Prevention Quality Indicators Research Articles

Zur Diskussion: Qualitätssicherung in der Pflege – mit PKMS auf dem richtigen Weg?

Hospitals are legally obliged to take part in external comparative quality assurance programs. Quality indicators for pressure ulcer prevention are among the most widely used for geriatric clinical institutions. To enable more precise risk adjustment established risk factors are employed in conjunction with the OPS 9-200. Using a PKMS case to produce an OPS 9-200 is far too heterogeneous, sketchy and vague to create an accurate and satisfactory pressure ulcer risk assessment for patients with varied and individual case factors. Therefore we propose to include risk factors which, according to experts, are clearly and specifically related to pressure ulcers (e.g. immobility and incontinence) and matched by unique ICD codes.

Association Between Imposition of a Maintenance of Certification Requirement and Ambulatory Care–Sensitive Hospitalizations and Health Care Costs

In 1990, the American Board of Internal Medicine (ABIM) ended lifelong certification by initiating a 10-year Maintenance of Certification (MOC) program that first took effect in 2000. Despite the importance of this change, there has been limited research examining associations between the MOC requirement and patient outcomes. To measure associations between the original ABIM MOC requirement and outcomes of care. Quasi-experimental comparison between outcomes for Medicare beneficiaries treated in 2001 by 2 groups of ABIM-certified internal medicine physicians (general internists). One group (n = 956), initially certified in 1991, was required to fulfill the MOC program in 2001 (MOC-required) and treated 84 215 beneficiaries in the sample; the other group (n = 974), initially certified in 1989, was grandfathered out of the MOC requirement (MOC-grandfathered) and treated 69 830 similar beneficiaries in the sample. We compared differences in outcomes for the beneficiary cohort treated by the MOC-required general internists before (1999-2000) and after (2002-2005) they were required to complete MOC, using the beneficiary cohort treated by the MOC-grandfathered general internists as the control. Quality measures were ambulatory care-sensitive hospitalizations (ACSHs), measured using prevention quality indicators. Ambulatory care-sensitive hospitalizations are hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care. Other outcomes included health care cost measures (adjusted to 2013 dollars). Annual incidence of ACSHs (per 1000 beneficiaries) increased from the pre-MOC period (37.9 for MOC-required beneficiaries vs 37.0 for MOC-grandfathered beneficiaries) to the post-MOC period (61.8 for MOC-required beneficiaries vs 61.4 for MOC-grandfathered beneficiaries) for both cohorts, as did annual per-beneficiary health care costs (pre-MOC period, $5157 for MOC-required beneficiaries vs $5133 for MOC-grandfathered beneficiaries; post-MOC period, $7633 for MOC-required beneficiaries vs $7793 for MOC-grandfathered beneficiaries). The MOC requirement was not statistically associated with cohort differences in the growth of the annual ACSH rate (per 1000 beneficiaries, 0.1 [95% CI, -1.7 to 1.9]; P = .92), but was associated with a cohort difference in the annual, per-beneficiary cost growth of -$167 (95% CI, -$270.5 to -$63.5; P = .002; 2.5% of overall mean cost). Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries.

Postpartum haemorrhage in midwifery care in the Netherlands: validation of quality indicators for midwifery guidelines.

BackgroundPostpartum haemorrhage (PPH) is still one of the major causes of severe maternal morbidity and mortality worldwide. Currently, no guideline for PPH occurring in primary midwifery care in the Netherlands is available. A set of 25 quality indicators for prevention and management of PPH in primary care has been developed by an expert panel consisting of midwives, obstetricians, ambulance personal and representatives of the Royal Dutch College of Midwives (KNOV) and the Dutch Society of Obstetrics and Gynecology (NVOG). This study aims to assess the performance of these quality indicators as an assessment tool for midwifery care and suitability for incorporation in a professional midwifery guideline.MethodsFrom April 2008 to April 2010, midwives reported cases of PPH. Cases were assessed using the 25 earlier developed quality indicators. Quality criteria on applicability, feasibility, adherence to the indicator, and the indicator’s potential to monitor improvement were assessed.Results98 cases of PPH were reported during the study period, of which 94 were analysed. Eleven indicators were found to be applicable and feasible. Five of these indicators showed improvement potential: routine administration of uterotonics, quantifying blood loss by weighing, timely referral to secondary care in homebirth and treatment of PPH using catherisation, uterine massage and oxytocin and the use of oxygen.ConclusionsEleven out of 25 indicators were found to be suitable as an assessment tool for midwifery care of PPH and are therefore suitable for incorporation in a professional midwifery guideline. Larger studies are necessary to confirm these results.

