Patient Healthcare Quality Research Articles

Concerns of stem cell transplant patients during routine ambulatory assessment

BackgroundStem cell transplant (SCT) is a treatment choice for many hematological malignancies. There is currently a lack of evidence regarding the self-reported concerns of SCT patients before and after SCT.Aim and designThis exploratory study performed a secondary analysis of self-reported, written concerns of SCT patients before and after transplant to determine patients’ concerns.MethodsContent analysis of text box entries of SCT patients collected between 2005 and 2007 at the Seattle Cancer Care Alliance. Text box entries were collected as part of symptom assessment using the Electronic Self-Report Assessment – Cancer instrument. The assessment was presented to 137 patients undergoing SCT at two time points: prior to ambulatory visits before any therapy had begun (T1) and at the first visit after hospital discharge following SCT (T2).ResultsText box entries were made before (n = 52) and after (n = 87) the transplant, resulting in 139 text box entries made by 137 patients representing 133 concerns. Using content analysis, the entries were categorized and ranked according to frequency. After symptom concerns, patients ranked work and financial issues the most frequent concerns prior to SCT. After SCT, symptoms remained the most frequently entered area of concern, followed by survival.ConclusionOncology providers need to assess SCT patients for work and financial concerns before and after transplant. Appropriate and timely referrals may ease the burden of these concerns for patients. Thus, assessment of financial and work concerns by the oncology team should be an integral part of quality health care for patients undergoing SCT.

A New Model for Companion-Animal Primary Health Care Education

The majority of graduates from veterinary schools in the United States and Canada join companion-animal practices. In most schools, their clinical learning and client interaction experiences occurred primarily in referral teaching hospitals. These specialty hospitals play an essential role in the veterinary care continuum by providing advanced training, clinically-based research, and sophisticated diagnostics and procedures. However, they are not ideal as the principal setting for preparing veterinarians to bring value to the primary health care practices that they join. A new model for companion-animal primary health care education and service delivery has been developed at the Ontario Veterinary College, University of Guelph. The nine integrated programs, which have defined learning objectives and outcome assessments, include communication, nutrition, rehabilitation, behavior, welfare, One Health (ecosystem approach to health), preventive and general medicine, good citizenship, and research. The learning experience begins with first-year student veterinarians and takes place in a practice setting with paying clients from the community. Significantly, the students are learning in an environment that emphasizes the importance of the client experience, teamwork, and practice management while ensuring quality health care for patients. The future of companion-animal primary health care and the optimal preparation of veterinarians are critical issues for the veterinary colleges and profession. Enhanced research into new models for primary health care education and service delivery is urgently needed.

Sharing Personal Health Information Via Service-Oriented Computing: A Case of Long-Term Care

Sharing personal health information among healthcare providers is a crucial business process not only for saving limited healthcare resources but also for increasing patient's healthcare quality. Building an effective personal health information sharing process from established healthcare systems is a challenge in terms of coordination different business operations among healthcare providers and restructuring technical details existed in different healthcare information systems. This study responds this challenge with a service-oriented approach and develops a business software application to describe how the challenge can be alleviated from both managerial and technical perspectives. The software application in this study depicts personal health information sharing process among different providers in a long-term care setting. The information sharing scenario is based on an industrial initiative, such as Integrating the Healthcare Enterprise (IHE) from healthcare domain and the technologies for implementing the scenario are Web Service technologies from Service-oriented computing paradigm. The implementation in this study can inform healthcare researchers and practitioners applying technologies from service-oriented computing to design and develop healthcare collaborative systems to meet the increasing need for personal health information sharing.

State Pathology Societies and the Future of Pathology

In this time of significant change in pathology and medicine, pathology's future is uncertain. Many issues, including the emergence of molecular medicine, the demand for personalized medicine, confusing payment schemes, increasing governmental regulation, medical education challenges, administrative relationships, and new malpractice concerns, are critical topics pathologists are addressing and must continue to address in the future to best assure quality health care for patients.

