Need For Improvement In Care Research Articles

Need for improvement in the care of patients with Clostridioides difficile infections (CDI) - expert opinion in international comparison

Clostridioides difficile infection (CDI), as a nosocomial disease, is associated with high morbidity and mortality. Even though the incidence of CDI has been declining in Germany in recent years, the individual infection may pose a medical challenge despite therapeutic advances. The aim here is to clarify which gaps practitioners consider to be particularly serious in care and in the existing evidence base. In a moderated workshop of German CDI experts the topics considered as relevant were identified. A survey already conducted in five other countries (Australia, France, Great Britain, Canada, and Italy) was adapted and processed by 27 practitioners. During the evaluation, the topics perceived as particularly important were identified, the statements of the specialist groups were compared and changes in opinion were considered. 27 fully completed questionnaires were evaluated. The need for improvement was primarily seen in the prevention of CDI recurrences (74.1%) and the treatment of recurrences (55.6%). Evidence deficits were noted in the treatment of recurrences (55.6%) and identification of risk factors for recurrences (48.1%). Improving care via fecal microbiota transfer (FMT) was named by 70.4%. For guidelines, more clarity (48.1%) and more regular updates (40.7%) were desired. For patients, better education on appropriate antibiotic use (52.0%) and choice of FMT were desired (48.1%). The German expert view and the international assessment is similar, when asked about the need for improvement in care and evidence gaps in the treatment of patients with CDI: The focus is on prevention and therapy of recurrent CDI. The problem of access to FMT is a German peculiarity that seems to need improvement.

Current spectrum and outcomes of infarct-related cardiogenic shock: insights from the CULPRIT-SHOCK registry and randomized controlled trial.

We analysed consecutive patients with acute myocardial infarction complicated by cardiogenic shock (CS) who were enrolled into the CULPRIT-SHOCK randomized controlled trial (RCT) and those with exclusion criteria who were included into the accompanying registry. In total, 1075 patients with infarct-related CS were screened for CULPRIT-SHOCK in 83 specialized centres in Europe; 369 of them had exclusion criteria for the RCT and were enrolled into the registry. Patients were followed over 1 year. The mean age was 68 years and 260 (25%) were women. 13.5%, 30.9%, and 55.6% had one-vessel, two-vessel, and three-vessel coronary artery disease (CAD), respectively. Significant left main (LM) coronary artery stenosis was present in 8.0%. 54.2% of the patients had cardiac arrest before admission. Thrombolysis in myocardial infarction (TIMI) 3 patency of the infarct vessel after percutaneous coronary intervention was achieved in 83.6% of all patients. Mechanical circulatory support was applied in one-third of patients. Total mortality after 30 days and 1 year was 47.6% and 52.9%. Mortality after 1 year was highest in patients with LM coronary artery stenosis (63.5%), followed by three-vessel (56.6%), two-vessel (49.8%), and one-vessel CAD (38.6%), respectively. Mechanical complications were rare (21/1008; 2.1%) but associated with a high mortality of 66.7% after 1 year. In specialized centres in Europe, short- and long-term mortality of patients with infarct-related CS treated with an invasive strategy is still high and mainly depends on the extent of CAD. Therefore, there is still a need for improvement of care to improve the prognosis of infarct-related CS.

Self-assessed quality of care among adults with diagnosed diabetes in Germany.

People who have diabetes require regular medical care. The views of patients about the quality of their care are becoming increasingly relevant when it comes to chronic diseases such as diabetes. As part of the nationwide study Disease Knowledge and Information Needs - Diabetes mellitus (2017), data on self-assessed quality of care by people with diagnosed diabetes was collected using the Patient Assessment of Chronic Illness Care - DAWN short form (PACIC-DSF, scale 1 to 5) and analysed for respondents aged 45 years or above. The average score for quality of care was 2.47 and was lower for women than for men (2.33 vs 2.58). The respondents assessed the quality of their care as being worse with rising age and size of the population in their residential area. No significant differences were observed by education group. Overall, people with diabetes in Germany consider the quality of their care to be moderate, which indicates a need for improvement in care.

