Measuring Quality Of Care Research Articles

Pediatric Rheumatology Care and Outcomes Improvement Network's Quality Measure Set to Improve Care of Children With Juvenile Idiopathic Arthritis.

To describe the selection, development, and implementation of quality measures (QMs) for juvenile idiopathic arthritis (JIA) by the Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), a multihospital learning health network using quality improvement methods and leveraging QMs to drive improved outcomes across a JIA population since 2011. An American College of Rheumatology-endorsed multistakeholder process previously selected initial process QMs. Clinicians in PR-COIN and parents of children with JIA collaboratively selected outcome QMs. A committee of rheumatologists and data analysts developed operational definitions. QMs were programmed and validated using patient data. Measures are populated by registry data, and performance is displayed on automated statistical process control charts. PR-COIN centers use rapid-cycle quality improvement approaches to improve performance metrics. The QMs are revised for usefulness, to reflect best practices, and to support network initiatives. The initial QM set included 13 process measures concerning standardized measurement of disease activity, collection of patient-reported outcome assessments, and clinical performance measures. Initial outcome measures were clinical inactive disease, low pain score, and optimal physical functioning. The revised QM set has 20 measures and includes additional measures of disease activity, data quality, and a balancing measure. PR-COIN has developed and tested JIA QMs to assess clinical performance and patient outcomes. The implementation of robust QMs is important to improve quality of care. PR-COIN's set of JIA QMs is the first comprehensive set of QMs used at the point-of-care for a large cohort of JIA patients in a variety of pediatric rheumatology practice settings.

Development and Description of a National Cohort of Patients With Chronic Limb-Threatening Ischemia.

Chronic limb-threatening ischemia (CLTI) is a common condition with high rates of morbidity and mortality. Despite extensive literature documenting poor outcomes in patients with CLTI, as well as racial, ethnic, socioeconomic, and geographic disparities in these outcomes, process measures for high-quality CLTI care have not been developed. We developed the Chronic Limb threatening Ischemia Process PERformace (CLIPPER) cohort to develop and test the validity of CLTI care quality measures. Using inpatient and outpatient claims data from patients with fee-for-service Medicare from 2010 to 2019, we created a coding algorithm to identify patients with CLTI. To qualify for a CLTI diagnosis, patients had to have either diagnostic codes for peripheral artery disease and for ulceration, infection, or gangrene on the same inpatient or outpatient claim or a CLTI-specific diagnostic code. Patients were also required to have a procedural code indicating arterial vascular testing within 6 months before or after the earliest qualifying CLTI diagnostic code(s). We describe baseline characteristics and long-term outcomes of this cohort. The final cohort comprised 1,130,065 patients diagnosed with CLTI between 2010 and 2019. Mean (±SD) age of the cohort was 75 ± 5.8 years; 48.4% were women, and 14.6% were Black. Within 30 days of CLTI diagnosis, 20.4% of patients underwent either percutaneous or surgical revascularization. Within 6 months, 3.3% of patients underwent major amputation; 16.7% of patients died within 1 year and 50.3% within 5 years. We described the development of a cohort of fee-for-service Medicare patients with CLTI using inpatient and outpatient Medicare claims data. CLIPPER will be a resource for developing a set of process measures that can be captured from administrative claims data, with plans to describe their association with limb outcomes and corresponding racial, ethnic, socioeconomic, sex-based, and geographic variability.

Development of American College of Rheumatology Quality Measures for Systemic Lupus Erythematosus: A Modified Delphi Process With Rheumatology Informatics System for Effectiveness (RISE) Registry Data Review.

