Primary Quality Measures Research Articles

Impact of Time-to-Antibiotic Delivery in Pediatric Patients With Cancer Presenting With Febrile Neutropenia.

Febrile neutropenia (FN) in pediatric patients with cancer can cause severe infections, and prompt antibiotics are warranted. Extrapolated from other populations, a time-to-antibiotic (TTA) metric of <60 minutes after medical center presentation was established, with compliance data factoring into pediatric oncology program national rankings. All FN episodes occurring at Vanderbilt Children's Hospital (2007-February 2022) and a sample of episodes from Colorado Children's Hospital (2012-2019) were abstracted, capturing TTA and clinical outcomes including major complications (intensive care unit [ICU] admission, vasopressors, intubation, or infection-related mortality). Odds ratios (ORs) were adjusted for age, treatment center, absolute neutrophil count, hypotension presence, stem-cell transplant status, and central line type. A total of 2,349 episodes were identified from Vanderbilt (1,920) and Colorado (429). Only 0.6% (n = 14) episodes required immediate ICU management, with a median TTA of 28 minutes (IQR, 20-37). For the remaining patients, the median TTA was 56 minutes (IQR, 37-90), and 54.3% received antibiotics in <60 minutes. There were no significant associations between TTA (<60 or ≥60 minutes) and major complications (adjusted OR, 0.99 [95% CI, 0.62 to 1.59]; P = .98), and a TTA ≥60 minutes was not associated with any type of complication. Similarly, TTA, when evaluated as a continuous variable, was not associated with a major (OR, 0.99 [95% CI, 0.94 to 1.04]; P = .69) nor any other complication in adjusted analysis. There is no clear evidence that a reduced TTA improves clinical outcomes in pediatric oncology FN and thus it should not be used as a primary quality measure.

Nurse-to-nurse shift handoffs on medical-surgical units: A process within the flow of nursing care.

To qualitatively investigate the medical-surgical nurse shift handoff as a process within the workflow of the exchanging nurses. Specifically, this study sought to identify the ideal handoff, ways the handoff deviated from ideal, and subsequent effect on nursing care. The functions as well as information content of the handoff have been studied. However, typical studies look at the handoff as an isolated activity utilising nurse perceptions as the primary measure of quality. Semi-structured focus groups were conducted to discuss nurses' perspectives on ideal handoffs, ways handoffs deviate from the ideal including frequent and significant deviations and the effects on subsequent care. Twenty-one medical-surgical nurses participated in one of five audio-taped focus group sessions. Three sessions were conducted at hospital A; two sessions at unaffiliated hospital B. The general inductive approach was used to analyse verbatim transcripts. Transcript segments relevant for answering the research questions were coded as ideal or not ideal. Conceptual themes were then developed. Two major themes were identified: teams/teamwork and constructing and communicating a shared understanding of the patients' conditions. The importance of nurse preparatory activities was revealed including the incoming nurses reading patients' health records and outgoing nurses rounding on patients. The impact of shared expectations was identified across the team, where teams include, in addition to the two nurses, the electronic health record, other hospital staff and patients/families with a bedside handoff. New potential nurse-centred process and outcome measures were proposed. Evaluating handoffs by their effect on the nursing performance both during and after the handoff offers a new framework to objectively assess handoff effectiveness. The handoff is a process which may significantly affect the incoming nurse's transition into and administration of nursing care.

IMPACT OF THE CMS NATIONAL PARTNERSHIP TO IMPROVE DEMENTIA CARE ON USE OF ANTIPSYCHOTICS AND OTHER PSYCHOTROPICS IN LONG-TERM CARE IN THE UNITED STATES