Home-based primary care and the risk of ambulatory care-sensitive condition hospitalization among older veterans with diabetes mellitus.

Primary care services based at home have the potential to reduce the likelihood of hospitalization among older adults with multiple chronic diseases. To characterize the association between enrollment in Home-Based Primary Care (HBPC), a national home care program operated by the US Department of Veterans Affairs (VA), and hospitalizations owing to an ambulatory care-sensitive condition among older veterans with diabetes mellitus. Retrospective cohort study. Patients admitted to VA and non-VA hospitals were followed up from January 1, 2006, through December 31, 2010. Veterans 67 years or older who were fee-for-service Medicare beneficiaries, were diagnosed as having diabetes mellitus and at least 1 other chronic disease, and had at least 1 admission to a VA or non-VA hospital in 2005 or 2006. Enrollment in HBPC, defined as a minimum of 2 HBPC encounters during the study period. Admission to VA and non-VA hospitals owing to an ambulatory care-sensitive condition, as measured by the Agency for Healthcare Research and Quality's Prevention Quality Indicators in VA medical records and Medicare claims. Outcomes were analyzed using distance from the veteran's residence to a VA facility that provides HBPC as an instrumental variable. Among 56 608 veterans, 1978 enrolled in HBPC. These patients were older (mean age, 79.1 vs 77.1 years) and had more chronic diseases (eg, 59.2% vs 53.5% had congestive heart failure). Multivariable predictors for HBPC enrollment included paralysis (odds ratio [OR], 2.11; 95% CI, 1.63-2.74), depression (OR, 1.99; 95% CI, 1.70-2.34), congestive heart failure (OR, 1.36; 95% CI, 1.17-1.58), and distance from the nearest HBPC-providing VA facility (OR, 0.59; 95% CI, 0.50-0.70 for >10-30 vs <5 miles). After controlling for selection using an instrumental variable analysis, HBPC was associated with a significant reduction in the probability of experiencing a hospitalization owing to an ambulatory care-sensitive condition (hazard ratio, 0.71; 95% CI, 0.57-0.89), with an absolute reduction in the probability of hospitalization of 5.8% in 1 year. Home-Based Primary Care is associated with a decreased probability of ambulatory care-sensitive condition hospitalization among elderly veterans with diabetes mellitus. In accountable care models, HBPC may have an important role in the management of older adults with multiple chronic diseases.

Psychometric properties of the Dutch National Prevalence Measurement of Care Problems used to measure quality of pressure ulcer care in Indonesian hospitals.

To evaluate the psychometric properties of the Indonesian version of the Dutch National Prevalence Measurement of Care Problems. The questionnaire consists of 6 parts: patient characteristics (including pressure ulcer [PrU] risk; assessed by the Braden Scale) and care dependency (assessed by the Care Dependency Scale [CDS]), PrU categorization, prevention, treatment, and structural quality indicators at ward and hospital level. A 3-phase design was used, including questionnaire translation and psychometric testing. The questionnaire was translated into Indonesian on March 2012. Content validity was assessed by 18 Indonesian experts on July 2012. The interrater agreement and reliability of the PrU categories, Braden Scale, and CDS were assessed on October 2012 in 4 Indonesian large public general hospitals. Most Indonesian experts (91.8%) rated the Indonesian version of the questionnaire as "good" on clarity of wording. The content validity indices of the questionnaire ranged from 0.50 to 1.00. The PrU categories assessed showed an interrater reliability of κ = 0.92 (95% confidence interval [CI], 0.87-0.97) and an interrater agreement of po = 98.6% (95% CI, 97.5-99.3). The interrater reliability intraclass correlation coefficient (1,1) of the Braden Scale sum score was 0.90 (95% CI, 0.85-0.93). The exact proportion of agreement sum score was 39%. The interrater reliability intraclass correlation coefficient (1,1) of the CDS sum score was 0.88 (95% CI, 0.83-0.92). There was a 45% exact agreement on the CDS sum scores. The questionnaire can be used in Indonesian hospitals to measure the PrU prevalence and quality of PrU care.