We aimed to develop readily measurable digital quality measure statements for clinical care in systemic lupus erythematosus (SLE) using a multistep process guided by consensus methods. Using a modified Delphi process, an American College of Rheumatology (ACR) workgroup of SLE experts reviewed all North American and European guidelines from 2000 to 2020 on treatment, monitoring, and phenotyping of patients with lupus. Workgroup members extracted quality constructs from guidelines, rated these by importance and feasibility, and generated evidence-based quality measure statements. The ACR Rheumatology Informatics System for Effectiveness (RISE) Registry was queried for measurement data availability. In 3 consecutive Delphi sessions, a multidisciplinary Delphi panel voted on the importance and feasibility of each statement. Proposed measures with consensus on feasibility and importance were ranked to identify the top 3 measures. Review of guidelines and distillation of 57 quality constructs resulted in 15 quality measure statements. Among these, 5 met high consensus for importance and feasibility, including 2 on treatment and 3 on laboratory monitoring measures. The 3 highest-ranked statements were recommended for further measure specification as SLE digital quality measures: 1) hydroxychloroquine use, 2) limiting glucocorticoid use >7.5 mg/day to <6 months, and 3) end-organ monitoring of kidney function and urine protein excretion at least every 6 months. The Delphi process selected 3 quality measures for SLE care on hydroxychloroquine, glucocorticoid reduction, and kidney monitoring. Next, measures will undergo specification and validity testing in RISE and US rheumatology practices as the foundation for national implementation and use in quality improvement programs.

Comparison of Ambulatory Quality Measures Between Shared Practice Panels and Independent Practice Panels

ObjectiveTo assess for differences in patient care outcomes in the primary care setting for patients assigned to an independent practice panel (IPP) or a shared practice panel (SPP). Patients and MethodsWe retrospectively reviewed the electronic health records of patients of 2 Mayo Clinic family medicine primary care clinics from January 1, 2019 to December 31, 2019. Patients were assigned to either an IPP (physician or advanced practice provider [APP]) or an SPP (physician and ≥1 APP). We assessed 6 measures of quality care and compared them between IPP and SPP groups: diabetes optimal care, hypertension control, depression remission at 6 months, breast cancer screening, cervical cancer screening, and colon cancer screening. ResultsThe study included 114,438 patients assigned to 140 family medicine panels during the study period: 87 IPPs and 53 SPPs. The IPP clinicians showed improved quality metrics compared with the SPP clinicians for the percentage of assigned patients achieving depression remission (16.6% vs 11.1%; P<.01). The SPP clinicians showed improved quality metrics compared with that of the IPP clinicians for the percentage of patients with cervical cancer screening (79.1% vs 74.2%; P<.01). The mean percentage of the panels achieving optimal diabetes control, hypertension control, colon cancer screening, and breast cancer screening were not significantly different between IPP and SPP panels. ConclusionThis study shows a considerable improvement in depression remission among IPP panels and in cervical cancer screening rates among SPP panels. This information may help to inform primary care team configuration.

Patient-centered medical home pharmacists’ impact on composite quality care measures for patients with uncontrolled type 2 diabetes

BackgroundPatients with uncontrolled diabetes are at risk for developing complications. Many health care systems have implemented multidisciplinary care models including pharmacists to help achieve quality care measures to reduce complications. ObjectiveThis study aimed to evaluate whether patients with uncontrolled type 2 diabetes mellitus (T2D) seen at patient-centered medical home (PCMH) clinics affiliated with an academic medical center are more likely to meet a composite of diabetes quality care measures with a pharmacist on their care team than usual care patients without a pharmacist on their care team. MethodsThis is a cross-sectional study. The setting included PCMH primary care clinics affiliated with an academic medical center from January 2017 to December 2020. Included were adults aged 18 to 75 years with a diagnosis of T2D, hemoglobin A1C (A1C) more than 9%, and established with a PCMH provider. The intervention is inclusion of PCMH pharmacist on the patient’s care team for management of T2D per a collaborative practice agreement. The main outcome measures included A1C ≤9% per last recorded value during observation period, a composite A1C ≤9% and completion of yearly laboratory tests, and a composite A1C ≤9%, completion of yearly laboratory tests, and statin prescription for adults aged 40-75 years. ResultsIdentified were 1807 patients in the usual care cohort with mean baseline A1C of 10.7% and 207 patients in the pharmacist cohort with mean baseline A1C of 11.1%. The pharmacist cohort was more likely to have an A1C of ≤9% at the end of the observation period (70.1% vs. 45.4%; P < 0.001), a composite of measures met (28.5% vs. 16.8%; P < 0.001), and a composite of measures met for patients aged 40-75 years (27.2% vs. 13.7%; P < 0.001). ConclusionPharmacist involvement in the multidisciplinary management of uncontrolled T2D is associated with a higher attainment of a composite of quality care measures at the population health level.

