Targets For Quality Improvement Research Articles

A quality improvement project on reducing antibiotic use duration in very low birth weight preterm infants in the neonatal intensive care unit

To develop effective measures to reduce antibiotic use duration in very low birth weight (VLBW) preterm infants in the neonatal intensive care unit through quality improvement methods. The study population consisted of hospitalized VLBW preterm infants, with the percentage of hospitalization time during which antibiotics were used from November 2020 to June 2021 serving as the baseline. The specific quality improvement goal was to reduce the duration of antibiotic use. Factors affecting antibiotic use duration in preterm infants were analyzed using Pareto charts. Key drivers were identified, and specific interventions were formulated based on the stages of antibiotic use. Changes in the percentage of antibiotic use duration were monitored with run charts until the quality improvement target was achieved. From November 2020 to June 2021, the baseline antibiotic use duration percentage was 49%, with a quality improvement target to reduce this by 10% within 12 months. The Pareto analysis indicated that major factors influencing antibiotic duration included non-standard antibiotic use; delayed cessation of antibiotics when no infection evidence was present; prolonged central venous catheter placement; insufficient application of kangaroo care; and delayed progress in enteral nutrition. The interventions implemented included: (1) establishing sepsis evaluation and management standards; (2) educating medical staff on the rational use of antibiotics for preterm infants; (3) supervising the enforcement of antibiotic use standards during ward rounds; (4) for those without clear signs of infection and with negative blood cultures, discontinued the use of antibiotics 36 hours after initiation; (5) reducing the duration of central venous catheterization and parenteral nutrition to lower the risk of infection in preterm infants. The control chart showed that with continuous implementation of interventions, the percentage of antibiotic use duration was reduced from 49% to 32%, a statistically significant decrease. The application of quality improvement tools based on statistical principles and process control may significantly reduce the antibiotic use duration in VLBW preterm infants. Citation:Chinese Journal of Contemporary Pediatrics, 2024, 26(7): 736-742.

Outcomes after gastrectomy according to the Gastrectomy Complications Consensus Group (GCCG) in the Dutch Upper GI Cancer Audit (DUCA)

Abstract Background In 2019, the Gastrectomy Complications Consensus Group (GCCG) published a standardized set of complications aiming toward uniform reporting of post-gastrectomy complications. This study aimed to report outcomes after gastrectomy in the Netherlands according to GCCG definitions and compare them to previously reported national results and the European database reported by the GCCG. Methods This nationwide, population-based cohort study included all patients undergoing gastrectomy for gastric cancer registered in the DUCA in 2020–2021. Postoperative morbidity and 30-day/in-hospital mortality were analyzed according to the GCCG definitions. For all patients, baseline characteristics and outcomes were compared with the GCCG cohort consisting of 27 European expert centers (GASTRODATA; 2017–2018). Results In 2020–2021, 782 patients underwent gastrectomy in the Netherlands. Variation was seen in baseline characteristics between the Dutch and the GCCG cohort (N = 1349), most notably in minimally invasive surgery (80.6% vs 19.6%, p < 0.001). In the Netherlands, 223 (28.5%) patients developed a total of 407 complications, the most frequent being non-surgical infections (28.5%) and anastomotic leakage (13.4%). The overall complication and 30-day mortality rates were similar between the Dutch and GCCG cohort (28.5% vs 29.8%, p = 0.563; 3.7% vs 3.6%, p = 0.953). Higher surgical and endoscopic/radiologic reintervention rates were observed in the Netherlands compared to the GCCG cohort (10.7% vs 7.8%, p = 0.025; 10.9% vs 2.9%, p < 0.001). Conclusion Reporting outcomes according to the standardized GCCG definitions allows for international benchmarking. Postoperative outcomes were comparable between Dutch and GCCG cohorts, but both exceed the international benchmark for expert gastrectomy care, highlighting targets for national and international quality improvement.

