Health Care Quality Indicators Research Articles

Predictors of 1-month and 3-months Hospital Readmissions in Decompensated Cirrhosis: A Prospective Study in a Large Asian Cohort

Introduction and aimConsidered as a healthcare quality indicator, hospital readmissions in decompensated cirrhosis predispose the patients and the society to physical, social and economic distresses. Few studies involving North American cohorts have identified different predictors. The aim of this study was to determine and validate the predictors of 1-month and 3-months readmission in an Asian cohort. Material and methods.We prospectively studied 281 hospitalised patients with decompensated cirrhosis at a large tertiary care public hospital in India between August 2014 and August 2016 and followed them for 3 months. Data regarding demographic, laboratory and disease related risk factors were compiled. We used multivariate logistic regression to determine predictors of readmission at 1-month and 3-months and receiver operating curves (ROC) for significant predictors to obtain the best cut-offs. Results1-month and 3-months readmission rates in our study were 27.8% and 42.3%, respectively. Model for End stage Liver Disease (MELD) score at discharge (OR:1.24, p < 0.001) and serum sodium (OR:0.94, p-0.039) independently predicted 1-month and MELD score (OR:1.11, p-0.003), serum sodium (OR:0.94, p-0.027) and male gender (OR:2.19, p-0.008) independently predicted 3-months readmissions. Neither aetiology nor complications of cirrhosis emerged as risk factors. MELD score >14 at discharge and serum sodium < 133 mEq/L best predicted readmissions; MELD score being a better predictor than serum sodium (p - 0.0001). ConclusionsHigh rates of early and late readmissions were found in our study. Further, this study validated readmission predictors in Asian patients. Structured interventions targeting this risk factors may diminish readmissions in decompensated cirrhosis.

Ensinando a Escala de Braden como estratégia para melhoria da qualidade da assistência em enfermagem

Background: The rates of adverse events are used as indicators of quality of healthcare services. One of the indicators of healthcare quality is the absence or presence of Pressure Ulcer, which causes physical and emotional disorders to the patient, presenting a huge challenge for health institutions due to the long recovery time and permanence required by the injury, raising the costs of the hospital stay. Description of the experience: This is a descriptive study, based on a experience report about the activities developed in an Extension Project and the main goal of this study was to enable the nursing team to correctly fill the Braden Scale, in order to ensure safe patient care to the patients treated at a clinic in a public hospital in Belem-PA. It was developed from March/2016 to February/2017. A total of 43 nursing professionals were trained in the morning, afternoon and evening shifts, with 8 nurses, 16 technicians and 19 nursing assistants. First, a quantitative and qualitative analysis of the scales was carried out to evaluate if they were being correctly filled. Subsequently the team training was carried out, and then a new analysis was made to evaluate the impact of the training. Final considerations: After the training, there was a significant improvement in the Braden score, since the number of patients evaluated incorrectly reduced by 20%, and the number of non-evaluated scales reduced by 14%. It was found a slightly evolution of the partial filling of the scales of only 2.6%. These numbers show that scales are not only being filled, they also allow us to state that the quality of this assessment has also improved. Therefore, it was concluded that the permanent education in health is of fundamental importance and must be a constant in the hospital services, so that more and more professionals become aware and committed to develop a safer nursing care, guaranteeing higher quality of care to the patients.

Evaluating concordance between government administrative data and externally collected data among high-volume government health facilities in Uttar Pradesh, India

ABSTRACTBackground: Globally, opportunities to validate government reports through external audits are rare, notably in India. A cross-sectional maternal health study in Uttar Pradesh, India’s most populous state, compares government administrative data and externally collected data on maternal health service indicators.Objectives: Our study aims to determine the level of concordance between government-reported health facility data compared to externally collected health facility data on the same maternal healthcare quality indicators. Second, our study aims to explore whether the level of agreement between government administrative data versus the externally collected data differs by level of facility or by type of maternal health service.Methods: Facility assessment surveys were administered to key health staff by government-hired enumerators from January 2017 to March 2017 at nearly 750 government health facilities across UP. The same survey was re-conducted by external data collectors from August 2017 to October 2017 at 40 of the same facilities. We conduct comparative analyses of the two datasets for agreement among the same measures of maternal healthcare quality.Results: The findings indicate concordance between most indicators across government administrative data and externally collected health facility data. However, when stratified by facility-level or service type, results suggest significant over-reporting in the government administrative data on indicators that are incentivized. This finding is consistent across all levels of facilities; however, the most significant disparities appear at higher-level facilities, namely District Hospitals.Conclusion: This study has a number of important programmatic and policy implications. Government administrative health data have the potential to be highly critical in informing large-scale quality improvements in maternal healthcare quality, but its credibility must be readily verifiable and accessible to politicians, researchers, funders, and most importantly, the public, to improve the overall health, patient experience, and well-being of women and newborns.

