Large-scale Quality Improvement Research Articles

Lessons Learned from a National Hospital Antibiotic Stewardship Implementation Project

BackgroundThe goal of antibiotic stewardship programs (ASPs) is to ensure patients receive effective therapy while minimizing adverse events. To overcome barriers commonly faced in implementing successful ASPs, AHRQ established a multifaceted, nationwide Safety Program for Improving Antibiotic Use in 2018. This report summarizes the lessons learned from the implementation of this initiative based on structured interviews with ASP leaders. MethodsAt the completion of the one-year initiative, semi-structured exit interviews were conducted with site leaders at 151 of the 402 hospitals that participated. These interviews consisted of open-ended questions about the perceived effectiveness of components of the Safety Program. Qualitative analyses incorporated both deductive coding themes (based on existing literature) and an iteratively developed inductive coding framework (based on salient themes that emerged from a subset of interviews). ResultsSeveral components of the Safety Program were identified as effective in expanding local stewardship activities, including techniques and strategies to implement sustainable ASPs, access to Implementation Advisors to keep sites engaged, provision of local benchmarked antibiotic use data to compare to similar hospitals, and Safety Program materials such as the antibiotic time-out tool to integrate stewardship techniques into daily work flows. The biggest challenges to greater effectiveness were suboptimal frontline staff engagement and difficulty changing antibiotic prescribing culture. Some approaches used to overcome these barriers (i.e., peer-to-peer communication and education through team huddles, identifying physician champions, informal rounds to enhance collegiality and buy-in, and engagement of hospital leadership) were also identified. ConclusionsLessons learned from the Safety Program can be applied by other teams looking to promote an effective ASP at their hospital or system. The themes that emerged in this study likely also have relevance across a wide range of large-scale quality improvement initiatives.

Implementation strategies for large scale quality improvement initiatives in primary care settings: a qualitative assessment

Background and objectivesThe EvidenceNOW: Advancing Heart Health in Primary Care was designed to assist primary care practices in the US in implementing evidence-based practices in cardiovascular care and building capacity for quality improvement. EvidenceNOW, NCT03054090, was registered with ClinicalTrials.gov on 15/02/2017. The goals of this study were to gain a comprehensive understanding of perspectives from research participants and research team members on the value of implementation strategies and factors that influenced the EvidenceNOW initiative in Virginia.MethodsIn 2018, we conducted 25 focus groups with clinicians and staff at participating practices, including 80 physicians, advanced practice clinicians, practice managers and other practice staff. We also conducted face-to-face and telephone interviews with 22 research team members, including lead investigators, practice facilitators, physician expert consultants, and evaluators. We used the integrated-Promoting Action on Research Implementation in the Health Services (i-PARIHS) framework in our qualitative data analysis and organization of themes.ResultsImplementation strategies valued by both practice representatives and research team members included the kick-off event, on-site practice facilitation, and interaction with physician expert consultants. Remote practice facilitation and web-based tools were used less frequently. Contextual factors that influence quality improvement efforts include leadership support, access to resources, previous quality improvement experience, and practice ownership type (independent compared to health system owned). Many clinicians and staff were overwhelmed by day-to-day activities and experience initiative fatigue, which hindered their ability to fully participate in the EvidenceNOW initiative.ConclusionsThis study provides details on how the practice environment plays an essential role in the implementation of evidence-based practices in primary care. Future efforts to improve quality in primary care practices should consider the context and environment of individual practices, with targeted implementation strategies to meet the needs of independent and health system owned practices. Future efforts to improve quality in primary care practices require strategies to address initiative fatigue among clinicians and practice staff. External support for building capacity for quality improvement could help primary care practices implement and sustain evidence-based practices and improve quality of care.Trial registrationThis project was registered with ClinicalTrials.gov on 15/02/2017 and the identifier is NCT03054090.

Development and External Validation of an Artificial Intelligence Model for Identifying Radiology Reports Containing Recommendations for Additional Imaging.

