Measuring Quality Of Care Research Articles

Patient-Centered Quality Measures for Dialysis Care: A Report of a Kidney Disease Outcomes Quality Initiative (KDOQI) Scientific Workshop Sponsored by the National Kidney Foundation

Providing high-quality patient-centered care is the central mission of dialysis facilities. Assessing quality and patient-centeredness of dialysis care is necessary for continuous dialysis facility improvement. Based predominantly on readily measured items, current quality measures in dialysis care emphasize biochemical and utilization outcomes, with very few patient-reported items. Additionally, current metrics often do not account for patient preferences and may compromise patient-centered care by limiting the ability of providers to individualize care targets, such as dialysis adequacy, based on patient priorities rather than a fixed numerical target. Developing, implementing, and maintaining a quality program using readily quantifiable data while also allowing for individualization of care targets that emphasize the goals of patients and their care partners provided the motivation for a September 2022 Kidney Disease Outcomes Quality Initiative (KDOQI) Workshop on Patient-Centered Quality Measures for Dialysis Care. Workshop participants focused on 4 questions: (1) What are the outcomes that are most important to patients and their care partners? (2) How can social determinants of health be accounted for in quality measures? (3) How can individualized care be effectively addressed in population-level quality programs? (4) What are the optimal means for collecting valid and robust patient-reported outcome data? Workshop participants identified numerous gaps within the current quality system and favored a conceptually broader, but not larger, quality system that stresses highly meaningful and adaptive measures that incorporate patient-centered principles, individual life goals, and social risk factors. Workshop participants also identified a need for new, low-burden tools to assess patient goals and priorities.

Performance measurement and user-centeredness in the healthcare sector: Opening the black box adapting the framework of Donabedian.

The framework of Donabedian is widely applied to performance assessment at the healthcare system level. Donabedian categorised the care quality measurement around three dimensions, namely structure, process, and outcomes. The first dimension concerns the inputs; the second one, the combinations of factors and inputs; the last one, the effectiveness in terms of patients' health status. Donabedian early included in the last dimension the patient satisfaction. Nevertheless, nowadays, outcomes are generally measured through hard endpoints, such as re-admissions and mortality indicators. Recently, the Patient-Reported Outcome Measures (PROMs) have been included among the outcome measures within the Donabedian framework. How to move the concept of patient-centeredness to a macro level, including the patient point of view in care quality measurement, evaluation, and improvement? This paper integrates the Donabedian structure-process-outcome framework, by incorporating in the proper dimension the patient-indicators, namely the abovementioned PROMs and Patient-Reported Experience Measures (PREMs). While PROMs are clearly measures of outcome, PREMs can be collocated in the process dimension, since they can be useful for mapping processes and care pathways, in a lean perspective, as well as in the outcome dimension, because inherently linked to outcome, and enablers of patient-centeredness.

The Updated Global Malnutrition Composite Score Clinical Quality Measure: Its Relevance to Improving Inpatient Clinical Outcomes and Health Equity

Quality improvement has existed in health care for centuries with a dramatic transformation over time, largely motivated by the academic health quality movement. Throughout this evolution, the Centers for Medicare and Medicaid Services have been at the forefront of the development and provision of quality measures for health care in a variety of settings, including acute care. Quality initiatives aid in the evaluation of patient care to encourage quality improvement efforts, determine pay-for-performance rates, and help patients and consumers evaluate their care providers. The addition of the Global Malnutrition Composite Score as an electronic Clinical Quality Measure in 2022 highlights the key role nutrition plays in outcomes and quality of hospitalized patients. With this, credentialed nutrition and dietetics practitioners lie front and center for the development of quality improvement processes to help promote high quality standards of nutrition care, improve length of stay, and reduce health care costs and readmissions while addressing malnutrition, health equity, and nutrition care as a human right. As the Global Malnutrition Composite Score steward, it is the obligation of the Academy of Nutrition and Dietetics and the Commission on Dietetic Registration to promote the measure and support credentialed nutrition and dietetics practitioners in advocating for the implementation of this measure. Therefore, the purpose of this practice update is to provide necessary information to credentialed nutrition and dietetics practitioners and other health care leaders related to the history and implementation of the Global Malnutrition Composite Score, along with relevant updates to the measure and practice implications.