The Centers for Medicare and Medicaid Services (CMS) National Partnership to Improve Dementia Care in Nursing Homes (CMSNP) began in June 2012 with the stated goal of improving the standard of dementia care provided in long-term care settings. However, the primary quality measure was use of antipsychotic medications. While antipsychotic use has declined with the CMSNP, it is unclear if that is a result of increased use of non-pharmacological strategies (i.e., taking the place of antipsychotics) vs. compensatory increases in use of other psychotropic medications. We used a national 20% sample of Medicare Parts A, B, and D and identified beneficiaries in long-term care between 2008 and 2013. We determined the quarterly prevalent use of antipsychotics and other psychotropic medications (mood stabilizers, antidepressants, non-benzodiazepine [BZD] sedative-hypnotics [Medicare Part D did not cover BZD during the entire study period]). For this analysis, we compare rates of psychotropic use in the quarter before CMSNP began (April-June 2012) and the final quarter of 2013 (Oct-Dec 2013), with rates compared by Z-test. The sample included 343,981 residents of long-term care; the mean age was 77.8 years (standard deviation 13.7y). 69.4% were female; 80.2% were non-Hispanic white and 11.7% were African-American. The overall rate of antipsychotic use decreased from 20.8% to 18.7% (p<0.001). The prevalence of antidepressants and non-BZD sedative-hypnotics both decreased as well (44.3% to 43.9% and 7.8% to 6.9%, respectively; both p<0.001), while the use of mood stabilizers increased from 19.7% to 21.0% (p<0.001). While BZD were not covered by Medicare pre-CMSNP, by the end of 2013 (when Part D began to cover BZD), BZD were prescribed to 20.6% of the residents. The overall rate of non-antipsychotic psychotropic use, including the newly-covered BZD, appears to have increased from 54.8% to 58.7% (p<0.001). While the first 1.5y of CMSNP appears to have led to reductions in antipsychotic use, use of mood stabilizers, possibly as a substitute treatment for BPSD, increased. This suggests that, rather than increasing use of non-pharmacological or ecobiopsychosocial interventions to address BPSD, facilities and providers may have responded by substitution of other non-antipsychotic psychotropic medications.

Distributed fuzzy logic based energy‐aware and coverage preserving unequal clustering algorithm for wireless sensor networks

SummaryIn an energy‐constrained wireless sensor networks (WSNs), clustering is found to be an effective strategy to minimize the energy depletion of sensor nodes. In clustered WSNs, network is partitioned into set of clusters, each having a coordinator called cluster head (CH), which collects data from its cluster members and forwards it to the base station (BS) via other CHs. Clustered WSNs often suffer from the hot spot problem where CHs closer to the BS die much early because of high energy consumption contributed by the data forwarding load. Such death of nodes results coverage holes in the network very early. In most applications of WSNs, coverage preservation of the target area is a primary measure of quality of service. Considering the energy limitation of sensors, most of the clustering algorithms designed for WSNs focus on energy efficiency while ignoring the coverage requirement. In this paper, we propose a distributed clustering algorithm that uses fuzzy logic to establish a trade‐off between the energy efficiency and coverage requirement. This algorithm considers both energy and coverage parameters during cluster formation to maximize the coverage preservation of target area. Further, to deal with hot spot problem, it forms unequal sized clusters such that more CHs are available closer to BS to share the high data forwarding load. The performance of the proposed clustering algorithm is compared with some of the well‐known existing algorithms under different network scenarios. The simulation results validate the superiority of our algorithm in network lifetime, coverage preservation, and energy efficiency.

연관성 규칙 수의 추정을 위한 일반적인 비선형 회귀모형에서의 표준화 향상도 활용 방안

최근에 많이 활용되고 있는 데이터 분석을 위한 연관성 규칙 마이닝은 대용량 데이터베이스에 많이 활용되고 있는 서 두 항목간의 관계를 측도화 함으로써 두 개 이상의 항목간의 관련성을 표시하여 주는 기법이다. 연관성 규칙의 여부를 판단하기 위한 연관성 평가 기준에는 지지도, 신뢰도, 그리고 향상도 등이 있으며, 이들 세 가지 기준을 이용하여 연관성 규칙 생성 여부를 판단하게 된다. 이에 대한 기존의 연구 결과는 결정함수를 이용하는 방법과 회귀모형을 이용하는 방법으로 분류할 수 있다. 회귀모형을 이용하여 수행한 연구에는 지지도와 신뢰도에 의한 모형, 세 가지 평가 기준의 쌍에 의한 모형, 표준화 향상도를 포함한 세 가지 평가 기준의 쌍에 의한 모형, 그리고 세 가지 평가 기준 전부를 고려한 모형 등이 있다. 본 논문에서는 기존의 연구를 확장하는 의미에서 표준화 향상도를 포함한 세가지 평가 기준 전부를 고려한 비선형 회귀모형을 이용하여 연관성 규칙의 수를 추정하는 방안에 대해 강구하고자 한다. 또한 분산분석에서의 F 통계량과 수정 결정계수를 이용하여 각 모형의 유의한 정도를 비교하는 동시에 분산팽창계수에 의한 공선성 문제를 진단함으로써 가장 유용한 회귀 모형을 탐색하고자 한다. Among data mining techniques, the association rule is one of the most used in the real fields because it clearly displays the relationship between two or more items in large databases by quantifying the relationship between the items. There are three primary quality measures for association rule; support, confidence, and lift. We evaluate association rules using these measures. The approach taken in the previous literatures as to estimation of association rule number has been one of a determination function method or a regression modeling approach. In this paper, we proposed a few of non-linear regression equations useful in estimating the number of rules and also evaluated the estimated association rules using the quality measures. Furthermore we assessed their usefulness as compared to conventional regression models using the values of regression coefficients, F statistics, adjusted coefficients of determination and variation inflation factor.