Healthcare quality in systemic lupus erythematosus: using Donabedian’s conceptual framework to understand what we know

Healthcare quality improvement has the potential to reduce the striking disparities in health outcomes among patients with systemic lupus erythematosus (SLE). Donabedian's framework for assessment of healthcare quality, which divides factors impacting quality into structures, processes and outcomes, provides a theoretical framework for research and interventions in quality improvement. This review applies Donabedian's model to current research describing quality of care in SLE, highlighting structures and processes that may lead to improved outcomes. Work remains to be done to develop meaningful metrics to assess quality and to understand the structures and processes that improve outcomes. Quality indicators have emerged as an important tool to measure quality, but further validation is required to define their validity and feasibility in clinical practice, as well as their association with improved outcomes. Implementation science also shows promise as a means to create meaningful systematic improvements in healthcare quality for patients with SLE.

The role of patients in UK primary care: from the extraordinary to the essential.

Why involve patients in primary care practice, research, or policy at all? Surely the trained health professional or policy maker knows best? I believe that every GP, researcher, and policy maker works to improve the healthcare system and the quality of healthcare for patients. Working closely with patients and the public can help GPs, researchers, and policy makers to improve their work, and can also create a virtuous circle, leading to improved quality of care for patients. Traditionally, the doctor ‘took’ a history, hardly ever admitting ignorance or uncertainty and when a test was inconclusive had a tendency to imply that the lack of diagnostic certainty was somehow the patient's fault. In her 1880s diary, Alice James sums up the effect that the medical interview could have on patients: > ‘One has a greater sense of intellectual degradation after an interview with a doctor than from any human experience.’1 I fear things have not changed as much as doctors might believe. I have felt like this in the past and, in my years as a participant, volunteer, and employee of the Expert Patients Programme (EPP) it came up time and time again. Patient and public involvement (PPI) in primary care research and policy began with the changes in society of the 1960s, with mental …

The Evolution of Chest Pain Pathways

Patients presenting to the emergency department with chest pain require prompt identification and referral, as early treatment of patients with an acute coronary syndrome (ACS) is crucial to decrease morbidity and mortality (Steurer et al, Emerg Med J. 2010;27:896-902). Although rule-in ACS is critical and time dependant, other difficulties arise during the rule-out ACS process (Steurer et al, Emerg Med J. 2010;27:896-902). Inappropriate discharge of patients with misdiagnosed acute myocardial infarction is associated with significant morbidity and mortality. Concerns relating to inappropriate discharge result in readmission with resultant lengthy hospital stays, high costs, and contribute to overcrowding and bed block (Amsterdam et al, J Am Coll Cardiol. 2002;40:251-256; Cardiol Clin. 2005;23:503-516; Furtado et al, Emerg Med. In press; Karlson, Am J Cardiol. 1991;68:171-175; Ng et al, Am J Cardiol. 2001;88:611-617; Ramakrishna et al, Mayo Clin Proc. 2005;80:322-329; Stowers, Crit Pathw Cardiol. 2003;2:88-94). The challenge of chest pain diagnosis has led to a number of associated problems within the health care system. The growing need for improvements in consistency of patient care, resource efficiency, and quality of patient healthcare has led to the development of chest pain pathways (Erhardt et al, Eur Heart J. 2002;23:1153-1176). The development and implementation of chest pain pathways is not without difficulties. These may arise from differences in the management approaches of health practitioners, poor adherence to guidelines, and concerns for costs. New procedures such as new cardiac injury markers, stress testing, and specialized chest pain units have led to a reduction in admission rates and length of stay, reduced costs, and a reduction of inappropriate discharge of patients with ischemic heart disease.

Keep Special Interest Groups Out of Healthcare: Allow Direct Access to Physical Therapy

As our state and federal governments continue to search for ways to reduce growing health care costs through restructuring, we must keep in mind that one of the best methods of reducing costs and improving healthcare is free market competition. One of the largest impediments to competition, especially in healthcare, is special interest group legislation that forbids or severely inhibits competition in the healthcare industry. Michigan preventing patients from having direct access to physical therapy is a perfect example of a law that inhibits competition in the healthcare industry to shelter a politically powerful group, the physician and chiropractor lobbies. Denying patients’ direct access to physical therapy significantly increases the cost of healthcare to patients, increases the waiting time for already backlogged physicians who are facing shortages, reduces the availability of alternative healthcare options thereby reducing the general quality of healthcare for patients.

