Hospital-based Quality Improvement Research Articles

#1259 Relationship between renal dysfunction, non-obstructive ACS and in-hospital prognosis: findings from the CCC-ACS project

Abstract Background and Aims Acute coronary syndrome (ACS) is an acute and critical condition of coronary heart disease (CHD) with high mortality and poor prognosis. The prevalence of non-obstructive ACS is about 5% ∼ 15%. Among patients with non-obstructive ACS, which patients are more prone to poor prognosis is a concern. Chronic kidney disease (CKD) is an important risk factor for cardiovascular disease, and due to its special pathophysiological mechanism, non-obstructive ACS may not be uncommon in CKD patients. Therefore, the aim of this study was to investigate the relationship between renal function, the occurrence and prognosis of non-obstructive ACS. Method Improving Care for Cardiovascular Disease in China - Acute Coronary Syndrome (CCC-ACS), a hospital-based medical quality improvement project, is a hospital-based medical quality improvement project to improve the compliance of ACS guidelines in China and improve the prognosis of patients. It was jointly sponsored by the American Heart Association (AHA) and the Chinese Society of Cardiology (CSC) in 2014, with 240 hospitals participating, representing different levels of ACS management in Chinese hospitals. We analyzed patients who underwent coronary angiography from November 2014 to July 2019 in CCC-ACS. Patients were divided into eGFR <60 ml/min·1.73 m² and eGFR≥60 ml/min·1.73 m² groups according to estimated glomerular filtration rate (eGFR) calculated by the EPI formula. According to the results of coronary angiography, the patients were divided into obstructive ACS group and non-obstructive ACS group (obstructive ACS group was defined as at least one coronary artery stenosis ≥ 50%; the others were non-obstructive ACS group). Outcome was defined as in-hospital all-cause mortality and in-hospital MACEs. Results A total of 77 586 patients were included, including 2 292 patients (3.0%) with non-obstructive ACS and 75 294 patients (97.0%) with obstructive ACS. After adjusting for confounding factors using a multivariate logistic regression model, patients with eGFR<60 ml/min·1.73 m² had an approximately 20% increased risk of non-obstructive ACS compared with patients with eGFR≥60 ml/min·1.73 m². The comparison of in-hospital outcomes between the patients with non-obstructive ACS and obstructive ACS is shown in Fig. 1. In-hospital outcomes showed that although the obstructive ACS group had a worse in-hospital prognosis than the non-obstructive ACS group, and the eGFR<60 ml/min·1.73 m² group had a worse in-hospital prognosis than the eGFR≥60 ml/min·1.73 m² group, further grouping of patients showed that the non-obstructive ACS group with eGFR<60 ml/min·1.73 m² had a worse prognosis than the obstructive ACS group with eGFR≥60 ml/min·1.73 m². Confounding factors adjusted for non-obstructive ACS showed that lower eGFR was associated with a higher risk of in-hospital MACEs. After analyzing the in-hospital medication and discharge medication of patients, it was found that the standardized cardiovascular drug therapy was inadequate in patients with non-obstructive ACS. Conclusion Patients with non-obstructive ACS have worse renal function than patients with obstructive ACS, and the proportion of patients with eGFR<60 ml/min·1.73 m² is higher. In patients with non-obstructive ACS, the risk of in-hospital MACEs significantly increased as eGFR decreased. This suggests that we may consider giving standardized cardiovascular drug therapy to patients with non-obstructive ACS, especially those with non-obstructive ACS combined with abnormal renal function, in order to improve the prognosis of patients. This needs to be confirmed by more randomized controlled trial results.

Hospital-Based Pediatric Quality Improvement Interventions and Health Disparities: A Scoping Review of the Literature.

