Quality Of Disease Management Research Articles

"Assessing Today for a Better Tomorrow": An observational cohort study about quality of care, mortality and morbidity among newborn infants admitted to neonatal intensive care in Guinea.

BackgroundNeonatal mortality in Guinea accounts for about 30% of all fatalities in children younger than five years. Countrywide, specialized neonatal intensive care is provided in one single clinic with markedly limited resources. To implement targeted measures, prospective data on patient characteristics and factors of neonatal death are needed.ObjectiveTo determine the rates of morbidity and mortality, to describe clinical characteristics of admitted newborns requiring intensive care, to assess the quality of disease management, and to identify factors contributing to neonatal mortality.MethodsProspective observational cohort study of newborns admitted to the hospital between mid-February and mid-March 2019 after birth in other institutions. Data were collected on maternal/prenatal history, delivery, and in-hospital care via convenience sampling. Associations of patient characteristics with in-hospital death were assessed using cause-specific Cox proportional-hazards models.ResultsHalf of the 168 admitted newborns underwent postnatal cardiopulmonary resuscitation. Reasons for admission included respiratory distress (49.4%), poor postnatal adaptation (45.8%), prematurity (46.2%), and infections (37.1%). 101 newborns (61.2%) arrived in serious/critical general condition; 90 children (53.9%) showed clinical signs of neurological damage. Quality of care was poor: Only 59.4% of the 64 newborns admitted with hypothermia were externally heated; likewise, 57.1% of 45 jaundiced infants did not receive phototherapy. Death occurred in 56 children (33.3%) due to birth asphyxia (42.9%), prematurity (33.9%), and sepsis (12.5%). Newborns in serious/critical general condition at admission had about a fivefold higher hazard to die than those admitted in good condition (HR 5.21 95%-CI 2.42–11.25, p = <0.0001). Hypothermia at admission was also associated with a higher hazard of death (HR 2.00, 95%-CI 1.10–3.65, p = 0.023).ConclusionNeonatal mortality was strikingly high. Birth asphyxia, prematurity, and infection accounted for 89.3% of death, aggravated by poor quality of in-hospital care. Children with serious general condition at admission had poor chances of survival. The whole concept of perinatal care in Guinea requires reconsideration.

The Impact of Patient-Centered Medical Homes on Quality of Care and Medication Adherence in Patients with Diabetes Mellitus.

Current evidence suggests that patient-centered medical homes (PCMHs) potentially increase overall quality of disease management, including preventive care. However, there are mixed findings regarding quality of diabetes care, and little evidence exists with respect to the effect of PCMHs on medication adherence in patients with diabetes. To investigate associations between PCMHs and process measures of diabetes care, as well as adherence to oral hypoglycemic agents (OHAs) in patients with diabetes in a nationally representative U.S. Using the 2009-2013 longitudinal data files from the Medical Expenditure Panel Survey, adult diabetes patients were identified. Patients whose usual sources of care have all PCMH features at baseline (i.e., enhanced access after hours and online, shared decision making, and enhanced patient engagement) were categorized as the PCMH group, which was compared with patients without PCMH features. Process measures of diabetes care included ≥ 2 hemoglobin A1c tests and ≥ 1 cholesterol test, foot examination, dilated eye examination, and flu vaccination during 1 year of follow-up. Medication possession ratio (MPR) during follow-up was calculated for patients with OHAs without any insulin use, with MPR ≥ 80% considered to be adherent to OHAs. Univariate and multivariate regression models considering sampling strata and weights were used to examine the association between the PCMH and study outcomes. A total of 3,334 patients with diabetes was identified, representing 61 million U.S. lives. The mean (SE) age was 61.6 (0.3) years, and 52.4% of patients were female. The mean (SE) years of having diabetes was 12.0 (0.2) years. Approximately 11.4% of the patients were categorized as the PCMH group at baseline, and only 3.6% of those patients remained in the PCMH group for 2 years. Of the diabetic patients identified, only 26.9% met all of the diabetes care process measure criteria defined in this study. A higher proportion of patients met process measure criteria in the PCMH group compared with the non-PCMH group (33.8% vs. 26.0%, respectively, P = 0.015). The weighted mean MPR (95% CI) of OHAs from the 2 groups were not statistically different (0.68, 95% CI = 0.63-0.74 for the PCMH group; 0.77, 95% CI = 0.72-0.82 for the non-PCMH group, P = 0.675), resulting in 47.4% of adherent patients in the study population. Overall, the PCMH group was associated with improvement in the process measures of diabetes care (adjusted odds ratios [OR] = 1.42, 95% CI = 1.06-1.91). The effect was greater among the patients who stayed in the PCMH group for 2 years (OR = 2.09, 95% CI = 1.27-3.45); were aged < 65 years (OR = 2.19, 95% CI = 1.47-3.28); or had less than 3 comorbid conditions (OR = 2.38, 95% CI = 1.46-3.88). However, the PCMH group was not associated with an increased adherence to OHAs (P = 0.495) or an increase in MPR (P = 0.570). Patients with all PCMH features were associated with improvement in the process measures of diabetes care, but not in adherence to OHAs. Future studies should investigate the mechanism of PCMHs in overall quality of care, as well as medication adherence. No outside funding supported this study. The author reports no conflicts of interests.