BACKGROUND. Reported rates of recommendations for additional imaging (RAIs) in radiology reports are low. Bidirectional encoder representations from transformers (BERT), a deep learning model pretrained to understand language context and ambiguity, has potential for identifying RAIs and thereby assisting large-scale quality improvement efforts. OBJECTIVE. The purpose of this study was to develop and externally validate an artificial intelligence (AI)-based model for identifying radiology reports containing RAIs. METHODS. This retrospective study was performed at a multisite health center. A total of 6300 radiology reports generated at one site from January 1, 2015, to June 30, 2021, were randomly selected and split by 4:1 ratio to create training (n = 5040) and test (n = 1260) sets. A total of 1260 reports generated at the center's other sites (including academic and community hospitals) from April 1 to April 30, 2022, were randomly selected as an external validation group. Referring practitioners and radiologists of varying sub-specialties manually reviewed report impressions for presence of RAIs. A BERT-based technique for identifying RAIs was developed by use of the training set. Performance of the BERT-based model and a previously developed traditional machine learning (TML) model was assessed in the test set. Finally, performance was assessed in the external validation set. The code for the BERT-based RAI model is publicly available. RESULTS. Among a total of 7419 unique patients (4133 women, 3286 men; mean age, 58.8 years), 10.0% of 7560 reports contained RAI. In the test set, the BERT-based model had 94.4% precision, 98.5% recall, and an F1 score of 96.4%. In the test set, the TML model had 69.0% precision, 65.4% recall, and an F1 score of 67.2%. In the test set, accuracy was greater for the BERT-based than for the TML model (99.2% vs 93.1%, p < .001). In the external validation set, the BERT-based model had 99.2% precision, 91.6% recall, an F1 score of 95.2%, and 99.0% accuracy. CONCLUSION. The BERT-based AI model accurately identified reports with RAIs, outperforming the TML model. High performance in the external validation set suggests the potential for other health systems to adapt the model without requiring institution-specific training. CLINICAL IMPACT. The model could potentially be used for real-time EHR monitoring for RAIs and other improvement initiatives to help ensure timely performance of clinically necessary recommended follow-up.

Implementation of an enhanced recovery after surgery (ERAS) protocol for total abdominal hysterectomies in the division of gynecologic oncology: a network-wide quality improvement initiative.

Enhanced Recovery After Surgery (ERAS) protocols have been shown to decrease length of stay and postoperative opioid usage in colorectal and bariatric surgeries performed at large academic centers. Hysterectomies are the second most common surgical procedure among women in the United States. Hysterectomies performed in an open fashion, or total abdominal hysterectomies (TAHs), account for a large portion of procedures performed by gynecologic oncologists secondary to current oncology guidelines and surgical complexity. Implementation of an ERAS protocol for gynecologic oncology TAHs is one way in which patient outcomes may be improved. An ERAS protocol for gynecologic oncology surgeries performed in a community hospital was instituted with the goal to optimize patient outcomes preoperatively. The primary outcome of interest was to reduce patient opioid usage. Secondary outcomes included compliance with the ERAS protocol, length of stay, and cost. Thirdly, this study aimed to demonstrate the unique challenges of implementing a large-scale protocol across a community network. An ERAS protocol was implemented in 2018, with multidisciplinary input from the Departments of Gynecologic Oncology, Anesthesia, Pharmacy, Nursing, Information Technology, and Quality Improvement to develop a comprehensive ERAS order set. This was implemented across a 12-site hospital system network that consisted of both urban and rural hospital settings. A retrospective review of patient charts was performed to assess measured outcomes. Parametric and nonparametric tests were utilized for statistical analysis with p<0.05 denoting statistical significance. If the p value was >0.05 and <0.09, this was considered a trend toward significant. A total of 124 patients underwent a TAH utilizing the ERAS protocol during 2018 and 2019. The control arm consisted of 59 patients who underwent a TAH prior to the ERAS protocol intervention, which was the standard of care in 2017. After 2 years of implementation of the ERAS protocol intervention, we found that 48 % of the ERAS patients had minimal opioid requirements after surgery (oral morphine equivalent [OME] range 0-40) with decreased postoperative opioid requirements in the ERAS group (p=0.03). Although not statistically significant, utilization of the ERAS protocol for gynecologic oncology TAHs trended toward shorter hospital length of stay from 5.18 to 4.17days (p=0.07). The median total hospital costs per patient also showed a nonsignificant decrease in cost from $13,342.00 in the non-ERAS cohort and $13,703.00 in the ERAS cohort (p=0.8). A large-scale quality improvement (QI) initiative is feasible utilizing a multidisciplinary team to implement an ERAS protocol for TAHs in the division of Gynecologic Oncology with promising results. This large-scale QI result was comparable to studies that conducted quality-improvement ERAS initiatives at single academic institutions and should be considered within community networks.

Order Set Usage is Associated With Lower Hospital Mortality in Patients With Sepsis.

