransplant, and having an expanded criteria donor were associated with EHR post-transplant. The cumulative probability of death censored graft failure, as well as total graft failure, was higher among the 90-d EHR group as compared to patients with no EHR. While multivariable models found no significant association between EHR and patient mortality, patients with EHR were at an increased risk of late hospital readmissions, poorer kidney function throughout the 1st year post-transplant, and higher hospital-based care costs within the 1st year of follow-up. EHRs are associated with suboptimal outcomes after kidney transplant and increased financial burden on the healthcare system. The results warrant the need for effective strategies to reduce post-transplant EHR.

A Scoping Review of Adult Inpatient Satisfaction with Mental Health Services.

Patient satisfaction with hospital services has been increasingly discussed as an important indicator of healthcare quality. It has been demonstrated that improving patient satisfaction is associated with better compliance with treatment plans and a decrease in patient complaints regarding doctors' and nurses' misconduct. This scoping review's objective is to investigate the pertinent literature on the experiences and satisfaction of patients with mental disorders receiving inpatient psychiatric care. Our goals are to highlight important ideas and explore the data that might serve as a guide to enhance the standard of treatment and patient satisfaction in acute mental health environments. This study is a scoping review that was designed in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) statement. A systematic search was conducted in the following databases: PubMed, MEDLINE, PsycINFO, CINAHL, and EMBASE. A comprehensive review was completed, including articles from January 2012 to June 2022. Qualitative and quantitative studies were included in this review based on our eligibility criteria, such as patient satisfaction as a primary outcome, adult psychiatric inpatients, and non-review studies published in the English language. Studies were considered ineligible if they included nonpsychiatric patients or patients with neurocognitive disorders, review studies, or study measure outcomes other than inpatient satisfaction. For the eligible studies, data extraction was conducted, information was summarized, and the findings were reported. A total of 31 studies representing almost all the world's continents were eligible for inclusion in this scoping review. Different assessment tools and instruments were used in the included studies to measure the level of patients' satisfaction. The majority of the studies either utilized a pre-existing or newly created inpatient satisfaction questionnaire that appeared to be reliable and of acceptable quality. This review has identified a variety of possible factors that affect patients' satisfaction and can be used as a guide for service improvement. More than half of the included studies revealed that the following factors were strongly recommended to enhance inpatient satisfaction with care: a clear discharge plan, less coercive treatment during the hospital stay, more individualized, higher quality information and teaching about the mental disorder to patients by staff, better therapeutic relationships with staff, and specific treatment components that patients enjoy, such as physical exercise sessions and music therapy. Patients also value staff who spend more time with them. The scope of patient satisfaction with inpatient mental health services is a growing source of concern. Patient satisfaction is associated with better adherence to treatment regimens and fewer complaints against health care professionals. This scoping review has identified several patient satisfaction research gaps as well as important determinants of satisfaction and how to measure and utilize patient satisfaction as a guide for service quality improvement. It would be useful for future research and reviews to consider broadening their scope to include the satisfaction of psychiatric patients with innovative services, like peer support groups and other technologically based interventions like text for support. Future research also could benefit from utilizing additional technological tools, such as electronic questionnaires.

Accounting for clustering in automated variable selection using hospital data: a comparison of different LASSO approaches

BackgroundAutomated feature selection methods such as the Least Absolute Shrinkage and Selection Operator (LASSO) have recently gained importance in the prediction of quality-related outcomes as well as the risk-adjustment of quality indicators in healthcare. The methods that have been used so far, however, do not account for the fact that patient data are typically nested within hospitals.MethodsTherefore, we aimed to demonstrate how to account for the multilevel structure of hospital data with LASSO and compare the results of this procedure with a LASSO variant that ignores the multilevel structure of the data. We used three different data sets (from acute myocardial infarcation, COPD, and stroke patients) with two dependent variables (one numeric and one binary), on which different LASSO variants with and without consideration of the nested data structure were applied. Using a 20-fold sub-sampling procedure, we tested the predictive performance of the different LASSO variants and examined differences in variable importance.ResultsFor the metric dependent variable Duration Stay, we found that inserting hospitals led to better predictions, whereas for the binary variable Mortality, all methods performed equally well. However, in some instances, the variable importances differed greatly between the methods.ConclusionWe showed that it is possible to take the multilevel structure of data into account in automated predictor selection and that this leads, at least partly, to better predictive performance. From the perspective of variable importance, including the multilevel structure is crucial to select predictors in an unbiased way under consideration of the structural differences between hospitals.