Diagnostic diversity - an indicator of institutional and regional healthcare quality.

Our aim was to estimate the diagnostic performance of institutions and healthcare regions from a nationwide hospitalisation database. The Shannon diversity index was used as an indicator of diagnostic performance based on the International Classification of Disease, 10th revision, German Modification (ICD-10-GM codes). The dataset included a total of 9,325,326 hospitalisation cases from 2009 to 2015 and was provided by the Swiss Federal Office for Statistics. A total of 16,435 diagnostic items from the ICD-10-GM codes were taken as the basis for the calculation of the diagnostic diversity index (DDI). Numerical simulations were performed to evaluate the effect of misdiagnoses in the DDI. We arbitrarily defined the minimum clinically important difference (MCID) as 10% misdiagnoses. The R statistical software was used for all analyses. Diagnostic performance of institutions and healthcare regions as measured by the DDI were strongly associated with caseload and number of inhabitants, respectively. A caseload of &gt;7217 hospitalisations per year for institutions and a population size &gt;363,522 for healthcare regions were indicators of an acceptable diagnostic performance. Among hospitals, there was notable heterogeneity of diagnostic diversity, which was strongly associated with caseload. Application of misdiagnosis-thresholds within each ICD-10-GM category allowed classification of hospitals in four distinct groups: high-volume hospitals with an all-over comprehensive diagnostic performance; high- to mid-volume hospitals with extensive to relevant basic diagnostic performance in most categories; low-volume specialised hospitals with a high diagnostic performance in a single category; and low-volume hospitals with inadequate diagnostic performance in all categories. The diagnostic diversity observed in the 26 Swiss healthcare regions showed relevant heterogeneity, an association with ICD-10-GM code utilisation, and was strongly associated with the size of the healthcare region. The limited diagnostic performance in small healthcare regions was partially, but not fully, compensated for by consumption of health services outside of their own healthcare region. Calculation of the DDI from ICD-10 codes is easy and complements the information derived from other quality indicators as it sheds a light on the fitness of the institutionalised interplay between primary and specialised medical inpatient care. &nbsp.

Nurse-staffing level and quality of acute care services: Evidence from cross-national panel data analysis in OECD countries

BackgroundMost of previous studies aimed to estimate the effect of nurse staffing on quality of acute hospital care have used stochastic methods and their results are mixed. ObjectiveTo measure the magnitude of effect of nurse-staffing level on increasing quality of acute care services in long-run. DataThe number of practicing nurses’ density per 1000 population as the proxy of nurse-staffing level and three Health Care Quality Indicators (HCQI) included 30-day mortality per 100 patients based on acute myocardial infarction (MORTAMIO), hemorrhagic stroke (MORTHSTO) and ischemic stroke (MORTISTO) were collected as a part of ongoing project by OECD.org in panels of 26 OECD countries over 2005–2015 period. MethodPanel data analysis. ResultsThere were committed relationships from nurse-staffing level to the enhancement of HCQI i.e. 1% increase in nurse-staffing level would reduce the rates of patient mortality based on MORTAMIO, MORTHSTO and MORTISTO by 0.65%, 0.60% and 0.80%, respectively. Furthermore, the role of nurse-staffing level in increasing overall HCQI were simulated at the highest level in Sweden (−3.53), Denmark (−3.31), Canada (−2.59), Netherlands (−2.33), Finland (−2.09), Switzerland (−1.72), Australia (−1.64) and United States (−1.53). ConclusionA higher proportion of nurses-staffing level is associated with higher quality of acute care services in OECD countries. Also, the nursing characteristics of Sweden, Denmark, Canada, Netherlands, Finland, Switzerland, Australia and United States would be good patterns for other countries to maximize nursing outcomes in the care of patients with acute and life-threatening conditions by reducing the risk of complication, mortality and adverse clinical outcomes.

