Health System Quality Research Articles

The normalised mortality, a new measure to ensure valid conclusions from cardiovascular mortality

Abstract Background The quality and efficacy of health systems is assessed by comparing age-standardised mortality (ASM) from cardiovascular diseases (CVD), as they are regarded avoidable by health care. Differences in CVD mortality in West-Europe are surprising and hard to explain: in 2018, ASM for CVD in Germany was much higher (women: 102, men: 155/100,000) than in the Netherlands (65 and 97). Yet, these differences do not root in health system quality, but in different shares of CVD deaths among all deaths (DE: 39%, NL: 25%), which strongly effect CVD mortality. We developed a mortality measure less sensible to differences in shares of CVD deaths to increase plausibility of comparisons and validity of conclusions. Methods WHO data on sex-specific all and CVD deaths, ASM for CVD and all-causes for 2000-2018 for Western-European countries was used to calculate the share of CVD deaths among all deaths. ASM for CVD was divided by the share of CVD deaths resulting in a mortality measure normalized for 1% of CVD deaths. ASM and normalized mortality for CVD were used in comparative analyses. Strength of linear association between total and (normalized) ASM for CVD was estimated (adj. R²). Results Normalised CVD mortality ranked from 2.0 (CHE in women) to 4.9 (SVN in men) in 2018. While ASM for CVD was lowest in Danish women and Dutch men, Switzerland leads both rankings using the normalised CVD mortality. While ASM for CVD was much higher in Germany than in the Netherlands, the countries had the same normalized CVD mortality (2.6). ASM for CVD was moderately associated with all-cause mortality only in men (adj. R² 0.33; in women: -0.06). Using the normalized CVD mortality yielded an adj R² of 0.66 in women and 0.94 in men. The normalised CVD mortality ensures reliable comparisons of CVD mortality eliminating the effect of different shares of CVD deaths. It yields plausible results and enables valid conclusions about health system quality and better decisions for public health. Key messages • Age-standardised CVD mortality rates are effected by different shares of CVD deaths in countries and hinder valid conclusions on health systems efficacy and quality of health systems. • The normalised mortality rate eliminates the effect of different shares of CVD deaths in countries and allows to validly compare CVD mortality.

Power, data and social accountability: defining a community-led monitoring model for strengthened health service delivery.

Despite international commitment to achieving the end of HIV as a public health threat, progress is off-track and existing gaps have been exacerbated by COVID-19's collision with existing pandemics. Born out of models of political accountability and historical healthcare advocacy led by people living with HIV, community-led monitoring (CLM) of health service delivery holds potential as a social accountability model to increase the accessibility and quality of health systems. However, the effectiveness of the CLM model in strengthening accountability and improving service delivery relies on its alignment with evidence-based principles for social accountability mechanisms. We propose a set of unifying principles for CLM to support the impact on the quality and availability of health services. Building on the social accountability literature, core CLM implementation principles are defined. CLM programmes include a community-led and independent data collection effort, in which the data tools and methodology are designed by service users and communities most vulnerable to, and most impacted by, service quality. Data are collected routinely, with an emphasis on prioritizing and protecting respondents, and are then be used to conduct routine and community-led advocacy, with the aim of increasing duty-bearer accountability to service users. CLM efforts should represent a broad and collective community response, led independently by impacted communities, incorporating both data collection and advocacy, and should be understood as a long-term approach to building meaningful engagement in systems-wide improvements rather than discrete interventions. The CLM model is an important social accountability mechanism for improving the responsiveness of critical health services and systems to communities. By establishing a collective understanding of CLM principles, this model paves the way for improved proliferation of CLM with fidelity of implementation approaches to core principles, rigorous examinations of CLM implementation approaches, impact assessments and evaluations of CLM's influence on service quality improvement.

Aligning quality improvement, research, and health system goals using the QUERI priority-setting process: A step forward in creating a learning health system.

Aligning quality improvement, research, and health system goals using the QUERI priority-setting process: A step forward in creating a learning health system.

Shared-Care in Complex Malignant Hematology: An Integrative Review Using the RE-AIM Evaluation Framework.