Development of a natural language processing model for deriving breast cancer quality indicators : A cross-sectional, multicenter study

ObjectivesMedico-administrative data are promising to automate the calculation of Healthcare Quality and Safety Indicators. Nevertheless, not all relevant indicators can be calculated with this data alone. Our feasibility study objective is to analyze 1) the availability of data sources; 2) the availability of each indicator elementary variables, and 3) to apply natural language processing to automatically retrieve such information. MethodWe performed a multicenter cross-sectional observational feasibility study on the clinical data warehouse of Assistance Publique – Hôpitaux de Paris (AP-HP). We studied the management of breast cancer patients treated at AP-HP between January 2019 and June 2021, and the quality indicators published by the European Society of Breast Cancer Specialist, using claims data from the Programme de Médicalisation du Système d'Information (PMSI) and pathology reports. For each indicator, we calculated the number (%) of patients for whom all necessary data sources were available, and the number (%) of patients for whom all elementary variables were available in the sources, and for whom the related HQSI was computable. To extract useful data from the free text reports, we developed and validated dedicated rule-based algorithms, whose performance metrics were assessed with recall, precision, and f1-score. ResultsOut of 5785 female patients diagnosed with a breast cancer (60.9 years, IQR [50.0–71.9]), 5,147 (89.0%) had procedures related to breast cancer recorded in the PMSI, and 3732 (72.5%) had at least one surgery. Out of the 34 key indicators, 9 could be calculated with the PMSI alone, and 6 others became so using the data from pathology reports. Ten elementary variables were needed to calculate the 6 indicators combining the PMSI and pathology reports. The necessary sources were available for 58.8% to 94.6% of patients, depending on the indicators.The extraction algorithms developed had an average accuracy of 76.5% (min-max [32.7%–93.3%]), an average precision of 77.7% [10.0%–97.4%] and an average sensitivity of 71.6% [2.8% to 100.0%]. Once these algorithms applied, the variables needed to calculate the indicators were extracted for 2% to 88% of patients, depending on the indicators. DiscussionThe availability of medical reports in the electronic health records, of the elementary variables within the reports, and the performance of the extraction algorithms limit the population for which the indicators can be calculated. ConclusionsThe automated calculation of quality indicators from electronic health records is a prospect that comes up against many practical obstacles.

The Usefulness of Present-on-Admission Data as an Indicator of Healthcare Quality Evaluation Using the Korean National Hospital Discharge in-Depth Injury Survey Data from 2006 to 2019.

Comorbidities of a principal diagnosis have varying impacts on disease and require different management depending on the onset timing. This study investigated the usefulness of present-on-admission (POA), specifically focusing on decubitus ulcers, delirium, and hypokalemia, as an indicator of healthcare quality. We analyzed patient discharge data for 14 years from 2006 to 2019 using Korean National Hospital Discharge In-Depth Injury Survey (KNHDIS). Out of 3,231,731 discharged patients, 19,871 had secondary diagnosis codes for decubitus ulcers (n=10,390, 52.3%), delirium (n=6103, 30.7%), or hypokalemia (n=3378, 17.0%). Analysis of patients with secondary diagnoses of decubitus ulcers, delirium, or hypokalemia revealed notable differences in demographics, including gender distribution, mean age, admission route, insurance type, surgical intervention rates, mortality rates, and length of stay (LOS). Among patients with one of the top 20 principal diagnoses, those with secondary diagnoses of decubitus ulcers, delirium, or hypokalemia exhibited higher odds of surgery, increased mortality risks, and longer LOS compared to those without these secondary diagnoses. All three of these diseases commonly occur postoperatively or during treatment and thus should be designated as potentially preventable complications that require special attention, and should also be considered as quality-of-care indicators.

Association of socioeconomic disadvantage with lower patient satisfaction at an academic radiation oncology center.