Higher Practice Intensity Is Associated with Higher Quality of Care but More Avoidable Admissions for Medicare Beneficiaries

The relationship between practice intensity and the quality and outcomes of care has not been studied. To examine the relationship between primary care physicians' costliness both for defined episodes of care and for defined patients and the quality and outcomes of care delivered to Medicare beneficiaries. Cross sectional analysis of physician survey data linked to Medicare claims. Physician costliness measures were calculated by comparing the episode specific and overall costs of care for their patients with the care delivered by other physicians. We studied physicians participating in the 2004-2005 Community Tracking Study Physician Survey linked with administrative claims from the Medicare program for the years 2004-2006. Proportion of eligible beneficiaries receiving each of seven preventive services and rates of preventable admissions for acute and chronic conditions. The 2,211 primary care physician respondents included 937 internists and 1,274 family or general physicians who were linked to more than 250,000 Medicare enrollees. Patients treated by more costly physicians (whether measured by the overall costliness index or the episode-level index) were more likely to receive recommended preventive services, but were also more likely to experience preventable admissions. For instance, physicians in the lowest quartile of costliness performed appropriate monitoring for hemoglobin A1C for diabetics 72.8% of the time, as compared with 81.9% for physicians in the highest quartile of costliness (p < 0.01). In contrast, patients treated by the physicians in the lowest quartile of episode costliness were admitted at a rate of 1.8/100 for both acute and chronic Prevention Quality Indicators (PQIs), as compared with 2.9/100 for both acute and chronic PQIs for those treated by physicians in the highest quartile of costliness (p < 0.001). Physician practice patterns are associated with the quality of preventive services delivered to Medicare patients. Ongoing efforts to influence physician practice patterns may have differential effects on different aspects of quality.

Pan-Canadian Development of Cardiac Rehabilitation and Secondary Prevention Quality Indicators

The Canadian Cardiovascular Society (CCS) is implementing the Canadian Heart Health Strategy and Action Plan recommendation to build knowledge infrastructure, through its Data Definitions and Quality Indicator (QI) project. The CCS selected cardiac rehabilitation (CR) and secondary prevention as a content area for QI development. In accordance with the CCS QI Best Practice Methodology, rapid reviews of the literature were conducted. A long list of 37 QIs, in the areas of structure, process, and outcome were developed. Through an online survey, 26 (42%) of all contacted external experts rated each QI on importance, scientific acceptability, and feasibility, using a 7-point scale. The overall mean rating was 5.4 ± 1.4. Through a consensus process, the working group excluded 8 QIs based on this feedback, and several others were revised. A 30-day Web consultation was then undertaken, to solicit input from the broader CCS and CR community. A “top 5” list of QIs was requested by the CCS, which were: (1) inpatients referred to CR; (2) wait times from referral to CR enrollment; (3) patient self-management education; (4) increase in exercise capacity; and (5) emergency response strategy. Knowledge translation activities are now under way to promote utilization of the QIs and ultimately improve CR care.

PC-FACS

PC-FACS

A138: Clinical Decision Support to Improve Preventive Care in Pediatric Systemic Lupus Erythematosus