Complex malignant hematology (CMH) shared-care programs have been established to support patients with access to care closer to home. This integrative review examined what is known about CMH shared-care using the RE-AIM evaluation framework. We searched five electronic databases for articles published until 16 January 2024. Articles were included if they were qualitative or quantitative studies, reviews or discussion papers, and reported on an experience with shared-care (defined as a reciprocal, ongoing patient-sharing relationship between a specialist centre and community hospital) for patients with hematological malignancies, and examined one or more aspects of the RE-AIM framework. The search yielded 6523 articles; 10 articles describing eight shared-care experiences. Indicators of reach were reported for 65% of the programs, and emphasized some patient eligibility criteria. Effectiveness indicators were reported for 28% of programs, and suggested favourable survival outcomes within a shared-care model; however, health system impact and quality of life studies were lacking. Indicators of adoption and implementation were reported for 56% and 42% of programs, respectively, and emphasized multidisciplinary teams, infrastructure support, and communication strategies. Maintenance was not reported. Common elements contribute to the implementation of existing CMH shared-care programs; however, a formal evaluation remains an area of need.

Use of an electronic wellness instrument in the integrated health and social care of older adults: a group concept mapping study

BackgroundHealth system fragmentation directly contributes to poor health and social outcomes for older adults with multiple chronic conditions and their care partners. Older adults often require support from primary care, multiple specialists, home care, community support services, and other health-care sectors and communication between these providers is unstructured and not standardized. Integrated and interprofessional team-based models of care are a recommended strategy to improve health service delivery to older adults with complex needs. Standardized assessment instruments deployed on digital platforms are considered a necessary component of integrated care. The aim of this study was to develop strategies to leverage an electronic wellness instrument, interRAI Check Up Self Report, to support integrated health and social care for older adults and their care partners in a community in Southern Ontario, Canada.MethodsGroup concept mapping, a participatory mixed-methods approach, was conducted. Participants included older adults, care partners, and representatives from: home care, community support services, specialized geriatric services, primary care, and health informatics. In a series of virtual meetings, participants generated ideas to implement the interRAI Check Up and rated the relative importance of these ideas. Hierarchical cluster analysis was used to map the ideas into clusters of similar statements. Participants reviewed the map to co-create an action plan.ResultsForty-one participants contributed to a cluster map of ten action areas (e.g., engagement of older adults and care partners, instrument’s ease of use, accessibility of the assessment process, person-centred process, training and education for providers, provider coordination, health information integration, health system decision support and quality improvement, and privacy and confidentiality). The health system decision support cluster was rated as the lowest relative importance and the health information integration was cluster rated as the highest relative importance.ConclusionsMany person-, provider-, and system-level factors need to be considered when implementing and using an electronic wellness instrument across health- and social-care providers. These factors are highly relevant to the integration of other standardized instruments into interprofessional team care to ensure a compassionate care approach as technology is introduced.

Adaptation of Physical Environment in Health Care Institutions for People with Disabilities Caused by Musculoskeletal System and Connective Tissue Disease

The UN World Health Organization has set a goal to ensure people-oriented universal, equal, sustainable and high quality health systems which would give priority to prevention of diseases, continuous perfection of quality, integrated provision of services, assurance of continuous care, development of patients’ self-care, relocation of care close to home by 2020. People with disabilities and their opportunities to equally participate in the health system like other citizens occurred in the high focus because over recent decades various international documents acknowledge that, despite various measures and obligations, people with disabilities face violations of their rights in various spheres of living worldwide. The paper presents the research that aimed at investigating the adaptation of physical environment in health care institutions focused on people with disabilities caused by the disease of the musculoskeletal system and connective tissue. The research suggests that people with disabilities caused by the disease of the musculoskeletal system and connective tissue face a greater burden, and the disability has become an obstacle to their enjoyment of human rights and freedoms in the health system. This testifies to the fact that the Lithuanian state does not guarantee this part of its citizens the same quality of health services as other citizens, as provided for in the United Nations Convention on the Rights of Persons with Disabilities (2006).

Factors shaping network emergence: A cross-country comparison of quality of care networks in Bangladesh, Ethiopia, Malawi, and Uganda.