Care coordination in homecare and its relationship with quality of care: A national multicenter cross-sectional study

IntroductionAs health care complexity increases, skilled care coordination is becoming increasingly necessary. This is especially true in homecare settings, where services tend to be highly interprofessional. Poor coordination can result in services being provided twice, at the wrong time, unnecessarily or not at all. In addition to risking harm to the client, such confusion leads to unnecessary costs. From the patient's perspective, then, professional coordination should help both to remove barriers limiting quality of care and to minimize costs. To date, though, studies examining the relationship between care coordination and care quality have faced multiple challenges, leading to mixed results. And in homecare contexts, where the clients are highly vulnerable and diverse care interfaces make coordination especially challenging, such studies are rare. ObjectivesTherefore, the aim of this study was to explore the relationship, from the perspectives of clients and of homecare professionals, between coordination and quality of care. For both groups, we hypothesized that better coordination would correlate with higher ratings of quality of care. For the clients, we predicted that higher coordination ratings would lead to lower incidence of unplanned health care use, i.e., emergency department (ED) visits, unscheduled urgent medical visits and hospitalizations. Design and methodsThis study is part of a national multi-center cross-sectional study in the Swiss homecare setting. We recruited 88 homecare agencies and collected data between January and September 2021 through written questionnaires for agencies' managers, employees (n = 3223) and clients (n = 1509). To test our hypotheses, we conducted multilevel analyses. ResultsEmployee-perceived care coordination ratings correlated positively with employee-rated quality of care (OR = 2.78, p < .001); client-perceived care coordination problems correlated inversely with client-reported quality of care (β = −0.55, p < .001).Client-perceived coordination problems also correlated positively with hospitalizations (IRR = 1.20, p < .05) and unscheduled urgent medical visits (IRR = 1.18, p < .05), but not significantly with ED visits. No associations were discernible between employee-perceived coordination quality and either health care service use or client quality-of-care ratings. DiscussionWhile results indicate relationships between coordination and diverse aspects of care quality, various coordination gaps (e.g., poor information flow) also became apparent. The measurement of both care coordination and quality of care remains a challenge. Further research should focus on developing and validating a coordination questionnaire that measures care coordination.

Variation in Health Care Processes, Quality and Outcomes According to Day and Time of Chest Pain Presentation via Ambulance.

Previous studies examining temporal variations in cardiovascular care have largely been limited to assessing weekend and after-hours effects. We aimed to determine whether more complex temporal variation patterns might exist in chest pain care. This was a population-based study of consecutive adult patients attended by emergency medical services (EMS) for non-traumatic chest pain without ST elevation in Victoria, Australia between 1 January 2015 and 30 June 2019. Multivariable models were used to assess whether time of day and week stratified into 168 hourly time periods was associated with care processes and outcomes. There were 196,365 EMS chest pain attendances; mean age 62.4 years (standard deviation [SD] 18.3) and 51% females. Presentations demonstrated a diurnal pattern, a Monday-Sunday gradient (Monday peak) and a reverse weekend effect (lower rates on weekends). Five temporal patterns were observed for care quality and process measures, including a diurnal pattern (longer emergency department [ED] length of stay), an after-hours pattern (lower angiography or transfer for myocardial infarction, pre-hospital aspirin administration), a weekend effect (shorter ED clinician review, shorter EMS off-load time), an afternoon/evening peak period pattern (longer ED clinician review, longer EMS off-load time) and a Monday-Sunday gradient (ED clinician review, EMS offload time). Risk of 30-day mortality was associated with weekend presentation (Odds ratio [OR] 1.15, p=0.001) and morning presentation (OR 1.17, p<0.001) while risk of 30-day EMS reattendance was associated with peak period (OR 1.16, p<0.001) and weekend presentation (OR 1.07, p<0.001). Chest pain care demonstrates complex temporal variation beyond the already established weekend and after-hours effect. Such relationships should be considered during resource allocation and quality improvement programs to improve care across all days and times of the week.

From measures to action: can integrating quality measures provide system-wide insights for quality improvement decision making?