Background/Purpose:Quality indicators, such as infection and cardiovascular disease (CVD) preventive care, for patients with systemic lupus erythematosus (SLE) have recently been published and can be utilized for assessing quality of care. Implementation of tools such as clinical decision support (CDS) within the electronic health record (EHR) can be utilized in quality care improvement efforts. The purpose of this quality improvement study is to test the chronic care model to study the relationship between CDS and rates of compliance with infection and CVD preventive care quality indicators for pediatric SLE patients at an outpatient rheumatology clinic.Methods:The study is a pilot retrospective design with a convenience sample. Documentation in the EHR of up to date vaccinations and lipid screen was measured before and after implementation of an electronic documentation template. Data for the comparative hypothesis was analyzed using Chi‐square test.Results:Baseline data was collected from 48 (70%) patient charts and post‐CDS data were collected from 20 (30%) patient charts. Before intervention, 15 (31.3%) patients received pneumonia vaccine and 17 (81.0%) of patients received vaccine after intervention. Sixteen (33.3%) patients received influenza vaccine before intervention and 20 (95.2%) received vaccine after intervention. Before intervention, 12 (25.0%) patients received lipid panels and 16 (76.2%) patients received lipid panels after intervention. All three differences were significantly different (Fisher's Exact p &lt; 0.001). Patents were 9 times more likely to receive the pneumococcal vaccination and lipid panels and 40 times more likely to receive the influenza vaccination post intervention than before intervention. Baseline QI rates, Post‐intervention QI rates, and statistical differences between groups PVX Vaccine Influenza Vaccine Lipid Panel Baseline patients meeting QI, n (%) 15 (31.3) 16 (33.3) 12 (25) Post CDS patients meeting QI, n (%) 17 (81) 20 (95) 16 (76) Fischer's Exact test significance .000 .000 .000 Cramer's V .459 .570 .480 Odds Ratio (95% CI) 9.35 (2.683–32.587) 40 (4.917–325.378) 9.6 (2.897–31.810) Pretest n = 48 (70%), poster intervention n = 20 (30%); p value &lt; 0.1Conclusion:Use of EHR CDS was associated with improved rates of preventive care for pSLE patients in the Pediatric Rheumatology outpatient setting. Our results suggested that patients were more likely to receive a screening lipid panel, influenza vaccination and pneumococcal vaccination if the health care provider used the EHR template with CDS.

AHRQ prevention quality indicators to assess the quality of primary care of local providers: a pilot study from Italy.

Background: Outside the USA, Agency for Healthcare Research and Quality (AHRQ) prevention quality indicators (PQIs) have been used to compare the quality of primary care services only at a national or regional level. However, in several national health systems, primary care is not directly managed by the regions but is in charge of smaller territorial entities. We evaluated whether PQIs might be used to compare the performance of local providers such as Italian local health authorities (LHAs) and health districts. Methods: We analysed the hospital discharge abstracts of 44 LHAs (and 11 health districts) of five Italian regions (including ≈18 million residents) in 2008–10. Age-standardized PQI rates were computed following AHRQ specifications. Potential predictors were investigated using multilevel modelling. Results: We analysed 11 470 722 hospitalizations. The overall rates of preventable hospitalizations (composite PQI 90) were 1012, 889 and 988 (×100 000 inhabitants) in 2008, 2009 and 2010, respectively. Composite PQIs were able to differentiate LHAs and health districts and showed small variation in the performance ranking over years. Conclusion: Although further research is required, our findings support the use of composite PQIs to evaluate the performance of relatively small primary health care providers (50 000–60 000 enrollees) in countries with universal health care coverage. Achieving high precision may be crucial for a structured quality assessment system to align hospitalization rate indicators with measures of other contexts of care (cost, clinical management, satisfaction/experience) that are typically computed at a local level.

Preventable Readmissions Within 30 Days of Ischemic Stroke Among Medicare Beneficiaries

The Centers for Medicare and Medicaid Services proposes to use 30-day hospital readmissions after ischemic stroke as part of the Hospital Inpatient Quality Reporting Program for payment determination beginning in 2016. The proportion of poststroke readmissions that is potentially preventable is unknown. Thirty-day readmissions for all Medicare fee-for-service beneficiaries aged≥65 years discharged alive with a primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification 433, 434, 436) between December 2005 and November 2006 were analyzed. Preventable readmissions were identified based on 14 Prevention Quality Indicators developed for use with administrative data by the US Agency for Healthcare Research and Quality. National, hospital-level, and regional preventable readmission rates were estimated. Random-effects logistic regression was also used to determine patient-level factors associated with preventable readmissions. Among 307 887 ischemic stroke discharges, 44 379 (14.4%) were readmitted within 30 days; 5322 (1.7% of all discharges) were the result of a preventable cause (eg, pneumonia), and 39 057 (12.7%) were for other reasons (eg, cancer). In multivariate analysis, older age and cardiovascular-related comorbid conditions were strong predictors of preventable readmissions. Preventable readmission rates were highest in the Southeast, Mid-Atlantic, and US territories and lowest in the Mountain and Pacific regions. On the basis of Agency for Healthcare Research and Quality Prevention Quality Indicators, we found that a small proportion of readmissions after ischemic stroke were classified as preventable. Although other causes of readmissions not reflected in the Agency for Healthcare Research and Quality measures could also be avoidable, hospital-level programs intended to reduce all-cause readmissions and costs should target high-risk patients.