The Quality-of-Care Network (QCN) was conceptualized by the World Health Organization (WHO) and other global partners to facilitate learning on and improve quality of care for maternal and newborn health within and across low and middle-income countries. However, there was significant variance in the speed and extent to which QCN formed in the involved countries. This paper investigates the factors that shaped QCN's differential emergence in Bangladesh, Ethiopia, Malawi, and Uganda. Drawing on network scholarship, we conducted a replicated case study of the four country cases and triangulated several sources of data, including a document review, observations of national-level and district level meetings, and key informant interviews in each country and at the global level. Thematic coding was performed in NVivo 12. We find that QCN emerged most quickly and robustly in Bangladesh, followed by Ethiopia, then Uganda, and slowest and with least institutionalization in Malawi. Factors connected to the policy environment and network features explained variance in network emergence. With respect to the policy environment, pre-existing resources and initiatives dedicated to maternal and newborn health and quality improvement, strong data and health system capacity, and national commitment to advancing on synergistic goals were crucial drivers to QCN's emergence. With respect to the features of the network itself, the embedding of QCN leadership in powerful agencies with pre-existing coordination structures and trusting relationships with key stakeholders, inclusive network membership, and effective individual national and local leadership were also crucial in explaining QCN's speed and quality of emergence across countries. Studying QCN emergence provides critical insights as to why well-intentioned top-down global health networks may not materialize in some country contexts and have relatively quick uptake in others, and has implications for a network's perceived legitimacy and ultimate effectiveness in producing stated objectives.

Etiopathogenesis of chronic obstructive pulmonary disease

Considered a major global health challenge, Chronic Obstructive Pulmonary Disease (COPD) has a high incidence and profoundly impacts people's quality of life and health systems. For this reason, this systematic review aims to explain the normal physiological mechanism and, subsequently, address the specific aspects present in COPD in terms of etiopathogenesis.

Dual Perspective Assessment on the Quality of Health System in Rosario, Batangas

Dual Perspective Assessment on the Quality of Health System in Rosario, Batangas

Sexually Transmitted Infection Prevention Services for Women Experiencing Homelessness: A Safety-Net Health System Quality Improvement Initiative.

Consistent use of sexually transmitted infection (STI) prevention methods is proven to decrease transmission of STIs. Yet, rates continue to rise within the US, particularly among high-risk populations. Women experiencing homelessness may face barriers to access reproductive healthcare. This quality improvement (QI) initiative sought to examine perceived barriers to STI prevention and opportunities for expanding STI prevention services and education for women experiencing homelessness. Surveys were administered during a one-day health event in August 2023 at a clinic that predominately serves persons experiencing homelessness in North Texas. Respondents included adult, non-pregnant, English-speaking, individuals assigned female at birth with a history of homelessness. Demographic characteristics, sexual history, participants' knowledge of STIs, and perceived barriers to obtaining sexual health care were gathered. Participants had the opportunity to suggest methods for improving access to STI care. Among participants (n = 36), over half (59%) were tested for STIs within the past year. Most preferred condoms for STI prevention. The average knowledge score among questions about STI transmission and methods of prevention was 65%, with the lowest scores observed among trichomoniasis (39% correct), pre-exposure prophylaxis (PrEP; 31%), and dental dams (25%). Common barriers included cost (33%) and side effects (33%). One-third (36%) of participants reported no barriers to the use of prevention products. Findings highlight the need for educational opportunities among this population to increase knowledge of STI transmission and prevention. Patients may benefit from clinicians emphasizing education and increasing the visibility of services.

Dual Perspective Assessment on the Quality of Health System in Rosario, Batangas

Dual Perspective Assessment on the Quality of Health System in Rosario, Batangas

Men’s Satisfaction with General Health Services is Associated with Future Use of HIV Testing in Malawi: A Community-Representative Survey