The perspective of a breast cancer patient: A survey study assessing needs and expectations.

32 Background: Patient satisfaction is one of the key indicators of health care quality. We aim to identify patients’ needs and expectations in a breast cancer clinic to provide a patient-centered care and better overall satisfaction. Methods: A 17-item survey was administered to 49 patients at a breast cancer clinic. The survey was designed after a thorough literature review and approved by an oncologist and a palliative care physician. Results: Self-reported knowledge about disease was reported adequate by 95.9% of our patients yet only 46.9% of our patients could identify the stage of their cancer. More education was desired by 39% of patients including various treatment options (35%), common complications (29%), prognosis (22%) and risk factors (14%). Cancer-related emotional stress and physical symptoms were reported by 53% of our patients. Social/professional life was affected by cancer in 49% of the patients. Majority of our patients (57%) wanted their oncologist to address social/emotional issues and 28% felt the need of more focus on physical symptoms in their subsequent visits. End-of-life care (EoLC) discussions were considered an integral component of overall care by 22% of our patients. Components of EoLC discussions that patients stated they could benefit from included prognosis (24.5%), life expectancy (24.5%), treatment effect on quality of life (20.4%), palliative care (10.2%), hospice (10.2%), advance directives (14.3%), and family involvement in medical decision-making (12.2%). More patients wanted to initiate EoLC discussions when they requested it (30.6%) or their oncologist thought it was appropriate (30.6%) as compared to when it may change treatment course (12.2%) or at diagnosis (8.2%). More patients wanted to have EoLC discussions only once (40.8%) as compared to at regular intervals (32.7%). Conclusions: A discrepancy between self-reported and actual knowledge in breast cancer patients emphasizes the need of patient education. Most patients rely on their oncologist for their diagnosis related emotional and social issues. Surprisingly, a quarter of our patients consider EoLC discussions important even though majority of our patients were healthy and having stage I disease.

Healthcare quality for people with Down Syndrome: the patient perspective

Introduction: Down Syndrome (DS) is the most prevalent chromosomal anomaly among people with intellectual disability. Because DS is associated with a large variety of chronic comorbidities, people with DS need lifelong healthcare with many different professionals involved. In the past decades, many DS-specialized healthcare initiatives have been introduced. However, little is known about their quality, which hampers monitoring and improvement, and reduces transparency for people with DS and their parents. Quality indicators (QIs) can provide insight into healthcare quality, unhide opportunities for improvement, and increase transparency. Our study aims to identify starting points for QIs by exploring how qualitative good healthcare contributes to a good life quality of people with DS, thereby answering the question how healthcare quality for this group with special healthcare needs can be measured best. Healthcare quality is increasingly described in terms of outcomes adding value for patients. Our current study focuses on adding value for patients by exploring the patient perspective on healthcare quality for people with DS. This is done by involving people with DS and their parents/family members. Their professional carers (in case of residential care) will be involved later, because they also play an important role in the lives of people with DS. Methods: The study has a qualitative design including semi-structured individual interviews with people with DS (n=18) and parents (n=15). Topics discussed during the interviews included experiences with received healthcare, influence on life quality and healthcare improvement. Results: According to interviewed people with DS (^) and parents (*): Healthcare quality is: Patient-centered care: Optimal functioning of the person with DS is central*; Taking context and life stage of the person with DS into account^*; Respectful doctor-patient communication adapted to the abilities of the person with DS^*. Effective, efficient and accessible care: Care providers with DS-expertise nearby^*; Information about available care*. Multidisciplinary care including actors outside healthcare (e.g. school, work) and good coordination and integration*: Information sharing (between providers); Synchronized planning of consultations. Healthcare largely contributes to wellbeing^*. In the Netherlands, healthcare to people with DS is quite good, although transition from paediatric to adult care needs improvements^*. Parents experience more problems with finding appropriate developmental/social support*. Discussion: To our knowledge, this is the first research project developing QIs for DS healthcare, and the first involving patients and their carers. By focusing on the patient perspective we expect to develop QIs which enable healthcare improvements that are truly relevant to people with DS, add value to their lives, and enhance efficiency within the healthcare system. Conclusion: The issues mentioned by people with DS and parents (above) will be used as starting point for the development of QIs measuring healthcare quality for people with DS. Lessons learned: Involving people with DS by interviewing them is challenging but worthwhile. Limitations: Interviewing people with DS may influence the validity of our findings. However, we minimised this influence by adapting the interviews to the abilities of the interviewees. Suggestions for future research: A next step should be to involve care providers.