Enabling Technologies Facilitate New Healthcare Delivery Models for Acute Stroke

Delivering quality health care for patients with acute stroke in a timely and affordable fashion is a major challenge in the early 21st century. This is especially true given the shortage of qualified physicians willing and able to treat stroke. This is occurring against a backdrop whereby in the United States, the need for healthcare reform has been identified as urgent and one of the most important national agenda items that needs to be addressed. Developing alternative networks for the delivery of health care has been a stated goal in the debate on healthcare reform. There is the acknowledged need to innovate toward new healthcare models that reduce cost and yet improve quality and accessibility.1 The purpose of this letter is to outline the revolution of new technologies that are becoming available that can fundamentally change and improve how we deliver healthcare for acute stroke. More specifically, today’s communication and network technologies can be used to enable healthcare experts to deliver care remotely. Remotely enabled care allows patients the ability to access the right expertise from wherever they are, thereby improving the quality of care they can receive. Conversely, it also allows healthcare professionals the ability to provide their expertise to patients anywhere they are and at anytime and to do so more efficiently than traveling to the patient’s location. Consequently, remote care has the opportunity to significantly improve the quality care and to do so at a lower cost. Although this remotely enabled care concept applies to healthcare delivery in general, stroke is an ideal application that can lead the way to a new and improved paradigm of healthcare delivery. Stroke is ideal because it is a large societal problem both with regard to cost and quality of life for patients with stroke. Strokes are also unscheduled and …

Tendering Short-Term Pricing Policies and the Impact on Patients, Governments and the Sustainability of the Generic Medicines Industry

The provision of affordable, high-quality health care is a political priority in Europe, and expenditure on pharmaceutical products is an important component of total health-care costs. The search by governments and health insurers to reduce health-care budgets has shown the importance of generic medicines, which are acquiring greater relevance. Generic medicines signify clear long-term savings to national health-care budgets.1 In this context, generic medicines are an essential part of the equation to the sustainability of the EU health-care system. Although the short-term results and price-cutting policies are only recent additions to the retail pharmaceutical market, the latest evidence shows that tendering and similar procurement systems play a negative role in patient health-care quality, government budgets and generic medicines industry sustainability and the capacity to continue to supply affordable prices.

Responding to the Language Challenge: Kaiser Permanente's Approach

To inform current debates on improving health care quality for patients with limited English proficiency by identifying the drivers and processes for one large health care delivery system's implementation of particular models, key success factors, and remaining challenges for the field. A qualitative case study of the Kaiser Permanente (KP) San Francisco Medical Center's approach to developing linguistic access services and subsequent organizationwide initiatives. We conducted semistructured interviews with eight current and former clinical and administrative leaders from the KP San Francisco Medical Center and national headquarters. Interviews were analyzed for key themes. KP San Francisco Medical Center developed linguistic and cultural services in response to a confluence of external and internal factors, including changing demographics, care quality challenges, and patient and clinician satisfaction issues. Early strategies included development of language-specific care modules focused on Chinese- and Spanish-speaking members while meeting broader linguistic access and cultural-competency needs through a centralized Multicultural Services Center. Additional approaches across KP regions have focused on improving interpreter services, optimizing use of bilingual staff, and creating a translation infrastructure to improve quality and reduce redundancy in written translation efforts. KP's experiences developing linguistic and cultural care and services since the 1990s provide lessons about decision-making processes and approaches that may guide other health systems, insurers, and policy makers striving to improve care quality and safety for patients with limited English proficiency.

A quality indicator set for systemic lupus erythematosus

To systematically develop a quality indicator (QI) set for systemic lupus erythematosus (SLE). We used a validated process that combined available scientific evidence and expert consensus to develop a QI set for SLE. We extracted 20 candidate indicators from a systematic literature review of clinical practice guidelines pertaining to SLE. An advisory panel revised and augmented these candidate indicators and, through 2 rounds of voting, arrived at 25 QIs. These QIs advanced to the next phase of the project, in which we employed a modification of the RAND/UCLA Appropriateness Method. A systematic review of the literature was performed for each QI, linking the proposed process of care to potential improved health outcomes. After reviewing this scientific evidence, a second interdisciplinary expert panel convened to discuss the evidence and provide final ratings on the validity and feasibility of each QI. The final expert panel rated 20 QIs as both valid and feasible. Areas covered included diagnosis, general preventive strategies (e.g., vaccinations, sun avoidance counseling, and screening for cardiovascular disease), osteoporosis prevention and treatment, drug toxicity monitoring, renal disease, and reproductive health. We employed a rigorous multistep approach with systematic literature reviews and 2 expert panels to develop QIs for SLE. This new set of indicators provides an opportunity to assess health care quality in patients with SLE and represents an initial step toward the important goal of improving care in this patient population.