Abstract 16207: Deep Learning-Based Natural Language Processing of Discharge Summaries for Automated Identification of Heart Failure With Reduced Ejection Fraction

Background: Implementation of a national program to improve guideline-directed care in heart failure with reduced ejection fraction (HFrEF) has been limited by the lack of automated tools to measure care quality. A key challenge for this approach is to identify patients with HFrEF at hospital discharge, an opportunity to evaluate and improve care. Methods: We developed a novel deep-learning language model to detect patients with HFrEF from discharge summaries using a semi-supervised learning framework. Hospitalizations with heart failure (HF) at Yale New Haven Hospital between 2015-2019 were labeled as HFrEF if left ventricular ejection fraction was under 40% on antecedent echocardiography. The model was internally validated with model-based net reclassification improvement (NRI) assessed against chart-based diagnosis codes. We externally validated the model on discharge summaries from hospitalizations with HF at Northwestern Medicine, community hospitals of Yale Health, and MIMIC-III database, confirmed with chart abstraction. Results: A total of 13,251 notes from 5,392 individuals (age 73 ± 14 years, 48% female), including 2,487 (46.1%) patients with HFrEF were used for model development (train/validation/test: 70/15/15%). The model achieved an AUROC 0.97 and AUPRC 0.97 in detecting HFrEF on the test set. In external validation, the model had high performance in identifying HFrEF with AUROC 0.91-0.95 and AUPRC 0.91-0.96 among 19,242 discharge summaries at Northwestern Medicine, 139 notes from Yale community hospitals, and 146 notes from MIMIC-III. Model predictions corresponded to an NRI of 28 ± 7% compared to chart diagnosis (p< 0.001) and identified significant gaps in the use of guideline-directed therapies (Figure). Conclusions: We developed and validated an NLP model that automates the identification of HFrEF from clinical notes with high precision and accuracy, representing a key element to automate quality-of-care measurements in HFrEF.

Quality of Care Among Emerging Adults with Sickle Cell Disease Using the Ascq-ME Qoc Measure: Baseline ST3P-up Study Data Results

ASCQ-Me ® ( Adult Sickle Cell Quality of Life Measurement Information System) is a disease specific patient-reported outcome measurement system to evaluate and track the physical, mental, and social well-being of adults living with sickle cell disease (SCD). It includes a mixed format ASCQ-Me Quality of Care (QOC) measure which aims to quantitatively, and qualitatively, understand the way adults living with SCD experience healthcare. The ASCQ-Me QOC measure follows the Donabedian's model that evaluates health services research around structure, process, and outcomes of healthcare system interactions.1 Prior and ongoing research report that adults with SCD avoid going to the emergency department (ED) for acute symptoms.2,3 Poor provider knowledge and understanding of SCD feeds a misperception as drug seeking and heightens the structural inequities and racial stigma of living with the disease.4 This is further compounded by poor adherence to acute triage guidelines, disbelief in patient reports of pain and of their usual care plan, severe delays in receiving acute care, poor provider patient communication and distrust. The Sickle Cell Trevor Thompson Transition Project (ST3P-UP), a multicenter, comparative effectiveness study of a structured education-based transition program +/- peer mentoring to improve acute care utilization for SCD ages 16-26y was conducted at 14 SCD clinical sites.5 Each site was required to engage a community-based organization (CBO) and had established community advisory boards (CABs) focused on collaborative partnerships to improve access to and experience of care. The study captured baseline and longitudinal reports of patients' experiences with health care using the ASCQ-Me QOC measure on all enrolled participants with annual rescoring as part of routine care. ST3P-UP study demographics: N=291, mean age 18.8y (SD1.5); 52% F; 96% Black; 3.6 acute care visits/yr. at baseline (range 0-31, SD4.9). Over 84% of participants reported being usually or always satisfied with the QOC when care was needed right away. Overall health care was rated between 7-10 (10 = best care possible) by 83%; 73% reported they usually or always were able to access care right away when needed while 78% usually or always waited <2h to receive treatment for their acute pain. These reports were equivalent to that reported when SCD experts care for SCD patients. QOC scores for ED care were higher than previously published and also better than anecdotal reports. Specifically, patients reported that they felt the doctors (84% of the time) and nurses (83% of the time) usually or always seemed to really care about them and that when they needed care right away, they were treated with courtesy and respect by clerks and receptionists usually or always 87% of the time. Only 11% of participants reported that providers were able to only help their pain “a little or not at all” and that providers “ did not” or “only slightly” believed their report of pain, respectively. Participants were usually or always satisfied with the care received in the ED 94.1% of the time. However, a bad experience continues to drive the decision to avoid going to the ED for care in 63% of participants. A previous report by Kanter et al cited only 51% of adults with SCD were usually or always satisfied with the ED care received and 52% indicated a bad experience in the ED led them to decide to avoid seeking care.6 These results demonstrate a surprisingly higher satisfaction with the quality, process and outcomes of ED care delivered and less discrepancy between ambulatory vs. ED care than expected compared to published and anecdotal reports. This could reflect the bias of ST3P-UP study enrollment and a younger patient population with ~25% having <1 baseline acute visits /yr. ST3P-UP sites had existing strong partnerships with providers, a local CBO and established CABs thus care may not be generalizable to the broader SCD care ecosystem. While longitudinal survey results will be important as comparison, our data highlights the value of objectively quantifying ambulatory and ED experiences soon after a visit to gain quantitative insights into these experiences. Our results do not obviate the need for subjective reports on specific experiences however both types of data can guide local and systemic improvement efforts with attention on identifying subpopulations differently affected and interventions that lower the risk for poor QOC experiences.

Has the Oncology Care Model improved quality of oncology care?

2 Background: The Oncology Care Model (OCM) was a voluntary episode-based alternative payment model designed to improve the value of care for fee-for-service Medicare beneficiaries receiving systemic therapy for cancer. Participating practices received monthly payments to support care transformation and could earn performance-based payments (or be responsible for recoupments) dependent on meeting quality and spending goals during 6-month episodes. We examined OCM impacts on quality, including measures on which performance-based payments were based and other measures of timely and effective care. Methods: We evaluated OCM impacts on care quality during 6-month episodes before (July 2014-January 2016) and after (July 2016-June 2021) OCM began using a difference-in-differences design. Patient episodes were attributed to OCM-participating practices (n=202) or propensity score-matched comparison practices (n=534). We examined 3 of the 5 quality measures used to determine OCM performance-based payments in OCM - measures that we could assess for both OCM and comparison episodes - and nine additional measures of oncology care quality endorsed by the Centers for Medicare & Medicaid Services, the National Quality Forum, the American Society of Clinical Oncology, or national guidelines. Statistical significance was defined as p<0.10 to avoid missing program impacts. Results: We studied 1,502,665 OCM and 1,662,859 comparison episodes. There was no impact of OCM on quality measures for determining performance-based payments (Table). There was no or modest impact on other measures of oncology care quality (Table). Conclusions: Both OCM and comparison groups showed improvements across quality measures, but OCM practices did not improve significantly more than the comparison practices. [Table: see text]

Implementation of EMR-integrated ovarian cancer clinical pathways.

577 Background: Adhering to National Comprehensive Cancer Network (NCCN) Guidelines correlates with higher survival in ovarian cancer and serves as a measure of care quality. Adherence to guidelines however is relatively low, routinely reported to be less than 50%. Integration of clinical pathways into the Electronic Medical Record (EMR) is a practical approach to incorporate decision-making tools in a user-friendly interface, ensuring appropriate diagnostic testing and treatment is offered to all ovarian cancer patients. Kaiser Permanente (KP) is an integrated national healthcare delivery organization caring for 12.7 million patients across the United States. Embedded clinical pathways created by KP optimize clinical decision-making and provide treatment recommendations according to established evidence-based guidelines. This report presents data on the adherence to ovarian cancer clinical pathways within KP. Methods: Beginning in January 2021 a multidisciplinary national team at KP (gynecologic and medical oncologists, pharmacists, geneticists, pathologists, and radiation oncologists) established evidence-based clinical pathways for ovarian cancer treatment which were subsequently integrated into the Epic Systems EMR. Oncologists can use the pathways to place diagnostic and treatment orders for patient care. EMR data analytics were utilized to track adherence to the consensus-defined clinical pathways among treatment orders placed for ovarian cancer within KP nationally between January 2021 and February 2023. Treatments were considered adherent for which the order was placed through the pathway; treatments for ovarian cancer indications ordered outside of the pathway interface were non-adherent. Results: Between January 2021 and February 2023, 3721 treatment plans were initiated within KP nationally for ovarian cancer, for a median 144 plans monthly. Adherence nationally to the ovarian cancer treatment pathway varied from 16% monthly at inception to 64% in early 2023 with a high of 71% in late 2022. The median pathway adherence rates per quartile were 20%, 37%, 59%, 55% in 2021, and 62%, 66%, 70%, 67% in 2022, and 64% in January through February 2023. The increases in adherence were consistent between geographic regions and indications of treatment. Conclusions: Integration of clinical pathways into the EMR is a promising means of encouraging appropriate testing and therapy for ovarian cancer. As clinicians retained the option to initiate treatment orders outside of the embedded KP pathways, our data is limited to measuring KP pathway use, not evaluating whether treatments given were concordant with NCCN Guidelines. Treatments initiated outside the pathway may still be concordant with national guidelines. Measurement of pathway adherence is useful however to describe effective diagnostic and treatment pathway implementation across a large healthcare organization to facilitate the delivery of optimal care.

Defining the denominator for measuring quality of end-of-life care in children with cancer: Results of a nominal group technique.

227 Background: National Quality Forum (NQF)-endorsed end-of-life (EOL) quality measures helped identify disparities in quality of EOL care in adults with cancer. In adults, those quality measures apply to all adults dying with cancer or those with Stage III or IV disease. Quality measures for EOL care for children with cancer were recently developed. However, identifying the denominator for EOL quality measures in children with cancer is more nuanced than in adults. Therefore, we utilized the Nominal Group Technique to determine to whom these EOL quality measures should be applied (i.e., the denominator). Methods: In a series of Nominal Groups, panelists answered the question: "Which children, diagnoses, conditions, or prognoses should be included when examining the quality of EOL care for children with cancer?" In each group, individuals first proposed answers to the group and then selected the 5 options they thought best answered the question. Five points were assigned to the statement that was the best answer, 4 the second best, etc. A team developed a framework of themes and subthemes based on the responses and coded each statement, with multiple meetings to develop consensus. Results: We conducted 5 separate Nominal Groups with a total of 44 participants. Most identified as female (88%) and Non-Hispanic White (86%). Seventy-nine percent were pediatric palliative care, pediatric oncology, pediatric critical care, or hospice clinicians, 40% researchers, and 12% bereaved parents. Responses fell into 5 themes: (1) Poor prognosis cancer (e.g. a child with a relapsed or refractory cancer); (2) Specific treatment scenarios (e.g. children who have no further curative treatment options available); (3) Certain populations (e.g. all adolescent and young adult patients); (4) Certain symptoms (e.g. respiratory depression related to brain malignancy); (5) Specific utilization scenarios (patients requiring two or more life-sustaining therapies). Poor prognosis cancer and specific treatment scenarios received the most points (320 points [49%] and 146.5 points [23%], respectively). Conclusions: Interprofessional Nominal Group participants created a framework for identifying children who should be included in EOL quality measures for children with cancer. This differs from similar work in adults in that it does not include all children with cancer or limit to patients with advanced disease. This framework will be a powerful tool for quality improvement, research, and clinical program development and is a critically important step to ensure all children with cancer receive high-quality EOL care.

Adult Congenital Heart Disease Care in Canada: Has Quality of Care Improved in the Last Decade?

BackgroundPatients with adult congenital heart disease (ACHD) are at increased risk of comorbidity and death compared with the age-matched population. Specialized care is shown to improve survival. The purpose of this study was to analyze current measures of quality of care in Canada compared with those published by our group in 2012. MethodsA survey focusing on structure and process measures of care quality in 2020 was sent to 15 ACHD centres registered with the Canadian Adult Congenital Heart Network. For each domain of quality, comparisons were made with those published in 2012. ResultsIn Canada, 36,708 patients with ACHD received specialized care between 2019 and 2020. Ninety-five cardiologists were affiliated with ACHD centres. The median number of patients per ACHD clinic was 2000 (interquartile range [IQR]: 1050, 2875). Compared with the 2012 results, this represents a 68% increase in patients with ACHD but only a 19% increase in ACHD cardiologists. Compared with 2012, all procedural volumes increased with cardiac surgeries, increasing by 12% and percutaneous intervention by 22%. Wait time for nonurgent consults and interventions all exceeded national recommendations by an average of 7 months and had increased compared with 2012 by an additional 2 months. Variability in resources were noted across provincial regions. ConclusionsOver the past 10 years, ACHD care gaps have persisted, and personnel and infrastructure have not kept pace with estimates of ACHD population growth. Strategies are needed to improve and reduce disparity in ACHD care relative to training, staffing, and access to improved care for Canadians with ACHD.

Cancer screening and socioeconomic insecurity in FQHCs: The COVID-19 pandemic and state Medicaid expansion.

112 Background: Previous studies reported improvements in multiple care quality measures, including cancer screening, in patients served in federally qualified health centers (FQHCs) located in Medicaid expansion states compared to non-expansion states. However, the COVID-19 pandemic disrupted delivery of routine primary care. Little is known about whether the COVID-19 pandemic disrupted or worsened cancer screening and socioeconomic insecurity in FQHC patients. Methods: Data on breast, cervical and colorectal cancer screening, and socioeconomic insecurity (food insecurity, financial strain, and lack of transportation to care) were obtained from the 2020 and 2021 Uniform Data System (UDS), a national report of care delivered by FQHCs. To balance clinic characteristics, the inverse probability of treatment weighting method was employed. Using a propensity score, the probability of being in a state that expanded Medicaid as of January 1, 2020, was measured. Clinics were then weighted conditional on the proportion best served in a language other than English and privately insured as well as rural location and which funding streams were received from section 330 of the Public Health Service Act. A weighted generalized estimating equation adjusted for random clustering of FQHCs within state with a Poisson distribution produced the prevalence ratios. Results: Between 2020-2021, approximately 2700 and 1300 clinics reported on cancer screening and socioeconomic insecurity. In 2020 and 2021, FQHCs in Medicaid expansion states had a higher patient screening prevalence for colorectal (2020: aPR: 1.16, 95% CI: 1.1-1.23; 2021: 1.13, 1.07-1.19) and breast (2020: 1.1, 1.05-1.17; 2021: 1.09, 1.03-1.14) cancer compared to clinics in non-Medicaid expansion states. Additionally, patient food (2021: 0.59, 0.36-0.97) and financial (2020: 0.57, 0.38-0.86; 2021: 0.58, 0.41-0.82) insecurity prevalence was lower in clinics in Medicaid expansion v. non-expansion states. Conclusions: State Medicaid expansion status was associated with higher cancer screening and lower socioeconomic insecurity within FQHCs during the COVID-19 pandemic. It remains an important policy intervention for vulnerable populations to receive care and mitigate disparities.[Table: see text]

Improving Cardiology-Rehospitalization Prediction Through the Synergy of Process Mining and Deep Learning: An Innovative Approach.

Nowadays, hospitals are facing the need for an accurate prediction of rehospitalizations. Rehospitalizations, indeed, represent both a high financial burden for the hospital and a proxy measure of care quality. The current work aims to address such a problem with an innovative approach, by building a Process Mining-Deep Learning model for the prediction of 6-months rehospitalization of patients hospitalized in a Cardiology specialty at San Raffaele Hospital, starting from their medical history contained in the Patients Hospital Records, with the double purpose of supporting resource planning and identifying at-risk patients.

Lactation Support as a Proxy Measure of Family-Centered Care Quality in Neonates with Life-Limiting Conditions-A Comparative Study.

Lactation support is an important measure of Family-Centered Care (FCC) in the Neonatal Intensive Care Unit (NICU). Life-limiting conditions (LLCs) raise complex ethical care issues for providers and parents in the NICU and represent a key and often overlooked population for whom FCC is particularly important. We investigated healthcare disparities in FCC lactation support quality in infants with LLCs. A retrospective cohort of inborn infants with or without LLCs admitted to the NICU between 2015-2023 included 395 infants with 219 LLC infants and 176 matched non-LLC infants and were compared on LLC supports. The LLC cohort experienced greater skin-to-skin support, but less lactation specialist visits, breast pumps provided, and human milk oral care use. LLC infants also experienced less maternal visitation, use of donor milk (LLC: 15.5%, non-LLC: 33.5%), and breastfeeds (LLC: 24.2%, non-LLC: 43.2%), with lower mean human milk provision (LLC: 36.6%, non-LLC: 67.1%). LLC infants who survived to discharge had similar human milk use as non-LLC infants (LLC: 49.8%, non-LLC: 50.6%). Lactation support was significantly absent for families and infants who presented with LLCs in the NICU, suggesting that policies can be altered to increase lactation support FCC quality for this population.

Improving Documentation of Impulse Control Disorders at a Movement Disorder Program During the COVID-19 Pandemic.

Impulse control disorders (ICD) are a group of behaviors in Parkinson disease (PD), (compulsive buying, gambling, binge eating, craving sweets, and hypersexuality) that occur in up to 20% of individuals with PD, sometimes with devastating results. We sought to determine the rate of ICD screening based on 2020 quality measures for PD care by the American Academy of Neurology. We conducted a quality improvement project to document and improve physician ICD screening in a tertiary movement disorder program. Serial medical records were reviewed for 5 weeks before and 13 weeks after an educational session and documentation tool deployments in 2020. Inclusion criteria included the following: idiopathic PD, PD dementia (PDD), or dementia with Lewy bodies (DLB). Individual encounters for 109 patients preintervention and 276 patients postintervention were reviewed. There was no difference between the preintervention and postintervention (pre-IG vs post-IG, respectively) in terms of age, male to female ratio, proportion of patients with PD, PDD, or DLB, duration of diagnosis, or levodopa equivalents. There was a shift to increased ICD queries above the median for the study period (28.8%) for 7 consecutive weeks in post-IG. The frequency of ICD diagnosis was not different from pre-IG to post-IG (95% confidence interval, 0-32.6 vs 2.7-13.4%, p = 0.444). ICD queries immediately after ICD education and dissemination of documentation tools increased. Both preintervention and postintervention groups were similar in demographic and clinical characteristics. This program was instituted at the height of wave 2 of the COVID-19 pandemic in Alberta during staff redeployment and 100% shift to telemedicine ambulatory care. Our results demonstrate that amid a crisis, quality improvement can still be effective with education and provision of tools for clinicians.

Impact of an Interprofessional HIV Quality Improvement Team on Patient Care and Resident Learning Opportunities.

Although human immunodeficiency virus (HIV) care is a recommended competency for family medicine training, many programs report a lack of HIV expertise among faculty. After the departure of faculty with HIV care experience, an interprofessional HIV quality improvement team (HIV-QIT) of physicians and pharmacists aimed to maintain on-site HIV care and retain learning opportunities for residents, using process improvement and panel reviews with a remote HIV specialist faculty member. This study reports on a multicycle quality improvement pilot project with pre- and postintervention chart reviews between December 2019 and May 2021. All patients received primary care and HIV-QIT chart reviews on-site. We compared patients with integrated HIV care on-site to those receiving external HIV specialty care. Primary outcomes included virologic suppression, CD4 count ≥200 cells/mm3, and adherence to guideline-recommended HIV care. In cycle 1 (January-June 2020), the HIV-QIT reviewed patient charts and sent guideline-based recommendations to physicians. In cycle 2 (July 2020-May 2021), the HIV-QIT implemented several HIV-specific processes, including decision support updates, note templates, order sets, and reference materials. Sustained process improvements included HIV panel chart audits every 3 to 6 months and subsequent provider education. Of 29 patients, more than half (55%, n=16) received integrated HIV care at the primary care site. We found no significant difference in care quality measures between primary and specialty care. Barriers to care completion included missed or canceled follow-up visits, on-site phlebotomy service closures, and declined HIV services. The HIV-QIT maintained on-site HIV treatment and retained experiential learning opportunities through process improvement and specialist-supported care recommendations to primary care physicians.

Perinatal Care Measures Are Incomplete If They Do Not Assess The Birth Parent-Infant Dyad As A Whole.

Measures of perinatal care quality and outcomes often focus on either the birth parent or the infant. We used linked vital statistics and hospital discharge data to describe a dyadic measure (including both the birth parent and the infant) for perinatal care during the birth hospitalization. In this five-state cohort of 2010-18 births, 21.6percent of birth parent-infant dyads experienced at least one complication, and 9.6percent experienced a severe complication. Severe infant complications were eight times more prevalent than severe birth parent complications. Among birth parents with a severe complication, the co-occurrence of a severe infant complication ranged from 2percent to 51percent, whereas among infants with a severe complication, the co-occurrence of a severe birth parent complication was rare, ranging from 0.04percent to 5percent. These data suggest that measures, clinical interventions, public reporting, and policies focused on either the birth parent or the infant are incomplete in their assessment of a healthy dyad. Thus, clinicians, administrators, and policy makers should evaluate dyadic measures, incentivize positive outcomes for both patients (parent and infant), and create policies that support the health of the dyad.

Improving Health Care Quality Measurement to Combat Clinician Burnout

This Viewpoint explores a critical source of administrative burden and physician frustration—the explosive growth of health care quality metrics—and how improving these metrics could combat clinician burnout.

Telemedicine and HIV Care Quality Measures During the COVID-19 Pandemic.

During the COVID-19 pandemic, telemedicine was adopted to ensure continuity of HIV care. We examined how introducing televisits affected technical quality of care for people with HIV (PWH) during this time. PWH receiving HIV care at Howard Brown Health Centers and Northwestern University in Chicago, Illinois were included. HIV care quality indicators were calculated using data extracted from electronic medical records during 4 timepoints every 6 months from March, March 1, 2020 to September 1, 2021. Generalized linear mixed models estimated differences in indicators across timepoints within each site while controlling for multiple observations of individuals. Generalized linear mixed models were also used to compare differences in outcomes among PWH who attended all versus a combination of in-person and televisits versus no televisits across the study time periods. 6447 PWH were included in the analysis. Compared with prepandemic levels, there were significant declines in care utilization and processes of care measures. Measures of HIV virologic suppression, blood pressure control, and HbA1C <7% (in both people with and without diabetes) were stable with no significant differences noted across the study timepoints. Similar trends were observed across all age, race, and sex subgroups. In multivariable models, televisits were not associated with decreased HIV viral suppression. During the COVID-19 pandemic and rapid implementation of televisits, indicators of care utilization and processes of care decreased compared with prepandemic levels. Among PWH who remained in care, televisits were not associated with worse virologic, blood pressure, and glycemic control in PWH.

The Patient-Centered Dental Home: A Framework for Quality Measurement, Improvement, and Integration.

This study completed the development of a standardized patient-centered dental home (PCDH) framework to align and integrate with the patient-centered medical home. This study identified measure concepts and specific measures and standards to complete the 4-level measurement framework to implement and evaluate a PCDH. This study built on prior model development, which identified the PCDH definition and characteristics and the components nested within those characteristics. An environmental scan identified existing oral health care quality measure concepts, measures, and standards for rating by the project's National Advisory Committee (NAC). A modified Delphi process, adapted from the RAND appropriateness method, was used to obtain structured feedback from the NAC. NAC members rated measure concepts on importance and, subsequently, specific measures and standards on feasibility, validity, and actionability using a 1 to 9 rating scale. Criteria for model inclusion were based on median ratings and rating dispersion. Open-ended comments were elicited to inform model inclusion as well as identify additional concepts. We identified more than 500 existing oral health care measures and standards. A structured process was used to identify a subset that best aligned with a PCDH for rating by the NAC. Four Delphi rounds were completed, with 2 rounds to rate measure concepts and 2 rounds to rate measures and standards. NAC quantitative ratings and qualitative comments resulted in a total of 61 measure concepts and 47 measures and standards retained for inclusion in the framework. The NAC ratings of measure concepts, and specific measures and standards nested within those concepts, completed the 4-level PCDH measurement framework. The resulting framework allows for the development and implementation of core measure sets to identify and evaluate a PCDH, facilitating quality improvement and dental-medical integration. Clinicians, payers, health care systems, and policy makers can use the results of this study to guide and assess implementation of the various components of a patient-centered dental home and to support dental-medical integration.

A small area model to assess temporal trends and sub-national disparities in healthcare quality

Monitoring subnational healthcare quality is important for identifying and addressing geographic inequities. Yet, health facility surveys are rarely powered to support the generation of estimates at more local levels. With this study, we propose an analytical approach for estimating both temporal and subnational patterns of healthcare quality indicators from health facility survey data. This method uses random effects to account for differences between survey instruments; space-time processes to leverage correlations in space and time; and covariates to incorporate auxiliary information. We applied this method for three countries in which at least four health facility surveys had been conducted since 1999 – Kenya, Senegal, and Tanzania – and estimated measures of sick-child care quality per WHO Service Availability and Readiness Assessment (SARA) guidelines at programmatic subnational level, between 1999 and 2020. Model performance metrics indicated good out-of-sample predictive validity, illustrating the potential utility of geospatial statistical models for health facility data. This method offers a way to jointly estimate indicators of healthcare quality over space and time, which could then provide insights to decision-makers and health service program managers.

Patients’ perspectives on the quality of care of a new complex psycho-oncological care programme in Germany – external mixed methods evaluation results

BackgroundGuideline-compliant provision of psycho-oncological (PO) care is still challenging in Germany. Hence, a new care programme, called integrated cross-sectoral psycho-oncology (isPO), was implemented to improve the integration of needs-oriented PO care. Quality of care (QoC) was externally evaluated from the patient’s perspective. We aim to gain insight into patients’ experiences with isPO and how their assessment affects relevant patient-reported outcomes (anxiety and depression, health status, and work ability).MethodsAn explanatory, sequential mixed-methods design was applied. Patients were surveyed twice during their 1-year care trajectory: after 3 (T1) and 12 (T2) months. Data sets were matched using pseudonyms. Care documentation data, including sociodemographic characteristics and the primary outcome variable (anxiety and depression), were matched. In the survey, patients rated their satisfaction with respective isPO service providers and the programme in general (QoC). Health status (EORTC-QLQ-C30) and work ability (WAS) were measured. Descriptive analyses and t-tests for dependent samples were conducted to assess changes in outcome variables over time. Linear regression analyses were conducted to assess whether care satisfaction predicted outcome variables. Patients who completed their isPO care trajectory were asked to participate in semi-structured telephone interviews to share their experiences. Purposeful sampling was applied. All 23 interviews were audiotaped, transcribed, and analysed via content-structuring method.ResultsPatients reported medium-to-high satisfaction with their isPO care. All patient-related outcomes significantly improved over time and QoC measures predicted those outcomes. Needs orientation (e.g., care intensity or mode of delivery) was perceived as essential for high QoC, and outpatient care with fixed contact persons as highly important for care continuity. Furthermore, patients identified programme optimisation needs, such as period of care or extension of care to relatives.ConclusionsPatients assessed the isPO programme’s QoC positively. They identified facilitators for QoC and optimisation needs. Therefore, data on QoC can function as an indicator for a programme’s feasibility and maturity within care reality. As patients’ care satisfaction positively influences important patient-related outcomes, it may be routinely considered for quality management. Based on patients’ perspectives, isPO seems to be recommendable for routine psycho-oncological care in Germany, if ongoing programme optimisation within structured quality management is guaranteed.Trial registrationThe study was registered in the German Clinical Trials Register (No. DRKS00015326) on 30.10.2018.