Review of Quality Measures for Breast Cancer Care by Country Income Level

Purpose Measurement of the quality of cancer care is essential for quality improvement and is widely implemented in oncology programs in high-income countries. Growing efforts are being made to measure care quality in emerging cancer care delivery systems in low- and middle-income countries (LMICs). This will require the development of measures that are clinically important, actionable, relevant to existing resources, and feasible to routinely evaluate. As part of a project to develop resource-adapted quality measures for Rwanda and other LMICs, we conducted a systematic review of the literature to identify published quality measures for the diagnosis and treatment of breast cancer. Methods We performed a literature search in accordance with PRISMA guidelines using the following terms in PubMed: ‘breast cancer’ and ‘quality indicator,’ ‘quality measure,’ or ‘quality metric’; and the following MeSH terms: ‘breast neoplasms’ and ‘healthcare quality indicator.’ We included English-language articles published before August 2017 that described the systematic identification of process measures for breast cancer diagnosis or treatment through literature review, clinical validation, and/or expert panel determination. We directly searched the Web sites of prominent cancer care organizations to identify additional publicly available measures. Income level was classified using World Bank definitions. Results We identified 521 published quality measures, including 419 measures from 27 peer-reviewed journal articles and 102 measures from the Web sites of national and international cancer care organizations. Twenty-five peer-reviewed publications (93%) originated from high-income countries, one from an upper-middle income country (People’s Republic of China), and one from the international Breast Health Global Initiative with process measures to assess the phased implementation of breast cancer services. No resources or articles other than that from the Breast Health Global Initiative provided suggestions for adapting measures to limited resources. Conclusion A large number of quality measures for breast cancer care have been identified and published in high-income countries; however, no breast cancer care quality measures have been systematically developed and validated for use in settings where resource limitations crucially affect care delivery and measurement feasibility. We are collaborating with clinicians in LMICs and global breast cancer experts to develop and validate quality measures that will enable quality improvement initiatives in Rwanda and other emerging cancer care delivery systems. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . No COIs from the authors.

PHP370 - AMBULATORY CARE TRENDS IN THE EMERGENCY DEPARTMENT

Ambulatory Care Sensitive Conditions (ACSCs) are illnesses where management should be achieved by regular consultation with a primary care physician. ACSCs are often a metric for access to primary care. The Patient Protection and Affordable Care Act(ACA) of 2010 offered significant regulatory changes expanding access to low income insurance (Medicaid). By evaluating the rate of ACSCs in the Emergency Department(ED) over time, we aimed to evaluate the impact of ACA Medicaid expansion. The US National Emergency Department Sample—a representative 20 percent sample of ED visits-- offering a sample of 25 million in 2006 and 31 million by 2014. ACSCs were adapted from the Agency for Healthcare Quality and Research(AHRQ) prevention quality indicators guidebook. Dental insurance was not impacted by ACA and therefore Dental ACSCs were evaluated as a baseline comparison. The rates of ACSCs remained largely unchanged at 7.68% of observations with a decrease of 0.33% over the study period. Dental specific ACSC rates were consistent as well starting at 1.63% and ending at 1.66%. Age, gender, and income bracket characteristics were consistent throughout the 9 year period. Congestive Heart Failure had the largest decrease of 0.55%. Urinary Tract Infections was the highest at 2.15% and grew the most by 0.32%. Evaluation of primary payer amongst ACSC specific events revealed the rate of privately insured patients decreased by 5.02% and Medicaid recipients increased by 9.63%. The rate of self-pay and Medicare offered slight decreases of 1.49% and 2.65% each. Payer changes indicate a significant shift in healthcare costs. Stable income bracket frequency juxtaposed to primary payer changes may reveal poorer citizens dropping low quality private plans upon Medicaid qualification. Despite payer shifts and payment access, there has not been a reduction in ACSC’s. Study extension is needed for further evaluation as States continue with ACA implementation.

Disparities in avoidable hospitalization by income in South Korea: data from the National Health Insurance cohort.