Sex Disparities After Coronary Artery Bypass Grafting and Hospital Quality

Concern has been raised about persistent sex disparities after coronary artery bypass grafting, with female patients having higher mortality. However, whether these disparities persist across hospitals of different qualities is unknown. To evaluate sex disparities in 30-day mortality after coronary artery bypass grafting across high- and low-quality hospitals. This cross-sectional, retrospective cohort study evaluated Medicare beneficiaries undergoing coronary artery bypass grafting between October 1, 2015, and March 31, 2020. Data analysis was performed from July 1, 2023, to December 1, 2023. The primary exposures were hospital quality and sex. For hospital quality, hospitals were placed into rank order by their overall risk-adjusted mortality rate and divided into quintiles. Risk-adjusted 30-day mortality using a logistic regression model accounting for patient factors, including sex, age, comorbidities, elective vs unplanned admission, number of bypass grafts, use of arterial graft, and year of surgery. A total of 444 855 beneficiaries (mean [SD] age, 71.5 [7.5] years; 120 333 [27.1%] female and 324 522 [72.9%] male) were studied. Compared with male beneficiaries, female beneficiaries were more likely to have an unplanned admission (66 425 [55.2%] vs 157 895 [48.7%], P < .001) and receive care at low-quality (vs high-quality) hospitals (odds ratio, 1.26; 95% CI, 1.23-1.29; P < .001). Overall, risk-adjusted female mortality was 4.24% (95% CI, 4.20%-4.27%), and male mortality was 2.75% (95% CI, 2.75%-2.77%), with an absolute difference of 1.48 (95% CI, 1.45-1.51) percentage points (P < .001). At the highest-quality hospitals, male mortality was 1.57% (95% CI, 1.56%-1.59%), and female mortality was 2.58% (95% CI, 2.54%-2.62%), with an absolute difference of 1.01 (95% CI, 0.97-1.04) percentage points (P < .001). At the lowest-quality hospitals, male mortality was 4.94% (95% CI, 4.88%-5.01%), and female mortality was 7.02% (95% CI, 6.90%-7.13%), with an absolute difference of 2.07 (95% CI, 1.95-2.19) percentage points (P < .001). Female beneficiaries receiving care at low-quality hospitals had a higher mortality than male beneficiaries receiving care at the high-quality hospitals (7.02% vs 1.57%, P < .001). In this cohort study of Medicare beneficiaries undergoing coronary artery bypass grafting, female beneficiaries were more likely to receive care at low-quality hospitals, where the sex disparity in mortality was double that of high-quality hospitals. Quality improvement targeting low-quality hospitals as well as equitable referral of female beneficiaries to higher-quality hospitals may narrow the sex disparity after coronary artery bypass grafting.

Improving symptom screening rates for patients with head and neck cancer.

e23246 Background: Effective symptom management in cancer care relies on regular and accurate reporting using validated patient-reported outcome measures (PROMs), such as the Edmonton Symptom Assessment System (ESAS). The ESAS measures nine common cancer symptoms, rating them on a scale from 0 to 10 to improve monitoring and communication regarding patient symptoms and prevent adverse outcomes such as emergency department visits. There is a need to enhance completion rates to ensure that head and neck cancer (HNC) symptoms are effectively addressed. High completion rates provide valuable data for cancer centers and clinicians to intervene early and support patients through their cancer journey. This makes it an important target for quality improvement (QI) with wide-ranging implications for patient outcomes and care quality. Our objectives were to: Investigate underlying reasons for poor ESAS completion rates. Lay the groundwork for strategic interventions aimed at bolstering symptom screening among HNC patients. Methods: This was a QI project targeting the HNC patient population at a regional cancer centre (RCC). Our approach included stakeholder engagement meetings alongside the expertise of QI specialists. Comprehensive data collection was conducted to analyze symptom screening rates and identify potential barriers to ESAS completion. We tracked ESAS completion on weekly HNC clinic days from 2022-2023 via manual and automated chart abstraction. Patient, staff, and volunteer interviews, along with direct clinic observations, provided data for Ishikawa diagrams, facilitating a root cause analysis. Results: We identified a marked decline in ESAS completion rates, steadily decreasing from an average of 29.4% during the 2022-2023 fiscal year to an average of 7.6% between April-November 2023, with rates dropping as low as 3.3% in September 2023. Root cause analysis pinpointed several barriers to ESAS completion, including the transition from paper-based assessments used during the pandemic to electronic formats, low patient awareness of the purpose of symptom screening, perceived lack of value in screening by patients and staff, and the absence of direct guidance from staff in helping patients complete their ESAS. Variable communication practices and inconsistencies in registration staff directing patients to kiosks was also observed. Improving infrastructure and support for volunteer services was identified as a potential solution, which may optimize their effectiveness in symptom screening roles. Conclusions: The project has laid the foundation for targeted QI interventions aimed at improving ESAS screening adherence. By addressing the identified barriers, this work endeavors to re-engage patients in active symptom reporting and to integrate this critical aspect of care into the daily routine of the outpatient hospital setting, thereby enhancing the overall management of HNC symptoms.

