Process-based Quality Indicators Research Articles

Associations between Family Satisfaction with End-of-Life Care and Chart-Derived, Process-Based Quality Indicators in Intensive Care Units.

Background/Objective: Evidence linking process-based, high-quality end-of-life (EOL) care indicators to family satisfaction with EOL care in intensive care units (ICUs) remains limited. This study aimed to fill this gap. Design/Setting/Subjects/Measures/Statistical Analysis: For this exploratory, prospective, longitudinal observational study, 278 family members were consecutively recruited from medical ICUs at two medical centers in Taiwan. Family satisfaction with ICU care was surveyed in the first month after patient death using the Family Satisfaction in the ICU questionnaire (FS-ICU). Associations between FS-ICU scores and process-based quality indicators collected over the patient's ICU stay were examined using generalized estimating equations. Results: Documentation of process-based indicators of high-quality EOL care was generally associated with higher scores for both the FS-ICU Care and FS-ICU Decision-Making domains. Higher family satisfaction with ICU care was significantly associated with physician-family prognostic communication (β [95% confidence interval (CI)]: 3.558 [2.963 to 4.154]), a do-not-resuscitate (DNR) order in place at death (23.095 [17.410 to 28.779]), and death without cardiopulmonary resuscitation (CPR) (13.325 [11.685 to 14.965]). Family members' satisfaction with decision making was positively associated with documentation of social worker involvement (4.767 [0.663 to 8.872]), a DNR order issued (10.499 [0.223 to 20.776]), and withdrawal of life-sustaining treatments (LSTs) before death (2.252 [1.834 to 2.670]). Conclusions: EOL care processes are associated with family satisfaction with EOL care in ICUs. Bereaved family members' satisfaction with EOL care in ICUs may be improved by promoting physician-family prognostic communication and psychosocial support, facilitating a DNR order and death without CPR, and withdrawing LSTs for patients dying in ICUs.

Surveillance for Outcomes Selected as Atrial Fibrillation Quality Indicators in Canada: 10-Year Trends in Stroke, Major Bleeding, and Heart Failure

BackgroundWhether advances in identification and management of atrial fibrillation and atrial flutter (collectively, AF) have led to improved outcomes is unclear. We sought to study trends in clinical outcomes selected as quality indicators for nonvalvular AF in Canada. MethodsWe identified hospitalized patients with a first diagnosis of nonvalvular AF between April 2006 and March 2015, in all of Canada except Quebec. We assessed trends in 1-year incidence of stroke/systemic embolism (SSE), major bleeding, and initial heart failure (HF) hospitalization. ResultsThe cohort included 466,476 patients. The median age was 77 years (interquartile range, 68-84 years), 46% were female, and 68% had a Congestive Heart Failure, Hypertension, Age (≥75 years), Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age (65-74 years), Sex (Female) (CHA2DS2-VASc) score > 3. Within 1 year of discharge, 3.5% were hospitalized for stroke or SSE, 1.6% for major bleeding, and 8.6% for new HF. Over the study period, the crude rate of SSE declined from 3.6% to 3.3% (P = 0.002), whereas the rates of hospitalization for new HF and for major bleeding did not significantly change. After adjustment for CHA2DS2-VASc score, the yearly rates of incident SSE (risk ratio, 0.99; 95% confidence interval [CI], 0.98-0.99; P = 0.002) and HF (risk ratio, 0.99; 95% CI, 0.99-1.00; P = 0.001) declined ≤ 1% absolute, whereas major bleeding remained unchanged (risk ratio, 1.00; 95% CI, 0.99-1.00; P = 0.28). ConclusionsAmong hospitalized patients with nonvalvular AF in Canada, the rate of SSE and new HF decreased modestly over a 10-year period, with no significant change in major bleeding. Efforts to study process-based quality indicators, with increased focus on HF prevention, are needed.

Quality improvement in healthcare for patients with inflammatory bowel disease.

Since inflammatory bowel diseases (IBD) are chronic disorders with typical remission and relapses and no cure, maintaining high quality of provided healthcare to patients with IBD plays a major role in the management and reducing disease-related morbidity. To hone process-based quality indicators in order to ameliorate quality of care, the indicators must be based on high quality evidence and expert consensus. ImproveCareNow (ICN) group gave us a great example of quality improvement (QI) by gaining experience in how to exercise, apply and implement QI methods in the care of children with IBD. "The American Gastroenterological Association" has developed an adult "IBD physician performance measures set" and both "Crohn's and Colitis Foundation of America" (CCFA) and "Crohn's and Colitis Canada" (CCC) have developed sets of most highly rated process and outcome measures. "The Emerging Practice in IBD Collaborative (EPIC) Canadian group" developed definitions of quality indicators for best-practice management of IBD in Canada. "Quality of Care through the Patient's Eyes (QUOTE-IBD)" was honed as a questionnaire to quantify quality of care in the eyes of patients with IBD. This is now widely used in several European countries. The current concepts of quality of care as well as quality indicators will be discussed in this article.