A total of 1 310 492 cases were included, in which the crude rate of avoidable hospitalizations was 1444.5 per 100 000 person years. Compared to the Q4 highest income group set as reference, the Q3 (RR 1.07, 95% CI 1.04-1.09), Q2 (RR 1.16, 95% CI 1.13-1.19) and Q1 (RR 1.20, 95% CI 1.17-1.24) income groups showed higher rates of avoidable hospitalizations. Risks of avoidable hospitalizations for ACSCs was higher in lower than higher income groups, implying that socioeconomic status is related to disparities in avoidable hospitalizations. The findings suggest the importance of monitoring the vulnerable groups identified in managing avoidable hospitalizations.

Vaginal birth after caesarean birth in Italy: variations among areas of residence and hospitals

BackgroundThe rates of caesarean section (CS) are increasing globally. CS rates are one of the most frequently used indicators of health care quality. Vaginal Birth After Caesarean (VBAC) could be considered a reasonable and safe option for most women with a previous CS. Despite this fact, in some European countries, many women who had a previous CS will have a routine CS subsequently and VBAC rates are extremely variable across countries. VBAC use is inversely related to caesarean use. The objective of the present study was to analyze VBAC rates with respect to caesarean rates and the variations among areas of residence, hospitals and hospital ownership types in Italy.MethodsThis study was based on information from the Hospital Information System (HIS). We collected data from all deliveries in Italy from January 1, 2010 to December 31, 2014 and we considered only deliveries with a previous caesarean section. Applying multivariate logistic regression analysis, the adjusted proportions of VBAC for each Local Health Units (LHU), each hospital and by hospital ownership types were calculated. Cross-classified logistic multilevel models were performed to analyze within geographic, hospitals and hospital ownership types variations.ResultsWe studied a total of 77,850 deliveries with a previous caesarean section in Italy between January 1, 2010 and December 31, 2014. The proportion of VBAC in Italy slightly increased in the last few years, from 5.8% in 2010 to 7.5% in 2014. Proportions of VBAC ranged from 0.29 to 50.05% in Italian LHUs. The LHUs with lower proportions of VBAC deliveries were characterized by higher values for primary caesarean deliveries. Private hospitals showed the lowest mean of crude VBAC proportions but the highest variation among hospitals, ranging from 0 to 47.1%.ConclusionsHospital rates of caesarean section for women with at least one previous caesarean section vary widely, and only some of the variation can be explained by case-mix and hospital-level factors, suggesting that additional factors influence practices. Identifying disparities in VBAC may have important implications for health services planning and targeted efforts to reduce overall rates of caesarean deliveries.

Predictors of 1-month and 3-months Hospital Readmissions in Decompensated Cirrhosis: A Prospective Study in a Large Asian Cohort

Introduction and aim. Considered as a healthcare quality indicator, hospital readmissions in decompensated cirrhosis predispose the patients and the society to physical, social and economic distresses. Few studies involving North American cohorts have identified different predictors. The aim of this study was to determine and validate the predictors of 1-month and 3-months readmission in an Asian cohort. Material and methods. We prospectively studied 281 hospitalised patients with decompensated cirrhosis at a large tertiary care public hospital in India between August 2014 and August 2016 and followed them for 3 months. Data regarding demographic, laboratory and disease related risk factors were compiled. We used multivariate logistic regression to determine predictors of readmission at 1-month and 3-months and receiver operating curves (ROC) for significant predictors to obtain the best cut-offs. Results. 1-month and 3-months readmission rates in our study were 27.8% and 42.3%, respectively. Model for End stage Liver Disease (MELD) score at discharge (OR:1.24, p &lt; 0.001) and serum sodium (OR:0.94, p-0.039) independently predicted 1- month and MELD score (OR:1.11, p-0.003), serum sodium (OR:0.94, p-0.027) and male gender (OR:2.19, p-0.008) independently predicted 3-months readmissions. Neither aetiology nor complications of cirrhosis emerged as risk factors. MELD score &gt;14 at discharge and serum sodium &lt; 133 mEq/L best predicted readmissions; MELD score being a better predictor than serum sodium (p - 0.0001). Conclusions. High rates of early and late readmissions were found in our study. Further, this study validated readmission predictors in Asian patients. Structured interventions targeting this risk factors may diminish readmissions in decompensated cirrhosis.