Quality improvement (QI) has the potential to reduce health disparities through multiple mechanisms, including by standardizing care and addressing social barriers to health. National organizations require that hospital systems integrate equity into quality efforts, but effective approaches remain unclear. We aimed to examine the association of hospital-based pediatric QI interventions and racial and ethnic, language, and socioeconomic disparities in health outcomes. Quantitative studies from January 1, 2000 to December 11, 2023 reporting the effects of pediatric hospital-based QI were selected from PubMed and Embase. Studies were excluded if outcomes were not stratified by race and ethnicity, language, or socioeconomic status. Studies were reviewed in duplicate for inclusion and by 1 author for data extraction. A total of 22 studies were included. Most studies (n = 19, 86%) revealed preexisting disparities, and 68% of those (n = 13) found disparities reductions post-intervention. Studies with disparity-focused objectives or interventions more commonly found reduced disparities than studies of general QI (85% vs 33%). Hospital-based process standardization was associated with reduced disparities in provider practices. Most interventions associated with reduced disparities in patient-facing outcomes involved community/ambulatory partnership. Limitations included potential exclusion of relevant studies, topic heterogenity, and risk of bias. Although the authors of few published hospital-based QI initiatives assessed their equity effect, intentionally designed QI studies were associated with reduced disparities. Interventions focused on care standardization may reduce disparities in care quality, although multilevel interventions are likely needed to affect the health care structures that influence more significant patient outcomes.

Implementation of a Multidimensional Strategy to Reduce Post-PCI Bleeding Risk.

The American College of Cardiology Reduce the Risk: PCI Bleed Campaign was a hospital-based quality improvement campaign designed to reduce post-percutaneous coronary intervention (PCI) bleeding events. The aim of the campaign was to provide actionable evidence-based tools for participants to review, adapt, and adopt, depending upon hospital resources and engagement. We used data from 8 757 737 procedures in the National Cardiovascular Data Registry between 2015 and 2021 to compare patient and hospital characteristics and bleeding outcomes among campaign participants (n=195 hospitals) and noncampaign participants (n=1384). Post-PCI bleeding risk was compared before and after campaign participation. Multivariable hierarchical logistic regression was used to determine the adjusted association between campaign participation and post-PCI bleeding events. Prespecified subgroups were examined. Campaign hospitals were more often higher volume teaching facilities located in urban or suburban locations. After adjustment, campaign participation was associated with a significant reduction in the rate of bleeding (bleeding: adjusted odds ratio, 0.61 [95% CI, 0.53-0.71]). Campaign hospitals had a greater decrease in bleeding events than noncampaign hospitals. In a subgroup analysis, the reduction in bleeding was noted in non-ST-segment-elevation acute coronary syndrome and ST-segment-elevation myocardial infarction patients, but no significant reduction was seen in patients without acute coronary syndrome. Participation in the American College of Cardiology Reduce the Risk: PCI Bleed Campaign was associated with a significant reduction in post-PCI bleeding. Our results underscore that national quality improvement efforts can be associated with a significant impact on PCI outcomes.

Abstract 14379: Get With The Guidelines ® Registry Data Tools and Analysis Platform

Introduction: The American Heart Association (AHA) Get With The Guidelines ® (GWTG) registry has emerged as a vital resource in hospital-based quality improvement and advancing the standards and practices for inpatient cardiovascular/stroke care. The GWTG registry data, with over 13 million records collected from over 2600 hospitals, has resulted in over 600 peer-reviewed publications. Goal: The goals of this project were to test new technology tools, including an interactive web-based interface connected to a database in a cloud-based workspace on the AHA Precision Medicine Platform (PMP) , to simplify GWTG data queries and analysis for researchers. Methods: A new GWTG database was built using the PostgreSQL relational database system. Integration between the database and the user interface was built using the Django web framework. Data processing and quality control was done through a series of steps including schema verification, documentation generation, and de-identification. The user interface was tested within an AHA PMP workspace that provides security, privacy, statistical analysis tools and computational power. Results: The interactive user interface and GWTG database will be accessible to researchers with approved manuscript proposals conducting their own analysis on the AHA PMP. As shown in the figure, the user-friendly interface allows researchers to efficiently filter large volumes of data using structured querying language or built-in filtering functions. Researchers can create the cohort needed and perform the approved analysis, leveraging the statistical tools within the secure and private workspace on the AHA PMP. Conclusion: The AHA is committed to the FAIR (Findable, Accessible, Interoperable, Reusable) guiding principles of data. We have launched this new technology to provide streamlined access to GWTG data, powerful analysis tools, and computational power for all researchers.