Do public nursing home care providers deliver higher quality than private providers? Evidence from Sweden

BackgroundSwedish nursing home care has undergone a transformation, where the previous virtual public monopoly on providing such services has been replaced by a system of mixed provision. This has led to a rapidly growing share of private actors, the majority of which are large, for-profit firms. In the wake of this development, concerns have been voiced regarding the implications for care quality. In this article, we investigate the relationship between ownership and care quality in nursing homes for the elderly by comparing quality levels between public, for-profit, and non-profit nursing home care providers. We also look at a special category of for-profit providers; private equity companies.MethodsThe source of data is a national survey conducted by the Swedish National Board of Health and Welfare in 2011 at 2710 nursing homes. Data from 14 quality indicators are analyzed, including structure and process measures such as staff levels, staff competence, resident participation, and screening for pressure ulcers, nutrition status, and risk of falling. The main statistical method employed is multiple OLS regression analysis. We differentiate in the analysis between structural and processual quality measures.ResultsThe results indicate that public nursing homes have higher quality than privately operated homes with regard to two structural quality measures: staffing levels and individual accommodation. Privately operated nursing homes, on the other hand, tend to score higher on process-based quality indicators such as medication review and screening for falls and malnutrition. No significant differences were found between different ownership categories of privately operated nursing homes.ConclusionsOwnership does appear to be related to quality outcomes in Swedish nursing home care, but the results are mixed and inconclusive. That staffing levels, which has been regarded as a key quality indicator in previous research, are higher in publicly operated homes than private is consistent with earlier findings. The fact that privately operated homes, including those operated by for-profit companies, had higher processual quality is more unexpected, given previous research. Finally, no significant quality differences were found between private ownership types, i.e. for-profit, non-profit, and private equity companies, which indicates that profit motives are less important for determining quality in Swedish nursing home care than in other countries where similar studies have been carried out.

Association Between Process-Based Quality Indicators and Mortality for Patients With Substance Use Disorders.

Substance use disorders (SUDs) are associated with elevated rates of mortality. Little is known about whether receiving appropriate care is associated with lower mortality for patients with SUDs. This study examined the association between the receipt of care for SUDs and subsequent 12- and 24-month mortality. This was a retrospective cohort study of veterans who received care for SUDs paid for by the Veterans Health Administration during October 2006- September 2007 (n = 339,966). Logistic regressions were used to examine the association between quality indicators measuring receipt of care and mortality while controlling for patient characteristics and facility service area. There were four quality indicators: SUD treatment initiation, SUD treatment engagement, SUD-related psychosocial treatment, and SUD-related psychotherapy. Outcomes measured were mortality 12 and 24 months after the end of the observation period, through September 2009. Receipt of indicated care ranged from 26.5% to 58.6%, and 12- and 24-month mortality rates were 3% and 6%, respectively. Adjusted odds ratios [95% CI] of 12-month mortality by indicator were: initiation, 0.86 [0.79, 0.93]; engagement, 0.65 [0.58, 0.74]; psychosocial treatment, 0.88 [0.84, 0.92]; and psychotherapy, 0.84 [0.79, 0.89]. For the 24-month mortality outcome, adjusted odds ratios were: initiation, 0.88 [0.84, 0.93]; engagement, 0.78 [0.71, 0.85]; psychosocial treatment, 0.91 [0.88, 0.94]; and psychotherapy, 0.87 [0.83, 0.91]. Results were similar when controlling for facility service area. Receiving appropriate care is associated with lower mortality for patients with SUDs. Significant overall and within-facility service area associations of quality indicators and mortality support their use in encouraging providers to deliver the indicated care. These indicators should be prioritized above others lacking comparably strong process-outcome associations.

Are Quality Indicators associated with Postoperative Outcomes after Resection for Pancreatic Adenocarcinoma?