Assessing the performance of ongoing national indicators on healthcare quality and safety: Development of the quid method and results on ten indicators

Introduction Since ten years, quality indicators (QI) are mandatorily measured in all French hospitals. They are used for hospital quality improvement, public disclosure and regulation goals. After a decade of use, the Ministry of Health and the French National Authority for Health set up a task force to evaluate these QI. The goal was to provide a decision aid to the Ministry and HAS in terms of suppressing or maintaining their use, or modifying their content. As there was no available integrated tool, the task force started with the development and test of a tool during the year 2015. This tool aimed at evaluating all components of their performance (measurement feasibility, metrological performance and relevance for users) of QIs according to each of the three goals. The objective was to define an operational and structured method allowing the overall appraisal of ongoing national QI in healthcare, to apply it on ten indicators and to study its impact. Methods The national expert workgroup was constituted by clinicians, epidemiologists, healthcare facility managers, quality managers, sociologists and a patients’ representative: step 1: a search for similar experiences in other countries; step 2: a literature review to identify relevant assessment criteria and methods; step 3: a consensus method between the members of the group to select the criteria: Using a modified Rand/UCLA Appropriateness Method, the appropriateness of these criteria was checked for evaluating the indicators according to each of the three goals. The group extracted a list of criteria for each goal. Each criterion was assessed using a quantitative approach or a qualitative approach; step 4: test and implementation of the method on 10 national QI to identify operational issues in the implementation of the method: The indicator's results collected the previous years were analyzed; the scientific soundness of the indicator development was reviewed; field hospital workers (doctors, nurses, managers), health authorities employees and patients were interviewed. All these data results were discussed by the task force, summarized and displayed on spider charts presenting standardized scores. This integrated tool was tested on ten national process QIs; step 5: assessment criteria of impact of the work: implementation of the recommendations by the Ministry and HAS. Results Twelve were selected as appropriate for the evaluation of QIs for regulation use: relevance (importance of the quality characteristic captured for the healthcare system; benefit/ability to take decision based on the results; potential risks/side effects), feasibility (understandability and Interpretability of the indicator and its results; barriers to implementation due to data collection effort; delays related to data production), scientific soundness of the indicator development (indicator evidence; validity; risk adjustment) and current metrological performance (indicator expression can be influenced by providers; discriminatory power; dynamics of change). Among these, 11 were selected for hospital improvement and 7 for public disclosure. The tool was applied on 10 process QIs. We proposed to suppress four of them and to modify or suspend the six others. The four QIs were suppressed, and the others have been or are currently in a process of modification. Conclusion By combining qualitative and quantitative evaluations, the QUID instrument offers a solid method for thoroughly appraising each indicator. The value of the QUID method was supported by the clear-cut conclusions on 10 QIs and subsequently by the decisions of the Ministry and the HAS to follow the recommendations. More research is needed to finalize the tool on other types of indicators.

Factors in facilitating an organisational culture to prevent pressure ulcers among older adults in health-care facilities.

Despite the availability of high-quality clinical practice guidelines, pressure ulcers (PU) continue to develop among older adults in acute and long-term health-care facilities. Except during acute medical crisis or near end-of-life, most PUs are preventable and their development is a health-care quality indicator. The aim of this study was to understand which factors facilitate pressure ulcer prevention among adults over 65 years-of-age receiving care in health-care facilities. A critical literature review from three scholarly databases examined components of organisational culture associated with PU prevention. Research papers involving adults >65 years-of-age who were admitted to acute and long-term health-care facilities with PU prevention programmes between 2010 and 2017 were included. A secondary manual search included literature discussing health-care organisational culture, with a total of 41 articles reviewed. Based on a synthesis of this literature, the Factors Facilitating Pressure Ulcer Prevention Model was developed to depict five multilevel factors for PU prevention among older adults in health-care facilities. These five factors are: senior leadership, education, ongoing quality improvement, clinical practice, and unit level champions. Ongoing prioritisation of these factors sustains PU prevention and assists health-care facilities to redefine their culture, expand education programmes, and promote accountability to improve health outcomes of older adults receiving care.

Determinants of satisfaction with motor rehabilitation in persons with cerebral palsy: A national survey in France (ESPACE)

User satisfaction is a key indicator of health-care quality. The aim of this study was to identify factors that influence satisfaction with motor rehabilitation (MR) in children and adults with cerebral palsy (CP). This study was part of a national survey coordinated by Fondation Paralysie Cérébrale/La Fondation Motrice aimed at documenting the views of persons with CP and their families on the provision of MR in France. A steering committee, that included persons with CP, representatives of patient and family organisations, professional and scientific societies, developed a questionnaire that included the 8-item Client Satisfaction Questionnaire (CSQ-8), which was the study primary outcome. The questionnaire was disseminated nationally and locally through advocacy groups, health care professional and social networks. It was answered by the person with CP or by the main carer, online or on paper then mailed. From June 2016 to June 2017, 1010 participants with validated entry criteria filled in a questionnaire (354 children, 145 youth and 511 adults) and 750 (75%) completed the CSQ-8. As for gross motor function, 12% reported GMFCS level I, 21% GMFCS II, 19% GMFCS III, 23% GMFCS IV, 25% GMFCS V. Univariate analysis showed that CSQ-8 was significantly related to (1) person with CP characteristics (age, GMFCS, MACS, associated deficiencies, occurrence of pain); (2) health care provision (organisation of physiotherapy sessions, continuity and coordination of health care); and (3) other environmental factors (regional, difficult access to available physiotherapists or to clinicians with specific training in CP). Multivariate analysis confirmed a large impact of age and GMFCS on CSQ-8. Key determinants of satisfaction with MR in CP were identified. Exploring changes in MR organisation and coordination, pain management and health care providers CP training may lead to improved motor rehabilitation care quality for persons with cerebral palsy.

Development of quality indicators for mental healthcare in the Danube region.

Quality indicators are quality assurance instruments for the evaluation of mental healthcare systems. Quality indicators can be used to measure the effectiveness of mental healthcare structure and process reforms. This project aims to develop quality indicators for mental healthcare systems in Bulgaria, the Czech Republic, Hungary and Serbia to provide monitoring instruments for the transformation of mental healthcare systems in these countries. Quality indicators for mental healthcare systems were developed in a systematic, multidisciplinary approach. A systematic literature study was conducted to identify quality indicators that are used internationally in mental healthcare. Retrieved quality indicators were systematically selected by means of defined inclusion and exclusion criteria. Quality indicators were subsequently rated in a two-stage Delphi study for relevance, validity and feasibility (data availability and data collection effort). The Delphi panel included 22 individuals in the first round, and 18 individuals in the second and final round. Overall, mental healthcare quality indicators were rated higher in relevance than in validity (Mean relevance=7.6, SD=0.8; Mean validity=7.1, SD=0.7). There was no statistically significant difference in scores between the four countries for relevance (X2 (3)=3.581, p=0.310) and validity (X2 (3)=1.145, p=0.766). For data availability, the appraisal of "YES" (data are available) ranged from 6% for "assisted housing" to 94% for "total beds for mental healthcare per 100,000 population" and "availability of mental health service facilities". Quality indicators were developed in a systematic and multidisciplinary development process. There was a broad consensus among mental healthcare experts from the participating countries in terms of relevance and validity of the proposed quality indicators. In a next step, the feasibility of these twenty-two indicators will be evaluated in a pilot study in the participating countries.

Retained foreign bodies and associated risk factors and outcomes in pediatric surgical patients

BackgroundRetained foreign bodies discovered after surgery are documented as Agency for Health Care Quality and Research Patient Safety Indicators. Our goal was to identify pediatric patient and procedure risk factors and outcomes associated with RFB based on AHRQ Definitions. MethodsWe performed a retrospective case–control study of children with RFB using the PHIS database. Patients were defined as having RFB based on the AHRQ PSI definition. Controls were matched in a 5:1 ratio on age, procedure date, and hospital. Our primary outcome was the presence of RFB. Secondary outcomes included hospital length of stay and mortality. ResultsPatients with RFB often underwent emergent procedures, experienced one or more chronic conditions, and required ICU admission or mechanical ventilation. Musculoskeletal procedures contribute the largest numbers of RFB (30.4%), but interventional radiology procedures had higher odds of having RFB (AOR 7.88, p < 0.0001). After multivariate adjustment, children with RFB required 4 more days of hospitalization (p < .001), but there was no difference in mortality (p = .579). ConclusionsThe implications of our study include identifying which administrative flags can be used to identify children at higher risks for RFB. Early identification of at-risk patients and prevention are key towards addressing the primary problem and corresponding sequela of RFB. Levels of EvidencePrognostic Study Level III.

Socio-demographic and medical factors associated with patients' satisfaction with nursing care and their perception of pain.

Patient satisfaction with nursing care is one of important indicators of health care quality. As for pain, it is an indicator of patient health. The goal of the study is to identify socio-demographic and medical factors that differentiate the assessment of satisfaction with nursing care of hospitalized patients. The study involved performing a diagnostic survey using standardized instruments, i.e. the Newcastle Satisfaction with Nursing Scale (NSNS) and the Visual Analog Scale by Barbara J. Headley for pain scoring. The study included 205 patients hospitalized for lumbar pain syndrome on two neurosurgery wards in Poland. The mean patient age was 51 years. Most respondents declared having high school or vocational education. The mean time of hospitalization before the study was 2 days. The results demonstrated that patient satisfaction with nursing care is independent of patient age, education, duration of hospitalization, or number of hospitalizations. In contrast, the experience of nursing care is dependent on education, and less educated patients (primary or vocational education) had higher scores in this category. With regards to pain, it was perceived as more intense by women and by patients hospitalized for a shorter period of time. Satisfaction with nursing care among patients with lumbar pain syndrome does not depend on socio-demographic or medical variables. Experience of nursing care depends on patient's education.

Possible Sources of Bias in Primary Care Electronic Health Record Data Use and Reuse.

BackgroundEnormous amounts of data are recorded routinely in health care as part of the care process, primarily for managing individual patient care. There are significant opportunities to use these data for other purposes, many of which would contribute to establishing a learning health system. This is particularly true for data recorded in primary care settings, as in many countries, these are the first place patients turn to for most health problems.ObjectiveIn this paper, we discuss whether data that are recorded routinely as part of the health care process in primary care are actually fit to use for other purposes such as research and quality of health care indicators, how the original purpose may affect the extent to which the data are fit for another purpose, and the mechanisms behind these effects. In doing so, we want to identify possible sources of bias that are relevant for the use and reuse of these type of data.MethodsThis paper is based on the authors’ experience as users of electronic health records data, as general practitioners, health informatics experts, and health services researchers. It is a product of the discussions they had during the Translational Research and Patient Safety in Europe (TRANSFoRm) project, which was funded by the European Commission and sought to develop, pilot, and evaluate a core information architecture for the learning health system in Europe, based on primary care electronic health records.ResultsWe first describe the different stages in the processing of electronic health record data, as well as the different purposes for which these data are used. Given the different data processing steps and purposes, we then discuss the possible mechanisms for each individual data processing step that can generate biased outcomes. We identified 13 possible sources of bias. Four of them are related to the organization of a health care system, whereas some are of a more technical nature.ConclusionsThere are a substantial number of possible sources of bias; very little is known about the size and direction of their impact. However, anyone that uses or reuses data that were recorded as part of the health care process (such as researchers and clinicians) should be aware of the associated data collection process and environmental influences that can affect the quality of the data. Our stepwise, actor- and purpose-oriented approach may help to identify these possible sources of bias. Unless data quality issues are better understood and unless adequate controls are embedded throughout the data lifecycle, data-driven health care will not live up to its expectations. We need a data quality research agenda to devise the appropriate instruments needed to assess the magnitude of each of the possible sources of bias, and then start measuring their impact. The possible sources of bias described in this paper serve as a starting point for this research agenda.

Exploring the Knowledge Structure of Nursing Care for Older Patients With Delirium: Keyword Network Analysis.

Prevention of delirium is considered a critical part of the agenda for patient safety and an indicator of healthcare quality for older patients. As the incidence rate of delirium for older patients has increased in recent years, there has been a significant expansion in knowledge relevant to nursing care. The purposes of this study were to analyze the knowledge structure and trends in nursing care for older adults with delirium based on a keyword network analysis, and to provide a foundation for future research. Data analysis showed that knowledge structure in this area consists of three themes of research: postoperative acute care for older patients with delirium, prevention of delirium for older patients in intensive care units, and safety management for the improvement of outcomes for patients with delirium. Through research trend analysis, we found that research on care for patients with delirium has achieved both quantitative and qualitative improvements over the last decades. Concerning future research, we propose the expansion of patient- and family-centered care, community care, specific nursing interventions, and the integration of new technology into care for patients with delirium. These results provide a reference framework for understanding and developing nursing care for older adults with delirium.