Methods progress note: Applying dissemination and implementation science models to enhance hospital-based quality improvement.

The authors declare no conflict of interest.

Subject Matter Expert Nurses in Safe Sleep Program Implementation.

Pennsylvania sudden unexpected infant death rates rank among the highest nationally. A nursing team developed, implemented, evaluated, and disseminated an evidence-based quality improvement (QI) program at birthing hospitals in Pennsylvania to address this issue. To facilitate implementation, clinical nurses were educated as Subject Matter Experts (SMEs) to empower them to transform and sustain outcomes-driven QI for infant safe sleep nursing practice. This descriptive study examined outcomes from 268 nurses who received comprehensive education on infant safe sleep and the SME role. Likert-type scale surveys measured knowledge gained and progress made in practice following education. A programmatic dashboard tracked program implementation. Descriptive statistics were used to report findings. SME nurses ( N = 268) completed two interactive learning modules addressing safe sleep guidelines and teaching strategies and attended a workshop to acquire skills for program implementation. Key competencies included data collection and dissemination, policy development, and communication techniques. Immediate posteducation surveys completed by SMEs indicated that over 98% of respondents strongly agreed or agreed they were able to effectively demonstrate communication strategies, identify SME role components, provide environment surveillance, and demonstrate best practices in infant safe sleep. To allow time for assimilation of the of SME role, a survey was initiated at 6 months to capture progress made. Seventy-eight SMEs responded to the survey and reported exceptional or substantial progress in 10 areas for SME responsibilities. Use of the SME role for program implementation led to highly favorable SME-reported outcomes in leading a hospital-based QI program.

Improving quality of surgical and anaesthesia care in sub-Saharan Africa: a systematic review of hospital-based quality improvement interventions

ObjectivesTo systematically review existing literature on hospital-based quality improvement studies in sub-Saharan Africa that aim to improve surgical and anaesthesia care, capturing clinical, process and implementation outcomes in order to...

Implementing Dysphagia Screening and Assessment in an Intermediate and Long-Stay Hospital: A Hospital-Based Quality Improvement Project

Dysphagia can occur due to a wide range of medical conditions including acute or progressive neurological disorders, trauma or surgery, with secondary effects such as dehydration and malnutrition causing an increase in morbidity and mortality rates. Dysphagia screening and assessment of swallowing function by a multidisciplinary care team is essential to identify, diagnose and manage patients with dysphagia. A cross-sectional study of dysphagia screening and assessment was performed from the 1st to the 15th of April 2022 on patients hospitalised in an intermediate and long-stay hospital in Cartagena in the southeast of Spain. The Eating Assessment Tool-10 (EAT-10) questionnaire was used as a direct-scoring screening test for dysphagia together with the standardised Volume-Viscosity Swallow Test (V-VST) in all patients with an EAT-10 score ≥ 3 points. After confirming dysphagia, different dietary and pharmaceutical interventions were performed. The following data were collected from the medical record program EKON®: age, gender, primary diagnosis, diet and texture and the use of thickener for liquids. A total of 86 patients were included in the study with a mean age of 80.0 ± 12.0 years. The mean EAT-10 score was 2.5 ± 1.7 points with 36 patients (43.9%) testing positive for being at risk of presenting dysphagia. Of these patients at risk, the V-VST detected dysphagia and the necessity of a nectar consistency in 24 patients, a honey consistency in 3 patients and a pudding consistency in 2 patients. Only 10 of the patients with dysphagia were using thickener prior to the screening and the assessment. Dietary and pharmaceutical interventions were made in the other 19 patients with dysphagia. Dysphagia screening in intermediate and long-stay hospitals is not common practice even though there is a high prevalence and important clinical repercussions. Implementing dysphagia screening and assessment protocols will improve quality of care in these patients.