Análise do histórico obstétrico e acompanhamento do pré-natal da gestação atual em puérperas em uma Maternidade do Tocantins

Introduction: The main purpose of prenatal and puerperal care is to welcome the woman from the beginning of pregnancy, ensuring, at the end of pregnancy, the birth of a healthy child and the guarantee of maternal and neonatal well-being. Objective: to characterize the puerperal women regarding obstetric history and prenatal care during the current pregnancy. Method: Quantitative cross-sectional study. Held at the Hospital and Public Maternity Hospital Dona Regina Siqueira Campos, Palmas - TO. The population consisted of 239 postpartum women. Results: Among the previous deliveries, 87 of them were cesarean and 61 were normal. Regarding live births, 132 mothers reported having other live children, with an average of 1.91 ± 1.46 live births, among them, 92.4% had one to three children. Regarding the current obstetric profile, it was found that 11.8% had their newborns preterm and 88.2% of them, at term, with 53.1% between 37 and 39 weeks and 35.1% between 40 to 42 weeks. About 55% (132) did not receive any information regarding childbirth during the entire prenatal period. Conclusion: This study evidenced the existence of weaknesses in prenatal care, which indicate a need for improvement in care in the care of pregnant women.

Retardo na chegada da pessoa com acidente vascular cerebral a um serviço hospitalar de referência

Objetivos: Analisar fatores que retardam o atendimento dos pacientes na fase aguda do Acidente Vascular Cerebral em um hospital público de referência. Métodos: Estudo de corte transversal, realizado na cidade de Salvador/Bahia com 50 pacientes através de dados em prontuários e por entrevista semiestruturada. Os dados foram analisados através do programa SPSS versão 21, utilizado o Qui-quadrado para as variáveis do tempo, com ní­vel de significância de 5%. Resultados: Evidenciou-se média de idade de 61,2 ± 13 anos, predominando o sexo masculino. A maioria dos pacientes não realizou trombólise devido a fatores de atraso como: utilização de carro próprio, não ter um familiar presente na hora do evento, chegada ao hospital fora da janela terapêutica e procura por outros serviços anteriormente. Conclusão: Diversos fatores retardam o atendimento ao paciente com Acidente Vascular Cerebral. Desta maneira, observa-se a necessidade de melhorias no atendimento associada í difusão de informações í população.

Care in the Ostomates Programs: the multidisciplinary team’s perspective

Objective: to interpret the multidisciplinary team’s perspective on care for ostomates. Methods: qualitative study involving five professionals from the multidisciplinary team of the Ostomates Program, based on the Social Model of Disability. To collect the data, a focus group, participant and non-participant observation were used, along with a field diary, interpreted using the thematic analysis method. Results: the experience of this team was interpreted based on the theme Challenges for the implementation of the Ostomates Program and the respective thematic nuclei: In search of teamwork and Specialized care demands for intestinal ostomates, which evidenced the influences on the work and the need for improvements in care, infrastructure and human resources. Conclusion: the health professionals’ integration among different public healthcare levels and the ostomates and families’ participation influence the care for ostomates.

Quality of life and body image of patients with urinary disorders.

to assess the quality of life and body image of men with difficulty urinating and indwelling urinary catheter users, integrating the socio-demographic, economic and morbidity variables. a cross-sectional analytical study with 64 male patients with urinary problems. Three questionnaires were used for data collection: one containing sociodemographic, economic and morbid data, the Medical Outcome Study 36-item short-form health survey to analyze quality of life, and the Body Dysmorphic Examination, which assesses body image. T-test, Mann-Whitney, Pearson, Spearman, Linear Regression and Stepwise were used. quality of life and body image were compromised in both groups, affecting emotional aspects, with a high degree of body dissatisfaction and altered physical and social adversity. changes in patients' quality of life and body image were observed, confirming the need for improvement in care.

Perioperative diabetes: the challenges and strategies for glycaemic control management

AbstractPerioperative diabetes care is an important area of focus for several reasons. As in the general population, the prevalence of diabetes in the surgical population is growing and remains associated with increased risks, including excess morbidity, mortality and prolonged length of stay. Secondly, reviews of the quality of inpatient diabetes care through the National Diabetes Inpatient Audit and the 2018 National Confidential Enquiry into Patient Outcome and Death Perioperative Diabetes report have emphasised the need for improvements in care which have the potential to improve outcomes for this group of patients. This article discusses some of the challenges and proposed strategies to tackle this issue including clinical leadership, updating processes and multidisciplinary working as well as the applications of new technologies. Copyright © 2019 John Wiley & Sons. Practical Diabetes 2019; 36(6): 207–211

Inequitable Long-Term Outcomes for an Indigenous Population After Definitive Treatment of Patients With Graves Disease.