BackgroundQuality improvement decision makers are left to develop an understanding of quality within their healthcare system from a deluge of narrowly focused measures that reflect existing fragmentation in care and...

Commensuration of health-care quality standards through hospital accreditation: from measurement weapon to management tool?

PurposeThe purpose of this study is to examine the management perceptions towards calculative practices behind the reconstruction of a mandatory hospital accreditation (HA) system that transforms multiple facets of health-care quality into a single performance index.Design/methodology/approachThis study contributes to the sociology of quantification mobilising the concept of commensuration as a social process to reflect on contemporary changes in managing HA systems. Data are collected adopting a case study of a Spanish public hospital drawing on semi-structured interviews, observation and documentary review.FindingsFindings emphasise a shift from standards’ compliance to a more comprehensive view encouraging continuous quality improvement. Accreditation acts as a tin opener to facilitate external inspection removing contextual differences amongst hospitals and reducing organisational practices into controllable objects. It also reveals underlying ethical concerns as the system was built as a care quality measure that promptly developed into an attainment goal.Practical implicationsThe valuable role of HA to enhance quality standards and the limitations resulting from its commensuration practices will be of interest to policymakers, organisational managers and researchers.Originality/valueDespite a growing emphasis on audit and valuation practices in health care, accounting studies examining the capacity of public hospitals to manage quality improvement are scarce. This study inspires further research on accreditation to overcome commensuration flaws regarding external transparency, evaluation ambiguity and extra incentives.

Dampak Implementasi Pembayaran Berbasis Kinerja (Pay-For-Performance) Pada Fasilitas Kesehatan Tingkat Pertama (FKTP) Terhadap Kualitas Layanan Kesehatan Di Berbagai Negara

The pay-for-performance (P4P) mechanism is a strategy in the health sector to increase the availability, quality and utilization of health services. In P4P, incentives are given after achieving a series of agreed outcomes by improving the performance of health workers in health facilities. This literature review was conducted with the aim of knowing the impact of implementing pay-for-performance at primary care (FKTP) on the quality of health services in various countries. The method is carried out by searching several databases, namely Pubmed, Embase, and Proquest with the main intervention being the implementation of pay-for-performance. The results of the review focused on the impact of implementing pay-for-performance at First Level Health Facilities on the quality of health services in various countries. From this study it can be concluded that pay-for-performance has been used in various countries with different numbers and areas (domains) of indicators adapted to the characteristics of primary care in a country. Some of the benefits of implementing pay-for-performance are that it can stimulate quality improvement in clinical care and improve patient experience of the role of general practitioners and the system of care. P4P can improve the process and outcome of cardiovascular treatment. Providing incentives can have an effect on improving the quality of performance in clinical practice. Providing P4P incentives can meet the quality measures of hypertension care recommended by the guidelines. In the United States, the provision of P4P incentives can increase physician compliance to provide hypertension drugs according to guidelines. Providing incentives can also have an impact on improving blood pressure control in hypertensive patients.

The Relation between Patient-Centered Care and Quality of Life in Women with Endometriosis

Objective: The objective of this study was to examine the hypothesis that experiences with patient-centered endometriosis care are related to the endometriosis-specific quality of life dimensions “emotional well-being” and “social support.” Design: A secondary regression analysis of two cross-sectional studies was conducted. Participants/Materials: In total, data from 300 women were eligible for analysis. The participating women all had surgically proven endometriosis. Setting: The study was conducted in one secondary and two tertiary endometriosis clinics in the Netherlands. Questionnaires were disseminated between 2011 and 2016. Methods: Both included studies investigated patient-centeredness of endometriosis care and endometriosis-specific quality of life using, respectively, the ENDOCARE questionnaire (ECQ) and the Endometriosis Health Profile 30 (EHP-30). To increase power, the regression analysis focused on the previously found relation between the ten dimensions of the ECQ and the EHP-30 domains “emotional well-being” and “social support” rather than all five EHP-30 domains. After the Bonferroni correction to limit type 1 errors, the adjusted p value was 0.003 (0.05/20). Results: The participating women had a mean age of 35.7 years and had predominantly been diagnosed with moderate to severe endometriosis. None of the relations between patient-centered endometriosis care and the EHP-30 domain “emotional well-being” were significant. Three dimensions of patient-centered endometriosis care proved to be significantly related to the EHP-30 domain “social support”: “information, communication, and education” (p < 0.001, beta = 0.436), “coordination and integration of care” (p = 0.001, beta = 0.307), and “emotional support and alleviation of fear and anxiety” (p = 0.002, beta = 0.259). Limitations: This cross-sectional study identified relations rather than proving causality between experiencing less patient-centeredness of care and having lower quality of life. Nevertheless, it is very tangible that some causality exists, either directly or indirectly (e.g., through empowerment) and that by improving patient-centeredness, quality of life might be improved as well. Conclusion: “Information, communication, and education”; “coordination and integration of care”; and “emotional support and alleviation of fear and anxiety” as dimensions of patient-centered endometriosis care are related to the quality of life domain “social support” of women with endometriosis. Improving the patient-centeredness of endometriosis care was already considered an important goal, but even more so given its relation with women’s quality of life, which is increasingly considered the ultimate measure of health care quality. Quality improvement projects focusing on “information, communication, and education” are expected to impact women’s quality of life the most.