Disparities in awareness and treatment among women with hypertension: Insights from the American Heart Association Research Goes Red Registry

Hypertension is an important modifiable risk factor for cardiovascular disease and affects nearly one-third of women in the U.S. Prior research has demonstrated declining rates of blood pressure (BP) control nationally among women, and there are significant racial and ethnic disparities in both hypertension prevalence and outcomes among U.S. women. However, national-level data on attitudes and awareness of women with hypertension are limited. To address this gap, data were analyzed from participants with self-reported hypertension enrolled in the American Heart Association's Research Goes Red Registry. Of 6170 women who responded as of February 2023, 1835 (30 %) reported a history of hypertension. The top health concerns reported among women with hypertension were weight, healthcare access and costs, and hypertension. Health concerns varied significantly by age, race, and ethnicity; younger women and Black and Hispanic women were more likely to report hypertension as their top concern. Among women with self-reported hypertension, 77 % reported knowing their BP, and 90 % reported being on an anti-hypertensive. Black and Hispanic women were less likely to know their BP compared to White women. Younger women were less likely to be treated for hypertension, and there were also disparities in treatment by employment status and among uninsured women. In this national registry of women in the U.S., gaps and disparities exist in awareness and treatment of hypertension, highlighting targets for quality improvement in hypertension care for women.

Increasing Adoption of Left Atrial Appendage Occlusion in Isolated Coronary Artery Bypass Grafting

Recent randomized trial data showed fewer strokes with left atrial appendage occlusion (LAAO) following cardiac surgery in patients with atrial fibrillation. We developed a quality initiative to increase LAAO adoption. Among 11,099 patients undergoing isolated CABG between January 2019-March 2021 at 33 hospitals in Michigan, those with atrial fibrillation undergoing first-time, on-pump CABG were eligible (n=1,241). A goal LAAO rate of 75% was selected as a quality improvement target through a statewide collaborative. An interrupted time series analysis evaluated the change in LAAO rate before (January-December 2019) versus after (January 2020-March 2021) implementation. Implementation of the quality metric improved LAAO rate from 61% (357/581) before to 79% (520/660) after implementation (p<0.001). Compared to patients not undergoing concomitant LAAO, LAAO patients (71%, 877/1,241) were older, more frequently male, and had a lower STS-PROM (2.9±3.5% vs. 3.7±5.7%, p=0.003), while other baseline characteristics including CHA2DS2-VASc scores were similar. Mean bypass and cross-clamp times were 7 and 6 minutes longer, respectively, in the LAAO group among those who did not undergo concomitant ablation. Operative mortality, major morbidity, blood product administration, and thromboembolic events were similar between groups. Interrupted time series analysis showed a significant increase in LAAO rate after implementation (p=0.009). LAAO in patients with atrial fibrillation undergoing isolated CABG did not add operative risk versus isolated CABG without LAAO. A statewide quality improvement initiative was successful in increasing the rate of concomitant LAAO and could be further evaluated as a potential quality metric in cardiac surgery.

Reducing postoperative hypothermia in infants: Quality improvement in China.

Unintended postoperative hypothermia in infants is associated with increased mortality and morbidity. We noted consistent hypothermia postoperatively in more than 60% of our neonatal intensive care (NICU) babies. Therefore, we set out to determine whether a targeted quality improvement (QI) project could decrease postoperative hypothermia rates in infants. Our SMART aim was to reduce postoperative hypothermia (<36.5°C) in infants from 60% to 40% within 6 months. This project was approved by IRB at Guangzhou Women and Children's Medical Center, China. The QI team included multidisciplinary healthcare providers in China and QI experts from Children's Hospital of Philadelphia, USA. The plan-do-study-act (PDSA) cycles included establishing a perioperative-thermoregulation protocol, optimizing the transfer process, and staff education. The primary outcome and balancing measures were, respectively, postoperative hypothermia and hyperthermia (axillary temperature < 36.5°C, >37.5°C). Data collected was analyzed using control charts. The factors associated with a reduction in hypothermia were explored using regression analysis. There were 295 infants in the project. The percentage of postoperative hypothermia decreased from 60% to 37% over 26 weeks, a special cause variation below the mean on the statistical process control chart. Reduction in hypothermia was associated with an odds of 0.17 (95% CI: 0.06-0.46; p <.001) for compliance with the transport incubator and 0.24 (95% CI: 0.1-0.58; p =.002) for prewarming the OR ambient temperature to 26°C. Two infants had hyperthermia. Our QI project reduced postoperative hypothermia without incurring hyperthermia through multidisciplinary team collaboration with the guidance of QI experts fromthe USA.