Introduction: Although quality of care has become a central aspect of modern medicine, a definite relationship between quality indicators (QIs) and outcomes has not been fully established in patients with pancreatic cancer (PC). The primary aim of this study was to examine the possible association of established process-based QIs with short and long term outcomes in patients undergoing PC resection. Methods: All adult patients undergoing resection for PC in Nova Scotia between 2001 and 2011 were included in a retrospective cohort study. Logistic and Cox model regression analyses were used to test the hypothesis that meeting selected QIs was associated with improved perioperative morbidity, mortality and overall survival. Results: Pancreaticoduoedenectomy was performed in 82 (87%) patients and distal pancreatectomy in 12 patients (13%). Multivariable analysis adjusting for patient and tumour characteristics showed that only preoperative radiological staging obtained within 8 weeks from the date of surgery was associated with better survival (HR for death=0.34, 95% CI=0.14-0.84). Other QIs failed to show any association with perioperative morbidity and mortality and overall survival. Conclusions: With the exception of preoperative staging within the recommended time interval, meeting QIs was not associated with improved short and long term outcome in resected PC patients.

Association between quality of care and complications after abdominal surgery

Measuring the quality of surgical care is essential to identifying areas of weakness in the delivery of effective surgical care and to improving patient outcomes. Our objectives were to (1) assess the quality of surgical care delivered to adult patients; and (2) determine the association between quality of surgical care and postoperative complications. This retrospective, pilot, cohort study was conducted at a single university-affiliated institution. Using the institution's National Surgical Quality Improvement Program database (2009-2010), 273 consecutive patients ≥18years of age who underwent elective major abdominal operations were selected. Adherence to 10 process-based quality indicators (QIs) was measured and quantified by calculating a patient quality score (no. of QIs passed/no. of QIs eligible). A pass rate for each individual QI was also calculated. The association between quality of surgical care and postoperative complications was assessed using an incidence rate ratio, which was estimated from a Poisson regression. The mean overall patient quality score was 67.2±14.4% (range, 25-100%). The mean QI pass rate was 65.9±26.1%, which varied widely from 9.6% (oral intake documentation) to 95.6% (prophylactic antibiotics). Poisson regression revealed that as the quality score increased, the incidence of postoperative complications decreased (incidence rate ratio, 0.19; P=.011). A sensitivity analysis revealed that this association was likely driven by the postoperative ambulation QI. Higher quality scores, mainly driven by early ambulation, were associated with fewer postoperative complications. QIs with unacceptably low adherence were identified as targets for future quality improvement initiatives.

Identification of Quality of Care Deficiencies in Elderly Surgical Patients by Measuring Adherence to Process-Based Quality Indicators

The ability to measure surgical quality of care is important and can lead to improvements in patient safety. As such, processes should be carried out in an identical fashion for all patients, regardless of how vulnerable or complex they are. Our objectives were to assess quality of surgical care delivered to elderly patients and to determine the association between patient characteristics and quality of care. This is a retrospective pilot cohort study, conducted in a single university-affiliated hospital. Using the institution's National Surgical Quality Improvement Program (NSQIP) database (2009 to 2010), 143 consecutive patients 65 years or older, undergoing elective major abdominal surgery, were selected. Adherence to 15 process-based quality indicators (QIs) was measured, and a pass rate was calculated for each individual QI. The association between patient characteristics (age, sex, Charlson Comorbidity Index, functional status, wound class) and patient quality score was assessed using multiple linear regression. Quality indicators with the lowest pass rates included postoperative delirium screening (0%), level of care documentation (0.7%), cognition and functional assessment at discharge (4.9%), oral intake documentation (12.6%), and pressure ulcer risk assessment (35.0%). The mean patient quality score was 46.8% ± 10.7% (range 16.7% to 75.0%). No association was found between patient characteristics and patient quality score. Quality of care delivered to elderly patients undergoing major surgery at our institution was generally poor and independent of patient characteristics. Although quality appears to be uniform across different patients, these results provide targets for quality improvement initiatives.

Assessing the association between adherence to process-based quality indicators and surgical outcomes

Hamadani, Fadi BSc(Hons), MD; Bergman, Simon MD, MS, FRCSC, FACS; Deban, Melina BS; Martelli, Vanessa BS; Holcroft, Christina ScD; Sourial, Nadia MS; Monette, Michele MS; Zakrzewski, Helena BSc(Hons); Fraser, Shannon MD, MSc, FRCSC, FACS Author Information