Quality measures for palliative care in patients living with cancer in low- and middle-income countries: a scoping review protocol

IntroductionQuality assessment is a critical component of determining the value of medical services, including palliative care. The utilisation of palliative care quality measures could assist in assessing the degree to which patients living with cancer conform to best practice of palliative care, identifying gaps and monitoring changes in cancer care delivery models in different setting. This scoping review aims to map the available data on the usage of palliative care quality indicators that are relevant to cancer patients in low- and middle-income countries (LMICs).MethodsTo structure this study, we will use the framework developed by Arksey and O’Malley, the Levac et al. recommendations and the Joanna Briggs Institute recommendations. We will search EBSCOHost, Web of Science, ProQuest One Academic, MEDLINE and Google Scholar for evidence on palliative care quality measures applicable for patients living with cancer published from inception till 2022. We will search grey literature in the form of dissertations, conference proceedings and websites of international organisations such as the World Health Organisation (WHO) reporting palliative care quality measures applicable to patients living with cancer in LMICs.DiscussionThe purpose of this study is to establish the extent of existing research on the palliative care quality measures in LMICs. Although palliative care is still a new phenomenon, understanding of the palliative care quality measures applicable for cancer patients will assist to improve care across all components of health systems.Ethics and disseminationNo ethical approval is required for the study as the data collection and results of the proposed scoping review will be conducted and disseminated electronically using peer-reviewed journals, print and presentations at scientific conferences and stakeholder presentations.

How Long-Term Care Quality Measures Address Alzheimer's Disease and Related Dementias in European Countries.

Alzheimer's disease and related dementias (ADRD) are prevalent conditions in long-term care homes (LTCHs) with most LTCH residents living with ADRD in many countries. Despite the prevalence of ADRD in LTCHs, a recent examination of LTCH quality measurement programs in 4 countries revealed few LTCH quality measures addressed ADRD, most commonly as a risk adjuster. We sought to better understand how quality measurement programs address ADRD internationally. International comparative analysis. We examined LTCH quality measures in 4 European countries-Germany, Switzerland, Belgium, and the Netherlands. The specifications to calculate each measure were assessed to determine whether the measure was calculated without assessing for ADRD, included only residents with ADRD, excluded residents with ADRD, or was risk adjusted for the presence of ADRD among the LTCH residents. A total of 143 measures were examined across 4 quality measurement programs. Thirty-seven percent of the measures explicitly address ADRD. The programs addressed ADRD in starkly different ways. In Germany, most (13 of 15) measures addressed ADRD, and did so as an exclusion or inclusion criterion, and in Switzerland all the measures addressed ADRD through risk adjustment. In Flanders, Belgium, all measures were calculated without assessing for ADRD. In the Netherlands, one-third of the measures explicitly addressed ADRD by restricting the measure to psychogeriatric units. Although limited to examining measures from LTCH quality measurement programs in 4 European countries, this study adds evidence that ADRD tends not to be addressed by LTCH quality measures, but when ADRD is addressed, it tends to be through inclusion or exclusion criteria. LTCH regulators, policymakers, and providers can use this information to assess options for addressing ADRD in quality measurement programs. Future research is needed to assess how standard indicators of ADRD care quality differ across quality measurement programs.