The development of quality indicators for the prevention and management of postpartum haemorrhage in primary midwifery care in the Netherlands

BackgroundAt present, there are no guidelines on prevention and management of postpartum haemorrhage in primary midwifery care in the Netherlands. The first step towards implementing guidelines is the development of a set of quality indicators for prevention and management of postpartum haemorrhage for primary midwifery supervised (home) birth in the Netherlands.MethodsA RAND modified Delphi procedure was applied. This method consists of five steps: (1) composing an expert panel (2) literature research and collection of possible quality indicators, (3) digital questionnaire, (4) consensus meeting and (5) critical evaluation. A multidisciplinary expert panel consisting of five midwives, seven obstetricians and an ambulance paramedic was assembled after applying pre-specified criteria concerning expertise in various domains relating to primary midwifery care, secondary obstetric care, emergency transportation, maternal morbidity or mortality audit, quality indicator development or clinical guidelines development and representatives of professional organisations.ResultsAfter literature review, 79 recommendations were selected for assessment by the expert panel. After a digital questionnaire to the expert panel seven indicators were added, resulting in 86 possible indicators. After excluding 41 indicators that panel members unanimously found invalid, 45 possible indicators were assessed at the consensus meeting. During critical evaluation 18 potential indicators were found to be overlapping and two were discarded due to lack of measurability.ConclusionsA set of 25 quality indicators was considered valid for testing in practice.

AHRQ Prevention Quality Indicators to assess the quality of primary care of local providers: a pilot study from Italy

AHRQ Prevention Quality Indicators to assess the quality of primary care of local providers: a pilot study from Italy

International prevalence measurement of care problems: results

This report describes the results from the last international prevalence measurement of care problems in the Netherlands, Austria and Switzerland, including the course of the prevalence rates during the past 4 years. Basic care problems such as pressure ulcers, malnutrition and falls occur frequently in healthcare organizations. Measuring these care problems provides insight into their occurrence, and, while a measurement is included of the prevention, treatment and structural quality indicators, this gives institutions the possibility of improving their care regarding these care problems. An annual cross-sectional multicentre study. The prevalence measurement of care problems is conducted annually on one specific day in different healthcare settings, among which are hospitals and care homes. Data are collected by means of a comprehensive, standardized questionnaire that comprises three levels: institutional, ward/department and patient level. Besides general characteristics of patients, results are presented for prevalence rates, prevention, treatment and quality indicators regarding each care problem for each country.

PP1 - The Impact Of Massachusetts Health Care Reform On Patient Outcomes

Key provisions of the 2006 Massachusetts health care reform and national legislation passed in 2010 were individual mandates to obtain health insurance. Increasing health insurance coverage is thought to lead to increased access to primary/preventive health care and improved patient outcomes. We examined the impact of Massachusetts health reform on preventable hospitalizations and cancers. The Healthcare Cost and Utilization Project (HCUP), National Program of Cancer Registries (NPCR), and Surveillance, Epidemiology and End Results (SEER) databases were analyzed. Based on AHRQ’s Prevention Quality Indicators, preventable hospitalizations related to diabetes, hypertension, asthma, chronic obstructive pulmonary disease, and congestive heart failure (CHF) were analyzed. In addition, we examined incidence of preventable cancers (cervical and colon). Data from 2005 were compared to 2009/2010 data; changes were examined both in Massachusetts and compared to national trends. The proportion of uninsured patients in Massachusetts decreased in 2010 compared to 2005 across all 5 categories of preventable hospitalizations. In Massachusetts, preventable discharges decreased only for diabetes and CHF. While the magnitude of decrease was greater in diabetes (-0.02% Massachusetts vs.-0.004% nationally), this trend was reversed in CHF (-0.17% vs. -0.31%). Results were similarly mixed across the remaining preventable hospital conditions. SEER data indicate that incidence of cervical and colon cancer decreased in both Massachusetts (-3.2/100,000 and -5.4/100,000 for cervical and colon cancer, respectively) and nationally (-1.2/100,000 and -3.6/100,000) from 2005-2009: the magnitude of decrease was larger in Massachusetts. Similar trends in colon cancer were found in NPCR data: incidence of colon cancer declined by 10.4/100,000 patients in Massachusetts compared with 6.9/100,000 nationally. Massachusetts health care reform has increased insurance coverage, though its impact on patient outcomes is less clear. As similar national legislation is implemented, research is needed to determine whether and how increased insurance coverage can be linked to improved patient outcomes.