The ‘Emergency Stone Clinic’ – improving patient care: A collaborative, hospital-based quality improvement project

Introduction & Aims: There is a current drive nationally to improve the management of acute ureteric colic. Management targets set by the British Association of Urological Surgeons (BAUS) include a 4-week target for the time from diagnosis-to-definitive management, or to clinic review in patients managed expectantly. The motivation to review our acute stone service stemmed from concerns that we did not have the capacity to consistently offer primary definitive treatment or timely clinic review to patients. We aimed to restructure our service using Plan-Do-Study-Act (PDSA) cycles to achieve the BAUS targets. Method: All patients diagnosed with a ureteric stone between March and September 2017 were reviewed as a baseline. Our strategy for improvement involved implementing an emergency stone clinic (ESC) model. This was developed through collaboration between the key stakeholders and centred on a weekly consultant-led specialist clinic designed to review and make early management decisions for all patients referred with a ureteric stone meeting pre-agreed criteria. Post-intervention data were collected between June 2018 and January 2019. To assess whether we were able to meet these targets during the COVID-19 pandemic, data were also collected between January 2020 and October 2020. Results: Time from CT diagnosis to clinic review reduced from 77 to 9 days. Patients seen within 4 weeks of diagnosis improved from 2.9% to 90.5%. Of those requiring a procedure, the percentage receiving a primary intervention increased to 72.1%. Emergency stent insertion was reduced from 69% to 27.9%. The rate of patient re-presentation to A&E reduced from 3.0 to 1.6 episodes/month. The percentage receiving their definitive procedure within 4 weeks improved from 26.2% to 51.2% in the first post-intervention cycle and remained at 54.5% during the pandemic period. Conclusions: Implementing the ESC model led to substantial improvements in patient care and significant progress towards achieving the BAUS management targets while reducing the burden on our Emergency Department. Level of evidence: Not applicable

Abstract P194: Polypill Eligibility For Patients With Heart Failure With Reduced Ejection Fraction In South India: A Secondary Analysis Of A Prospective, Interrupted Time Series Study

In India, data from large HF registries has demonstrated significantly lower 5-year mortality rates for patients with HFrEF discharged on guideline-directed medical therapy (GDMT), revealing an important target for intervention to improve clinical outcomes. Hospital-based quality improvement initiatives to increase rates of GDMT at hospital discharge have had limited effect, suggesting additional strategies are needed to improve GDMT rates in HFrEF patients. Polypills for HFrEF have been proposed as an implementation strategy to simplify the current treatment paradigm for undertreated patients with HFrEF. However, the potential effect of HFrEF polypills on increasing GDMT rates in target populations is unknown. The objective of this secondary analysis is to describe eligibility for a potential HFrEF polypill in the context of GDMT prescription rates for South Indian patients with HFrEF. We analyzed data from a prospective, interrupted time series study in 2018 (HFQUIK) that evaluated the effect of a quality improvement intervention on process of care measures and clinical outcomes in patients hospitalized with acute HFrEF in 8 hospitals in South India. The primary outcome was prescription of GDMT defined as an ACE-I or ARB or ARNi, along with a beta-blocker and aldosterone antagonist. Participants were eligible for a HFrEF polypill containing GDMT if LVEF<40%, HR ≥50 beats/min, creatinine ≤2.5 mg/dL in men and ≤2 mg/dL in women, and potassium <5 mEq/L. We included 937 participants with HFrEF (n = 494 control period, n = 443 intervention period). Prescription rates of ACE-I or ARB or ARNi, beta-blocker, and aldosterone antagonists were low on hospital admission and increased at hospital discharge. The prescription of GDMT increased from 5.5% (27/494) to 28.8% (127/494) in the control period and from 4.5% (20/443) to 42.3% (171/443) in the intervention period. Notably, more than 80% of participants were eligible for a HFrEF polypill at hospital discharge during both control (364/494) and intervention (336/443) periods, with similar rates among female and male participants. In this study, than 80% of patients were eligible for a HFrEF polypill at discharge. Although the HF QUIK quality improvement intervention increased rates of GDMT at hospital discharge, routine administration of a HFrEF polypill could further increase this rate and improve adherence by 44% (95% CI: 26% to 65%) in a population that remains undertreated despite targeted quality improvement interventions. Availability of multiple HFrEF polypill doses could prioritize safety and tolerability with low-dose initiation and subsequent titration to higher-dose polypills. This analysis suggests a simplified polypill-based management strategy could be transformative for closing the treatment gap in HFrEF inequities in India and globally.