Measuring Pediatric Palliative Care Quality: Challenges and Opportunities.

Pediatric palliative care (PPC) programs vary widely in structure, staffing, funding, and patient census, resulting in inconsistency in service provision. Improving the quality of palliative care for children living with serious illness and their families requires measuring care quality, ensuring that quality measurement is embedded into day-to-day clinical practice, and aligning quality measurement with healthcare policy priorities. Yet, numerous challenges exist in measuring PPC quality. This paper provides an overview of PPC quality measurement, including challenges, current initiatives, and future opportunities. While important strides toward addressing quality measurement challenges in PPC have been made, including ongoing quality measurement initiatives like the Cambia Metrics Project, the PPC What Matters Most study, and collaborative learning networks, more work remains. Providing high-quality PPC to all children and families will require a multi-pronged approach. In this paper, we suggest several strategies for advancing high-quality PPC, which includes 1) considering how and by whom success is defined, 2) evaluating, adapting, and developing PPC measures, including those that address care disparities within PPC for historically marginalized and excluded communities, 3) improving the infrastructure with which to routinely and prospectively measure, monitor, and report clinical and administrative quality measures, 4) increasing endorsement of PPC quality measures by prominent quality organizations to facilitate accountability and possible reimbursement, and 5) integrating PPC-specific quality measures into the administrative, funding, and policy landscape of pediatric healthcare.

Sex differences in clinical outcomes amongst 1105 patients admitted with hip fractures.

Amongst hip fracture admissions, mortality is higher in men than in women. However, sex differences in other care-quality measures have not been well-documented. We aimed to examine sex differences in mortality as well as a wide range of underlying health indicators and clinical outcomes in adults ≥ 60year of age admitted with hip fractures from their own homes to a single NHS hospital between April-2009 and June-2019. Sex differences in delirium, length of stay (LOS) and mortality in hospital, readmission, and discharge destination, were examined by logistic regression. There were 787 women and 318 men of similar mean age (± SD): 83.1year (± 8.6) and 82.5year (± 9.0), respectively (P = 0.269). There were no sex differences in history of dementia or diabetes, anticholinergic burden, pre-fracture physical function, American Society of Anesthesiologists grades, or surgical and medical management. Stroke and ischaemic heart disease, polypharmacy, and alcohol consumption were more common in men. After adjustment for these differences and age, men had greater risk of delirium (with or without cognitive impairment) within one day of surgery: OR = 1.75 (95%CI 1.14-2.68), LOS ≥ 3weeks in hospital: OR = 1.52 (1.07-2.16), mortality in hospital: OR = 2.04 (1.14-3.64), and readmission once or more after 30days of a discharge: OR = 1.53 (1.03-2.31). Men had a lower risk of a new discharge to residential/nursing care: OR = 0.46 (0.23-0.93). The present study revealed that, in addition to a greater risk of mortality than women, men also had many other adverse health outcomes. These findings, which have not been well-documented, serve to stimulate future targeted preventive strategies and research.

Asthma control in children, socioeconomic inequality and health care

IntroductionSocioeconomic inequality (SEI) can adversely affect asthma control. The aim of this study was to establish the association of SEI with asthma control in children and caregiver quality of life. MethodsWe assessed socioeconomic status based on the area of residence, according to the at risk of poverty rate (ARPR). After stratifying the paediatric population of Castilla y León (Spain) in ARPR tertiles, we selected participants by stratified random sampling, and identified children with asthma aged 6–14 years from the health records of primary care centres. We collected data through questionnaires completed by parents. The primary outcomes were asthma control and caregiver quality of life. We assessed their association with SEI, health care quality measures and individual factors (such as parental educational attainment) by means of multivariate regression models. ResultThe ARPR tertile was not associated with asthma control, quality of life or health care quality. A medium or high maternal educational attainment was associated with a lower risk of making an unscheduled or urgent visit (OR = .50; 95% CI, .27–.95; P = .034) and paternal educational attainment was associated with a lower risk of uncontrolled asthma (OR = 0.51; 95% CI, .28–.94; P = .030). ConclusionIn the sample under study, SEI assessed at the local level was not associated with asthma control in children. Other factors, such as parental educational attainment, may have a protective effect.