To estimate the effect of sepsis order set usage on hospital mortality. Retrospective cohort study. Fifty-four acute care hospitals in the United States from December 1, 2020 to November 30, 2022 involving 104,662 patients hospitalized for sepsis. Hospital mortality. The sepsis order set was used in 58,091 (55.5%) patients with sepsis. Initial mean sequential organ failure assessment score was 0.3 lower in patients for whom the order set was used than in those for whom it was not used (2.9 sd [2.8] vs 3.2 [3.1], p < 0.01). In bivariate analysis, hospital mortality was 6.3% lower in patients for whom the sepsis order set was used (9.7% vs 16.0%, p < 0.01), median time from emergency department triage to antibiotics was 54 minutes less (125 interquartile range [IQR, 68-221] vs 179 [98-379], p < 0.01), and median total time hypotensive was 2.1 hours less (5.5 IQR [2.0-15.0] vs 7.6 [2.5-21.8], p < 0.01) and septic shock was 3.2% less common (22.0% vs 25.4%, p < 0.01). Order set use was associated with 1.1 fewer median days of hospitalization (4.9 [2.8-9.0] vs 6.0 [3.2-12.1], p < 0.01), and 6.6% more patients discharged to home (61.4% vs 54.8%, p < 0.01). In the multivariable model, sepsis order set use was independently associated with lower hospital mortality (odds ratio 0.70; 95% CI, 0.66-0.73). In a cohort of patients hospitalized with sepsis, order set use was independently associated with lower hospital mortality. Order sets can impact large-scale quality improvement efforts.

How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives?

To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care. Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720). Independent Variable: Cooperatives's experience level prior to EvidenceNOW, defined as a sustained track record in delivering large-scale quality improvement (QI) to primary care practices (high, medium, or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices' performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS); and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach. Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, P = .04), and made greater improvements in practices' QI capacity (CPCQ: +2.04, P < .001) and smoking performance (+6.43%, P = .003). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes. Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.

The development of the concept of return-on-investment from large-scale quality improvement programmes in healthcare: an integrative systematic literature review

BackgroundReturn on Investment (ROI) is increasingly being used to evaluate financial benefits from healthcare Quality Improvement (QI). ROI is traditionally used to evaluate investment performance in the commercial field. Little is known about ROI in healthcare. The aim of this systematic review was to analyse and develop ROI as a concept and develop a ROI conceptual framework for large-scale healthcare QI programmes.MethodsWe searched Medline, Embase, Global health, PsycInfo, EconLit, NHS EED, Web of Science, Google Scholar using ROI or returns-on-investment concepts (e.g., cost–benefit, cost-effectiveness, value). We combined this terms with healthcare and QI. Included articles discussed at least three organisational QI benefits, including financial or patient benefits. We synthesised the different ways in which ROI or return-on-investment concepts were used and discussed by the QI literature; first the economically focused, then the non-economically focused QI literature. We then integrated these literatures to summarise their combined views.ResultsWe retrieved 10 428 articles. One hundred and two (102) articles were selected for full text screening. Of these 34 were excluded and 68 included. The included articles were QI economic, effectiveness, process, and impact evaluations as well as reports and conceptual literature. Fifteen of 68 articles were directly focused on QI programme economic outcomes. Of these, only four focused on ROI. ROI related concepts in this group included cost-effectiveness, cost–benefit, ROI, cost-saving, cost-reduction, and cost-avoidance. The remaining articles mainly mentioned efficiency, productivity, value, or benefits. Financial outcomes were not the main goal of QI programmes. We found that the ROI concept in healthcare QI aligned with the concepts of value and benefit, both monetary and non-monetary.ConclusionOur analysis of the reviewed literature indicates that ROI in QI is conceptualised as value or benefit as demonstrated through a combination of significant outcomes for one or more stakeholders in healthcare organisations. As such, organisations at different developmental stages can deduce benefits that are relevant and legitimate as per their contextual needs.Trial registrationReview registration: PROSPERO; CRD42021236948.

Identifying and Overcoming Racial Disparities in Multiple Myeloma Care: Results from a Large-Scale Equity-Focused Quality Improvement Initiative

Background A prior quality improvement (QI) initiative (Mikhael ASH 2020) was conducted to address root causes of racial disparities in care delivery among patients with relapsed/refractory (R/R) multiple myeloma (MM) in 2 large oncology systems. Preliminary survey data suggested discordant beliefs regarding patients’ primary treatment concerns. Thus, this study was scaled up to 4 community-based oncology practices to greater evaluate disparities with electronic medical record (EMR) audits and team-based audit-feedback (AF) sessions to identify factors which could enhance more equitable care. Methods This QI initiative included patient and provider surveys, baseline and follow-up EMR audits, and small-group, team-based AF sessions at each participating clinic. Surveys were completed by 59 hematology/oncology healthcare providers (HCPs) and 100 R/R MM patients (Table 1; N=47 Black, N=50 White/Non-Hispanic) to examine alignments and discordances in attitudes, beliefs, perceptions, and practices regarding MM care. A baseline EMR audit of 200 R/R MM patients (Table 1; N=32 Black, N=122 White/Non-Hispanic) was conducted to identify patient/disease characteristics, treatment history, clinical practice metrics, and patient-centered measures (e.g., shared decision-making). During 1-hour AF sessions, HCP cohorts (Table 1) (a) assessed clinic-specific practice gaps identified by the patient-provider surveys and baseline EMR audit, (b) prioritized areas for improvement, and (c) developed action plans to address root causes. Surveys completed before (N=59) and after (N=41) the AF sessions measured changes in participants’ beliefs and confidence in care delivery. A follow-up EMR audit after completion of the AF sessions was performed to assess behavioral and practice change. Results Patient and HCP tethered survey data revealed discordant beliefs about patients’ primary treatment concerns. HCPs overestimated patients concern regarding treatment cost (32% vs 9%) and treatmentrisks (55% vs 29%), but underestimated patient's largest reported challenge in feeling confident that their treatment plan is the best for their cancer (18% vs 32%). Providers reported the most challenging aspect of MM management was individualizing treatment plans. There was large divergence between HCPs and all patients’ top goals (Figure 1) and stark racial disparities were observed in improving quality of life, preventing progression or recurrence, and surviving as long as possible (Figure 1). Disparities also persisted among patients who reported being on track or somewhat on track to achieve their treatment goals (76% White vs 54% Black/Hispanic, p = 0.021). Regarding shared decision-making (SDM) with their HCP, only 14% of Black/Hispanic patients felt completely involved in treatment decision making compared to 54% of White patients (p = < 0.001). EMR audits revealed fewer Black patients using maintenance therapy (63% vs 71% non-Black) and greater numbers of stem cell transplants (53% Black vs 44% non-Black). Following AF sessions 55% of HCPs set action plans to incorporate strategies to eliminate disparities in care for diverse MM patient populations and 48% to develop personalized treatment plans incorporating patient-specific factors and preferences. To achieve these goals, providers committed to engage patients in shared decision-making (17% pre-AF vs 38% post-AF), and provide adequate patient education about treatments (17% pre-AF vs 28% post-AF). Participants’ views of the impact of race and socioeconomic factors on equitable MM care changed as a result of the program increasing from 37% to 54% reporting a considerable or a great deal of impact. Conclusions Barriers to equitable, patient-centered care in patients with R/R MM included inadequate education and personalizing of treatment plans by HCPs as well as ineffective SDM. Discordances were observed between providers and all patients in describing the goals of treatment, and between White and Black/Hispanic patients in the challenges faced in their MM care. Action plans developed during this QI initiative intend to address identified gaps and improve equitable care for patients with R/R MM. Study Sponsor Statement The study reported in this abstract was funded by independent educational grants from AbbVie, Inc. Bristol-Myers Squibb, and Janssen Biotech Inc., who had no role in the study design, execution, analysis, or reporting. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives?

To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care. Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720). Independent Variable: Cooperatives's experience level prior to EvidenceNOW, defined as a sustained track record in delivering large-scale quality improvement (QI) to primary care practices (high, medium, or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices' performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS); and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach. Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, P = .04), and made greater improvements in practices' QI capacity (CPCQ: +2.04, P < .001) and smoking performance (+6.43%, P = .003). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes. Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.

Identifying and understanding benefits associated with return-on-investment from large-scale healthcare Quality Improvement programmes: an integrative systematic literature review

BackgroundWe previously developed a Quality Improvement (QI) Return-on-Investment (ROI) conceptual framework for large-scale healthcare QI programmes. We defined ROI as any monetary or non-monetary value or benefit derived from QI. We called the framework the QI-ROI conceptual framework. The current study describes the different categories of benefits covered by this framework and explores the relationships between these benefits.MethodsWe searched Medline, Embase, Global health, PsycInfo, EconLit, NHS EED, Web of Science, Google Scholar, organisational journals, and citations, using ROI or returns-on-investment concepts (e.g., cost–benefit, cost-effectiveness, value) combined with healthcare and QI. Our analysis was informed by Complexity Theory in view of the complexity of large QI programmes. We used Framework analysis to analyse the data using a preliminary ROI conceptual framework that was based on organisational obligations towards its stakeholders. Included articles discussed at least three organisational benefits towards these obligations, with at least one financial or patient benefit. We synthesized the different QI benefits discussed.ResultsWe retrieved 10 428 articles. One hundred and two (102) articles were selected for full text screening. Of these 34 were excluded and 68 included. Included articles were QI economic, effectiveness, process, and impact evaluations as well as conceptual literature. Based on these literatures, we reviewed and updated our QI-ROI conceptual framework from our first study. Our QI-ROI conceptual framework consists of four categories: 1) organisational performance, 2) organisational development, 3) external outcomes, and 4) unintended outcomes (positive and negative). We found that QI benefits are interlinked, and that ROI in large-scale QI is not merely an end-outcome; there are earlier benefits that matter to organisations that contribute to overall ROI. Organisations also found positive aspects of negative unintended consequences, such as learning from failed QI.Discussion and conclusionOur analysis indicated that the QI-ROI conceptual framework is made-up of multi-faceted and interconnected benefits from large-scale QI programmes. One or more of these may be desirable depending on each organisation’s goals and objectives, as well as stage of development. As such, it is possible for organisations to deduce incremental benefits or returns-on-investments throughout a programme lifecycle that are relevant and legitimate.

Implementing Large-Scale Data-Driven Quality Improvement in Assisted Living.

Develop and evaluate the implementation of a proposed model for large-scale data-driven quality improvement in assisted living. We conducted a mixed-methods evaluation of the implementation of a large-scale data-driven quality improvement collaborative of Wisconsin assisted living communities (ALCs). The model has been voluntarily implemented by 810 Wisconsin-licensed ALCs serving >20,000 residents. The model was codesigned iteratively 2009-2012 by a public-private multistakeholder advisory group. Using system usage statistics and project records, we evaluated implementation outcomes: appropriateness, acceptability, adoption, feasibility, fidelity, penetration, and sustainability. Implementation for ≥1 quarter was feasible for 92% of the 810 ALCs that enrolled. The model has been deemed appropriate and acceptable by public-private stakeholders representing residents, providers, regulators, and payers, and appropriateness for ALCs serving different populations has been iteratively improved through targeted workgroups. The model is currently adopted in Wisconsin by 31% of the 1573 ALCs in provider associations. Among adopters, 88% on average implemented the model with fidelity to key membership rules per quarter. The model achieved demographic and institutional penetration by currently reaching 24% of Wisconsin ALC residents and by leveraging initial grant funding to become integrated in Wisconsin's annual Medicaid budget and being central to Wisconsin's incentive program to managed care organizations. Model implementation for 8years has been sustained by member enrollment for nearly 4years on average, with 71% of members enrolled >2years and sustained early adopters representing 37% that have been enrolled >5years. This is the first implementation study of large-scale data-driven quality improvement in assisted living, despite its demonstrated value in other health care sectors. The article proposes a model with core components and implementation strategies drawing on a decade-long public-private collaboration. The implementation study findings establish a promising path and future directions for wider implementation.

Natural language processing for automated surveillance of intraoperative neuromonitoring in spine surgery

We sought to develop natural language processing (NLP) methods for automated detection and characterization of neuromonitoring documentation from free-text operative reports in patients undergoing spine surgery. We included 13,718 patients who received spine surgery at two tertiary academic medical centers between December 2000 – December 2020. We first validated a rule-based NLP method for identifying operative reports containing neuromonitoring documentation, comparing performance to standard administrative codes. We then trained a deep learning model in a subset of 993 patients to characterize neuromonitoring documentation and identify events indicating change in status or difficulty establishing baseline signals. Performance of the deep learning model was compared to gold-standard manual chart review. In our patient population, 3,606 (26.3%) patients had neuromonitoring documentation identified using NLP. Our NLP method identified notes containing neuromonitoring documentation with an F1-score of 1.0, surpassing performance of standard administrative codes which had an F1-score of 0.64. In the subset of 993 patients used for training, validation, and testing a deep learning model, the prevalence of change in status was 6.5% and difficulty establishing neuromonitoring baseline signals was 6.6%. The deep learning model had an F1-score = 0.80 and AUC-ROC = 1.0 for identifying change in status, and an F1-score = 0.80 and AUC-ROC = 0.97 for identifying difficulty establishing baseline signals. Compared to gold standard manual chart review, our methodology has greater efficiency for identifying infrequent yet important types of neuromonitoring documentation. This method may facilitate large-scale quality improvement initiatives that require timely analysis of a large volume of EHRs.

Achieving Large-Scale Quality Improvement in Primary Care Annual Wellness Visits and Hierarchical Condition Coding.

BackgroundCompletion of Medicare Annual Wellness Visits (AWV) and documentation of Hierarchical Condition Categories (HCC) are important metrics in accountable care organizations (ACO) with quality and financial implications. To improve performance in large healthcare organizations, quality improvement (QI) efforts need to be scaled up in a way that is feasible within available system-wide resources.ObjectiveWe describe a 3-year effort using a multifaceted QI framework called the fractal management system for AWV and HCC performance.DesignPre-post evaluation of a multi-level, health system–wide QI management system intervention between 2018 and 2020. The system provided project management, coaching, communications, feedback of performance, and health informatics.ParticipantsThe intervention was delivered to all 97 primary care practices within an Ohio-based accountable care organization, comprising 72,603 attributed Medicare and Medicare Advantage patients as of 2018. Eighty-nine of these practices were included in the analysis.ApproachAWV completion was defined as percent of eligible patients with a documented AWV during the calendar year. HCC completion was defined as documented reassessment of all prior-year HCC conditions.Key ResultsAWV completion at the practice level increased from 23.7% (SD .14) in 2018 to 34.9% (SD .18) in 2019, and 59.8% (SD .17) in 2020. This was a statistically significant effect of time on AWV completion rates overall (F[2, 87] = 164.43, p < .000). More than half (56.2%) of practices met or exceeded the 60% goal in 2020. Practice-level HCC completion tracking started in 2019 (M = 75.9%, SD 7.4%) and increased in 2020 (M = 79.7%, SD 7.1%); t(172) = 2.0, p < .001.ConclusionsAWV and HCC performance goals were met in 2020, despite service disruptions due to COVID-19. The QI approach we used is applicable to other problems and other large healthcare systems.

Pathways for Improving Inpatient Pediatric Asthma Care (PIPA): A Multicenter, National Study

This study was aimed at improving inpatient asthma care in the pediatric population through the implementation of visual evidence-based guidelines, called pathways, in diverse hospital settings.Pediatric patients (ages 2–17) hospitalized with a primary diagnosis of asthma in diverse hospital settings across the United States.From January 2018 through March 2019, clinicians from >250 hospitals that varied in size, location (urban versus rural), ownership (private versus nonprofit), and type (community versus children’s) were recruited to participate in the study. Clinicians were identified through the Value in Inpatient Pediatrics electronic mailing list. Participating hospitals were given evidence-based pathways and order sets as well as various support services for pathway implementation (educational seminars, quality improvement training, and monthly video conferences). Data on hospital characteristics were collected through a survey of implementation leaders. Outcomes data were collected via chart review. The primary outcome was inpatient length of stay (LOS), and secondary outcomes included early administration of bronchodilator via metered-dose inhaler (MDI), screening for secondhand tobacco smoke exposure, referral of caregivers to smoking cessation resources, hospital readmission within 7 days of discharge, and emergency department revisits within 7 days of discharge.A total of 85 hospitals were enrolled in the study, and 68 hospitals completed the study (participated for the full 15-month duration). There was diversity in the types of hospitals that completed the study in terms of size, type, and location. Pathway implementation was not associated with significant changes in LOS, but it was associated with statistically significant increases in early administration of bronchodilators versus MDI as well as caretaker referral to smoking cessation resources. Specific interventions, including implementation of MDI dosing guidance and reminders for smoking cessation resources, were associated with improvements in early administration of MDI and referral to smoking cessation resources, respectively. These improvements were noted with pathway initiation and not just study enrollment. Hospital level analysis revealed that most hospitals (65%) had significant improvements in >1 outcome. Only 2 hospitals had increases in 7-day hospital readmission or emergency department revisits (balancing measures).Overall, pathway implementation was not associated with statistically significant changes in LOS but was associated with improvements in the quality of care being provided, specifically in increasing early administration of bronchodilators via MDI and referring caretakers to smoking cessation resources.Childhood asthma is a major cause of pediatric hospitalization and associated health care costs. Pathways or evidence-based visual guidelines for the treatment of asthma have previously been shown to improve the quality of care of pediatric asthma patients. Large-scale quality improvement projects are extremely difficult to implement because of variations at each site. However, standardization of care can be attained through automated measures, particularly within the electronic medical record. Similar to other large-scale projects across multiple sites, this project did not move the needle overall for their predetermined primary outcome measure, but it did reveal that pathways helped improve other quality care measures, such as early MDI use and provision of smoking cessation resources. Additionally, this study reveals that use of pathways may be beneficial across a diverse array of hospitals, not just large, tertiary care children’s hospitals.

Health care ethics programs in U.S. Hospitals: results from a National Survey

BackgroundAs hospitals have grown more complex, the ethical concerns they confront have grown correspondingly complicated. Many hospitals have consequently developed health care ethics programs (HCEPs) that include far more than ethics consultation services alone. Yet systematic research on these programs is lacking.MethodsBased on a national, cross-sectional survey of a stratified sample of 600 US hospitals, we report on the prevalence, scope, activities, staffing, workload, financial compensation, and greatest challenges facing HCEPs.ResultsAmong 372 hospitals whose informants responded to an online survey, 97% of hospitals have HCEPs. Their scope includes clinical ethics functions in virtually all hospitals, but includes other functions in far fewer hospitals: ethical leadership (35.7%), regulatory compliance (29.0%), business ethics (26.2%), and research ethics (12.6%). HCEPs are responsible for providing ongoing ethics education to various target audiences including all staff (77.0%), nurses (59.9%), staff physicians (49.0%), hospital leadership (44.2%), medical residents (20.3%) and the community/general public (18.4%). HCEPs staff are most commonly involved in policy work through review of existing policies but are less often involved in development of new policies. HCEPs have an ethics representative in executive leadership in 80.5% of hospitals, have representation on other hospital committees in 40.7%, are actively engaged in community outreach in 22.6%, and lead large-scale ethics quality improvement initiatives in 17.7%. In general, major teaching hospitals and urban hospitals have the most highly integrated ethics programs with the broadest scope and greatest number of activities. Larger hospitals, academically affiliated hospitals, and urban hospitals have significantly more individuals performing HCEP work and significantly more individuals receiving financial compensation specifically for that work. Overall, the most common greatest challenge facing HCEPs is resource shortages, whereas underutilization is the most common greatest challenge for hospitals with fewer than 100 beds. Respondents’ strategies for managing challenges include staff training and additional funds.ConclusionsWhile this study must be cautiously interpreted due to its limitations, the findings may be useful for understanding the characteristics of HCEPs in US hospitals and the factors associated with these characteristics. This information may contribute to exploring ways to strengthen HCEPs.

Women and babies are dying from inertia: a collaborative framework for obstetrical drug development is urgently needed

Obstetrical complications, often referred to as the "great obstetrical syndromes," are among the most common global causes of mortality and morbidity in young women and their infants. However, treatments for these syndromes are underdeveloped compared with other fields of medicine and are urgently needed. This current paucity of treatments for obstetrical complications is a reflection of the challenges of drug development in pregnancy. The appetite of pharmaceutical companies to invest in research for obstetrical syndromes is generally reduced by concerns for maternal, fetal, and infant safety, poor definition, and high-risk regulatory paths toward product approval. Notably, drug candidates require large investments for development with an unguaranteed return on investment. Furthermore, the discovery of promising drug candidates is hampered by a poor understanding of the pathophysiology of obstetrical syndromes and their uniqueness to human pregnancies. This limits translational extrapolation and de-risking strategies in preclinical studies, as available for other medical areas, compounded with limited fetal safety monitoring to capture early prenatal adverse reactions. In addition, the ethical review committees are reluctant to approve the inclusion of pregnant women in trials, and in the absence of regulatory guidance in obstetrics, clinical development programs are subject to unpredictable regulatory paths. To develop effective and safe drugs for pregnancy complications, substantial commitment, and investment in research for innovative therapies are needed in parallel with the creation of an enabling ethical, legislative, and guidance framework. Solutions are proposed to enable stakeholders to work with a common set of expectations to facilitate progress in this medical discipline. Addressing this significant unmet need to advance maternal and possibly perinatal health requires the involvement of all stakeholders and specifically patients, couples, and clinicians facing pregnancy complications in the dearth of appropriate therapies. This paper focused on the key pharmaceutical research and development challenges to achieve effective and safe treatments for obstetrical syndromes.

Reduction in Racial Disparities in Severe Maternal Morbidity From Hemorrhage in a Large-scale Quality Improvement Collaborative

(Am J Obstet Gynecol. 2020;223:123.e1–14) Racial and ethnic disparities in maternal morbidity and mortality continue to persist in the United States. Maternal death is 3-4 times more likely in black women than in white women, and the risk for severe maternal morbidity (SMM) is 2 times greater among black women than white women. Many of these cases are believed to be preventable by addressing the quality of care. Quality improvement (QI) collaboratives have been put forth as one way to reduce these disparities, but little is known about their effectiveness on racial/ethnic disparities in maternal outcomes. The aim of this study was to investigate whether a QI collaborative could narrow the difference in the rates of SMM from hemorrhage between black and white pregnant women.

The Forgotten Epidemic: A Niagara Health System Initiative to Reduce Postoperative Opioid Consumption

Opioid over-prescription is a great driver in the opioid epidemic, and there is significant variability in post-surgical prescriptions. This paper describes a large-scale quality improvement campaign at the Niagara Health System (NHS) to reduce postoperative opioid prescriptions.

Preliminary Report From the Pelvic Floor Disorders Consortium: Large-Scale Data Collection Through Quality Improvement Initiatives to Provide Data on Functional Outcomes After Rectal Prolapse Repair.

The surgical management of rectal prolapse is constantly evolving, yet numerous clinical trials and meta-analyses studying operative approaches have failed to make meaningful conclusions. The purpose of this study was to report on preliminary data captured during a large-scale quality improvement initiative to measure and improve function in patients undergoing rectal prolapse repair. This was a retrospective analysis of prospectively collected surgical quality improvement data. This study was conducted at 14 tertiary centers specializing in pelvic floor disorders from 2017 to 2019. A total of 181 consecutive patients undergoing external rectal prolapse repair were included. Preoperative and 3-month postoperative Wexner incontinence score and Altomare obstructed defecation score were measured. The cohort included 112 patients undergoing abdominal surgery (71 suture rectopexy/56% minimally invasive, 41 ventral rectopexy/93% minimally invasive). Those offered perineal approaches (n = 68) were older (median age, 75 vs 62 y; p < 0.01) and had more comorbidities (ASA 3-4: 51% vs 24%; p < 0.01) but also reported higher preintervention rates of fecal incontinence (Wexner 11.4 ± 6.4 vs 8.6 ± 5.8; p < 0.01). Patients undergoing perineal procedures had similar incremental improvements in function after surgery as patients undergoing abdominal repair (change in Wexner, -2.6 ± 6.4 vs -3.1 ± 5.6, p = 0.6; change in Altomare, -2.9 ± 4.6 vs -2.7 ± 4.9, p = 0.8). Similarly, patients undergoing posterior suture rectopexy and ventral mesh rectopexy had similar incremental improvements in overall scores; however, patients undergoing ventral mesh rectopexy had a higher decrease in the need to use pads after surgery. The study was limited by its retrospective data analysis and 3-month follow-up. Functional outcomes improved in all of the patients undergoing prolapse surgery. Larger cohorts are necessary to show superiority among surgical procedures. Quality improvement methods may allow for systematic yet practical acquisition of information and data analysis. We call for the creation of a robust database to benefit this patient population. See Video Abstract at http://links.lww.com/DCR/B581. ANTECEDENTES:El tratamiento quirúrgico del prolapso rectal está evolucionando constantemente, sin embargo, numerosos estudios clínicos y metaanálisis que evalúan los tratamientos quirúrgicos no han logrado demostrar conclusiones significativas.OBJETIVO:Reportar datos preliminares obtenidos a gran escala durante una iniciativa de mejoramiento de la calidad para medir y mejorar la función en pacientes sometidos a reparación de prolapso rectal.DISEÑO:Análisis retrospectivo de datos recolectados prospectivamente de mejoramiento de la calidad quirúrgica.ENTORNO CLINICO:Este estudio se realizó en 14 centros terciarios especializados en trastornos del piso pélvico del 2017 al 2019.PACIENTES:Un total de 181 pacientes consecutivos sometidos a reparación de prolapso rectal externo.PRINCIPALES MEDIDAS DE VALORACION:Escala de incontinencia de Wexner y de defecación obstruida de Altomare preoperatoria y tres meses postoperatoria.RESULTADOS:El cohorte incluyó 112 pacientes sometidos a cirugía abdominal (71 rectopexia con sutura / 56% minimally invasive, 41 rectopexia ventral / 93% minimally invasive). Aquellos a los que se les realizaron abordajes perineales (n = 68) eran mayores (edad media de 75 vs. 62, p <0,01) y tenían mayorcomorbilidades (ASA 3-4: 51% vs. 24%, p <0,01), además reportaron una mayor tasa de incontinencia fecal previo a la intervención (Wexner 11,4 ± 6,4 vs. 8,6 +/- 5,8, p <0,01). Posterior a la cirugía, los pacientes sometidos a procedimientos perineales tuvieron mejoría progresiva en la función similar que los pacientes sometidos a reparación abdominal (cambio en Wexner -2,6 ± 6,4 vs. -3,1 ± 5,6, p = 0,6; cambio en Altomare -2,9 ± 4,6 vs. -2,7 ± 4,9, p = 0,8). De manera similar, los pacientes con rectopexia posterior con sutura y rectopexia ventral con malla tuvieron mejoría progresiva similares en las escalas generales; no obstante, pacientes con rectopexia ventral con malla tuvieron una mayor disminución en la necesidad de usar paños protectores después de la cirugía.LIMITACIONES:Análisis de datos retrospectivo y seguimiento de tres meses.CONCLUSIONES:Los resultados funcionales mejoraron en todos los pacientes sometidos a cirugía de prolapso. Se necesitan cohortes más grandes para demostrar superioridad entre los procedimientos quirúrgicos. Métodos de mejoramiento de la calidad pueden permitir la adquisición sistemática, pero práctica de información y análisis de datos. Hacemos un llamado para la creación de una base de datos sólida para beneficiar a esta población de pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B581. (Traducción- Dr Francisco M. Abarca-Rendon).

Qualitative evaluation of a mandatory provincial programme auditing emergency department return visits

ObjectiveThe objective of this qualitative study was to evaluate the perceived impact and value of the Return Visit Quality Programme (RVQP), a mandatory province-wide emergency department audit programme.DesignWe employed an...