BackgroundMāori, the indigenous people of Aotearoa/New Zealand, have an increased incidence of Graves disease and often require more than one radioiodine (RAI) dose, raising the question as to whether surgery may be preferable in this population. However, there is a lack of outcome data after definitive therapy in an indigenous population.AimTo assess ethnic differences in thyroid status after definitive therapy for Graves disease.MethodsSingle-center retrospective review of patients treated by RAI or thyroidectomy from 1 December 2001 to 31 March 2013. TSH levels at 1, 2, 5, and 10 years after treatment were recorded.ResultsA total of 798 patients were included: 589 received RAI, and 209 underwent surgery. Overall, 48% of patients were euthyroid at 1 year after definitive treatment, and 63.5% were euthyroid by 10 years. Māori were less likely to be euthyroid when compared with Europeans at all time points (e.g., 29.7% vs 57.3% at 1 year and 52.2% vs 70.9% at 10 years, P < 0.0005). Māori were more likely to receive more than one dose of RAI compared with Europeans (30.2% vs 14.2%, P < 0.0005). Persistent thyrotoxicosis at 1 year after RAI was seen in 25.8% of Māori compared with 8.3% of Europeans (P < 0.0005).ConclusionsMāori have lower rates of optimal thyroid levels than their European counterparts at all time points studied. Early disparity was associated with a higher RAI failure rate. Late differences were due to higher rates of untreated hypothyroidism. Overall, euthyroid rates were low, indicating the need for improvement in care, particularly for indigenous peoples.

The Impact of Diabetes and Time on the Atherosclerotic Plaque and Cardiovascular Outcome in Patients Undergoing Iliofemoral Endarterectomy

The incidence of diabetes is rapidly increasing and diabetes is associated with an increased risk of peripheral artery disease. Recent studies have shown a time dependent decline in vulnerable plaque features and secondary cardiovascular events in iliofemoral endarterectomy (IFE) patients. IFE patients with diabetes have a high risk of cardiovascular events. It is not known, however, whether vulnerable plaque features and cardiovascular events reduce over time in IFE patients with diabetes. Between 2003 and 2014, 691 atherosclerotic plaques were obtained by IFE, from 212 patients with and 479 patients without diabetes. Plaques were immunohistochemically stained and analysed for the presence of intraplaque haemorrhage, lipid core, calcification, collagen, smooth muscle cells, and macrophages. Patients were stratified according to their diabetic status and year of inclusion. All patients had a follow up of three years in which cardiovascular adverse events were recorded. A time dependent decrease was observed in intraplaque haemorrhage, plaque lipid core, and percentage of macrophages in IFE patients with diabetes. After multivariable correction for changes in risk factors over time, intraplaque haemorrhage (64.2% [2002-2005] vs. 39.6% [2012-2014], p=.01) became significantly less prevalent. Interestingly, the percentage of severely calcified plaques remained high over time. The number of secondary events decreased over time in patients without diabetes (HR 1.80, 95% CI 1.15-2.81 (p=.010) for 2002-2005 vs. 2012-2014), but remained high and unchanged in patients with diabetes. In patients with diabetes undergoing IFE, a time dependent stabilisation of atherosclerotic plaque features was found in line with previous observations in patients with severe atherosclerosis. The presence of severely calcified lesions remained high and unchanged. The secondary event rate remained high in patients with diabetes in contrast to a significant decrease in patients without diabetes. These findings stress the need for improvement of care in IFE patients with diabetes.

Patient-reported areas for quality improvement in general practice: a cross-sectional survey.