347 Background: The correlation between socioeconomic status and healthcare outcomes is well-established. Patient satisfaction serves as a crucial indicator of healthcare quality, however, it is unclear if patient satisfaction relates to patient socioeconomic status. To assess socioeconomic status, the Area Deprivation Index (ADI) is utilized, encompassing factors such as income, education, employment, and housing quality to measure the status of a neighborhood. The purpose of this study was to evaluate if there was a correlation between socioeconomic status and the likelihood a patient would recommend the facility or provider. Methods: This is a single-institution study evaluating the responses to a CMS approved patient satisfaction vendor survey of patients seen at an outpatient academic radiation oncology department from May 2021 through March 2023. ADI was collected using the Neighborhood Atlas, including both national percentiles and state deciles, with the higher values indicating greater socioeconomic disadvantage. Univariate (UVA) and multivariate (MVA) logistic regression analyses were conducted using the survey recommendation scores between 0 and 10 as the primary outcome. We used the score ≥9 to represent increased likelihood for recommendation for facility or provider and &lt;9 represented decreased likelihood. Results: There were 5,403 survey results included in our analysis. The mean state and national ADI in our cohort were 3.9 (range 1-10) and 50.35, respectively. Patients with state and national ADI scores below the mean were more likely to recommend the provider than those above the mean, 95.6% versus 93.6% (p=0.002) and 95.8% versus 93.6% (p&lt;0.001), respectively. There was no difference in the likelihood of recommending the facility between the groups. On univariate analysis state ADI &lt;3.9 (OR 1.46, p=0.016) and national ADI &lt;50.35 (OR 1.43, p=0.023) were associated with increased likelihood to recommend the facility or provider. On multivariate analysis, state ADI &lt;3.9 (OR 1.44, p=0.018) and national ADI &lt;50.35 (OR 1.40, p=0.033) remained significant. Conclusions: The findings of this study highlight the significance of socioeconomic status as an independent factor influencing patient satisfaction and their likelihood to recommend a healthcare provider. Providers should consider the unique needs of socioeconomically disadvantaged individuals.

Coverage uncertainty range: A new method for calculating uncertainty around summary statistics in healthcare quality indicators

Data from clinical health registries, such as medical quality registries, are often used as basis for healthcarequality indicators (QI). To aid the interpretation of quality indicators and support decisions, it is importantto quantify the uncertainty around the QI summary statistics. In this paper we suggest a novel method forquantifying such uncertainty: the Coverage uncertainty range. The method is based on the size of thepopulation present in the register relative to the total relevant population and does not make any assumptionsabout the sampling strategy or the value of the summary statistic. Furthermore, using both simulated dataand real-life data from a Norwegian medical quality registry, we illustrate why using confidence intervalswhen presenting healthcare quality indicators may lead to erroneous conclusions.

Characteristics of employment history and self-perceived barriers to healthcare access.

Research suggests that people in disadvantaged social positions are more likely to perceive barriers to accessing healthcare, especially to specialists and preventive services. In this study, we analyze if adversity during past employment histories (e.g. spells of unemployment) is linked to subsequent subjectively perceived barriers in healthcare access. Further, we investigate if the associations vary according to national healthcare access and quality indicators. We use data from the Survey of Health, Ageing and Retirement in Europe with a study sample of 31 616 men and women aged 52-80 from 25 countries. Data include retrospective information on employment histories allowing us to derive characteristics of past careers, including the number of unemployment periods, main occupational position and pension contributions. Barriers to healthcare access are measured by self-perceived forgone care due to costs and unavailability of services. We apply multilevel Poisson regression for binary outcomes and test for cross-level interactions between career characteristics and national healthcare system characteristics. Career characteristics are linked to later self-perceived healthcare access barriers, consistently in the case of cost barriers and less consistently for unavailability of services. Associations are similar for men and women, and persist after controlling for current income, wealth and subjective health. We find no cross-level interactions between career characteristics and country-level healthcare access and quality indicators. Self-perceived barriers to healthcare access are linked to people's past working lives. More in-depth investigation is needed to identify the reasons for the lingering effects of characteristics of employment history on reduced healthcare access.

Implementing and evaluating care and support planning: a qualitative study of health professionals’ experiences in public polyclinics in Singapore

BackgroundTwo polyclinics in Singapore modified systems and trained health professionals to provide person-centred Care and Support Planning (CSP) for people with diabetes within a clinical trial. We aimed to investigate health professionals’ perspectives on CSP to inform future developments.MethodsQualitative research including 23 semi-structured interviews with 13 health professionals and 3 co-ordinators. Interpretive analysis, including considerations of how different understandings, enactments, experiences and evaluative judgements of CSP clustered across health professionals, and potential causal links between them.ResultsBoth polyclinic teams introduced CSP and sustained it through COVID-19 disruptions. The first examples health professionals gave of CSP ‘going well’ all involved patients who came prepared, motivated and able to modify behaviours to improve their biomedical markers, but health professionals also said that they only occasionally saw such patients in practice. Health professionals’ accounts of how they conducted CSP conversations varied: some interpretations and reported enactments were less clearly aligned with the developers’ person-centred aspirations than others. Health professionals brought different communication skill repertoires to their encounters and responded variably to challenges to CSP that arose from: the linguistic and educational diversity of patients in this polyclinic context; the cultural shift that CSP involved; workload pressures; organisational factors that limited relational and informational continuity of care; and policies promoting biomedical measures as key indicators of healthcare quality. While all participants saw potential in CSP, they differed in the extent to which they recognised relational and experiential benefits of CSP (beyond biomedical benefits), and their recommendations for continuing its use beyond the clinical trial were contingent on several considerations. Our analysis shows how narrower and broader interpretive emphases and initial skill repertoires can interact with situational challenges and respectively constrain or extend health professionals’ ability to refine their skills with experiential learning, reduce or enhance the potential benefits of CSP, and erode or strengthen motivation to use CSP.ConclusionHealth professionals’ interpretations of CSP, along with their communication skills, interact in complex ways with other features of healthcare systems and diverse patient-circumstance scenarios. They warrant careful attention in efforts to implement and evaluate person-centred support for people with long-term conditions.