Reduction in camera-specific variability in [(123)I]FP-CIT SPECT outcome measures by image reconstruction optimized for multisite settings: impact on age-dependence of the specific binding ratio in the ENC-DAT database of healthy controls.

Quantitative estimates of dopamine transporter availability, determined with [(123)I]FP-CIT SPECT, depend on the SPECT equipment, including both hardware and (reconstruction) software, which limits their use in multicentre research and clinical routine. This study tested a dedicated reconstruction algorithm for its ability to reduce camera-specific intersubject variability in [(123)I]FP-CIT SPECT. The secondary aim was to evaluate binding in whole brain (excluding striatum) as a reference for quantitative analysis. Of 73 healthy subjects from the European Normal Control Database of [(123)I]FP-CIT recruited at six centres, 70 aged between 20 and 82years were included. SPECT images were reconstructed using the QSPECT software package which provides fully automated detection of the outer contour of the head, camera-specific correction for scatter and septal penetration by transmission-dependent convolution subtraction, iterative OSEM reconstruction including attenuation correction, and camera-specific "to kBq/ml" calibration. LINK and HERMES reconstruction were used for head-to-head comparison. The specific striatal [(123)I]FP-CIT binding ratio (SBR) was computed using the Southampton method with binding in the whole brain, occipital cortex or cerebellum as the reference. The correlation between SBR and age was used as the primary quality measure. The fraction of SBR variability explained by age was highest (1) with QSPECT, independently of the reference region, and (2) with whole brain as the reference, independently of the reconstruction algorithm. QSPECT reconstruction appears to be useful for reduction of camera-specific intersubject variability of [(123)I]FP-CIT SPECT in multisite and single-site multicamera settings. Whole brain excluding striatal binding as the reference provides more stable quantitative estimates than occipital or cerebellar binding.

Public reporting of colonoscopy quality is associated with an increase in endoscopist adenoma detection rate

Colonoscopy is the predominant method for colorectal cancer screening in the United States. Previous studies have documented variation across physicians in colonoscopy quality as measured by the adenoma detection rate (ADR). ADR is the primary quality measure of colonoscopy examinations and an indicator of the likelihood of subsequent colorectal cancer. There is interest in mechanisms to improve the ADR. In Central Illinois, a local employer and a quality improvement organization partnered to publically report physician colonoscopy quality. We assessed whether this initiative was associated with an improvement in the ADR. We compared ADRs before and after public reporting at a private practice endoscopy center with 11 gastroenterologists in Peoria, Illinois, who participated in the initiative. To generate the ADR, colonoscopy and pathology reports from examinations performed over 4 years at the endoscopy center were analyzed by using previously validated natural language processing software. A central Illinois endoscopy center. The ADR in the pre-public reporting period was 34.3% and 39.2% in the post-public reporting period (an increase of 4.9%, P < .001). The increase in the right-sided ADR was 5.1% (P < .01), whereas the increase in the left-sided ADR was 2.1% (P < .05). The increase in the ADR was 7.8% for screening colonoscopies (P < 0.05) and 3.5% for nonscreening colonoscopies (P < .05). All but 1 physician's ADR increased (range -2.7% to 10.5%). There was no statistically significant change in the advanced ADR (increase of 0.8%, P = .22). There was no concurrent control group to assess whether the increased ADR was due to a secular trend. A public reporting initiative on colonoscopy quality was associated with an increase in ADR.

Adenoma Detection Rate (ADR) Strongly Correlates With Detection Rate of Sessile Serrated Adenomas (SSADR) Supporting ADR as a Primary Quality Measure for Reducing Interval Colorectal Cancers

Adenoma Detection Rate (ADR) Strongly Correlates With Detection Rate of Sessile Serrated Adenomas (SSADR) Supporting ADR as a Primary Quality Measure for Reducing Interval Colorectal Cancers