Organizational Context and Facilitation Interactions on Delirium Risk in Long-Term Care: A Cross-Sectional Study

ObjectivesOrganizational context (eg, leadership) and facilitation (eg, coaching behaviors) are thought to interact and influence staff best practices in long-term care (LTC), including the management of delirium. Our objective was to assess if organizational context and facilitation—individually, and their interactions—were associated with delirium in LTC. DesignRetrospective cross-sectional analysis of secondary data. Setting and ParticipantsWe included 8755 residents from 281 care units in 86 LTC facilities in 3 Canadian provinces. MethodsDelirium (present/absent) was assessed using the Resident Assessment Instrument-Minimum Data Set 2.0 (RAI-MDS 2.0). The Alberta Context Tool (ACT) measured 10 modifiable features of care unit organizational context. We measured the care unit's total care hours per resident day and the proportion of care hours that care aides contributed (staffing mix). Facilitation included the facility manager's perception of RAI-MDS reports' adequacy and pharmacist availability. We included unit managers' change-oriented organizational citizenship behavior (OCB) and an item reflecting how often care aides recommended policy changes. Associations of organizational context, facilitation, and their interactions with delirium were analyzed using mixed-effects logistic regressions, controlling for covariates. ResultsDelirium symptoms were prevalent in 17.4% of residents (n = 1527). Manager-perceived adequacy of RAI-MDS reports was linked to reduced delirium symptoms [odds ratio (OR) = 0.63]. Higher care hours per resident day (OR = 1.2) and an available pharmacist in the facility (OR = 1.5) were associated with increased delirium symptoms. ACT elements showed no direct association with delirium. However, on care units with low social capital scores (context), increased unit managers' OCB decreased delirium symptoms. On care units with high vs low evaluation scores (context), increased staffing mix reduces delirium symptoms more substantially. Conclusions and ImplicationsUnit-level interactions between organizational context and facilitation call for targeted quality improvement interventions based on specific contextual factors, as effectiveness may vary across contexts.

Quality improvement and outcomes for neonates with hypoxic-ischemic encephalopathy: obstetrics and neonatal perspectives

Despite significant improvement in perinatal care and research, hypoxic ischemic encephalopathy (HIE) remains a global healthcare challenge. From both published research and reports of QI initiatives, we have identified a number of distinct opportunities that can serve as targets of quality improvement (QI) initiatives focused on reducing HIE. Specifically, (i) implementation of perinatal interventions to anticipate and timely manage high-risk deliveries; (ii) enhancement of team training and communication; (iii) optimization of early HIE diagnosis and management in referring centers and during transport; (iv) standardization of the approach when managing neonates with HIE during therapeutic hypothermia; (v) and establishment of protocols for family integration and follow-up, have been identified as important in successful QI initiatives. We also provide a framework and examples of tools that can be used to support QI work and discuss some of the perceived challenges and future opportunities for QI targeting HIE.

Prevalence of Antibiotic Prescription in Primary Healthcare Settings in the Municipality of Prishtina, Kosovo

Background: Antibiotics remain among the most prescribed drugs in primary healthcare, contributing to increased antibiotic resistance in the community and prevailing as an emerging global health concern. We aimed to quantify the prevalence and quality of antibiotic prescription in primary healthcare settings in the Municipality of Prishtina to identify targets for quality improvement.Methods and Results: This study represents a population-based, retrospective cohort, including data from eight randomly selected family medical centers in the Municipality of Prishtina. Each 150th patient on medical records was assessed for demographic data, diagnosis (ICD-10), antibiotic prescription, antibiotic class, and antibiotic form. In total, the study included 1614 cases reviewed. The antibiotic prescription rate was 16%. The health condition for which most of the cases received antibiotics was J18 - Pneumonia, unspecified organism (67%), followed by J03 - Acute tonsillitis (54%), J42 - Unspecified chronic bronchitis (46%), and N39 - Other disorders of the urinary system (43%) Broad-spectrum antibiotics, such as co-amoxiclav (17.7%), amoxicillin (16.5%), and ceftriaxone (12.6%), featured among the most routinely prescribed antibiotics. The antibiotic prescription rate was the highest for cases in the 3-5 age group, of whom 27% received an antibiotic prescription. In 73% of cases, oral antibiotics were prescribed, 69% of which belong to the WHO AWaRe (Access, Watch, Reserve) essential medicines list. Only 18% of antibiotics were prescribed with their generic names. Conclusion: The prevalence of antibiotic prescription in primary healthcare settings in Prishtina is moderately low. These data cannot be extrapolated to other municipalities in Kosovo or other countries due to different organizational levels. High antibiotic prescription rates for young age groups, prescription of broad-spectrum antibiotics, and high rates of parenteral antibiotics were identified as targets for quality improvement.

Full adherence to cirrhosis quality indicators is associated with lower mortality in acute variceal bleeding: Nationwide audit.

Acute variceal bleeding (AVB) is a major complication in cirrhosis patients. Using a nationwide AVB audit, we performed a nested cohort study to determine whether full adherence to the AVB quality indicator (QI) improves clinical outcomes in patients with cirrhosis and AVB. We assessed real-world adherence to AVB QI among patients with cirrhosis admitted for AVB in all public hospitals in Singapore between January 2015 and December 2020. Full adherence was considered when all five QIs were fulfilled: prophylactic antibiotics, vasoactive agents, timely endoscopy, endoscopic hemostasis during index endoscopy, and nonselective beta-blockers after AVB. We compare 6-weeks mortality between the full adherence and suboptimal adherence groups using a propensity-matched cohort. A total of 989 patients with AVB were included. Full adherence to all AVB QI was suboptimal (56.5%). Analysis of the propensity-matched cohort with comparable baseline characteristics showed that full adherence was associated with a lower risk of early infection (20.0% vs. 26.9%), early rebleeding (5.2% vs. 10.2%), and mortality at 6-week (8.2% vs. 19.7%) and 1 year (21.3% vs. 35.4%) (p<0.05 for all). While full adherence was associated with a lower 6-week mortality regardless of the MELD score, non-adherence was associated with a higher 6-week mortality despite a lower predicted risk of 6-week mortality. Despite high adherence with the recommended process measures, patients with CTP-C remain at a higher risk of rebleeding, 6-week and 1-year mortality. Full adherence to the AVB QI should be the target for quality improvement in patients with cirrhosis.

Identifying Age-Specific Risk Factors for Poor Outcomes After Trauma With Machine Learning

IntroductionRisk stratification for poor outcomes is not currently age-specific. Risk stratification of older patients based on observational cohorts primarily composed of young patients may result in suboptimal clinical care and inaccurate quality benchmarking. We assessed two hypotheses. First, we hypothesized that risk factors for poor outcomes after trauma are age-dependent and, second, that the relative importance of various risk factors are also age-dependent. MethodsA cohort study of severely injured adult trauma patients admitted to the intensive care unit 2014-2018 was performed using trauma registry data. Random forest algorithms predicting poor outcomes (death or complication) were built and validated using three cohorts: (1) patients of all ages, (2) younger patients, and (3) older patients. Older patients were defined as aged 55 y or more to maintain consistency with prior trauma literature. Complications assessed included acute renal failure, acute respiratory distress syndrome, cardiac arrest, unplanned intubation, unplanned intensive care unit admission, and unplanned return to the operating room, as defined by the trauma quality improvement program. Mean decrease in model accuracy (MDA), if each variable was removed and scaled to a Z-score, was calculated. MDA change ≥4 standard deviations between age cohorts was considered significant. ResultsOf 5489 patients, 25% were older. Poor outcomes occurred in 12% of younger and 33% of older patients. Head injury was the most important predictor of poor outcome in all cohorts. In the full cohort, age was the most important predictor of poor outcomes after head injury. Within age cohorts, the most important predictors of poor outcomes, after head injury, were surgery requirement in younger patients and arrival Glasgow Coma Scale in older patients. Compared to younger patients, head injury and arrival Glasgow Coma Scale had the greatest increase in importance for older patients, while systolic blood pressure had the greatest decrease in importance. ConclusionsSupervised machine learning identified differences in risk factors and their relative associations with poor outcomes based on age. Age-specific models may improve hospital benchmarking and identify quality improvement targets for older trauma patients.

Facility-Level Variation in Racial Disparities in Anticoagulation for Atrial Fibrillation: The REACH-AF Study.

Oral anticoagulation reduces stroke risk for patients with atrial fibrillation (AF). Prior research demonstrates lower anticoagulant prescribing in Black than in White individuals but few studies have examined racial differences in facility-level anticoagulant prescribing for AF. To assess variation in anticoagulant initiation by race within Veterans Health Administration (VA) facilities. Retrospective cohort study. Black and White patients enrolled in the VA with incident AF from 2020 through 2021. The primary outcome was rate of any anticoagulant initiation (i.e., warfarin or direct oral anticoagulant [DOAC]) or any DOAC therapy within 90days of an AF diagnosis, overall and for Black and White patients at each facility. We also estimated the adjusted Black-White risk difference. In 82 VA facilities serving 26,832 Black and White patients, overall unadjusted rates of any anticoagulant therapy ranged from 56.8 to 87.1% across facilities; the corresponding ranges for Black and White patients were 47.6 to 91.3% and 58.2 to 87.1%, respectively. Overall unadjusted rates of DOAC therapy ranged from 55.1 to 85.5% by facility; ranges for Black and White patients were 42.8 to 86.9% and 56.4 to 85.5%, respectively. The adjusted risk difference between Black and White patients ranged from - 29.9 (95% CI, - 54.9 to - 4.8) to 14.2 (95% CI, - 9.1 to 25.0) across facilities for any anticoagulant therapy and from - 28.8 (95% CI, - 58.3 to 0.8) to 15.0 (95% CI, - 8.0 to 38.1) for DOAC therapy.For any anticoagulant therapy there were 3 facilities where prescribing was statistically higher in White than Black patients; for DOAC therapy there were 5 such facilities. In a national cohort of patients with AF, we observed large facility-level variation and adjusted risk differences in any anticoagulant and DOAC initiation, overall and by race. These findings represent a target for local quality improvement in AF care.

Collateral Benefit of Systematic Improvement in Bariatric Surgery Outcomes Following a Single Quality Improvement Project for Bleeding.

The study's aim was not only to use quality improvement system techniques to improve patient care specifically for bleeding but also to track other adverse outcomes. Key drivers were identified and mapped to interventions, namely venous thromboembolism prophylaxis, root cause analysis, indications conference, and operative technique standardization. Bleeding was reduced by 88%, and overall postoperative complications also fell by 63%. A targeted quality improvement project not only was effective in improving outcomes for the specific aim of bleeding but also resulted in improvement for other patient outcomes.

A pilot study to evaluate the quality of care in oral anticoagulant and antiplatelet use in patients with permanent atrial fibrillation in Irish general practice

Abstract Aim: The aim of this pilot study is to determine the pattern of oral anticoagulant and antiplatelet use in patients with permanent atrial fibrillation (AF) in Irish general practice. Background: Worldwide, AF is the most common sustained cardiac arrhythmia in adults and poses a significant burden to patients, physicians and healthcare systems. There is a five-fold increased risk of stroke with AF, and AF-related strokes are associated with higher levels of both morbidity and mortality compared to other stroke subtypes. Thankfully, appropriate use of oral anticoagulation (OAC) for AF can reduce the risk of stroke by up to 64%. However, we know that patients are commonly undertreated with OAC, prescribed inappropriate doses of OAC and have prolonged use of an antiplatelet agent in addition to OAC without indication. Methods: A descriptive, cross-sectional observational study was undertaken. Proportionate sampling was used across 11 practices from the Ireland East practice-based research network. The general practitioners completed a report form on each patient provided by the research team by undertaking a retrospective chart review. Findings: Eleven practices participated with a total number of 1855 patients with AF. We received data on 153 patients. The main findings from this pilot project are that: 1. 11% of patients were undertreated with OAC 2. 20 % of patients were on an incorrect non-vitamin K antagonist oral anticoagulant dose 3. 28 patients (18%) were inappropriately prescribed combination antithrombotic therapy Undertreatment and underdosing of OAC expose patients to higher risk of thromboembolic events, bleeding and all-cause mortality. Prolonged combination antithrombotic therapy is associated with serious increased risk of bleeding with no additional stroke protection. This pilot project highlights several gaps between guidelines and clinical practice. By identifying these areas, we hope to develop a targeted quality improvement intervention using the electronic health records in general practice to improve the care that those with AF receive.

Paths to low-carbon development in China: The role of government environmental target constraints

Research background: To achieve the targets for carbon peak and air quality improvement, local governments should propose environmental targets and develop realization paths that are tailored to their unique local conditions. They then promote low-carbon development through the implementation of multiple measures. Purpose of the article: As the government performance appraisal system im-proves, the question arises as to whether governments take the initiative to com-bine environmental policies with government target constraints to reduce carbon emissions. Methods: The announcement of environmental target constraints by local governments in government work reports is considered a quasi-natural experiment. This study examines the effect of government environmental target constraints (GETC) on carbon emissions (CEs) using differences-in-differences (DID), propensity score matching-DID (PSM-DID), and spatial-DID (SDID) with data from 241 Chinese cities from 2003 to 2019. Findings &amp; value added: The results demonstrate that GETC can effectively reduce local CEs, with the inhibitory effect being most effective in the first two years after setting environmental targets, but diminishing in the third year. GETC can reduce local CEs through three paths: reducing energy consumption, promoting industrial structure optimization, and encouraging green technology innovation. Spatial spillover effects show that GETC reduces local CEs while exacerbating CEs in neighboring cities, indicating a beggar-thy-neighbor effect in conventional environmental regulation policy. This effect is observed mainly in the geographic matrix and the economic-geographic matrix, but not in the economic matrix. According to heterogeneity analysis, GETC in the eastern and central cities can significantly reduce CEs. The inhibitory effect of GETC on local CEs is stronger in cities where secretaries and mayors have longer tenures and higher levels of education. The paper's theoretical value lies in exploring the reduction of CEs through the combination of government self-restraint and environmental policies, providing a new solution for local governments to achieve CEs reduction. Furthermore, it offers practical insights into the improvement of the Chinese government assessment system.

Using the settings approach to health promotion in hospital and health services to support collaboration, engagement, and partnership in integrated care systems.

Introduction: Hospitals and health services within integrated care systems can implement the 2020 Standards for Health Promoting Hospitals and Health Services to promote the mutual values reflected in the nine pillars of integrated care, such as shared vision and multisectoral action, improving population health, people-centered care, community participation, staff health, leadership, and quality improvement. After the impact of the COVID-19 pandemic, a shift towards these shared values is needed to better address burnout and a decreasing workforce.&#x0D; Intervention: The International Network of Health Promoting Hospitals &amp; Health Services’ (HPH) 600 members from 33 countries work towards supporting the integration of health promotion into the organizational structure and culture of organizations to create health promoting settings. To operationalize this vision and guide decision makers in transforming their institutions into settings that support collaboration, engagement, and partnership, the 2020 Standards for Health Promoting Hospitals and Health Services and complimentary Self-Assessment tools were conceived. &#x0D; Five overarching standards, 18 substandards, and 86 standard statements resulted from a methodological consolidation of existing HPH standards (addressing equity, mental health, the environment, health literacy, patient-centered care, groups such as the elderly, children, and adolescents) and from two Delphi consultation rounds with HPH subject experts. The standards reflect over 30 years of knowledge and international experience in health promotion implementation across various areas of policy, practice, and evidence within the International HPH Network. Complementary self-assessment tools, developed with input from 14 countries, can be used to identify key members of multidisciplinary steering teams, to compare data and monitor progress, and develop targeted quality improvement plans based on data collected. Currently, the Standards are available in 11 languages on the HPH website.&#x0D; Outcomes: Hospitals and health services who adopt a comprehensive health promotion approach are agile, better able to respond to challenges and are receptive to change. During Delphi consultation rounds to define the standards, high ratings of relevance were given to population health needs, organizational commitment, and environmental health amongst countries contributing to the design of the Standards. The standards, therefore, strongly focus on organizational collaboration; engagement of patients, family, staff, and the community; and building alliances and partnerships between stakeholders along a patients’ care pathway. Organizations adopting this holistic approach are efficient, leading to better health outcomes, satisfaction for all involved, and lower costs, which are shared aims of integrated care. Health promoting settings are supportive of integrated care and can be implemented as a first step in a system-wide transformation. &#x0D;

Population analysis of temporal trends and between-hospital variation in mortality, readmission and prolonged length-of-stay between 2008 and 2018: improving integrated care by knowledge sharing of hospitals’ care progress

Background: Despite the benefits of studying multiple patient outcomes together, research on between-hospital variation has often focused on single outcomes or disease-specific study populations. In the study we would like to present, we examined nationwide temporal trends and between-hospital variation in three important patient outcomes: (1) in-hospital mortality as a pinnacle measure of patient safety; (2) 30-day readmissions as an accountability measure for hospitals; and (3) prolonged length-of-stay, i.e. a length-of-stay above the All-Patient-Refined Diagnoses-Related-Group (APR-DRG)-specific 90th percentile (pLOS) because of its correlations with complications and costs of care.&#x0D; Who is it for: This study is highly relevant for both clinicians and policymakers on hospital and governmental level. &#x0D; Methods: In this observational study, we made use of a large administrative dataset that is today primarily used for financial purposes (Minimum Hospital Data). We modelled 13,660,187 admissions between 2008 and 2018 in 90 (89%) Belgian acute-care hospitals using APR-DRG-specific logistic regression. We studied temporal trends in outcomes, hospital-level associations between outcomes, associations of outcomes with hospitals characteristics, and evaluated how many and which APR-DRGs explained between-hospital variation. &#x0D; Findings: Between 2008 and 2018, average standardised mortality decreased from 3.4% to 3.1% and pLOS from 10.6% to 8.1%, with significant decreases observed for 181 (out of 243) and 216 (out of 247) APR-DRGs respectively. Readmissions, however, increased from 4.8% to 5.2%. Pearson correlations between rates in 2008 and 2018 were 0.53, 0.49, and 0.74 for mortality, readmission, and pLOS, respectively. Apart from the positive correlation between mortality and pLOS (ρ=0.46), no associations between outcomes were observed in 2018. For many APR-DRGs, the odds of mortality and pLOS were higher in Brussels and Wallonia than in Flanders and higher for general than for academic hospitals, whereas the opposite was observed for readmissions. We discovered that hospitals that performed well in 2008 continued to outperform other hospitals in 2018. Finally, we found that the significance of standardised outcomes seemed to be driven by a considerable number of APR-DRGs. For instance, hospitals with pLOS higher than expected had on average (range) 61 (25-142) APR-DRGs with significantly elevated pLOS.&#x0D; Interpretation: Between-hospital variation in outcomes is likely due to systemic hospital factors, rather than due to specific clinical groups. This urges a healthcare policy reform wherein longitudinal follow-up and benchmarking of outcomes should become the starting point towards targeted quality improvement interventions. As we will demonstrate during this presentation, using administrative data can be a valuable tool for this longitudinal follow-up, as it requires no additional workload, is readily available and reliable when applying adequate statistical modelling. &#x0D;

Stakeholders’ perspectives on barriers to and facilitators of school-based HPV vaccination in the context of COVID-19 pandemic-related disruption: a qualitative mixed methods study

ABSTRACT Despite successfully implementing the Human Papilloma Virus Vaccine (HPVV) program, Saskatchewan (SK) struggled to improve HPVV uptake rates. This suboptimal uptake of HPVV with a status quo of HPV-linked cervical cancer incidence rate is mainly because HPVV’s impact on cancer prevention has not been realized adequately by vaccine providers and receivers. Further exploration of determinants of HPVV uptake is required to uncover high-resolution quality improvement targets for investment and situate contextually appropriate policies to improve its uptake. The study undertook a qualitative inquiry into understanding stakeholders’ perspectives on HPVV experience through school-based programmes. It collected data through semi-structured initial interviews (N = 16) and follow-up interviews (N = 10) from across Saskatchewan’s four Integrated Service Areas. Document analysis was conducted on all publicly available documents that included information on HPVV from January 2015 to July 2023. Thematic analysis of the data identified that inadequate information, awareness and education about HPV infection and HPVV among several groups, especially, parents, youth and school staff, was the main barrier to optimal HPVV uptake. Vaccine-related logistics, including the technical and text-heavy vaccine information sheet, understaffing, and time constraints, were other important factors that impeded HPVV uptake. A person-centred approach could educate parents in multiple dimensions.

659. Geographical Clustering of the Likelihood of Treatment in Histologically Diagnosed Helicobacter pylori in the BOSTON-HP Cohort

Abstract Background The BIDMC Optimization &amp; Standardization for Treatment Outcomes in New England for Helicobacter Pylori (BOSTON-HP) study included 1002 patients with confirmed Helicobacter pylori (HP) via gastric histopathology from 2016-2022 to evaluate the effects of a Multidisciplinary Division Wide Program. Our previous data showed that demographic factors, such as race/ethnicity and preferred language, are associated with treatment, test-of-cure, and eradication outcomes. We hypothesize that given an unlikely even geographic distribution of demographic factors, HP outcomes may cluster geographically. Methods The BOSTON-HP cohort patient addresses were transformed to georeferenced coordinates which were mapped using QGIS (3.30 's-Hertogenbosch) onto OpenStreetMap. We calculated the maximum Euclidean distance matrix to assign heatmap weights for each outcome, and calculated global spatial autocorrelation to evaluate the extent of spatial clustering. Results Eight hundred and sixty-eight patients (86.6%) received treatment with confirmed eradication in 416 (47.9%) of them. A statistically significant positive spatial autocorrelation of clusters (Moran’s I = 0.080, p =0.003, z=2.787) was observed for the likelihood of treatment. Layering transportation and healthcare units revealed key clustering patterns (see Figures 1. &amp; 2.). Clusters in the vicinity of Longwood Medical Area (LMA), and South Cove Medical Center (SCMC) were more likely to receive treatment, while those in the Brighton collegiate area (BCA) and along the Red Line Axis in Roxbury-Dorchester (RLRD) were less likely to receive treatment. Test-of-cure and eradication success were not statistically significant for clustering (Moran’s I = 0.007, p =0.388, z=0.284) (Moran’s I = 0.006, p =0.441, z=0.149), respectively.Figure 1. BOSTON-HP Treatment Cohort.Figure 2. Untreated in the BOSTON-HP Cohort. Conclusion A moderate and significant spatial correlation existed between the likelihood of HP treatment and the geographic location of the patient’s residence. Identification of groups for targeted quality improvement interventions (RLRD) and models of success within the system (SCMC) can help improve treatment outcomes and reduce geographic disparities. Disclosures Javier Villafuerte-Gálvez, MD, Milky Way Biosciences: Partial Research Support.