Across sub-Saharan Africa, men are less likely to know their HIV status than women, leading to later treatment initiation. Little is known about how experiences with general health services affect men’s use of HIV testing. We used data from a 2019 community-representative survey of men in Malawi to understand frequency and cause of men’s negative health service experiences (defined as men reporting they “would not recommend” a facility) and their association with future HIV testing. We conducted univariable and multivariable logistic regressions to determine which aspects of health facility visits were associated with would-not-recommend experiences and to determine if would-not-recommend experiences 12–24 months prior to the survey were associated with HIV testing in the 12 months prior to the survey. Among 1,098 men eligible for HIV testing in the 12 months prior to the survey, median age was 34 years; 9% of men reported at least one would-not-recommend experience, which did not differ by sociodemographics, gender norm beliefs, or HIV stigma beliefs. The factors most strongly associated with would-not-recommend experiences were cost (aOR 5.8, 95%CI 2.9–11.4), cleanliness (aOR 4.2, 95%CI 1.8–9.9), medicine availability (aOR 3.3, 95%CI 1.7–6.4), and wait times (aOR 2.7, 95%CI 1.5-5.0). Reporting a would-not-recommend experience 12–24 months ago was associated with a 59% decrease in likelihood of testing for HIV in the last 12 months (aOR 0.41; 95% CI:0.17–0.96). Dissatisfaction with general health services was strongly associated with reduced HIV testing. Coverage of high-priority screening services like HIV testing may benefit from improving overall health system quality.

Relationship between health system quality and racial and ethnic equity in diabetes care.

Failing to consider disparities in quality measures, such as by race and ethnicity, may obscure inequities in care, which could exist in facilities with overall high-quality ratings. We examined the relationship between overall quality and racial and ethnic disparities in diabetes care quality by health care facility-level performance on a diabetes-related quality measure within a national dataset of veterans using Veterans Health Administration (VA) ambulatory care between March 1, 2020 and Feburary 28, 2021, and were eligible for diabetes quality assessment. We found racial and ethnic disparities in diabetes care quality existed in top-performing VA medical centers (VAMCs) among American Indian or Alaska Native (AIAN) (predicted probability = 30%), Black (predicted probability = 29%), and Hispanic VA-users (predicted probability = 30%) vs White VA-users (predicted probability = 26%). While disparities among Black and Hispanic VA-users were similar relative to White VA-users across VAMCs at all performance levels, disparities were exacerbated for AIAN and Native Hawaiian or Other Pacific Islander VA-users in bottom-performing VAMCs. Equity remains an issue even in facilities providing overall high-quality care. Integrating equity as a component of quality measures can incentivize greater focus on equity in quality improvement.

Validation of a natural language processing algorithm using national reporting data to improve identification of anesthesia-related ADVerse evENTs: The “ADVENTURE” study

BackgroundReporting and analysis of adverse events (AE) is associated with improved health system learning, quality outcomes, and patient safety. Manual text analysis is time-consuming, costly, and prone to human errors. We aimed to demonstrate the feasibility of novel machine learning and natural language processing (NLP) approaches for early predictions of adverse events and provide input to direct quality improvement and patient safety initiatives. MethodsWe used machine learning to analyze 9559 continuously reported AE by clinicians and healthcare systems to the French National Health accreditor (HAS) between January 1, 2009, and December 31, 2020 . We validated the labeling of 135,000 unique de-identified AE reports and determined the associations between different system's root causes and patient consequences. The model was validated by independent expert anesthesiologists. ResultsThe machine learning (ML) and Artificial Intelligence (AI) model trained on 9559 AE datasets accurately categorized 8800 (88%) of reported AE. The three most frequent AE types were “difficult orotracheal intubation” (16.9% of AE reports), “medication error” (10.5%), and “post-induction hypotension” (6.9%). The accuracy of the AI model reached 70.9% sensitivity, 96.6% specificity for “difficult intubation”, 43.2% sensitivity, and 98.9% specificity for “medication error.” ConclusionsThis unsupervised ML method provides an accurate, automated, AI-supported search algorithm that ranks and helps to understand complex risk patterns and has greater speed, precision, and clarity when compared to manual human data extraction. Machine learning and Natural language processing (NLP) models can effectively be used to process natural language AE reports and augment expert clinician input. This model can support clinical applications and methodological standards and used to better inform and enhance decision-making for improved risk management and patient safety. Trial RegistrationThe study was approved by the ethics committee of the French Society of Anesthesiology (IRB 00010254-2020-20) and the CNIL (CNIL: 118 58 95) and the study was registered with ClinicalTrials.gov (NCT: NCT05185479).