Explaining Racial Disparities in Outcomes After Cardiac Surgery

Racial disparities in mortality rates after coronary artery bypass graft (CABG) surgery are well established. We have yet to fully understand how care at high-mortality, low-quality hospitals contributes to racial disparities in surgical outcomes. To determine the effects of hospital quality on racial disparities in mortality rates after CABG surgery. The national Medicare database (2007-2008) was used to identify 173,925 patients undergoing CABG surgery in US hospitals. Our primary measure of quality was the risk-adjusted mortality rate for each hospital. Logistic regression was used to determine the relationship between race and mortality rates, accounting for patient characteristics, socioeconomic status, and hospital quality. Nonwhite patients had 33% higher risk-adjusted mortality rates after CABG surgery than white patients (odds ratio [OR], 1.33; 95% CI, 1.23-1.45). In hospitals treating the highest proportion of nonwhite patients (>17.7%), the mortality was 4.8% in nonwhite and 3.8% in white patients. When assessed independently, differences in hospital quality explained 35% of the observed disparity in mortality rates (OR, 1.22; 95% CI, 1.12-1.34). We were able to explain 53% of the observed disparity after adjusting for differences in socioeconomic status and hospital quality. However, even after these factors were taken into account, nonwhite patients had a 16% higher mortality (OR, 1.16; 95% CI, 1.05-1.27). Hospital quality contributes significantly to racial disparities in outcomes after CABG surgery. However, a significant fraction of this racial disparity remains unexplained. Efforts to decrease racial disparities in health care should focus on underperforming centers of care treating disproportionately high numbers of nonwhite patients.

A Measure to Combat “One and Done”

The adenoma detection rate (ADR) is currently the primary measure of quality of mucosal inspection during colonoscopy and has been shown to be a

확률적 흥미도를 이용한 유사성 측도의 연관성 평가 기준

연관성 규칙 기법은 대용량데이터베이스에 있는 항목들 간의 관련성을 수치화 하는 것으로 데이터 마이닝 기법 중에서는 가장 많이 활용되고 있다. 연관성 규칙을 탐사하기 위한 연관성 규칙 평가 기준에는 지지도, 신뢰도, 향상도 등이 있다. 이들 중에서 가장 중심이 되는 신뢰도는 비대칭적 측도일 뿐만 아니라 항상 양의 값만을 취하고 있어서 항목 간에 연관성 규칙을 생성하는 데 여러가지 문제가 존재한다. 이러한 문제를 해결하기 위해 본 논문에서는 확률적 흥미도 측도 기반, 특히 주변 비율을 고려하지 않은 유사성 측도를 연관성 평가 기준으로 적용하는 방안에 대해 연구하였다. 예제에 의한 비교를 통하여 Yule과 Michael의 유사성 계수와 Pearson의 파이 계수는 신뢰도와 동일하게 연관성의 정도를 파악할 수 있는 동시에 부호를 포함하고 있어서 연관성의 방향도 알 수 있었으나, 카이 제곱 통계량 기반 측도들은 항상 양의 값만 나타날 뿐만 아니라 신뢰도와는 변화하는 양상이 다르다는 것을 확인할 수 있었다. Association rule mining is the method to quantify the relationship between each set of items in a large database. One of the well-studied problems in data mining is exploration for association rules. There are three primary quality measures for association rule, support and confidence and lift. We generate some association rules using confidence. Confidence is the most important measure of these measures, but it is an asymmetric measure and has only positive value. Thus we can face with difficult problems in generation of association rules. In this paper we apply the similarity measures by probabilistic interestingness measure to find a solution to this problem. The comparative studies with support, two confidences, lift, and some similarity measures by probabilistic interestingness measure are shown by numerical example. As the result, we knew that the similarity measures by probabilistic interestingness measure could be seen the degree of association same as confidence. And we could confirm the direction of association because they had the sign of their values.

Explaining racial disparities in mortality after abdominal aortic aneurysm repair

Black patients have a higher mortality rate than nonblacks after abdominal aortic aneurysm repair. We sought to understand the factors responsible for this racial disparity in the mortality rate after aneurysm repair. The Medicare database (2001-2006) was used to identify 160,785 patients undergoing open and endovascular abdominal aortic aneurysm repairs. We used risk-adjusted mortality as our primary measure of quality and logistic regression to determine the relationship between race and mortality, sequentially adding contributing factors including patient characteristics, the type of repair (endovascular vs open repair), socioeconomic status, and hospital quality. From these sequential regression models, we estimated the proportion of the disparity that can be explained by each factor. Black patients had a 36% higher risk-adjusted mortality after aneurysm repair than nonblack patients (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.20-1.53). Even after accounting for the type of repair, a significant difference in mortality remained (OR, 1.33; 95% CI, 1.18-1.50). Mortality rates were higher in hospitals treating a higher proportion of black patients. Adjusting for these differences in hospital quality, this disparity was no longer significant (OR, 1.07; 95% CI, 0.93-1.25). We estimate that 29% of the observed disparity in mortality is caused by patient comorbidities, 6% from the use of endovascular repairs, 26% due to socioeconomic factors, and 25% because black patients receive care in lower-quality hospitals. Although many factors contribute, a large proportion of observed disparities in outcomes are attributable to black patients receiving care in lower-quality hospitals. Efforts aimed at improving disparities must focus on improved access to high-quality hospitals and improved resources at the hospitals that treat higher proportions of black patients.