Is there an association between out-of-pocket hospital costs, quality and care outcomes? A systematic review of contemporary evidence

BackgroundOut of pocket (OOP) costs vary substantially by health condition, procedure, provider, and service location. Evidence of whether this variation is associated with indicators of healthcare quality and/or health outcomes is lacking.MethodsThe current review aimed to explore whether higher OOP costs translate into better healthcare quality and outcomes for patients in inpatient settings. The review also aimed to identify the population and contextual-level determinants of inpatient out-of-pocket costs. A systematic electronic search of five databases: Scopus, Medline, Psych Info, CINAHL and Embase was conducted between January 2000 to October 2022. Study procedures and reporting complied with PRISMA guidelines. The protocol is available at PROSPERO (CRD42022320763).FindingsA total of nine studies were included in the final review. A variety of quality and health outcomes were examined in the included studies across a range of patient groups and specialities. The scant evidence available and substantial heterogeneity created challenges in establishing the nature of association between OOP costs and healthcare quality and outcomes. Nonetheless, the most consistent finding was no significant association between OOP cost and inpatient quality of care and outcomes.InterpretationThe review findings overall suggest no beneficial effect of higher OOP costs on inpatient quality of care and health outcomes. Further work is needed to elucidate the determinants of OOP hospital costs.FundingThis study was funded by Medibank Better Health Foundation.

The femtech revolution-A new approach to pregnancy management: Digital transformation of maternity care-The hybrid e-health perinatal clinic addressing the unmet needs of low- and middle-income countries.

Prenatal care and infant mortality rates are crucial indicators of healthcare quality. However, millions of women in low-income countries lack access to adequate care. Factors such as high-risk pregnancies and unmanaged diet increase the risk of developing complications during pregnancy, highlighting the need for continuous monitoring of maternal health. The increasing burden of non-communicable diseases represents a significant threat to fragile health systems. The lack of access to appropriate prenatal care and poor maternal and newborn health outcomes are major concerns in low- and middle-income countries (LMICs). It emphasizes the need for innovative, integrative approaches to healthcare delivery, especially in pregnant women. The health services need to be reorganized holistically and effectively, focusing on factors that directly impact maternal, neonatal, and infant mortality, resulting in improved access to maternity services and survival of "at-risk" mothers and their offspring in many LMICs. Based on the FIGO (the International Federation of Gynecology & Obstetrics) recommendations of extending preconception care to the postpartum stage, the authors of this review have developed a new model of care-PregCare-based on the triple-intervention-based holistic and multidisciplinary maternal and fetal medicine model for low-risk pregnancies. This model will help transform the traditional model's high visitation frequency into a safe and reduced office visit, while increasing virtual connections, point of care and self-care with doctors, nurses, and community-based providers of self-care. This shall be based on a sophisticated central PregCare call center powered by innovative technologies combined with experienced personnel in perinatal management (doctors and nurses/midwives).

A small area model to assess temporal trends and sub-national disparities in healthcare quality

Monitoring subnational healthcare quality is important for identifying and addressing geographic inequities. Yet, health facility surveys are rarely powered to support the generation of estimates at more local levels. With this study, we propose an analytical approach for estimating both temporal and subnational patterns of healthcare quality indicators from health facility survey data. This method uses random effects to account for differences between survey instruments; space-time processes to leverage correlations in space and time; and covariates to incorporate auxiliary information. We applied this method for three countries in which at least four health facility surveys had been conducted since 1999 – Kenya, Senegal, and Tanzania – and estimated measures of sick-child care quality per WHO Service Availability and Readiness Assessment (SARA) guidelines at programmatic subnational level, between 1999 and 2020. Model performance metrics indicated good out-of-sample predictive validity, illustrating the potential utility of geospatial statistical models for health facility data. This method offers a way to jointly estimate indicators of healthcare quality over space and time, which could then provide insights to decision-makers and health service program managers.