Abstract B82: Beyond October: A multisite breast care patient navigation program

Abstract Background: Insufficient access to mammography and early detection are contributing factors to the racial disparity in breast cancer mortality in Chicago (Chicago Breast Cancer Quality Consortium, 2010). Patient navigators provide information, support, and guidance that can help remove barriers to care and improve the quality of disease management for underserved patients (Vargas et al, 2008). The Metropolitan Chicago Breast Cancer Task Force developed a patient navigation program called Beyond October to provide free mammograms to uninsured and underserved women throughout Metropolitan Chicago. Our goal is to develop a replicable and effective means for patient navigation across multiple sites. Through navigation from Task Force staff, these women received timely and managed care through the screening, and if necessary, diagnostic and treatment processes. Methods: Nine facilities in various locations throughout Chicago donated free mammograms in order to meet our program's goal of 800 mammograms completed from November 1, 2012 to October 31, 2013. Participants were identified through community events, online applications, personal referrals, and referrals from other hospitals and organizations. To be eligible participants were over 40 years of age, uninsured and without symptoms. Eligible participants received culturally sensitive navigation throughout the screening and, if needed, diagnostic process from bilingual staff navigators. A staff navigator (4 navigators in total) verified the patient's eligibility prior to the patient completing intake and HIPAA authorization forms necessary to receive an appointment. Participants were navigated to a facility that was most convenient to their home address and received a packet of site-specific forms, as well as a voucher, to take to their appointment. Each patient received reminder and follow-up calls to assure appointment attendance. If the initial appointment was missed, a patient would receive one more attempt at attending the appointment. Navigators ensured appointments were scheduled, prior mammogram films were requested and obtained. After the appointment, results were communicated effectively and the necessary follow-up imaging and procedures were scheduled. Any patients requiring follow-up imaging and/or biopsies who did not receive their initial mammogram at a site that donated diagnostic mammograms, were referred to an IBCCP (state funded) facility. Women diagnosed with breast cancer received free treatment through the Treatment Act. Results: Based on preliminary data, a total of 662 mammograms were completed across nine Chicago facilities. From this pilot, successful outcomes were observed in the areas of client recruitment, communication of results, and care management for each woman. The program identified economic, language, and administrative /health system barriers as the main challenges faced by women. These barriers were addressed by: 1) providing access to free screening and diagnostic breast health care, 2) providing translation assistance for Spanish speaking clients, and 3) obtaining PCP orders and prior medical information to reduce health system barriers. Developing site specific protocols, providing patients with site specific forms, and having designated facility contacts decreased scheduling times and increased the rate of completion of the specific care plan for each participant. Delays occurred when medical information had to be sent across multiple sites, requests for prior medical history were not properly documented, and patients had a high number of forms to complete. Conclusion: A multi-site, culturally sensitive navigation program that takes into account both patient and facility needs can reduce screening barriers and increase access to quality breast health care for uninsured women. Citation Format: Jimmie Knight, III, Teena L. Francois. Beyond October: A multisite breast care patient navigation program. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B82. doi:10.1158/1538-7755.DISP13-B82

Determinants of outcome in childhood epilepsy

Possible outcomes with regard to seizures include remission (i.e. no seizures without drug treatment), conditional remission (i.e. no seizures under treatment) and treatment resistance. Several factors have been identified which are associated with favourable or unfavourable outcomes. These include syndrome diagnosis (benign vs severe epilepsy syndromes), seizure types (kind and number), severity of epilepsy, response to treatment (immediate vs delayed, monotherapy vs combinations), and concomitant neurological and psychiatric disorders. However, the quality of disease management by caretakers also has an important influence on the outcome. To determine full remission in patients who are seizure-free with treatment, antiepileptic drugs need to be tapered; generally speaking, this seems to be less risky in children than in adults. However, even if remission without treatment has been reached, an elevated risk of seizures may persist compared with that of the general population. The outcome of epilepsy should not be considered with respect to seizures alone, but should also include more global aspects of performance and quality of life. These may depend on the causes of epilepsy as much as, or more than, on the seizure disorder itself, but may also be related to treatment.