Neonatal hyperbilirubinemia management: a model for change

Currently, active public health surveillance of hyperbilirubinemia and kernicterus is lacking. Recently, the Hospital Corporation of America (HCA), a private health care system with an estimated quarter of a million births annually, instituted recommendations to provide universal hyperbilirubinemia screening before discharge for all infants born within their system. Over 98% of the infants born at HCA hospitals were screened within the first year of the recommendations. From May to December 2004, 13 infants were identified with total serum bilirubin (TSB) >/=30 mg per 100 ml, but that number was reduced in 2006, with only seven infants born in HCA hospitals developing a TSB of >/=30 mg per 100 ml. This program provides a model for actively monitoring the occurrence of hyperbilirubinemia and for tracking its occurrence, thus improving health care quality for patients while collecting important public health information.

Patient-Physician Language Concordance and Lifestyle Counseling Among Spanish-Speaking Patients

Patient-physician language discordance is associated with worse quality of healthcare for patients with limited English proficiency. Patients with language-discordant physicians have more problems understanding medical situations. The impact of patient-physician language concordance on lifestyle counseling among Spanish-speaking patients is not known. We performed a retrospective medical record review and identified 306 Spanish-speaking patients who used interpreter services between June 2001 and June 2006 in two Boston-based primary care practices. Our primary outcome was counseling on exercise, diet, and smoking. Our main predictor of interest was patient-physician language concordance. Patients with language-concordant physicians were more likely to be counseled on diet and physical activity compared to patients with language-discordant physicians. After adjustment for age, sex, insurance status, number of primary care visits, and comorbidity score, these differences in counseling persisted for diet [odds ratio (OR) = 2.2, CI 1.3-3.7] and physical activity (OR = 2.3, CI 1.4-3.8). There was no significant difference with regard to discussion of smoking (OR = 1.3, CI 0.8-2.1). Spanish-speaking patients are more likely to discuss diet and exercise modification if they have a Spanish-speaking physician compared to those having a non-Spanish-speaking physician. Further research is needed to explore whether matching Spanish-speaking patients with Spanish-speaking providers may improve lifestyle counseling.

¿Es posible alcanzar en la práctica clínica los objetivos de control metabólico establecidos para pacientes con diabetes mellitus tipo 1

To evaluate the quality of healthcare in patients with type 1 diabetes attended in the Endocrinology and Clinical Nutrition Unit of the Hospital Puerta del Mar in Cadiz (Spain). : The database included in the computer application HP-Doctor used for all patients attended in our unit (admissions, consultations and peripheral centers) was analyzed. All patients with a principal or secondary diagnosis of type 1 diabetes were included. The quality indicators analyzed were selected from the main clinical practice guidelines for these patients. A large cohort of patients with type 1 diabetes (n=489) followed-up from 2005 to 2007 was analyzed. During the study period, the mean glycated hemoglobin level (HbA(1c)) decreased from 7.78% to 7.36%, the percentage of patients with HbA(1c) lower than 7% increased from 24.6% to 27.1% and the percentage patients with a mean HbA(1c) of more than 8% decreased from 42.6% to 38.7%. In 2007, only 35.5% of patients maintained low-density lipoprotein concentrations of less than 100 mg/dl. Despite the improvement obtained in metabolic control parameters, most of the patients with type 1 diabetes studied showed inadequate glycemic and lipid control.