OBSTRUCTIVE SLEEP APNEA – IMPACT ON QUALITY OF LIFE AND HEALTH SYSTEM

Obstructive sleep apnea affects a large proportion of working-age people. It causes symptoms, physical and psychological consequences not only for patients but the entire health sector. Obstructive sleep apnea contributes to the pathogenesis of systemic diseases such as arte­rial hypertension, myocardial infarction, coronary heart disease, or diabetes. A lot of attention is paid to more accurate and patient-oriented diagnostic and treatment methods. Drug-induced sleep endoscopy is one of those instruments. Results of surgical treatment are generally better when surgery is performed on the basis of data collected via drug-induced sleep endoscopy. Also, com­paring the results of sleep endoscopy before and after surgery can be used to evaluate the effectiveness of the procedures performed.

SHORTAGE OF ESSENTIAL MEDICINES DURING THE COVID-19 PANDEMIC: CROSS SECTIONAL STUDY FROM COMMUNITY PHARMACIES

Background: The drug shortage is a very serious issue regarding the quality of Health System of any country. The problem is increased in the pandemic causing serious issues to the health system. Objectives: The objective of current study was to evaluate the factors responsible for the drug shortages in Pakistan and way forward to avoid these problems in the future. Methodology: A cross-sectional observational study was carried out in different cities of Pakistan. An online form was designed after thorough literature review. The study population included Staff pharmacists, Pharmacy managers and pharmacists self-owning pharmacies. Data was then collected, analyzed using SPSS-26. Results: The majority of pharmacists agreed that Global restrictions on trade activities added to drug shortage during COVID-19. The knowledge was relatively higher in pharmacists of Punjab as compared to pharmacists of other provinces. Majority of pharmacist (52%) from Punjab province of Pakistan strongly believed that Provincial drug regulatory department should play its role effectively during the emergency crisis to prevent drug shortages during the pandemic. Conclusion: In order to prevent the problem of drug shortages, efforts should be made to control the factors responsible for the drug shortages and local production should be enhanced along with proper control by regulatory authorities.

Relationship between wait times and postatrial fibrillation ablation outcomes: A population-based study

BackgroundRhythm control is a cornerstone of atrial fibrillation (AF) management. Shorter time between diagnosis of AF and receipt of catheter ablation is associated with greater rates of therapy success. Previous work considered diagnosis-to-ablation time as a binary or categorical variable and did not consider the unique risk profile of patients after a referral for ablation was made. ObjectiveThe purpose of this study was to comprehensively assess the impact of diagnosis-to-ablation and referral-to-ablation time on postprocedural outcomes at a population level. MethodsThis observational cohort study included patients who received catheter ablation to treat AF in Ontario, Canada. Patient demographics, medical comorbidities, AF diagnosis date, ablation referral date, and ablation date were collected. The primary outcomes of interest included a composite of death and hospitalization/emergency department visit for AF, heart failure, or ischemic stroke. Multivariable Cox models assessed the impact of diagnosis-to-ablation and referral-to-ablation times on the primary outcome. ResultsOur cohort included 7472 patients who received ablation for de novo AF between April 1, 2016, and March 31, 2022. Median [interquartile range] diagnosis-to-ablation time was 718 [399–1274] days and median referral-to-ablation time was 221 [117–363] days. Overall, 911 patients (12.2%) had the composite endpoint within 1 year of ablation. Increasing diagnosis-to-ablation time was associated with a greater incidence for the primary outcome (hazard ratio [HR]1.02; 95% confidence interval [CI] 1.01–1.02 per month). Increasing referral-to-ablation time did not impact the primary outcome (HR 1.00; 95% CI 0.98–1.01 per month). ConclusionDelays between AF diagnosis and ablation referral may contribute to adverse postprocedural outcomes and provide an opportunity for health system quality improvements.