Incorporating Quality Improvement Projects Into Stroke Care and Research.

Incorporating Quality Improvement Projects Into Stroke Care and Research.

COVID-19-Mediated Strengths and Challenges for 2021 Nursing Graduates: Implications for Nurse Leaders and Educators

The purpose of this hospital-based quality improvement project was to ascertain 18 clinical instructors’ perceptions regarding senior nursing students’ strengths and challenges in the time of COVID-19. Constant comparative method yielded 4 themes suggesting 2021 diversity in senior nursing students’ clinical strengths and challenges, as well COVID-19’s implications for students’ professional identity development and transition to professional practice. Findings also suggested significant implications for nurses in professional development roles.

Antibiotic use in acute upper respiratory tract infections and uncomplicated lacerations in the Gaza Strip: clinical audit and re-audit

BackgroundOveruse of antibiotics is increasing worldwide and has led to a marked increase in multidrug-resistant pathogens. Acute upper respiratory tract infections and uncomplicated lacerations do not require antibiotics. We assessed adherence to the best international standards of antibiotic prescribing for these conditions. MethodsWe did an audit and reaudit at Nasser Hospital in the Gaza Strip. The audit included patients presenting from January to March, 2017, with acute upper respiratory tract infections or uncomplicated lacerations. Random selection, stratified by condition, was used to assign patients to the audit or reaudit. After the audit an action plan was implemented focusing on education of health-care providers and patients for one year. The reaudit was done in 2018, from January to March. Ethics approval was obtained from the Palestinian Ministry of Health. Findings240 patients were included overall, 60 with each condition in the audit and 60 with each condition in the reaudit. The 60 patients in the first audit with acute upper respiratory tract infections had a mean age of 32·1 (SD 6·4) years. 25 (42%) had throat examinations, of which 20 (33%) were normal. 52 (87%) of these 60 patients were prescribed antibiotics, which were used by 29 (48%) who cited that they believed it was important to do so. The 60 patients presenting with uncomplicated lacerations had a mean age of 14·5 (SD 10·3) years. Injuries were closed by sutures in 59 (98%) patients, who all received antibiotics. 52 (87%) of 60 patients with lacerations believed that antibiotics accelerate healing. Reaudit after the action plan was implemented showed that antibiotics were prescribed to 43 (71%) patients with acute upper respiratory tract infections (p=0·002) for difference and to 50 (84%) with uncomplicated lacerations. InterpretationDespite some improvement in appropriate antibiotic use for acute upper respiratory tract infections after hospital-based quality improvement efforts, physicians did not generally follow international guidelines for appropriate antibiotic use and patients believed that their use was important. Development of evidence-based guidelines and education of patients are needed. FundingNone.

Financial Incentives to Enhance Participation of Resident Physicians in Hospital-Based Quality Improvement Projects.

Methods to promote successful trainee participation in quality improvement projects are poorly studied. This project studied the effects of a trainee pay-for-performance program and quality improvement education at a safety-net hospital. In this program, trainees worked with quality improvement faculty, participated in projects aligned with the hospital's priorities, and designed their program-specific project. Each trainee who worked at least 88 days in the institution was eligible to earn $400 for every target achieved for at least six months (maximum of $1,200). Among hospitalwide goals, needlestick injuries per quarter decreased from [mean (standard deviation; SD)] 18 (4.6) to 12 (2.6), 95% confidence interval (CI) = -10.1-1.9, p = 0.02; percentage of excellent provider communication improved from 76.8% to [mean (SD)] 80.5% (2.9), 95% CI = 0.8-8.3, p = 0.08; and mean length of stay for discharged emergency department patients requiring specialist consultation decreased from [mean (SD)] 523 (120) to 461 (40) minutes, 95% CI = -162-37.2, p = 0.11. Among resident-initiated projects, the percentage of Family Medicine patients undergoing colorectal screening increased from 65.1% to [mean (SD)] 67.7% (0.4), 95% CI = 1.7-3.5, p = 0.01; percentage of at-risk patients receiving naloxone at hospital discharge increased from 9% to [mean (SD)] 63% (7.2), 95% CI = 36.1-71.9, p = 0.01; percentage of adolescents screened for chlamydia increased from 34% to [mean (SD)] 55.8% (6.4), 95% CI = 5.9-37.6, p = 0.03; and percentage of high-dose opioid prescriptions following cesarean section decreased from 28% to [mean (SD)] 1.7% (2.9), 95% CI = -33.5 to -19.2, p = 0.001. Eleven of 14 programs achieved three goals. All resident-led goals were met. A pay-for-performance improvement program that aligns educational and hospital priorities can provide meaningful experiential learning for trainees and improve patient care.

Impact of Hospital-based Quality Improvement in Bronchiolitis on Community Outpatient Care

Impact of Hospital-based Quality Improvement in Bronchiolitis on Community Outpatient Care

Association of acute resuscitation and post-resuscitation survival with overall risk-standardized survival to discharge for in-hospital cardiac arrest

Abstract Background Although survival for in-hospital cardiac arrest (IHCA) varies markedly across sites, it remains unknown whether high survival at top-performing hospitals is due to high rates of acute resuscitation survival (i.e., achievement of return of spontaneous circulation [ROSC]), post-resuscitation survival (i.e., survival to discharge among patients who achieved ROSC), or both. Methods Using 2015–2018 Get With The Guidelines (GWTG)-Resuscitation data, we identified 290 hospitals (86,426 patients) with IHCA. For each hospital, we calculated overall risk-standardized survival (RSSR) to discharge for IHCA using a previously validated hierarchical regression model and categorized hospitals into quartiles based on that metric. Risk-adjusted rates of acute resuscitation survival (defined as return of spontaneous circulation for >20 minutes [ROSC]) and post-resuscitation survival (defined as the proportion of patients achieving ROSC who survived to hospital discharge) were also computed for each hospital. We examined the correlation between a hospital's overall RSSR with its risk-adjusted rate of acute resuscitation and post-resuscitation survival. Results Among study hospitals, the median RSSR was 25.1% (inter-quartile range [IQR]: 21.9%–27.7%). The median risk-adjusted rate of acute resuscitation survival was 72.4% (IQR: 67.9%–76.9%) and post-resuscitation survival was 34.0% (IQR: 31.5%–37.7%). Hospital rates of RSSR were less strongly correlated with risk-adjusted rates of acute resuscitation survival (rho=0.50, P<0.001) than post-resuscitation survival (rho=0.90, P<0.001). Compared with hospitals in the lowest quartile of RSSR, hospitals in the highest quartile had substantially higher rates of acute resuscitation survival (Q4: 75.4% vs. Q1: 66.8%; P<0.001) and post-resuscitation survival (Q4: 40.3% vs. Q1: 28.7%; P<0.001). Notably, there was no correlation between hospital risk-adjusted rates of acute resuscitation survival and post-resuscitation survival (rho=0.09, P=0.11). Conclusion Hospital that excel in overall IHCA survival in general excel in either acute resuscitation or post-resuscitation care. As most hospital-based quality improvement initiatives largely focus on acute resuscitation survival, our findings suggest that efforts to strengthen post-resuscitation care may offer additional opportunities to improve IHCA survival. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): NHLBI

Admission fasting plasma glucose is associated with in-hospital outcomes in patients with acute coronary syndrome and diabetes: findings from the improving Care for Cardiovascular Disease in China - Acute Coronary Syndrome (CCC-ACS) project

BackgroundThe discrepancy between glycosylated hemoglobin (HbA1c) and fasting plasma glucose (FPG) in clinical practice may be related to factors such as acute stress, renal dysfunction, and anemia, and its relationship with in-hospital outcomes is uncertain. The aim of this study was to investigate the association between the type of discrepancy between HbA1c and FPG and in-hospital outcomes in patients with acute coronary syndrome (ACS) and diabetes.MethodsThe Improving Care for Cardiovascular Disease in China - Acute Coronary Syndrome (CCC-ACS) project is a national, hospital-based quality improvement project with an ongoing database. Patients with ACS, diabetes and complete HbA1c and FPG values at admission were included. The consistent group included patients with HbA1c < 6.5% and FPG < 7.0 mmol/L or HbA1c ≥ 6.5% and FPG ≥ 7.0 mmol/L. The discrepancy group included patients with HbA1c ≥ 6.5% and FPG < 7.0 mmol/L (increased HbA1c group) or HbA1c < 6.5% and FPG ≥ 7.0 mmol/L (increased FBG group).ResultsA total of 7762 patients were included in this study. The numbers of patients in the consistent and discrepancy groups were 5490 and 2272 respectively. In the discrepancy group, increased HbA1c accounted for 77.5% of discrepancies, and increased FPG accounted for 22.5% of discrepancies. After adjusting for confounders, patients in the increased FPG group had a 1.6-fold increased risk of heart failure (OR, 1.62; 95% CI, 1.08–2.44), a 1.6-fold increased risk of composite cardiovascular death and heart failure (OR, 1.63; 95% CI, 1.09–2.43), and a 1.6-fold increased risk of composite major adverse cardiovascular and cerebrovascular events (MACCEs) and heart failure (OR, 1.56; 95% CI, 1.08–2.24) compared to patients in the increased HbA1c group.ConclusionsPatients with an increased FPG but normal HbA1c had a higher risk of in-hospital adverse outcomes than those with increased HbA1c but normal FPG. This result may indicate that when HbA1c and FPG are inconsistent in patients with ACS and diabetes, the increased FPG that may be caused by stress hyperglycemia may have a more substantial adverse effect than increased HbA1c, which may be caused by chronic hyperglycemia. These high-risk patients should be given more attention and closer monitoring in clinical practice.Trial registryClinicaltrial.gov, NCT02306616. Registered 29 November 2014.

Racial Inequities in Preventable Pregnancy-Related Deaths in Louisiana, 2011-2016.

To examine preventable pregnancy-related deaths in Louisiana by race and ethnicity and maternal level of care to inform quality improvement efforts. We conducted a retrospective observational descriptive analysis of Louisiana Pregnancy-Associated Mortality Review data of 47 confirmed pregnancy-related deaths occurring from 2011 to 2016. The review team determined cause of death, preventability, and contributing factors. We compared preventability by race-ethnicity and maternal level of care of the facility where death occurred (from level I: basic care to level IV: regional perinatal health center) using odds ratios (ORs) and 95% CIs. The rate of pregnancy-related death among non-Hispanic black women (22.7/100,000 births, 95% CI 15.5-32.1, n=32/140,785) was 4.1 times the rate among non-Hispanic white women (5.6/100,000, 95% CI 2.8-10.0, n=11/197,630). Hemorrhage (n=8/47, 17%) and cardiomyopathy (n=8/47, 17%) were the most common causes of pregnancy-related death. Among non-Hispanic black women who experienced pregnancy-related death, 59% [n=19] of deaths were deemed potentially preventable, compared with 9% (n=1) among non-Hispanic white women (OR 14.6, 95% CI 1.7-128.4). Of 47 confirmed pregnancy-related deaths, 58% (n=27) occurred at level III or IV birth facilities. Compared with those at level I or II birth facilities (n=2/4, 50%), pregnancy-related deaths occurring at level III or IV birth facilities (n=14/27, 52%) were not less likely to be categorized as preventable (OR 2.0, 95% CI 0.5-8.0). Compared with non-Hispanic white women, pregnancy-related deaths that occurred among non-Hispanic black women in Louisiana from 2011 to 2016 were more likely to be preventable. The proportion of deaths that were preventable was similar between lower and higher level birth facilities. Hospital-based quality improvement efforts focused on addressing hemorrhage, hypertension, and associated racial inequities may prevent pregnancy-related deaths in Louisiana.

The Pediatric American Pain Society Patient Outcomes Questionnaire (Pediatric APS-POQ): Development and Initial Psychometric Evaluation of a Brief and Comprehensive Measure of Pain and Pain Outcomes in Hospitalized Youth

Pediatric pain assessment in the hospital traditionally involves the patient's self-report of pain intensity using a numeric rating scale, which does not capture the complexity of the pain experience. No valid, comprehensive measure of pain in hospitalized youth exists. This study was designed to develop and conduct initial psychometric testing of the Pediatric American Pain Society Patient Outcomes Questionnaire (Pediatric APS-POQ), a comprehensive patient-reported measure of pain and pain outcomes in hospitalized youth. A multidisciplinary group of pediatric pain researchers and clinicians collaborated to adapt the adult APS-POQ Revised to pediatrics, including a patient-report and parent proxy version. The adapted measures were administered to 218 pediatric inpatients (age M = 13.4 years, 56% female) and 214 of their parents (80% mothers) at 4 US children's hospitals. The measure was feasible to administer within the inpatient setting and was acceptable and understandable to pediatric patients and their parents. Internal consistency was adequate for both patient-report and parent proxy (α = 0.77). Confirmatory factor analysis supported the following 6 domains, consistent with the adult measure: pain intensity, functional interference, emotional response, side effects, perceptions of care, and usual pain. Additional research is needed to further support the reliability and validity of this measure in diverse clinical populations. PerspectiveTo reduce the impact of pain on hospitalized youth, pediatric pain assessment must move beyond ratings of pain intensity. The Pediatric APS-POQ provides a brief but comprehensive assessment of pain and pain outcomes in hospitalized children and adolescents, which will allow for greater individualization in hospital-based pain management and quality improvement purposes.

Hospital-Based Quality Improvement Interventions for Patients With Acute Coronary Syndrome: A Systematic Review.

Quality improvement initiatives have been developed to improve acute coronary syndrome care largely in high-income country settings. We sought to synthesize the effect size and quality of evidence from randomized controlled trials (RCTs) and nonrandomized studies for hospital-based acute coronary syndrome quality improvement interventions on clinical outcomes and process of care measures for their potential implementation in low- and middle-income country settings. We conducted a bibliometric search of databases and trial registers and a hand search in 2016 and performed an updated search in May 2018 and May 2019. We performed data extraction, risk of bias assessment, and quality of evidence assessments in duplicate. We assessed differences in outcomes by study design comparing RCTs to nonrandomized quasi-experimental studies and by country income status. A meta-analysis was not feasible due to substantial, unexplained heterogeneity among the included studies, and thus, we present a qualitative synthesis. We screened 5858 records and included 32 studies (14 RCTs [n=109 763] and 18 nonrandomized quasi-experimental studies [n=54-423]). In-hospital mortality ranged from 2.1% to 4.8% in the intervention groups versus 3.3% to 5.1% in the control groups in 5 RCTs (n=55 942). Five RCTs (n=64 313) reported 3.0% to 31.0% higher rates of reperfusion for patients with ST-segment-elevation myocardial infarction in the intervention groups. The effect sizes for in-hospital and discharge medical therapies in a majority of RCTs were 3.0% to 10.0% higher in the intervention groups. There was no significant difference in 30-day mortality evaluated by 4 RCTs (n=42 384), which reported 2.5% to 15.0% versus 5.9% to 22% 30-day mortality rates in the intervention versus control groups. In contrast, nonrandomized quasi-experimental studies reported larger effect sizes compared to RCTs. There were no significant consistent differences in outcomes between high-income and middle-income countries. Low-income countries were not represented in any of the included studies. Hospital-based acute coronary syndrome quality improvement interventions have a modest effect on process of care measures but not on clinical outcomes with expected differences by study design. Although quality improvement programs have an ongoing and important role for acute coronary syndrome quality of care in high-income country settings, further research will help to identify key components for contextualizing and implementing such interventions to new settings to achieve their desired effects. Systematic Review Registration: URL: https://www.crd.york.ac.uk/PROSPERO/. Unique identifier: CRD42016047604.