How Do SLPs Improve Outcomes in Adults in Home Care?

Home care agencies that have not employed speech—language pathologists (SLPs) may not be aware of their potential to advance other rehab and nursing goals for patients with communication, swallowing, and cognitive impairments. This article provides an overview of the professional requirements and scope of speech—language pathology practice. Quality reporting in health care and various organizations engaged in performance measurement are described. The American Speech-Language-Hearing Association’s National Outcomes Measurement System has developed specific outcomes measures to track SLP intervention. Case studies illustrate how speech—language pathology services can enhance the effectiveness of other rehabilitation services and have an impact on hospital readmission, a primary quality measure in home care.

On the need for a process for making reliable quality comparisons with industrial data

Many factors influence quality data obtained from industrial case studies making comparisons difficult. In this paper, two longitudinal industrial case study experiences are shared which illustrate the complications that can arise. The first is a case study of an IBM team that transitioned to the use of test-driven development. The primary quality measure was functional verification test defects normalized by lines of code. The second case study was performed with an Extreme Programming team at Sabre Airline Solutions. Both test defects and field defects were compared. In both case studies, differences existed which made the comparisons indicative but not absolute.

Accountable Welfare Reform: What Consumers Think

In the wave of organizational change that is now sweeping the public sector, there is considerable focus on the need to define performance standards, ensure quality of care, and guarantee efficient, effective service delivery (Dilulio, Garvey, and Kettl, 1993; Osborne and Plastrik, 1997). One area of public service currently undergoing significant change is the public welfare system. In the wake of the 1996 Personal Responsibility Act, public welfare programs are facing their greatest change since the program's inception. Although the majority of these changes have focused on limiting client benefits, imposing sanctions, and addressing linkages between welfare and work, there is general understanding that the mission of the public welfare system is different. This change in mission provides an opportunity for the public welfare system to revitalize its current service, redesign its procedures, and expand on its outcomes evaluation. Critical work will be needed to develop performance standards and quality service indicators to guide such efforts. This article argues and demonstrates that we can develop these service standards and measures for the new public welfare system by listening to recipients as consumers of service. Literature Review Demands for more efficient operations have resulted in the public sector's use of private market concepts (Osborne and Gaebler, 1992; Osborne and Plastrik, 1997). Instituting such processes as re-engineering, performance-based budgeting, and consumer-driven service is posited to improve public sector performance (Kettl and Dilulio, 1995; Kettl and Milward, 1996). The introduction of consumer satisfaction as a measure of service quality and the implementation of continuous improvement processes in the public sector have begun in earnest (Myers and Lacey, 1996), while evidence for links between satisfaction and service outcome is being explored (Halachmi and Bockaert, 1996). As public sector agencies are pushed toward management for performance and results, attention to consumer satisfaction may improve service quality and assist in maintaining citizen confidence in these organizations. There are many reasons why consumer satisfaction should be considered as a primary measure of quality. In particular, there is growing evidence from the health care field that treatment outcomes are positively correlated with patient satisfaction. Several studies have documented the negative impact of patient dissatisfaction on health care. Dissatisfied patients are less likely to keep scheduled appointments, to follow medical regimens and instructions, or to take medication as prescribed (Linn, Linn, and Stein, 1982; Ware and Davies, 1983; Weiss, 1988; Zimmerman, 1988). They are more likely to avoid routine visits and, when they do seek care, it may require more costly treatment (Mechanic, 1980). Patients who like their doctor and are satisfied with their health care organization are less likely to switch physicians or to disenroll from plans (Hsieh and Kagle, 1991; Ware and Davies, 1983). There is a strong economic incentive to minimize patient behavior that results in changing providers, delaying healthcare helpseeking, and decreasing medical noncompliance. Enhancing patient satisfaction can serve as a strategy for improving health behavior, marketing services, and controlling costs. Recent social marketing literature suggest that one critical way to improve social welfare services is attention to consumer satisfaction (Andreasen, 1995). Re-engineering in the public sector should target customer service and consumer-focused organizations in its efforts to improve performance (Halachmi and Bockaert, 1996). Consumers and public sector employees working in tandem, instead of cross-purposes, might minimize missed appointments, dissatisfaction with workers, and noncooperation with short- and long-term goals. Both groups could contribute to improved organizational performance. …