A new scale to assess health-facility level management: the development and validation of the facility management scale in Ghana, Uganda, and Malawi

BackgroundThe increased recognition of governance, leadership, and management as determinants of health system performance has prompted calls for research focusing on the nature, quality, and measurement of this key health system building block. In low- or middle-income contexts (LMIC), where facility-level management and performance remain a challenge, valid tools to measure management have the potential to boost performance and accelerate improvements. We, therefore, sought to develop a Facility-level Management Scale (FMS) and test its reliability in the psychometric properties in three African contexts.MethodsThe FMS was administered to 881 health workers in; Ghana (n = 287; 32.6%), Malawi (n = 66; 7.5%) and Uganda (n = 528; 59.9%). Half of the sample data was randomly subjected to exploratory factor analysis (EFA) and Monte Carlo Parallel Component Analysis to explore the FMS’ latent structure. The construct validity of this structure was then tested on the remaining half of the sample using confirmatory factor analysis (CFA). The FMS’ convergent and divergent validity, as well as internal consistency, were also tested.ResultsFindings from the EFA and Monte Carlo PCA suggested the retention of three factors (labelled ‘Supportive Management’, ‘Resource Management’ and ‘Time management’). The 3-factor solution explained 51% of the variance in perceived facility management. These results were supported by the results of the CFA (N = 381; χ2 = 256.8, df = 61, p < 0.001; CFI = 0.94; TLI = 0.92; RMSEA [95% CI] = 0.065 [0.057–0.074]; SRMR = 0.047).ConclusionThe FMS is an open-access, short, easy-to-administer scale that can be used to assess how health workers perceive facility-level management in LMICs. When used as a regular monitoring tool, the FMS can identify key strengths or challenges pertaining to time, resources, and supportive management functions at the health facility level.

Mitigating the impact of COVID-19 on primary healthcare interventions for the reduction of under-5 mortality in Bangladesh: Lessons learned through implementation research.

The COVID-19 pandemic posed unprecedented challenges and threats to health systems, particularly affecting delivery of evidence-based interventions (EBIs) to reduce under-5 mortality (U5M) in resource-limited settings such as Bangladesh. We explored the level of disruption of these EBIs, strategies and contextual factors associated with preventing or mitigating service disruptions, and how previous efforts supported the work to maintain EBIs during the pandemic. We utilized a mixed methods implementation science approach, with data from: 1) desk review of available literature; 2) existing District Health Information System 2 (DHIS2) in Bangladesh; and 3) key informant interviews (KIIs), exploring evidence on changes in coverage, implementation strategies, and contextual factors influencing primary healthcare EBI coverage during March-December 2020. We used interrupted time series analysis (timeframe January 2019 to December 2020) using a Poisson regression model to estimate the impact of COVID-19 on DHIS2 indicators. We audio recorded, transcribed, and translated the qualitative data from KIIs. We used thematic analysis of coded interviews to identify emerging patterns and themes using the implementation research framework. Bangladesh had an initial drop in U5M-oriented EBIs during the early phase of the pandemic, which began recovering in June 2020. Barriers such as lockdown and movement restrictions, difficulties accessing medical care, and redirection of the health system's focus to the COVID-19 pandemic, resulted in reduced health-seeking behavior and service utilization. Strategies to prevent and respond to disruptions included data use for decision-making, use of digital platforms, and leveraging community-based healthcare delivery. Transferable lessons included collaboration and coordination of activities and community and civil society engagement, and investing in health system quality. Countries working to increase EBI implementation can learn from the barriers, strategies, and transferable lessons identified in this work in an effort to reduce and respond to health system disruptions in anticipation of future health system shocks.

Worker's Compensation Injury and Illness Care: A Global Round Table.

Work-related injuries and diseases have a significant impact on workers and their families, society, and the economy. There is a gap in the literature regarding the structures, content, quality, and outcomes of international occupational health systems serving injured and ill workers. This global round table was an attempt to elucidate, evaluate, and identify areas needing improvement. International occupational health professionals were identified via chain/snowball sampling and asked to answer five questions designed to evaluate the structures, processes, and outcomes of the workers' compensation systems in each country. Areas for improvement identified during this round table included timely access, reducing the impact of liability and eligibility determinations on access to medical care, equitable access to care, and the accuracy of reporting. Canada had successfully utilized a virtual approach to care for the geographically remote worker. International workers' compensation structures are designed to ensure timely access to quality care and services. Financial incentives optimize the safety of the working environment. There remain areas for improvement. Resources are limited, especially within the public health systems, which may delay care and affect quality. Informal and remote workers often do not have the same access to care. Occupational Health Services (OHS) and national reporting databases exist throughout the world but may not accurately capture data on informal, self-employed, small business, migrant, and remote workers.