Abstract 6: What Proportion of High-Cost Patients’ Inpatient Spending is Preventable?

Objective: A small proportion of patients accounts for a substantial proportion of healthcare spending in the U.S., and the majority of costs in this group are due to inpatient hospitalizations. Many interventions targeting high-cost patients have aimed to prevent hospitalizations for common medical conditions. However, there is surprisingly little data on the proportion of inpatient hospitalizations among high-cost patients that are potentially preventable. We sought to determine the proportion and dollar value of preventable hospitalizations among the high-cost Medicare population, and if these patterns differ for non-high-cost beneficiaries. Methods: We assigned standardized costs to each inpatient and outpatient service contained in standard 5% Medicare files from 2009. Patients under the age of 65, those with any Medicare Advantage enrollment, and those who died during in 2009 were excluded. Costs were summed across the year and across settings for each patient in our sample. We defined those in the top decile of cost as “high-cost” patients. We then used the Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQIs) to identify potentially preventable hospitalizations. These include conditions such as heart failure, diabetes, hypertension, and asthma, for which good outpatient care can potentially prevent the need for hospitalization. We calculated the proportion of short-stay acute-care hospital costs that were accounted for by these preventable hospitalizations for the high-cost and non-high-cost patient groups. All costs are projected to the total Medicare sample. Results: There were 1,710,989 patients in our sample. High-cost patients were older (median age 75 versus 73), more often male (43.2% versus 39.3%), and more often black (12% versus 9%) than non-high-cost patients, and had a higher burden of comorbid illnesses. Inpatient spending, projected to the total Medicare population, was $90.3 billion. The 10% of Medicare patients that made up the “high-cost” cohort accounted for 72% ($65 billion) of all inpatient spending. However, within the high-cost group, only 9.7% of the spending ($6.3 billion) was due to preventable hospitalizations, while the remaining 90.3% ($58.9 billion) was spent on other causes of hospitalization. Within the non-high-cost group, though their overall spending was lower, a slightly higher proportion of hospitalizations were potentially preventable (14.7%, or $3.7 billion). Conclusions: Though high-cost patients account for the majority of inpatient spending, fewer than one in ten of their hospitalizations are potentially preventable through better outpatient care. Thus, focusing on outpatient interventions such as case management may not be optimally targeted. We also need strategies that make hospital care more efficient so that each episode of inpatient care is less expensive regardless of its cause.

Pressure ulcer prevalence and quality of care in stroke patients in an Indonesian hospital

To explore the quality of pressure ulcer (PU) care in stroke patients in an Indonesian stroke-specialised hospital. The prevalence, prevention, wound treatment and hospital facilities related to PU structural quality indicators at the ward and institutional levels were assessed. A multi-level cross-sectional survey was performed over three days in an Indonesian stroke-specialised hospital. All stroke patients present on the day of the measurement were included. The European Pressure Ulcer Prevalence Study Minimum Data Set and the Dutch National Prevalence Measurement of Care Problems (Landelijke Prevalentiemeting Zorgproblemen, LPZ) questionnaire were used. The prevalence rates of PUs, including and excluding Category I were high in this hospital (28% and 17%, respectively). More than half of the patients/families (56%) received education about PU prevention and 74% of the patients were repositioned, although irregularly, by nurses or families. No treatment was applied to Category I PUs. Category II PUs were treated by using NaCl 0.9% solution to cleanse the wound without dressings. Category III PUs were mainly treated by using anti-microbial gauze dressing. No patient suffered a Category IV PU. Only a few structural quality indicators of PU care at ward and hospital level were met. PUs were quite prevalent in these stroke patients. The quality of PU care in this hospital could be improved, especially in the areas of prevention, treatment and structural quality indicators.