Developing Quality Indicators for Elderly Surgical Patients

To develop process-based quality indicators to improve perioperative care for elderly surgical patients. The population is aging and expanding, and physicians must continue to optimize elderly surgical care to meet the anticipated increase in surgical services. We sought to develop process-based quality indicators applicable to virtually all disciplines of surgery to identify necessary and meaningful ways to improve surgical care and outcomes in the elderly. We identified candidate perioperative quality indicators for elderly patients undergoing ambulatory, or major elective or nonelective inpatient surgery through structured interviews with thought leaders and systematic reviews of the literature. An expert panel of physicians in surgery, geriatrics, anesthesia, critical care, internal, and rehabilitation medicine formally rated the indicators using a modification of the RAND/UCLA Appropriateness Methodology. Ninety-one of 96 candidate indicators were rated as valid. They were categorized into 8 domains: comorbidity assessment, elderly issues, medication use, patient-provider discussions, intraoperative care, postoperative management, discharge planning, and ambulatory surgery. Of note, 71 (78%) of the indicators rated as valid address processes of care not routinely performed in younger surgical populations. Attention to the quality of care in elderly patients is of great importance due to the increasing numbers of elderly undergoing surgery. This project used a validated methodology to identify and rate process measures to achieve high quality perioperative care for elderly surgical patients.

The Quality of Obstructive Lung Disease Care for Adults in the United States as Measured by Adherence to Recommended Processes

The extent to which patients with obstructive lung disease receive recommended processes of care is largely unknown. We assessed the quality of care delivered to a national sample of the US population. We extracted medical records for 2 prior years from consenting participants in a random telephone survey in 12 communities and measured the quality of care provided with 45 explicit, process-based quality indicators for asthma and COPD developed using the modified Delphi expert panel methodology. Multivariate logistic regression evaluated effects of patient demographics, insurance, and other characteristics on the quality of health care. We identified 2,394 care events among 260 asthma participants and 1,664 events among 169 COPD participants. Overall, participants received 55.2% of recommended care for obstructive lung disease. Asthma patients received 53.5% of recommended care; routine management was better (66.9%) than exacerbation care (47.8%). COPD patients received 58.0% of recommended care but received better exacerbation care (60.4%) than routine care (46.1%). Variation was seen in mode of care with considerable deficits in documenting recommended aspects of medical history (41.4%) and use of diagnostic studies (40.1%). Modeling demonstrated modest variation between racial groups, geographic areas, insurance types, and other characteristics. Americans with obstructive lung disease received only 55% of recommended care. The deficits and variability in the quality of care for obstructive lung disease present ample opportunity for quality improvement. Future endeavors should assess reasons for low adherence to recommended processes of care and assess barriers in delivery of care.

Developing Quality Indicators for Elderly Patients Undergoing Abdominal Operations

Although the expanding and aging population will likely increase demand for surgical services, surgeons and other providers must develop strategies to optimize care. We sought to develop process-based quality indicators for elderly patients undergoing abdominal operations to identify necessary and meaningful ways to improve care in this cohort. Through structured interviews with thought leaders and systematic reviews of the literature, we identified candidate quality indicators addressing perioperative care in elderly patients undergoing abdominal operations. Using a modification of the RAND/UCLA Appropriateness Methodology, an expert panel of physicians in surgery, geriatrics, anesthesia, internal, and rehabilitation medicine formally rated and discussed the indicators. Eighty-nine candidate indicators were identified and categorized into seven domains: comorbidity assessment (eg, cardiopulmonary disease), elderly issues (eg, cognition), medication use (eg, polypharmacy), patient-to-provider discussions (eg, life-sustaining preferences), intraoperative care (eg, preventing hypothermia), postoperative management (eg, preventing delirium), and discharge planning (eg, home health care). Of the 89 candidate indicators, 76 were rated as valid by the expert panel. Importantly, the majority of indicators rated as valid address processes of care not routinely performed in younger surgical populations. Attention to the quality of surgical care in elderly patients is of great importance because of the increasing numbers of elderly undergoing operations. This project used a validated methodology to identify and rate process measures to achieve high-quality perioperative care for elderly surgical patients. This is the first time quality indicators have been developed in this regard.

Licensing Reliable Embedded Software for Safety-Critical Applications

This article offers an overview on existing approaches for assessing the reliability of complex software with safety demands. It addresses both inherent difficulties as well as observable trends towards international standardized procedures. The contribution distinguishes between product-based and process-based quality indicators and comments on the applicability of existing techniques to evaluate them qualitatively and quantitatively. In particular, it focusses on licensing the re-use of pre-developed software components. In the light of lessons learnt from real-world accidents it proposes to adopt a procedure supporting the re-usability of component certification when licensing software systems for new safety applications.