Integrating patient empowerment as an essential characteristic of the discipline of general practice/family medicine

Background: Efforts to improve the quality of healthcare for patients with chronic conditions have resulted in growing evidence supporting the inclusion of patient empowerment as a key ingredient of care. In 2002, WONCA Europe issued the European Definition of General Practice/Family Medicine, which is currently considered the point of reference for European health institutions and general medical practice. Patient empowerment does not appear among the 11 characteristics of the discipline. Objectives: The aim of this study is to show that many characteristics of general practice are already oriented towards patient empowerment. Therefore, promoting patient empowerment and self-management should be included as a characteristic of the discipline. Methods: The following investigation was conducted: analysing the concept and approach to empowerment as applied to healthcare in the literature; examining whether aspects of empowerment are already part of general medical practice; and identifying reasons why the European definition of general practice/family medicine should contain empowerment as a characteristic of the discipline. Results: General practice/family medicine is the most suitable setting for promoting patient empowerment, because many of its characteristics are already oriented towards encouraging it and because its widespread presence can ensure the generalization of empowerment promotion and self-management education to the totality of patients and communities.Conclusion: “Promoting patient empowerment and self-management” should be considered one of the essential characteristics of general practice/family medicine and should be included in its definition.

Strategies to Overcome Barriers to Effective Nurse Practitioner and Physician Collaboration

Nurse practitioners (NPs) and physicians have worked together to manage patients since the inception of the NP role in the 1960s. 1 Because the underserved and rural areas lacked primary and specialty care physicians, the NP role eventually evolved to one of a collaborating midlevel provider. 2 The integrated use of NPs and physicians together has positively affected the health care system, yet barriers to effective collaboration continue to exist, and this may lead to a reduced level of quality health care for patients. The barriers to effective collaboration between NPs and physicians are important to consider because the main goals of any NP–physician collaborative team are positive patient care outcomes.

Measuring Process of Arthritis Care: The Arthritis Foundation’s Quality Indicator Set for Rheumatoid Arthritis

To describe the scientific evidence that supports each of the explicit process measures in the Arthritis Foundation's Quality Indicator Set for Rheumatoid Arthritis. For each of the 27 measures in the Arthritis Foundation's Quality Indicator set, a comprehensive literature review was performed for evidence that linked the process of care defined in the indicator with relevant clinical outcomes and to summarize practice guidelines relevant to the indicators. Over 7500 titles were identified and reviewed. For each of the indicators the scientific evidence to support or refute the quality indicator was summarized. We found direct evidence that supported a process-outcome link for 15 of the indicators, an indirect link for 7 of the indicators, and no evidence to support or refute a link for 5. The processes of care described in the indicators for which no supporting/refuting data were found have been assumed to be so essential to care that clinical trails assessing their importance have not, and probably never will be, performed. The process of care described in all but 2 of the indicators is recommended in 1 or more practice guidelines. There are sufficient scientific evidence and expert consensus to support the Arthritis Foundation's Quality Indicator Set for Rheumatoid Arthritis, which defines a minimal standard of care that can be used to assess health care quality for patients with rheumatoid arthritis.

Hong Kong Nurses' Perceptions of and Participation in Continuing Nursing Education

As medical technologies change, practicing nurses need to update their knowledge and skills to ensure quality health care for patients and to minimize possible health hazards in the workplace. This article describes a study that explored Hong Kong hospital nurses' perceptions of and participation in continuing nursing education. It found that Hong Kong nurses participate actively in continuing education out of a sense of professional responsibility and personal interest. However, consistent with findings from other studies, the major factors hindering nurses' participation are finances, family commitments, and time.

Paper tigers—Do clinical guidelines improve health care quality in patients with testicular germ cell tumors in Germany?

In Germany, germ cell tumors are characterized by a marked excess mortality, i.e. a discrepancy between the actual mortality and the mortality expected with adequate implementation of the standard therapy. Moreover, Germany not only has a significantly increased mortality in an international comparison but also shows marked regional differences in the quality of medical care. This is partly due to difficulties in implementing the standard therapy. An attempt was made to improve the quality of medical care by setting up evidence-based diagnostic and therapeutic guidelines in 1996. Contrary to expectations, however, these guidelines have thus far remained largely ineffective, their implementation being hampered by a solely passive dissemination strategy. Added to this are inadequate medical care structures in which the guidelines cannot be properly implemented because of the organizational, social and professional context. Decisive for a quality improvement in the diagnosis, therapy and care of germ cell tumor patients is active dissemination of the guidelines supplemented by a change in the care structure. It is also important to establish indicators for measuring the success of guideline implementation and to perform continuous progress monitoring in order to specifically overcome evident barriers. Future research is required to create a better theoretical basis and to develop further strategies for guideline dissemination and implementation.