Implementation of universal umbilical cord pH analysis in Denmark. A national register-based study.

Umbilical cord blood gas analysis provides information about intrapartum hypoxia and is considered an important measure of quality in maternity care. Universal measurement of umbilical cord pH (UC-pH), as part of umbilical cord blood gas analysis, has been recommended in Denmark since 2009. The recommendation is that UC-pH is measured from the umbilical cord artery (pHUA ) and vein (pHUV ). The aim of this study was to evaluate the national implementation of universal measurement of UC-pH. The study consisted of two parts. First, an evaluation of the implementation, that is, the proportion of births with measured UC-pH since the recommendation was introduced. Second, an evaluation of the cases in which UC-pH was missing. This analysis only involved births with gestational age ≥35 + 0 weeks. In the period 2009 to 2018 there were 560 889 singleton, live births with registered gestational age in Denmark. The proportion of births with measured pHUA and pHUV increased from 12.4% in 2009 to 82.8% in 2015 and then declined to 76.9% in 2018 (p < 0.001). When comparing the group with missing pH from one or both vessels to the group with both pHUA and pHUV we found lower occurrence of pregnancy and births complications in the first group, body mass index ≥35 (unadjusted RR: 0.89, 95% CI: 0.85-0.93), pregnancy induced medical conditions (RR: 0.86, 95% CI: 0.84-0.89), fetal distress during birth (RR: 0.77, 95% CI: 0.76-0.79), emergency cesarean section (RR: 0.80, 95% CI: 0.78-0.83) and serious births events (RR: 0.80, 95% CI: 0.74-0.86). In contrast, the occurrence of placental insufficiency (RR: 1.07, 95% CI: 1.03-1.11), small for gestational age (RR: 1.36, 95% CI: 1.30-1.43, for <2.3th percentile), hypothermia treatment (RR: 1.60, 95% CI: 1.21-2.14) and neonatal death (RR: 1.96, 95% CI: 1.40-2.74) were higher in the group without measured pHUA and pHUV . The use of UC-pH measurement has increased markedly in Denmark since universal measurement was recommended in 2009. Missing UC-pH from one or both vessels was associated with less complicated pregnancies and with small for gestational age, hypothermia treatment and neonatal death.

Evaluation of effective coverage for type 2 diabetes in Mexican primary care health information systems: a retrospective registry analysis

BackgroundAs the leading cause of disability and the fourth leading cause of premature death in Mexico, type 2 diabetes (T2D) represents a serious public health concern. The incidence of diabetes has increased dramatically in recent years, and data from the Mexican National Health and Nutrition Survey (ENSANUT) indicate that many people remain undiagnosed. Persistent socioeconomic health care barriers exacerbate this situation, as T2D morbidity and mortality are worsened in vulnerable populations, such as those without social security. We evaluated the performance of public primary health centers (PHCs) in T2D medical attention through the measure of effective coverage (EC, a combined measure of health care need, use, and quality) at national, state, health jurisdiction, and municipality levels.MethodsThis retrospective analysis used blinded data recorded during 2017 in the Non-communicable Diseases National Information System (SIC) and T2D prevalence reported in 2018 ENSANUT to evaluate the EC achieved. We included individuals ≥ 20 years old without social security who did not declare the use of private health care services. Each EC component (need, use, and quality) was estimated based on the Shengelia adapted framework. The Kruskal–Wallis test was applied to evaluate the associations among EC quintiles and demographics.ResultsIn 2017, 26.5 million individuals, aged ≥ 20 years, without social security, and without the use of private health care services, were under the care of 12,086 PHCs. The national prevalence of T2D was 10.3%, equivalent to 2.6 million people living with T2D in need of primary health care. Large contrasts were seen among EC components between and within Mexican states. We found that only 37.1% of the above individuals received health services at PHCs and of them, 25.8% improved their metabolic condition. The national EC was 9.3%, and the range (by health jurisdiction) was 0.2%–38.6%, representing a large geographic disparity in EC. We found an evident disconnect among need, utilization, and quality rates across the country.ConclusionsExpansion and improvement of EC are urgently needed to address the growing number of people living with T2D in Mexico, particularly in states with vulnerable populations.