GPs are often a patient's first point of contact with the health system. The increasing demands imposed on GPs may have an impact on the quality of care delivered. Patients are well placed to make judgements about aspects of care that need to be improved. To determine whether general practice patients perceive that the care they receive is 'patient-centred' across eight domains of care, and to determine the association between sociodemographic, GP and practice characteristics, detection of preventive health risks, and receipt of patient-centred care. Cross-sectional survey of patients attending Australian general practice clinics. Patients completed a touchscreen survey in the waiting room to rate the care received from their GP across eight domains of patient-centred care. Patients also completed the Patient Health Questionnaire (PHQ-9) and self-reported health risk factors. GPs completed a checklist for each patient asking about the presence of health risk factors. In total 1486 patients and 51 GPs participated. Overall, 83% of patients perceived that the care they received was patient-centred across all eight domains. Patients most frequently perceived the 'access to health care when needed' domain as requiring improvement (8.3%). Not having private health insurance and attending a practice located in a disadvantaged area were significantly associated with perceived need for improvements in care (P<0.05). Patients in general practice report that accessibility is an aspect of care that could be improved. Further investigation of how indicators of lower socioeconomic status interact with the provision of patient-centred care and health outcomes is required.

Prevalence of Dystrophic Epidermolysis Bullosa in Spain: A Population-Based Study Using the 3-Source Capture–Recapture Method. Evidence of a Need for Improvement in Care

BackgroundDystrophic epidermolysis bullosa (DEB) is a rare disease that represents a heavy burden for both the patient and the health care system. There are currently no data on the prevalence of DEB in Spain. ObjectiveTo determine the prevalence of DEB in Spain. MethodsWe used data from 3 incomplete population-based sources (hospital dermatology departments, diagnostic laboratories performing antigenic mapping, genetic testing or both, and the Spanish Association of Epidermolysis Bullosa Patients [DEBRA]) and combined them using the 3-source capture–recapture methodology. ResultsWe identified 152 living DEB patients. The estimated prevalence of DEB was 6.0 cases per million (95% CI, 4.2–11.8) in adults and 15.3 (95% CI, 10.4–40.8) in children under 18 years of age. The data indicated that 77% of the patients were not being followed up in specialized centers of reference; 65% had not had a genetic diagnosis, and 76% were not members of DEBRA. ConclusionsThe prevalence of DEB in Spain is 6.0 patients per million (95% CI, 4.2–11.8), a figure higher than previous estimates in many areas, but similar to those found in other southern Europe countries. The north–south difference may represent real geographic differences in prevalence, but it might be due to the fact that most of the data come from registries with a lower than expected catchment. Many patients are not being followed up in centers of reference, do not have genetic diagnosis, and are not members of patients’ associations, suggesting that there is room for considerable improvement in their care.

Prevalence of Dystrophic Epidermolysis Bullosa in Spain: A Population-Based Study Using the 3-Source Capture–Recapture Method. Evidence of a Need for Improvement in Care

BackgroundDystrophic epidermolysis bullosa (DEB) is a rare disease that represents a heavy burden for both the patient and the health care system. There are currently no data on the prevalence of DEB in Spain. ObjectiveTo determine the prevalence of DEB in Spain. MethodsWe used data from 3 incomplete population-based sources (hospital dermatology departments, diagnostic laboratories performing antigenic mapping, genetic testing or both, and the Spanish Association of Epidermolysis Bullosa Patients [DEBRA]) and combined them using the 3-source capture–recapture methodology. ResultsWe identified 152 living DEB patients. The estimated prevalence of DEB was 6.0 cases per million (95% CI, 4.2–11.8) in adults and 15.3 (95% CI, 10.4–40.8) in children under 18 years of age. The data indicated that 77% of the patients were not being followed up in specialized centers of reference; 65% had not had a genetic diagnosis, and 76% were not members of DEBRA. ConclusionsThe prevalence of DEB in Spain is 6.0 patients per million (95% CI, 4.2–11.8), a figure higher than previous estimates in many areas, but similar to those found in other southern Europe countries. The north–south difference may represent real geographic differences in prevalence, but it might be due to the fact that most of the data come from registries with a lower than expected catchment. Many patients are not being followed up in centers of reference, do not have genetic diagnosis, and are not members of patients’ associations, suggesting that there is room for considerable improvement in their care.

All-Cause and Disease-specific Mortality and Morbidity in Patients With Congenital Hypothyroidism Treated Since the Neonatal Period: A National Population-based Study

Little is known about the long-term health of patients treated for congenital hypothyroidism since the neonatal period. To evaluate the causes of mortality and comorbidity in a population-based registry of young adult patients. All 1772 eligible patients diagnosed during the first decade after the introduction of neonatal screening in France participated in the study. Follow-up data on vital status were available, in May 2010, for 99.5% of the patients. Completed questionnaires were obtained from 1202 of the selected patients. All-cause and cause-specific mortality and comorbidity. All-cause mortality in the congenital hypothyroidism (CH) patients was slightly higher than expected on the basis of year, age, and sex (standardized mortality ratio [SMR] 1.24, 95% CI: 0.81-1.82). SMRs for each category of underlying cause of death showed mortality due to diseases of the central nervous system (SMR 5.22, 95% CI: 1.68-12.17) and congenital malformations (SMR 3.15, 95% CI: 1.86-6.49) to be significantly higher than expected in the CH patients. The risk of developing an associated chronic disease in the 1202 patients who completed the questionnaire was twice that for the reference population (odds ratio 2.0 [1.32-3.03]). Neurologic or mental diseases and congenital malformations were the most frequent (odds ratios 2.54 [1.12-5.86], 4.18 [1.27-13.76], and 4.36 [1.24-15.34], respectively). Overall, mortality and morbidity were not affected by sex, disease severity, cause of CH, or adequacy of treatment. Prognosis has improved considerably, but a few patients diagnosed during the first 10 years of screening in France nonetheless displayed comorbidity and mortality due to various neurodevelopmental disorders and associated malformations. These results reveal a continuing need for improvements in care and studies to provide knowledge about the full spectrum of the disease and the mechanisms underlying these developmental abnormalities.

Trends in Perinatal Mortality in Tribhuvan University Teaching Hospital: 13 Years Review

Introduction: The perinatal mortality rate (PMR) in Nepal is still very high. In major hospitals of Nepal, it is still ranging from 20-30 per thousand births. This study was carried out with the objective to review PMR and classifying it according to Wigglesworth classification to identify the causes of perinatal deaths at Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal over the past 13 years and assess need for improvement in care. Material and Methods: It was a retrospective study carried out in TUTH. Data of all stillbirths from 28 weeks of pregnancy and neonatal deaths within first seven days of life in the hospital was taken from monthly perinatal audit and annual mortality review. All the perinatal deaths were then classified according to Wigglesworth classification. Results: Over a 13 year period, there were total 42,746 births and 921 perinatal deaths giving a perinatal mortality of 21.5 per thousand births. Over this period PMR has decreased from 31 to 18 per thousand births. Still births contributed almost 50% of the perinatal deaths; deaths related to prematurity show an increasing trend and have increased by almost 70% in past 5 years. Deaths due to perinatal asphyxia were static. Conclusion: PMR over the years has shown declining trend at TUTH. There is need to improve antenatal, obstetric as well as intrapartum services to further reduce the still birth as well as deaths due to prematurity and perinatal asphyxia. J. Nepal Paediatr. Soc. 32(2) 2012 150-153 doi: http://dx.doi.org/10.3126/jnps.v32i2.6898

Effects of Depressive Syndromes on the Everyday Competence of Nursing Home Residents with Dementia

Depression in dementia is very common and has significant effects on the functional impairment of nursing-home residents. This study assesses depression, depression diagnosis, cognitive status, status of medication and functional status in 138 residents. Results: (1) 34.1% of the demented residents had a depressive symptomatology. (2) No diagnosis of “depression” was documented for a high percentage of depressed residents. (3) No correlation between depressive symptoms and treatment with antidepressants was present. (4) There was no correlation between the stage of dementia and the rate of depression. (5) There were significant differences in the everyday competence between depressive and nondepressive residents with dementia. The data suggest the need for an adequate diagnosis and treatment of depressive residents with dementia and underlines the need for improvement in care and treatment in primary care and nursing homes.

Why are bereaved family members dissatisfied with specialised inpatient palliative care service? A nationwide qualitative study

In order to improve the quality of palliative care, we can learn from bereaved families who were dissatisfied with the care they received. The primary aim of this study was to explore why bereaved families were dissatisfied with specialized inpatient palliative care. This qualitative study formed part of a nationwide questionnaire survey administered to 1225 bereaved family members of cancer patients who died in certified palliative care units in Japan. The participants were 22 consecutive family members who reported a greater need for improvement in care. Data were analysed by the content analysis. The reasons that the bereaved families listed are classified into 27 categories and seven themes: (1) lack of perceived support for maintaining hope; (2) lack of perceived respect of individuality, especially in attitudes toward death; (3) perceived poor quality of care, especially psychological care, not being treated with dignity and inadequate explanation from physicians; (4) inadequate staffing and equipment, especially physician availability; (5) unavailability of timely administration; (6) lack of accurate information about palliative care units; and (7) family's practical and economic burden. This study identified the multiple sources of dissatisfaction with specialized inpatient palliative care for bereaved families. These findings could be useful in developing a more desirable system of specialised inpatient palliative care.

Staff Perceptions of End-of-Life Care in Long-Term Care

Objective Although residential care/assisted living facilities and nursing homes have increasingly become a significant site of death for older Americans, little is known about staff perceptions of end-of-life care, perceived need for improvement in care, and differences by type of setting. Design, Setting, and Participants Ninety-nine staff provided their perceptions of end-of-life care for 99 decedents from 74 residential care/assisted living facilities and nursing homes in four states as part of a larger cohort study. Staff were interviewed retrospectively regarding care provided during residents’ last month of life. Measurements Staff reported on 11 areas of end-of-life care, describing the importance of each area and the level of improvement they felt was indicated. Weighted “need for change” scores were calculated as the product of perceived importance and need for improvement. Results Both residential care/assisted living and nursing home staff reported a need for more staff education and nursing assistant time, as well as more use of volunteers. The two lowest ranked items for both facility types were involvement of hospice and encouragement for staff to attend funeral services. Nursing home staff perceived a greater need for improvement than residential care/assisted living staff in all 11 areas. Conclusion Results underscore the staffing demands of end-of-life care across facility types, and staff desires to be able to provide quality care throughout the dying process. Although residential care/assisted living facilities and nursing homes have increasingly become a significant site of death for older Americans, little is known about staff perceptions of end-of-life care, perceived need for improvement in care, and differences by type of setting. Ninety-nine staff provided their perceptions of end-of-life care for 99 decedents from 74 residential care/assisted living facilities and nursing homes in four states as part of a larger cohort study. Staff were interviewed retrospectively regarding care provided during residents’ last month of life. Staff reported on 11 areas of end-of-life care, describing the importance of each area and the level of improvement they felt was indicated. Weighted “need for change” scores were calculated as the product of perceived importance and need for improvement. Both residential care/assisted living and nursing home staff reported a need for more staff education and nursing assistant time, as well as more use of volunteers. The two lowest ranked items for both facility types were involvement of hospice and encouragement for staff to attend funeral services. Nursing home staff perceived a greater need for improvement than residential care/assisted living staff in all 11 areas. Results underscore the staffing demands of end-of-life care across facility types, and staff desires to be able to provide quality care throughout the dying process.

Staff Perceptions of End-of-Life Care in Long-Term Care

Although residential care/assisted living facilities and nursing homes have increasingly become a significant site of death for older Americans, little is known about staff perceptions of end-of-life care, perceived need for improvement in care, and differences by type of setting. Ninety-nine staff provided their perceptions of end-of-life care for 99 decedents from 74 residential care/assisted living facilities and nursing homes in four states as part of a larger cohort study. Staff were interviewed retrospectively regarding care provided during residents' last month of life. Staff reported on 11 areas of end-of-life care, describing the importance of each area and the level of improvement they felt was indicated. Weighted "need for change" scores were calculated as the product of perceived importance and need for improvement. Both residential care/assisted living and nursing home staff reported a need for more staff education and nursing assistant time, as well as more use of volunteers. The two lowest ranked items for both facility types were involvement of hospice and encouragement for staff to attend funeral services. Nursing home staff perceived a greater need for improvement than residential care/assisted living staff in all 11 areas. Results underscore the staffing demands of end-of-life care across facility types, and staff desires to be able to provide quality care throughout the dying process.