Schizophrenia and potentially preventable hospitalizations in the United States: a retrospective cross-sectional study.

BackgroundPersons with schizophrenia may face barriers to high quality primary care due to communication difficulties, cognitive impairment, lack of social support, and fragmentation of healthcare delivery services. As a result, this group may be at high risk for ambulatory care sensitive (ACS) hospitalizations, defined as hospitalizations potentially preventable by timely primary care. The goal of this study was to determine if schizophrenia is associated with overall, acute, and chronic ACS hospitalizations in the United States (US).MethodsWe conducted a retrospective cross-sectional study. Hospitalization data for the US were obtained from the Nationwide Inpatient Sample for years 2003–2008. We examined 15,275,337 medical and surgical discharges for adults aged 18–64, 182,423 of which had a secondary diagnosis of schizophrenia. ACS hospitalizations were measured using the Agency for Healthcare Research and Quality’s Prevention Quality Indicators (PQIs). We developed logistic regression models to obtain nationally-weighted odds ratios (OR) for ACS hospitalizations, comparing those with and without a secondary diagnosis of schizophrenia after adjusting for patient, hospitalization, and hospital characteristics.ResultsSchizophrenia was associated with increased odds of hospitalization for acute ACS conditions (OR = 1.34; 95% CI: 1.31, 1.38), as well as for chronic ACS conditions characterized by short-term exacerbations. Schizophrenia was associated with decreased odds of hospitalization for diabetes mellitus long-term complications and diabetes-related lower extremity amputation, conditions characterized by long-term deterioration.ConclusionsAdditional research is needed to determine which individual and health systems factors contribute to the increased odds of hospitalization for acute PQIs in schizophrenia.

Incidence, costs and outcomes of avoidable hospitalizations in a southern European country: is there room for improvement?

In healthcare, as in other areas, performance evaluation and outcomes monitoring are an ever increasing priority. This can be accomplished using quality indicators: monitoring and benchmarking tools which allow spatial and temporal comparisons. In the 1990's, following the work of John Billings and colleagues, the Agency for Healthcare Quality and Research (AHRQ), developed a set of area-level Prevention Quality Indicators (PQI), which can be calculated using readily available administrative data. PQIs are based on the concept of avoidable hospitalizations (AH): conditions for which adequate and timely primary care (PC) could have prevented or reduced the need for hospitalization (e.g. heart failure, hypertension, diabetes). We aim to apply these indicators to the Portuguese national health system (NHS), a state-financed universal coverage system, and ascertain time and regional trends and the AH financial and mortality burden.

Organizational and Environmental Correlates to Preventive Quality of Care in US Rural Health Clinics

To identify organizational and environmental correlates to rural health clinics' preventive quality of care in the United States. A retrospective observational cohort study design was applied under Donabedian's Structure-Process-Outcome framework. Three structure measures of care (proportion of nonphysicians, absence of physicians, and provider affiliation) and three measures of process (total clinical visits, prevention use for congestive heart failure and diabetes) were used as explanatory variables. Five environmental correlates were included. The Centers for Medicare and Medicaid Services National Medicare Chronic Care Condition Data Warehouse for 2007 was used to obtain clinical data. Preventive quality of care outcomes were measured through Agency for Healthcare Research and Quality prevention quality indicators. The indicators were risk adjusted for age, sex, race, severity, and comorbidity of patients. Structural equation modeling with maximum likelihood estimation was used. Provider affiliation (P = .03), absence of physicians (P = .007), and higher proportion of nonphysicians (P = .007) were negatively related to preventive quality of care. Lower cause-specific mortality rate at the county level as compared to the United States average (P = .05) and rural location (P = .001) were positively related to quality of care. The results of the study showed the need to attract and retain physicians in rural health clinics. The positive relationship between rural location and quality of care reflects more on the limited access to hospitals in remote areas.