DNP preparation of primary care nurse practitioners and clinical outcomes for patients with chronic conditions

BackgroundMany professional nursing organizations have proposed that the Doctor of Nursing Practice (DNP) is the most appropriate entry-level degree for nurse practitioners (NPs). There have been no studies to date examining the impact of DNP preparation on quality of care or patient outcomes. PurposeTo examine differences in emergency department utilization and hospitalizations among patients with chronic conditions cared for by Master of Science in Nursing (MSN)- and DNP-prepared primary care NPs. MethodsWe use survey data from over 1,000 primary care NPs in 6 states linked to Medicare claims data. Using regression models, we controlled for various patient, NP, and practice characteristics that might confound the relationship. ResulsWe find that patient outcomes are not statistically different between patients attributed to MSN- and DNP-prepared primary care NPs. DiscussionThese findings suggest that there remains little evidence that DNP education has led to significant improvements in patient outcomes. ConclusionsFurther empirical analysis related to the clinical outcomes other than health care utilization of the DNP degree is warranted. Future studies might consider examining (a) NPs in settings other than primary care, (b) practice-wide or system-wide outcomes, (c) other measures of care quality, and (d) impact of DNP program content.

A215 EVALUATING THE COMPARABILITY OF CARE FOR PERSONS ADMITTED TO TORONTO AREA HOSPITALS WITH ACUTE SEVERE ULCERATIVE COLITIS

Abstract Background Approximately 20% of patients with ulcerative colitis will experience an acute severe exacerbation requiring hospitalization. Acute severe ulcerative colitis (ASUC) is a medical emergency associated with significant morbidity and a mortality rate of 1%. Timely initiation of treatment and assessment of clinical response is critical in the management of ASUC. With an aim to reduce treatment variability and improve outcomes, multiple gastrointestinal societies have published guidelines highlighting recommendations for optimal care in ASUC. It remains unclear how closely these guidelines are implemented in clinical practice. Measuring adherence to these recommended processes of care may act as a surrogate measure for quality of care and a way to indirectly evaluate outcomes in the management of patients with ASUC. Studies have shown that even amongst experienced providers practice pattern variability exists. Identifying significant variations in the management of patients with ASUC will highlight where improvement in guideline dissemination and greater adherence is required. Purpose We sought to evaluate how quality of care indicators varied across 7 hospital sites for patients admitted ASUC in the Greater Toronto Area. Method Using GEMINI, a research collaborative that collects and analyses data from inpatient admissions at 7 Toronto area hospitals, we identified patients admitted to hospital with ASUC from June 2016-December 2019. Hospital sites were further categorized into 3 hospital types; 1 IBD specialty centre (ISC), 3 other academic centres (AC) and 3 community centres (CC). Process measures assessed included proportion tested for C-reactive protein at baseline and following treatment initiation, duration of corticosteroid use, timing and initiation of biologic agents, rates of venous thromboembolism prophylaxis and opioid use. Outcome measures included hospital length of stay, rates of colectomy and mortality. Result(s) 765 hospitalizations were included in the study; 320 occurring at ISC, 308 at AC and 137 at CC. Corticosteroid use on admission were highest at the ISC at 78% compared to 64% at AC and 63% at CC (p &amp;lt;0.001). Among those who received steroids on admission, 47% of patients remained on intravenous corticosteroids for at least 5 days in the ISC compared to 39% in AC and 75% in CC (p&amp;lt; 0.001). Initiation of biologic rescue therapy was highest at the ISC occurring in 37% of hospitalizations compared to 22% in AC and 23% in CC (p&amp;lt;0.001). In addition, VTE prophylaxis rates were highest at the ISC at 83% followed by 60% in AC and 45% in CC (p&amp;lt;0.001). Rates of colectomy were highest at ISC (12% of hospitalizations vs. 7% in AC). Conclusion(s) Greater adherence to indicators of quality of care were seen at the ISC compared to ACs and CCs, although patient outcomes assessed were not clearly different between sites. Further strategies are required to improve adherence to markers of quality care for patients admitted with ASUC. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared